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SCIENTIFIC PROGR AM

THE PREMIER ANNUAL MEETING FOR

VASCULAR HEALTH PROFESSIONALS

JUNE 5–7, 2014 All events held at Hynes Convention Center unless otherwise noted.

Pre-Meeting Program Wednesday, June 4, 2014 www.VascularWeb.org


The Society for Vascular Surgery would like to thank the following companies for their support of the 2014 Vascular Annual Meeting and participation in the SVS Corporate Partners Program.

PLATINUM CIRCLE

Gore & Associates, Inc.

Booth #530

Medtronic, Inc.

Booth #520

Abbott Vascular

Booth #904

GOLD CIRCLE

Boston Scientific Corporation

Booth #414

Booth #321

Cook Medical

SILVER CIRCLE

Atrium Medical Corporation Cordis速, a Johnson & Johnson company

Booth #226 Booth #109

BRONZE CIRCLE Argon Medical Devices, Inc. Bard Peripheral Vascular, Inc.

Booth #505 Booth #915 Booth #1104 Booth #121 Booth #921 Booth #1015

Bolton Medical Covidien Endologix, Inc. Sanofi Biosurgery


PROGRAM GUIDE

June 5 – 7, 2014 Hynes Convention Center Boston, Massachusetts

Society for Vascular Surgery ®

SVS Corporate Partners Program Participants�������������������������Inside Front Cover General Information Overview������������������������������������������������������������������������������������������������������������1 Education������������������������������������������������������������������������������������������������������������7 Poster Competition Details�������������������������������������������������������������������������������������9 Speaker Guidelines�������������������������������������������������������������������������������������������� 11 Financial Disclosures�������������������������������������������������������������������������������������������13 SVS Board of Directors and Committees���������������������������������������������������������������23 Past Meetings�����������������������������������������������������������������������������������������������������25 SVS Awards History��������������������������������������������������������������������������������������������27 Welcome Letter from Mayor Walsh����������������������������������������������������������������������28 SVS Foundation Donors���������������������������������������������������������������������������������������29 Program Schedule At a Glance�������������������������������������������������������������������������35 Wednesday, June 4���������������������������������������������������������������������������������������������39 Thursday, June 5�������������������������������������������������������������������������������������������������85 Friday, June 6�����������������������������������������������������������������������������������������������������107 Friday, June 6 Poster Session�������������������������������������������������������������������������� 131 Saturday, June 7�����������������������������������������������������������������������������������������������233 Fellow/General Surgery Resident/Student Programs���������������������������������277 Exhibits and Floor Plans Exhibit Hall Location and Hours�������������������������������������������������������������������������285 Floor Plan: Exhibit Hall��������������������������������������������������������������������������������������286 Exhibitor Listing by Category�����������������������������������������������������������������������������287 Exhibitor Directory��������������������������������������������������������������������������������������������294 Floor Plans: Hynes Convention Center���������������������������������������������������������������� 312 Floor Plans: Sheraton Boston������������������������������������������������������������������������������ 315 Future Meeting Dates and Locations������������������������������������������Inside Back Cover The Premier Annual Meeting for Vascular Health Professionals Society for Vascular Surgery • Vascular and Endovascular Surgery Society Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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Download the Vascular Annual Meeting Mobile App

•C  omprehensive — Review all program content, including abstracts. •S  earchable — Find sessions and topics of interest with a quick search. • Interactive — Network with colleagues, ask speakers questions, and rate programs. Compatible with Apple, Android and Blackberry devices. Available at

Or visit vsweb.org/mobileapp for other devices. -


SCHEDULE AT A GLANCE WEDNESDAY, June 4 6:00 a.m. – 6:30 p.m. Registration 7:00 a.m. – 5:00 p.m. POSTGRADUATE COURSES Separate Registration Required 6:00 – 7:00 a.m. Postgraduate Courses Breakfast 7:00 – 10:00 a.m. CONCURRENT SESSIONS P1: Critical Issues in Managing Lower Extremity PVD P2: Advanced Chronic Venous Treatment: Superficial to Deep 10:00 – 10:15 a.m. Coffee Break 10:15 a.m. – 1:15 p.m. CONCURRENT SESSIONS P3: O  pen Surgical Techniques of the Aorta and Aortic Branches P4: Innovation and Invention: A Vascular Surgeon’s Primer 1:15 – 2:00 p.m. Postgraduate Courses Lunch 2:00 – 5:00 p.m. CONCURRENT SESSIONS P5: Thoracic Aortic Disease Management: From the Aortic Valve to the Bifurcation P6: SVS Leadership Program — Leadership Styles & Versatility

8:30 a.m. – Noon V1: Vascular and Endovascular Surgery Society (VESS)* Paper Session I *formerly known as PVSS 1:00 – 4:30 p.m. V2: Vascular and Endovascular Surgery Society (VESS)* Paper Session II *formerly known as PVSS 2:00 – 6:00 p.m. General Surgery Resident/Medical Student Scholarship Program – Open and Endovascular Training Scholarship Recipients Only 4:00 – 6:00 p.m. C1: International Forum 5:00 – 6:30 p.m. CONCURRENT BREAKOUT SESSIONS C2: Vascular Surgery in the VA: Issues for VA Surgeons and What Can We All Learn? C3: S  VS Young Surgeons Committee/VESS Session: Preparing Young Surgeons for the Future C4: R  oles and Controversies Surrounding Technology, Policy and Clinical Practice in Vascular Surgery 6:45 – 8:15 p.m. Welcome Reception for Medical Students and General Surgery Residents

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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THURSDAY, June 5 6:00 a.m. – 6:00 p.m. Registration 6:30 – 8:00 a.m. CONCURRENT BREAKFAST SESSIONS B1: Hemodialysis Access: Challenges and Breakthroughs B2: Changing Paradigms in Asymptomatic Carotid Disease B3: P  ost-EVAR Management: Surveillance Endoleaks and When to Intervene 6:30 – 8:00 a.m. General Surgery Resident Program Breakfast

Noon – 6:30 p.m. Exhibit Hall Open

Noon – 1:20 p.m. Lunch in Exhibit Hall and Vascular Live Presentations Noon – 6:30 p.m. Poster Set-Up 1:20 – 2:30 p.m. S2: SVS Plenary Session II

6:30 – 8:00 a.m. Medical Student Program Breakfasts MS1/MS2 MS3/MS4

2:30 – 3:00 p.m. E2: Roy Greenberg Distinguished Lecture New Horizons in Aortic Disease — The Lasting Legacy of a Visionary Innovator

8:00 – 8:30 a.m. Opening Ceremony

3:00 – 3:30 p.m. Awards Presentation

8:30 – 10:00 a.m. S1: William J. von Liebig Forum

3:30 – 4:00 p.m. Coffee Break and Vascular Live Presentations

10:00 – 10:30 a.m. E1: John Homans Lecture Carotid Surgery — Trials and Tribulations 10:30 a.m. – Noon F1: E. Stanley Crawford Critical Issues Forum Appropriate Use of Vascular Surgery Procedures: Do We Have a Problem?

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4:00 – 5:30 p.m. S3: SVS Plenary Session III 5:30 – 6:30 p.m. Opening Reception 7:00 – 10:00 p.m. Individual Alumni and Committee Receptions


FRIDAY, June 6 6:00 a.m. – 5:30 p.m. Registration

12:15 – 1:30 p.m. SVS Member Business Luncheon

6:30 – 8:00 a.m. CONCURRENT BREAKFAST SESSIONS B4: Current Management of Vascular Graft Infections from Head to Toe B5: Optimizing Wound Care and Amputation Management B6: T he Role of Vascular Surgery During Multispecialty Operations B10: P  opulation-Based Health Services Research: When, Where, How and Why

12:15 – 1:30 p.m. Non-Member Lunch in Exhibit Hall and Vascular Live Presentations

6:30 – 8:00 a.m. General Surgery Resident/Medical Student Program Breakfast — Surgical Skills Competition

1:30 – 3:00 p.m. S5: SVS Plenary Session V 3:00 – 3:30 p.m. Coffee Break and Vascular Live Presentations

8:00 – 9:30 a.m. S4: SVS Plenary Session IV

3:30 – 5:00 p.m. CONCURRENT BREAKOUT SESSIONS C5: SVS/ESVS Joint Debate Session C6: SVS/STS Joint Session C7: Collaborating on Resident/Student Education: Opportunities for Education Abroad and in North America

9:30 a.m. – 4:30 p.m. Exhibit Hall Open

3:30 – 5:00 p.m. C8: Poster Session

9:30 – 10:00 a.m. Coffee Break and Vascular Live Presentations

5:00 – 6:00 p.m. General Surgery Resident/Medical Student Program — Residency Fair

10:00 – 11:05 a.m. F2: Projects and Reports from the Vascular Quality Initiative 11:05 a.m. – 12:15 p.m. SVS Presidential Address Of Strategies and Chances

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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SATURDAY, JUNE 7 6:00 a.m. – 5:00 p.m. Registration

10:00 – 11:00 a.m. S6: SVS Plenary Session VI

6:30 – 8:00 a.m. CONCURRENT BREAKFAST SESSIONS B7: T he Vascular Surgeon in Elective Multispecialty Operations B8: Opportunities to Improve the Outcomes of Patients with Acute Aortic Syndromes B9: Closure and Arterial Access Conundrums

11:00 a.m. – Noon F4: Poster Runoff: Championship Round

6:30 – 8:00 a.m. SVS Leadership Roundtable: Breaking Through Ethnic and Gender Biases to Become a More Effective Leader *This program not eligible for CME credit 8:00 – 9:30 a.m. F3: B  eyond the Journal of Vascular Surgery: “Top Ten” Papers Relevant to Vascular Surgery 9:00 a.m. – 1:00 p.m. Exhibit Hall Open 9:30 – 10:00 a.m. Coffee Break and Vascular Live Presentations

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Noon – 1:00 p.m. Lunch in Exhibit Hall Noon – 1:00 p.m. Vascular Surgery Trainee Luncheon 1:00 – 2:10 p.m. R1: Rapid Paced Paper Session I 2:10 – 3:05 p.m. L1: Late-Breaking Clinical Trial Session 3:05 – 4:30 p.m. R2: Rapid Paced Paper Session II 4:30 p.m. 2014 Vascular Annual Meeting Adjourns


GENERAL INFORMATION Registration Hours The Society for Vascular Surgery (SVS) Vascular Annual Meeting Registration Area is located on Level 2 just outside Exhibit Hall C of the Hynes Convention Center. Registration hours are:

Wednesday, June 4 Thursday, June 5 Friday, June 6 Saturday, June 7

6:00 a.m. – 6:30 p.m. 6:00 a.m. – 6:00 p.m. 6:00 a.m. – 5:30 p.m. 6:00 a.m. – 5:00 p.m.

Exhibit Hall Hours Commercial exhibits are located in Exhibit Halls C and D on Level 2 of the Hynes Convention Center. Please be sure to visit the exhibitors, whose support is integral to the meeting. Thursday, June 5 Friday, June 6 Saturday, June 7

Noon – 6:30 p.m. 9:30 a.m. – 4:30 p.m. 9:00 a.m. – 1:00 p.m.

Don’t miss the new and innovative “Vascular Live” presentations scheduled in the Exhibit Hall each day. These presentations will focus on the latest products and research within the vascular community. Box lunches are available during SVS-scheduled coffee breaks, in designated coffee break areas in the Exhibit Hall. Special Events Wednesday, June 4 Welcome Reception for Medical Students and General Surgery Residents Co-sponsored by the SVS Young Surgeons Committee and the Vascular and Endovascular Surgery Society (VESS) 6:45 – 8:15 p.m., Sheraton Boston Hotel, Commonwealth Room, Third Floor International Guest Reception 6:00 – 7:00 p.m., Sheraton Boston Hotel, Back Bay Ballroom A/B, Second Floor Thursday, June 5 SVS Opening Ceremony 8:00 – 8:30 a.m., Hynes Convention Center, Ballroom A/B, Level 3 SVS Opening Reception 5:30 – 6:30 p.m., Hynes Convention Center, Exhibit Halls C/D, Level 2 SVS PAC Reception 7:00 – 8:30 p.m., Sheraton Boston Hotel, Independence East Ballroom, Second Floor Rep. Mike Burgess, MD (R-TX), sponsor of SGR repeal and reform bill, is our special guest SVS Women’s Leadership Dinner 7:00 – 9:00 p.m., Sheraton Boston Hotel, Republic Ballroom, Second Floor Co-sponsored by the SVS Diversity and Inclusion Committee and the Vascular and Endovascular Surgery Society (VESS)

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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Individual Alumni and Committee Receptions 7:00 – 10:00 p.m. Sheraton Boston Beth Israel Deaconess Alumni Reception 7:00 – 8:30 p.m. Sheraton Boston, Fairfax A Room, Third Floor Brigham & Women’s Hospital Alumni Reception 7:00 – 8:30 p.m. Sheraton Boston, Fairfax A Room, Third Floor Cleveland Clinic Alumni Reception 7:00 – 8:30 p.m. Sheraton Boston, Fairfax B Room, Third Floor Harvard Vascular Surgeons’ Alumni Reception 7:00 – 8:30 p.m. Sheraton Boston, Fairfax A Room, Third Floor Henry Ford Health Systems Alumni Reception 7:00 – 8:30 p.m. Sheraton Boston, Exeter Room, Third Floor Massachusetts General Hospital Alumni Reception 7:00 – 8:30 p.m. Sheraton Boston, Fairfax A Room, Third Floor Mayo Clinic Alumni Reception 7:00 – 9:00 p.m. Sheraton Boston, Beacon D Room, Third Floor NYU Langone Medical Center Alumni Reception 7:00 – 10:00 p.m. Sheraton Boston, Commonwealth Room, Third Floor OHSU Alumni and Friends Reception 7:00 – 9:00 p.m. Sheraton Boston, Beacon E, Third Floor Penn Vascular Surgery Alumni Reception 7:00 – 9:00 p.m. Sheraton Boston, Independence West Ballroom, Second Floor Stanford University Alumni Reception 7:00 – 10:00 p.m. Sheraton Boston, Hampton Room, Third Floor UCLA Division of Vascular Surgery Alumni Reception 7:00 – 8:30 p.m. Sheraton Boston, Dalton Room, Third Floor University of Washington Alumni Reception 7:00 – 8:30 p.m. Sheraton Boston, Clarendon Room, Third Floor Washington University St. Louis Alumni Reception 7:00 – 9:00 p.m. Sheraton Boston, Beacon A Room, Second Floor Friday, June 6 SVS Member Business Luncheon 12:15 – 1:30 p.m., Hynes Convention Center, Ballroom C, Level 3 Saturday, June 7 SVS Leadership Roundtable Sponsored by the SVS Diversity and Inclusion Committee 6:30 – 8:00 a.m., Hynes Convention Center, Room 210 SVS Vascular Surgery Trainee Luncheon Noon – 1:00 p.m., Hynes Convention Center, Room 313 2


WHAT’S NEW AT THE 2014 VASCULAR ANNUAL MEETING Plenary Session Broadcast Watch the plenary sessions while you visit the Exhibit Hall. All plenary sessions will be broadcast throughout the Exhibit Hall during the meeting. Introducing Vascular Live Don’t miss these new and innovative sessions each day during scheduled breaks and the lunch hour. The latest products and developments related to vascular surgery will be presented in a theater-in-the round setting in Exhibit Halls C and D. Scheduled presentations include: THURSDAY, JUNE 5 Noon – 1:00 p.m., Exhibit Hall C Sponsored by Bard Peripheral Vascular, Inc. “A Discussion of Lutonix® Drug Coated Balloon Technology” This session will be moderated by Edward Woo, MD, Director, Medstar Regional Vascular Program. Preclinical Safety Data and Technology Overview Presented by Elena Ladich, MD, CV Path Institute, Inc. LEVANT 2: A Prospective, Randomized Trial of Paclitaxel-Coated Balloons vs. Standard Balloon Angioplasty. Critical Limb Ischemia and the Role of DCBs Below the Knee presented by Patrick Geraghty, MD, Washington University. Noon – 12:30 p.m., Exhibit Hall D Sponsored by Gore & Associates “From Creation to Revision — New Solutions for Dialysis Patients” Why early cannulation matters: Shifting the patient care paradigm presented by Marc Glickman, MD and Primary stenting with the GORE® VIABAHN® Endoprosthesis for cost-effective AV access revision presented by Tom Vesely, MD. 12:30 – 1:00 p.m., Exhibit Hall D Sponsored by Gore & Associates “The Latest Solutions for Patients with PAD” Can superior clinical outcomes in surgical bypass and cost effectiveness coexist? How to save limbs and lower costs by 33% presented by Richard Neville, MD and Continued innovation of the GORE® VIABAHN® Endoprosthesis presented by Dennis Gable, MD 3:30 – 4:00 p.m., Exhibit Hall C Sponsored by Aptus Endosystems, Inc. “Managing Complex EVAR Cases with the Aptus Heli-FX EndoAnchor System” Tailor seal and fixation with the objective to improve patient long-term outcomes. Clinical case examples and ANCHOR Registry results presented by Bart Muhs, MD, PhD and William Jordan, MD.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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FRIDAY, JUNE 6 9:30 – 10:00 a.m., Exhibit Hall C Sponsored by CryoLife, Inc. “HeRO® Graft Clinical Update” Clinical Update on the HeRO Graft, indications for use, case presentation and implant techniques presented by Shawn Gage, PA-C. 9:30 – 10:00 a.m., Exhibit Hall D Sponsored by Hansen Medical “Real World Intravascular Robotics Implementation: Clinical Experiences and Lessons Learned” John Matsuura, MD shares experiences with implementation of the Magellan™ Robotic System for at Miami Valley Hospital in Dayton, OH; including the strategic and clinical rationale for Intravascular Robotics, as well as clinical case experiences and lessons learned. 12:15 – 12:45 p.m., Exhibit Hall C Sponsored by Gore & Associates “Branched Device Clinical Trials from Gore” The GORE® EXCLUDER® Iliac Branch Endoprosthesis clinical trial update presented by Darren Schneider, MD and the GORE®TAG® Thoracic Branch Endoprosthesis clinical trial overview presented by Michael D. Dake, MD. 12:15 – 12:45 p.m., Exhibit Hall D Sponsored by MAQUET Medical Systems “The FUSION BIOLINE Heparain-Coated Vascular Graft: Superior Patency and Improved Outcomes Compared to Standard ePTFE Grafts” Review of the FUSION BIOLINE Heparin Coated Vascular Graft and the Prospective, Randomized, Controlled FINEST Trial, presented by Alan Lumsden, MD. 12:45 – 1:15 p.m., Exhibit Hall C Sponsored by Gore & Associates “Type B Dissection: Who Should be Treated with TEVAR?” Controversial topics, including which Type B dissection patients should be treated with TEVAR and strategies for treating complicated vs. uncomplicated as well as acute vs. chronic Type B dissections, presented by Alan Lumsden, MD. 3:00 p.m. – 3:30 p.m., Exhibit Hall C Sponsored by Lombard Medical Technologies, Inc. “Clinical Experience Treating Highly Angulated AAAs On-Label using the Aorfix™ Endovascular Stent Graft” Pythagoras clinical trial, resulting in 0 to 90 degree neck angulation indication, with case review and discussion presented by Mark Fillinger, MD. SATURDAY, JUNE 7 9:30 – 10:00 a.m., Exhibit Hall C Sponsored by Philips Healthcare “Advanced Imaging Tools in the Hybrid OR” The Beth Israel Deaconess Medical Center in Boston, MA has successfully led an Endovascular Surgery program in their Hybrid OR complex for the past few years. Marc Schermerhorn, MD and Lars Stangenberg, MD will share how advanced imaging tools like “on-table” 3D imaging, Dynamic 3D RoadMap and Puncture Guidance allow for safer and less invasive procedures. Vascular Live presentations are not part of the ACCME-accredited portion of the Vascular Annual Meeting. 4


BACK BY POPULAR DEMAND Wednesday Afternoon Concurrent Sessions Several concurrent sessions will be offered on Wednesday, June 4 from 5:00 to 6:30 p.m. Plan to attend these exciting presentations. International Forum The International Forum promotes exchange among vascular surgeons around the world. The forum, held at 4:00 p.m. on Wednesday, June 4, features abstracts submitted by international authors. A reception for all international guests follows the forum at 6:00 p.m. at the Sheraton Boston Hotel. Mobile Device Charging Stations Sponsored by Sanofi Biosurgery Mobile device charging stations are available on levels 2 and 3 of the Hynes Convention Center with chargers for iOS and Android devices. Electrical outlets are also available for recharging laptops. Please be sure to bring your laptop cord. Vascular Annual Meeting Mobile App Sponsored by Bard Peripheral Vascular, Inc. Connect with colleagues and exhibitors, ask speakers questions, build your own schedule, consult Exhibit Hall and Convention Center maps, and review abstracts from your mobile phone or tablet with the Vascular Annual Meeting app, compatible with iOS, Android and Blackberry devices. Download the app from iTunes, Google Play or visit www.vsweb.org/2014app for other devices. Complimentary Wi-Fi is available throughout the Hynes Convention Center. Poster Competition A moderated poster competition convenes Friday, June 6 at 3:30 p.m. in the Exhibit Hall. Accepted abstracts, selected by the SVS Program Committee for poster presentation, will go through a 2-round judging process with the final round and prize presentation on Saturday, June 7. Attendees will use a response system keypad to vote for the top 3 posters. Video Presentations Each plenary session of the Vascular Annual Meeting includes a 5-minute video presentation of an open or endovascular procedure performed by an SVS member or sponsored guest, and is followed by 5 minutes of comments and questions from the floor. Clinical Debate Session Observe the clinical debate session 3:30 to 5:00 p.m. on Friday, June 6. There will be 3 debate topics and audience members will vote for the best debate using a response system keypad. Opening Reception Plan to attend this year’s opening reception at 5:30 p.m. on Thursday, June 5 in the Exhibit Hall. Enter the raffle to win complimentary 2015 meeting registration and 2 complimentary airline tickets good for travel anywhere in the continental U.S.* *Airline restrictions apply. Prize is not transferable and may not be redeemed for cash.

Claim Your CME For your convenience, you can claim your CME credits online during the meeting and at vascularweb.org after the meeting. CME counters are available in the Registration Area of the Hynes Convention Center beginning at noon on Thursday, June 5.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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Cyber Café The Cyber Café, located in Exhibit Hall C of the Hynes Convention Center, is open during exhibit hours. Attendees may use Cyber Café computer stations to check or send email; locate meeting attendees and exhibiting companies; or print boarding passes. Don’t forget to check the scrolling-message monitor for communiqués from colleagues. Please be courteous and limit computer station time during peak hours. Follow the Red Carpet A red carpet leads from the plenary session room to the entrance of the Exhibit Hall. Be sure to visit the exhibits and support partnering sponsors. They are an integral part of the Vascular Annual Meeting and contribute to keeping registration fees reasonable. Plenary and Breakfast Session Downloads Supported by Medtronic, Inc. Once again, plenary and breakfast session downloads are available in the Exhibit Hall after the sessions have been presented. Visit Medtronic Booth #520 in the Exhibit Hall during exhibit hours. Flash drives will be distributed to each professional attendee in the Registration Area upon redemption of the voucher provided at registration. Video and Audio Recording Policy Video or audio recording of any Vascular Annual Meeting or postgraduate course session is not permitted. A SPECIAL THANK YOU TO OUR 2014 SUPPORTERS Vascular Annual Meeting Educational Grants Abbott Vascular Boston Scientific Corporation Cook Medical Cordis® a Johnson & Johnson company Gore & Associates, Inc. Medtronic, Inc. Vascular Annual Meeting Sponsorships American Registry for Diagnostic Medical Sonography (AARDMS) – One meter panel sign Argon Medical Devices, Inc. – Carpet logo Bard Peripheral Vascular, Inc. – Mobile app BLOXR Corporation – One meter panel sign Covidien – Headquarters hotel key cards Gore & Associates – Convention Center video monitors and two meter panel signs Medtronic, Inc. – Plenary and breakfast session downloads and flash drives Sanofi Biosurgery – Two mobile device charging stations

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EDUCATION Accreditation SVS is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. 2014 VASCULAR ANNUAL MEETING Designation of Credit SVS designates this live activity for a maximum of 32.25 AMA PRA Category 1 Credits.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity. Overall Learning Objectives The Vascular Annual Meeting is designed to provide a variety of learning opportunities in vascular surgical practice, research and science that supports individual educational needs and lifelong learning. At the conclusion of the meeting, participants should be able to apply the knowledge acquired to enhance patient care. Target Audience The Vascular Annual Meeting is designed for: • vascular surgeons • physicians in related specialties • fellows/residents in vascular surgery and general surgery training programs • interventional radiologists working in the vascular imaging and intervention field • physician assistants and nurses involved in the care of vascular surgical patients • vascular technologists and vascular lab administrators • researchers, administrators, practice managers and allied health professionals with an interest in the science and treatment of vascular disease • medical students with an interest in vascular surgery

2014 POSTGRADUATE COURSES DAY Designation of Credit SVS designates this live activity for a maximum of 9 AMA PRA Category 1 Credits.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity. Overall Learning Objectives The postgraduate courses are designed to provide a variety of learning opportunities in vascular surgical practice, research and science that supports individual educational needs and lifelong learning. At the conclusion of the meeting, participants should be able to apply the knowledge acquired to enhance patient care.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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Target Audience The postgraduate courses are designed for: • vascular surgeons • physicians in related specialties • fellows/residents in vascular surgery and general surgery training programs • interventional radiologists working in the vascular imaging and intervention field • physician assistants and nurses involved in the care of vascular surgical patients • vascular technologists and vascular lab administrators • researchers, administrators, practice managers and allied health professionals with an interest in the science and treatment of vascular disease • medical students with an interest in vascular surgery

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POSTER COMPETITION DETAILS Accepted abstracts, selected by the SVS Program Committee, go through a 2-round judging process. The first round is presentation of accepted posters divided into topic groups (e.g., venous, aortic disease, basic research, etc.) on Friday, June 6. The winners from each group proceed to a final round and present their posters in a plenary session entitled “Poster Runoff: Championship Round” on Saturday, June 7. First Round: Friday, June 6, 3:30 – 5:00 p.m. Authors in each topic group have 3 minutes for presentation and 2 minutes for discussion before an audience of peers and SVS Program Committee moderators. Presenting authors may present only 1 poster during this part of the competition. If the presenting author has more than 1 accepted poster, then another individual must present. The 5-minute limit is strictly enforced. Since this is a competition, it is expected that presenters will not be senior faculty. Ten to 12 groups present their posters concurrently. The authors and moderator of each group rate all posters in that group, so presenters are required to be present for the entire session. Based on a peer scoring system, winners are selected from each topic group and then proceed to the final round. Final Round: Saturday, June 7, 11:00 a.m. – Noon Winners (finalists) from each topic group present at the plenary session, using PowerPoint slides. Each finalist has 3 minutes for presentation and 2 minutes for discussion. The 5-minute limit is strictly enforced. The SVS President and President-Elect pose questions. Each finalist who makes a presentation will receive a cash prize, and the audience votes for the top 3 winners. Poster Presentation • Abstracts accepted for poster presentation will be displayed in the Exhibit Hall of the Hynes Convention Center, Boston, MA. • Poster presentation is scheduled with 3 minutes for presentation and 2 minutes for discussion. • Authors must be present during the entire 90-minute session to which they are assigned for peer grading of all abstracts in the group. • The presenting author must be registered for the Vascular Annual Meeting. • Presenting authors may present only 1 poster. If the presenting author has more than 1 accepted poster, then another individual must present. • Since this is a competition, it is expected that presenters will not be senior faculty. Display and Set-up • Accepted posters must fit on 1 side of a tack board 4-feet-high and 8-feet-wide for the first round. • Authors should prepare a PowerPoint presentation for the final round in case they win the first round. Winning authors will need to stop by the Speaker Ready Room (Hynes Convention Center, Room 300) to submit their presentations and confirm participation in the final round. Speaker guidelines appear on the next page. • Authors will be assigned a poster ID that will be displayed on their assigned poster board. • Posters can be set up on Thursday, June 5 from noon on, and may stay up until Saturday, June 7 at noon.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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• Posters not dismantled by noon on Saturday, June 7 will be discarded. SVS does not assume responsibility for loss or damage to posters. • Authors are responsible for costs associated with creating and shipping poster displays. Meeting Registration SVS does not reimburse expenses or cover meeting registration fees for poster presenters. You may visit www.VascularAnnualMeeting.org for details about online registration. Journal Publication Manuscript submission to the Journal of Vascular Surgery for those accepted to present at the poster presentation session is not a requirement, but is encouraged. Manuscripts should be submitted electronically to the Journal of Vascular Surgery at www.editorialmanager.com/jvs prior to presentation at the Vascular Annual Meeting and no later than June 16, 2014. PLEASE NOTE: Any abstract submission accepted for the SVS poster session that has not been submitted as a paper to the Journal of Vascular Surgery may be submitted as an abstract to the following regional and national society meetings: • Eastern Vascular Society* • New England Society for Vascular Surgery • Society for Clinical Vascular Surgery • Southern Association for Vascular Surgery • Vascular and Endovascular Surgery Society • Western Vascular Society* *These societies preclude presentation at the final, championship round if a paper has also been accepted at their annual meeting. The poster must still be presented at the initial poster session of the Vascular Annual Meeting.

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SPEAKER GUIDELINES SVS is pleased to have your active involvement during the 2014 Vascular Annual Meeting. The guidelines provided here enable our technical team to support you effectively, and give the team an opportunity to uncover any potential glitches in advance. Speakers Please stop by the Speaker Ready Room and check in upon your arrival at the meeting to confirm your arrival and participation. Please note: Internet access is NOT available in the Speaker Ready Room. If your presentation resides in DropBox or email, please download and copy to a flash drive before coming to the Speaker Ready Room. Speaker Ready Room Hours Hynes Convention Center, Room 300 Tuesday, June 3 3:00 p.m. – 6:00 p.m. (postgraduate courses, VESS) Wednesday, June 4 6:00 a.m. – 6:30 p.m. Thursday, June 5 6:00 a.m. – 5:30 p.m. Friday, June 6 6:00 a.m. – 5:00 p.m. Saturday, June 7 6:00 a.m. – 4:30 p.m. How it Works There will be a single Windows-based laptop at the podium. This laptop is connected via network to the computers located in the Speaker Ready Room. Once the graphics operator has checked in your presentation, it will be loaded onto the podium computer. This procedure eliminates mishaps that can occur due to incompatible devices and software, and also ensures the flow of the meeting is not interrupted. Please Note: Internet access will NOT be available on the presentation laptops. Format Guidelines We use PowerPoint 2010 on our computers. This version will accept files created in earlier versions of the software. Presentations created in Keynote, Prezi, Slide Rocket or other presentation software will not be accepted. Formats Accepted USB flash drive CD-ROM External USB hard drive Video Clip Format Recommended file formats to facilitate playback of video clips in a PowerPoint presentation are: WMV, MPG, AVI or MOV. Videos Embedded in PowerPoint 2010 It is recommended that you bring copies of all videos, even those embedded in your presentation. This will, if necessary, allow us to edit and/or re-import the video file to ensure your presentation runs smoothly. Plenary Session Video Presenters Video segments should be submitted on DVD (playable in a standard DVD player). Other formats accepted include MOV, WMV or MP4. Please note: It is extremely important that you specify whether your video will include sound.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

11


For Mac Users • Keynote users: Keynote cannot be played back on a PC. Please export your presentation as a PowerPoint file. • PowerPoint for Mac files should be tested on a PC before attending the event. • “Drag and Drop” placement of images is not supported in the PC version of PowerPoint. Please use the “Insert” drop down menu when placing graphics in your presentation. Important Reminders • Please do not take your laptop to the session room. Presenters who arrive at the session room with their laptops will be asked to go the Speaker Ready Room to upload their presentations. • Include a disclosure slide directly following your title slide that lists relationships and affiliations disclosed in your conflict-of-interest information. • Plenary presentations are 14 minutes in length (7-minute presentation, 7-minute question and answer). • Video presentations are 10 minutes in length (5-minute presentation, 5-minute question and answer). • Rapid-paced presentations are 5 minutes in length (3-minute presentation, 2-minute question and answer). • Invited speaker presentations vary in length from 5 to 45 minutes each. Please discuss your session time with the moderator. • VESS session presentations are 14 minutes in length (7-minute presentations, 7-minute question and answer). • International Forum presentations are 10 minutes in length (5-minute presentations, 5-minute question and answer). • Select plenary and breakfast sessions will be recorded for Web cast (streaming) 14 days after the meeting. Presentations (audio and slides) will be available for viewing on www.VascularWeb.org after the meeting. Presenters who do not wish to have their presentation recorded should so indicate when uploading presentations in the Speaker Ready Room. • Presenters will be asked to agree or disagree to the following: – Presenters hereby grant permission to allow the text and images of their presentations to be posted on the VascularWeb website after the meeting. Presenters will have the opportunity to delete or provide replacement slides (if necessary) within 7 days of the presentation. Presenters are responsible for obtaining all releases for any copyright-protected or proprietary content included in the material being presented.

12


FINANCIAL DISCLOSURES As an accredited sponsor of the Accreditation Council for Continuing Medical Education (ACCME), SVS must ensure balance, independence, objectivity and scientific rigor in all its individually sponsored educational activities. In accordance with ACCME guidelines and standards, all faculty participating in an accredited activity must disclose to the audience any significant financial interest or other relationship with 1) the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation and 2) any commercial supporters of the activity. (Significant financial interest or other relationships can include such things as grants or research support, employment, consultant, major stockholder, member of speakers’ bureau, etc.) Listed below are the disclosures provided by the faculty for this meeting.

Postgraduate Courses FACULTY

ROLE*

FDA, FINANCIAL RELATIONSHIP COMPANY/ORGANIZATION

Charles W. Acher, MD

Moderator

None

Cameron M. Akbari, MD

Speaker

None

Jose I. Almeida, MD

Speaker

Ownership Interest

Frank R. Arko, MD Speaker Consulting Fee Marvin D. Atkins Jr., MD

Speaker

None

Thomas C. Bower, MD

Speaker

None

Kellie R. Brown, MD

Moderator

None

Ruth L. Bush, MD, MPH

Moderator/Speaker

None

Richard P. Cambria, MD

Speaker

Contracted Research

Rocco G. Ciocca, MD

Speaker

None

Vascular Device Partners, LLC Gore, Medtronic, Endologix, Terveno, Penumbra, Abbott

PI of industry-sponsored trial

Daniel G. Clair, MD Speaker/Moderator Consulting Fee Other

Cordis, Covidien, Endologix, eV3, WL Gore Advisory Board - Boston Scientific, Medtronic

Anthony J. Comerota, MD Speaker

Consulting Fee Contracted Research

Tactile, Inc. Cook Inc, PI for Vivo Trial

Mark F. Conrad, MD, MMSc Speaker

Consulting Fee Other

Medtronic, Volcano BARD – member and CEC

Joseph S. Coselli, MD Speaker

Royalty Consulting Fees Contracted Research

Vascutek Terumo Vascutek Terumo, Medtronic Inc. Medtronic Inc., WL Gore & Associates

Enrique Criado, MD, PhD

Speaker

None

Frank J. Criado, MD, FACS Speaker

Consulting Fee Speakers Bureau

Brian G. DeRubertis, MD

None

Speaker

Alan M. Dietzek, MD Speaker

Consulting Fees Speakers Bureau

Ellen D. Dillavou, MD

Moderator/Speaker

None

Matthew J. Eagleton, MD

Speaker

Consulting Fees

Matthew S. Edwards, MD

Speaker

None

Medtronic Medtronic

Covidien Cook Medical, Boston Medical

Steve M. Elias, MD Speaker Moderator Consulting Fees

Covidien Inc., Vascular Insights LLC, LeMaitre Inc.

Mark A. Farber, MD Moderator/Speaker

Consulting Fee Speakers Bureau Contracted Research

Cook, Gore, Bolton Medical, Endologix Volcano Cook, Gore, Bolton, Endologix

Julie Ann Freischlag, MD

None

Speaker

Patrick Geraghty, MD Speaker Consulting Fees Speakers Bureau Contracted Research Bruce L. Gewertz, MD

Speaker

Boston Scientific Cook Medical, Bard Peripheral Vascular Cook Medical (FORMAT Trial National PI), Bard/Lutonix (BTK Trial Global PI), Covidien

None

*(i.e, course director, moderator, speaker)

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

13


FACULTY

ROLE*

FDA, FINANCIAL RELATIONSHIP COMPANY/ORGANIZATION

David L. Gillespie, MD Speaker

Royalty Speakers Bureau

Thomas S. Huber, MD

Speaker

None

Vikram S. Kashyap, MD

Discussant

None

Rebecca Kelso, MD

Speaker

None

Christopher J. Kwolek, MD Moderator Contracted Research Peter F. Lawrence, MD

Speaker

W. Anthony Lee, MD Speaker

Cook Medical Inc. Volcano Corp

Cordis, Silk Road Medical, Endologix, Terumo -– Sulzer Vascutek

None Consulting Fees Speakers Bureau

Sean P. Lyden, MD Speaker/Moderator Consulting Fee Contracted Research Other Robyn A. Macsata, MD

Speaker

None

Nitin G. Malhotra, MD

Speaker

None

Michael L. Marin, MD

Speaker

None

Cook Medical Cook Medical Cook Inc., Covidien Co-National PI Illumenate Trial Research trials, WL Gore, Cordis, Aptus, NIH, Cook, Dalichi, Silkroad, Trivascular Aruste Medical Scientific Advisory Board, Medtronic Branch Cessel Advisory Board, Covidien Scientific Advisory Board, Trivascular Scientific Advisory Board, VIVA Physicians 501C3 Board

John D. Martin, MD Speaker

Receipt of Intellectual Property Rights/ Patent Holder Speakers Bureau Ownership Interest

Mark H. Meissner, MD

Moderator/Speaker

None

Mark D. Morasch, MD

Spearker

Consulting Fee

WL Gore, Endologix

Patrick E. Muck, MD

Speaker

Speakers Bureau

Abbott Vascular

Firas F. Mussa, MD

Speaker

None

Kenneth Ouriel, MD Speaker

Salary Ownership Interest

John P. Pigott, MD

Speaker

None

Seshadri Raju, MD

Speaker

Ownership Interest

Linda M. Reilly, MD

Speaker

None

Adnan Z. Rizvi, MD

Speaker

None

Bhagwan Satiani, MD, MBA

Moderator/Speaker

None

LeMaime Vascular Medtronic Inc. LeMaime Vascular

Syntactz Syntactz Veniti, Inc.

Timur P. Sarac, MD Speaker

Receipt of Intellectual Property Rights/ Patent Holder Ownership Interest

Peritec Biosciences

Peter A. Schneider, MD Moderator Speaker

Royalty Contracted Research Other

Cook Medical Medtronic, Gore, Cordis Chief Medical Officer of Intact Vascular

Sunita D. Srivastava, MD

Speaker

None

Margaret Clarke Tracci, MD

Speaker

None

Raghuveer Vallabhaneni, MD

Speaker

Contracted Research

WL Gore – Local Principal Investigator

James H. Wagner, JD

Speaker

Salary

Cheetah Medical

Richard S. Wesorick, JD

Speaker

None

Edward Y. Woo, MD Moderator

Consulting Fees Speakers Bureau

Douglas L. Wooster, MD

Moderator/Speaker

None

Dai Yamanouchi, MD, PhD

Speaker

None

Christopher K. Zarins, MD

Speaker

Salary

*(i.e, course director, moderator, speaker)

14

Peritec Biosciences

Medtronic, Cook, Gore, Bard, Endologix Medtronic, Cook, Gore, Bard, Endologix

Heatflow, Inc.


Vascular Annual Meeting FACULTY

ROLE*

Christopher J. Abularrage, MD

Discussant None Moderator

FINANCIAL RELATIONSHIP COMPANY

Keith B. Allen, MD

Moderator/Discussant

None

Frank R. Arko, MD Discussant Consulting Fee

Gore, Medtronic, Endologix, Terumo, Penumbra, Abbot

Zachary M. Arthurs, MD

Speaker

Consulting Fees

Endologix

Bernadette Aulivola, MD

Moderator

None

Amir F. Azarbal, MD

Speaker

None

Igor L. Banzic, MD

Speaker

None

B. Timothy Baxter, MD

Speaker

None

Adam W. Beck, MD Speaker Consulting Fee Other Thomac C. Bower, MD

Moderator/Speaker

None

O. William Brown, MD, JD

Speaker

None

Richard P. Cambria, MD

Moderator/Speaker Speaker

Contracted Research

Piergiorgio Cao, MD

Moderator

None

Rabih A. Chaer, MD

Moderator Speaker

None

Elliot L. Chaikof, MD

Speaker

None

Ankur Chandra, MD

Moderator Speaker

Speakers Bureau

Charlie C. Cheng, MD

Speaker

None

Medtronic, Inc. Cook Medical, device proctoring services reimbursement; Terumo, peer-to-peer educational events reimbursement.

PI of industry-sponsored trial

Abbot Vascular

Timothy A.M. Chuter, MD Discussant

Royalty Receipt of Intellectual Property Rights/ Patent Holder Contracted Research

Cook Medical, Inc. Cook Medical, Inc.

Eric T. Choi, MD

Speaker

Speakers Bureau

Boston Scientific

W. Darrin Clouse, MD

Speaker

No

Mark F. Conrad, MD, MMSc Moderator

Consulting Fee Other

Matthew A. Corriere, MD

Speaker Speaker

None

Enrique Criado, MD, PhD

Speaker

None

Jack L. Cronenwett, MD

Moderator

None

John A. Curci, MD

Moderator

None

Michael D. Dake, MD Speaker Consulting Fees

Cook Medical, Inc.

Medtronic, Volcano BARD – member and CEC

Cook Medical, WL Gore, Abbott, Vascular Medtronic

Ronald L. Dalman, MD

Moderator

None

Alan Dardik, MD, PhD

Moderator

None

R. Clement Darling III, MD

Moderator

None

Jeffery B. Dattilo, MD

Moderator/Disscusant

None

Sebastian Debus, MD, PhD

Moderator

None

Ralph G. DePalma, MD, FACS

Speaker

None

Brian G. DeRubertis, MD

Moderator

None

Ellen D. Dillavou, MD

Moderator

None

Audra A. Duncan, MD

Speaker

None

Matthew J. Eagleton, MD

Speaker Moderator

Consulting Fees

Cook Medical, Boston Medical

William J. Ennis, MD

Speaker

Consulting Fees

Accelecare Wound Care Centers

Mark K. Eskandari, MD Moderator Other Ronald M. Fairman, MD

Moderator

None

Rumi Faizer, MD

Speaker

Speakers Bureau

Alik Farber, MD

Speaker Speaker

None

Mark A. Farber, MD Discussant

Consulting Fee Speakers Bureau Contracted Research

Timothy Ferris, MD

None

Speaker

Honoraria from Endologix director WL Gore course director Medtronic Inc.

Cook, Gore, Bolton Medical, Endologix Volcano Cook, Gore, Bolton, Endologix

*(i.e, course director, moderator, speaker)

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

15


FACULTY

ROLE*

FINANCIAL RELATIONSHIP COMPANY

Mark F. Fillinger, MD

Discussant

None

Julie Ann Freischlag, MD

Speaker Moderator Discussant

None

Vivian Gahtan, MD

Speaker

None

Joseph S. Giglia, MD

Speaker

None

Peter Gloviczki, MD

Moderator Speaker

None

Philip P. Goodney, MD, MS

Discussant Moderator Moderator

None

Vivienne J. Halpern, MD, FACS

Speaker

Ownership Interest

Pfizer, Kimberly Clark, GE

George Hamilton, MD

Speaker

Consulting Fees

Evexar Company Limited

Linda M. Harris, MD Speaker Contracted Research

Terumo Cardiovascular ev3, Inc. Talecris Biotherapeutics, Inc.

Stephan Haulon, MD, PhD

Speaker

Consulting Fees

Cook Medical, GE Healthcare

Peter K. Henke, MD

Speaker Moderator

None

Kim J. Hodgson, MD Moderator/Speaker

Consulting Fee Speakers Bureau

Jeffery E. Indes, MD

Moderator

None

Benjamin M. Jackson, MD, MS

Moderator

None

Louis Jacques, MD

Speaker

None

Jessie M. Jean-Claude, MD

Moderator

None

William C. Jennings, MD

Speaker

None

Manju Kalra, MD

Speaker

None

Vikram S. Kashyap, MD

Speaker

None

K. Craig Kent, MD

Speaker

None

Melina R. Kibbe, MD

Speaker Moderator

None

Lombard Medtronic

Philippe Kolh, MD, PhD Moderator

Consulting Fee Speakers Bureau

Astra Zeneca B. Braun

Panos Kougias, MD

Contracted Research

Covidien

Speaker

Christopher J. Kwolek, MD Discussant Contracted Research Glenn M. LaMuraglia, MD

Moderator

None

Peter F. Lawrence, MD

Moderator/Speaker

None

Jeffery H. Lawson, MD Speaker Consulting Fee Speakers Bureau Contracted Research

Cordis, Silk Road Medical, Endologix, Terumo – Sulzer Vascutek

Cryolife, Inc., Humacyte Inc., WL Gore, CR Bard WL Gore Humacyte Inc, Proteon Thearapeutics, Atrium/Maquet

Jason T. Lee, MD

Moderator

None

Joann M. Lohr, MD

Moderator

None

Consulting Fees

Consulting Fee Contracted Research

National Principle Investigator on Trial National Principle Investigator on Trial

Alan B. Lumsden, MD Moderator/Speaker

Sean P. Lyden, MD Moderator Consulting Fee Contracted Research Other Thomas G. Lynch, MD

Speaker

None

Shaun MacDonald, MD

Speaker

None

Robyn A. Macsata, MD

Moderator

None

Mahomoud B. Malas, MD, MHS

Moderator

None

Luke K. Marone, MD

Speaker

Consulting Fee

Cook Inc, Covidien Co-National PI on Illumenate Trial Research trials, WL Gore, Cordis, Aptus, NIH, Cook, Dalichi, Silkroad, Trivascular Aruste Medical Scientific Advisory Board, Medtronic Branch Cessel Advisory Board, Covidien Scientific Advisory Board, Trivascular Scientific Advisory Board, VIVA Physicians 501C3 Board

Abbot, A Bio Med

William A. Marston, MD Moderator/Speaker Consulting Fee

Organogenesis, Spiracur, Volcano, BSN Jobst

Tara M. Mastracci, MD

Discussant

Consulting Fees

Cook Medical

Jon S. Matsumura, MD

Moderator

Contracted Research

Abbott, Covidien, Gore, Cook, Endologix

*(i.e, course director, moderator, speaker)

16


FACULTY

ROLE*

FINANCIAL RELATIONSHIP COMPANY

Manish Mehta, MD Moderator Consulting Fee Speaker Contracted Research

WL Gore, Cook Medical, Trivascular Inc., Aptus Endosystems Inc, Endologix PI for WL Gore, Cook Medical, Trivascular Inc. Aptus Endovascular Inc., Cordis Corporation, Terumo Cardiovascular, Ev9 Endovascular Inc., Silkroad Medical Inc., NIH/Rutgers CREST Study, Bayer Medical Inc.

George H. Meier, MD

Speaker

Contracted Research

Cook, Medtronic, Harvest Technologies

Mark H. Meissner, MD

Moderator

None

Matthew W. Mell, MD

Speaker

None

Louis M. Messina, MD

Speaker

None

Joseph L. Mills, MD

Speaker

Royalty

Wesley S. Moore, MD

Speaker

None

Gregory L. Moneta, MD

Moderator

None

Bart E. Muhs, MD Speaker

Consulting Fees Speakers Bureau Ownership Interest

Firas F. Mussa, MD

Moderator

None

Peter R. Nelson, MD

Speaker

None

Gustavo S. Oderich, MD

Speaker Moderator Consulting Fee

Christopher D. Owens, MD, MSc Speaker

Salary Royalty Consulting Fee Speakers Bureau

C. Keith Ozaki, MD Speaker Other Jean M. Panneton, MD

Moderator/Speaker

None

Juan C. Parodi, MD

Moderator

None

Marc A. Passman, MD

Moderator/Speaker

None

Virendra I. Patel, MD

Discussant Speaker

None

Philip S.K. Paty, MD

Speaker

None

Benjamin J. Pearce, MD

Moderator

Contracted Research

Eric K. Peden, MD

Moderator/Speaker

None

Bruce A. Perler, MD

Moderator Discussant

None

William J. Quinones-Baldrich, MD

Moderator Speaker

None

Saum A. Rahimi, MD

Speaker

None

Kumud M. Rai, MD

Moderator

None

Elsevier, Publishing Royalties

Cook, Aptus, Endologix Cook, Endologix Aptus

Cook Medical, WL Gore, Money to Mayo Clinic Medtronic, NIH Book Publishing Medtronic Medtronic, Gore Unrestricted gift (used for research) from Smith & Nephew; joint research initiatives with Novartis Institutes for Biomedical Research, Inc.

Aptus, Gore, Medtronic

Ravi Rajani, MD Moderator Contracted Research

Cook Medical, ABBVIE Pharmaceuticals, Endologix, Grifols Pharmaceuticals

Michael J. Reardon, MD

Discussant

Consulting Fees

Medtronic Inc.

John E. Rectenwald, MD

Moderator

None

Amy B. Reed, MD

Moderator

None

Robert Y. Rhee, MD

Speaker

None

Jean-Baptise Ricco, MD, PhD

Speaker/Moderator

None

David A. Rigberg, MD Moderator Other Nirvana Sadaghianloo, MD

Speaker

None

Russell H. Samson, MD, FACS, RVT

Speaker

None

Salvatore T. Scali, MD

Speaker

None

Marc L. Schermerhorn, MD

Moderator Speaker

None

Gave two lectures that were paid for by WL Gore

Andres Schanzer, MD, MPH Speaker

Consulting Fee Contracted Research

Cook Medical, Boston Medical Cook Medical, Boston Medical

Peter A. Schneider, MD Moderator

Royalty Contracted Research Other

Cook Medical Medtronic, Gore, Cordis Chief Medical Officer of Intact Vascular

Malachi G. Sheahan III, MD

Moderator

None

Michael B. Silva Jr., MD, FACS

Moderator/Speaker

None

Niten Singh, MD

Moderator

None

*(i.e, course director, moderator, speaker)

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

17


FACULTY

ROLE*

FINANCIAL RELATIONSHIP COMPANY

Michael J. Singh, MD Speaker

Consulting Fees Speakers Bureau

Cook Medical Inc. Covidien

Benjamin W. Starnes, MD

Discussant Moderator/Speaker

Consulting Fee

Endologix, MAB

Jean E. Starr, MD

Moderator

Consulting Fee

Medtronix

W. Charles Sternbergh, MD

Speaker

None

Patrick A. Stone, MD

Speaker

Consulting Fees

David H. Stone, MD

Speaker

None

Gale L. Tang, MD

Speaker

None

Spence M. Taylor, MD

Speaker

None

Carlos H. Timaran, MD

Discussant Moderator/Speaker

None

Margaret Clarke Tracci, MD

Speaker

None

Gilbert R. Upchurch Jr., MD

Speaker

None

R. James Valentine, MD

Speaker

None

Ravi K. Veeraswamy, MD

Moderator

None

Frank J. Veith, MD

Moderator

None

Todd R. Vogel, MD, MPH

Speaker

None

Grace J. Wang, MD

Speaker

None

Rodney A. White, MD Speaker

Speakers Bureau Contracted Research

Jason Wiseman, MD

Speaker

None

Virginia L. Wong, MD

Speaker

None

Karen Woo, MD

Speaker

Contracted Research

Dai Yamanouchi, MD, PhD

Speaker

None

Wei Zhou, MD Moderator Speaker

Consulting Fees Speakers Bureau Fees for Non-CME Services Received Directly from a Commercial Interest or its Agent Contracted Research

Robert M. Zwolak, MD

None

Speaker

*(i.e, course director, moderator, speaker)

18

Cook, Gore

WL Gore, Medtronic, Volcano WL Gore, Medtronic, Volcano

Principal Investigator – Cook Silk Road Medical, LifeCell LifeCell Volcano


SVS Councils/Committees/Staff Disclosures

2014 Vascular Annual Meeting Program Committee FACULTY ROLE* CDA, Financial Company /Organization RElationship Christopher J. Abularrage, MD

Planner, Abstract Reviewer

None

Bernadette Aulivola, MD

Abstract Reviewer

None

Mark F. Conrad, MD, MMSc Planner, Abstract Reviewer

Consulting Fee Other

John A. Curci, MD

Planner, Abstract Reviewer

None

Ronald L. Dalman, MD

Planner, Abstract Reviewer

None

Ellen D. Dillavou, MD

Planner, Abstract Reviewer

None

Matthew J. Eagleton, MD

Planner, Abstract Reviewer

Consulting Fees

Ronald M. Fairman, MD

Planner, Abstract Reviewer

None

Roy K. Greenberg, MD

Planner, Abstract Reviewer

None

Jeffrey E. Indes, MD

Abstract Reviewer

None

Jeffrey Jim, MD

Abstract Reviewer

None

Jason T. Lee, MD

Planner, Abstract Reviewer

None

Joann M. Lohr, MD

Planner, Abstract Reviewer

None

Mahmoud B. Malas, MD, MHS

Planner, Abstract Reviewer

None

Jon S. Matsumura, MD Planner, Abstract Reviewer Contracted Research Mark H. Meissner, MD

Planner, Abstract Reviewer

Medtronic, Volcano BARD – member and CEC

Cook Medical, Boston Medical

Abbott, Covidien, Gore, Cook, Endologix

None

Manish Mehta, MD Planner, Abstract Reviewer Consulting Fee Contracted Research

WL Gore, Cook Medical, Trivascular Inc., Aptus Endosystems Inc., Endologix PI for WL Gore, Cook Medical, Trivascular Inc. Aptus Endovascular Inc., Cordis Corporation, Terumo Cardiovascular, Ev9 Endovascular Inc., Silk Road Medical Inc., NIH/ Rutgers CREST Study, Bayer Medical Inc.

Firas F. Mussa, MD

Abstract Reviewer

None

Benjamin J. Pearce, MD

Abstract Reviewer

Contracted Research

Aptus, Gore, Medtronic

Iraklis I. Pipinos, MD

Planner, Abstract Reviewer

Honorarium

AASTROM Biosciences

Amy B. Reed, MD

Planner, Abstract Reviewer

None

Eva M. Rzucidlo, MD

Planner, Abstract Reviewer

None

David A. Rigberg, MD Abstract Reviewer Other

Gave two lectures that were paid for by WL Gore

Murray L. Shames, MD Abstract Reviewer

Consulting Fee Speakers Bureau Medical Advisory

Gore, Medtronic, Cook Gore, Medtronic, LeMaitre Board Angiodynamics

Benjamin W. Starnes, MD

Planner, Abstract Reviewer

Consulting Fee

Endologix, MAB

Ravi K. Veeraswamy, MD

Planner, Abstract Reviewer

None

*(i.e, course director, moderator, speaker)

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

19


Postgraduate Education Committee FACULTY ROLE* CDA, Financial Company /Organization RElationship Kellie R. Brown, MD

Planner

None

Daniel G. Clair, MD Planner Consulting Fee Other

Cordis, Covidien, Endologix, eV3, WL Gore Advisory Board – Boston Scientific, Medtronic

Steve M. Elias, MD Planner Consulting Fees

Covidien Inc., Vascular Insights LLC, LeMaitre Inc.

Christopher J. Kwolek, MD Planner Contracted Research

Cordis, Silk Road Medical, Endologix, Terumo – Sulzer Vascutek

Alan B. Lumsden, MD Planner

National Principle Investigator on Trial National Principle Investigator on Trial

Consulting Fee Contracted Research

Jon S. Matsumura, MD Planner Contracted Research Robert B. McLafferty, MD

Planner

Abbott, Covidien, Gore, Cook, Endologix

None

Gustavo S. Oderich, MD Planner Consulting Fee

Cook Medical, WL Gore, money to Mayo Clinic

Peter A. Schneider, MD Planner

Royalty Contracted Research Other

Cook Medical Medtronic, Gore, Cordis Chief Medical Officer of Intact Vascular

Michael B. Silva Jr., MD

Planner

None

Niten Singh, MD

Planner

None

Jean E. Starr, MD

Planner

Consulting Fee

Edward Y. Woo, MD Planner Consulting Fees Speakers Bureau

Medtronic Medtronic, Cook, Gore, Bard, Endologix Medtronic, Cook, Gore, Bard, Endologix

Research and Education Committee

FACULTY ROLE* CDA, Financial Company /Organization RElationship Scott A. Berceli, MD, PhD

Abstract Reviewer

None

April J. Boyd, MD, PhD

Abstract Reviewer

None

Ankur Chandra, MD Abstract Reviewer

Consulting Fees Speakers Bureau

John A. Curci, MD

Abstract Reviewer

None

Katherine A. Gallagher, MD

Abstract Reviewer

None

Peter K. Henke, MD

Abstract Reviewer

None

Benjamin M. Jackson, MD, MS

Abstract Reviewer

None

Christopher D. Owens, MD, MSc Abstract Reviewer

Salary Royalty Consulting Fee Speakers Bureau

Kathleen G. Raman, MD

Abstract Reviewer

None

Ulka Sachdev, MD

Abstract Reviewer

None

Rajabrata Sarkar, MD

Abstract Reviewer

None

Christopher L. Skelly, MD Abstract Reviewer Ownership Interest Other *(i.e, course director, moderator, speaker)

20

Cook Medical Abbot Vascular

Medtronic, NIH Book Publishing Medtronic Medtronic, Gore

Maji Therapeutics Medical Director of U of C Vascular Laboratory. The Vascular Lab recieves royalties from proceeds of a recently published book: ”Inside Ultrasound, Vascular Reference Guide.


Video Review Committee FACULTY ROLE* CDA, Financial Company /Organization RElationship John Blebea, MD

Abstract Reviewer

None

Angela A. Kokkosis, MD

Abstract Reviewer

None

Mark D. Morasch, MD

Abstract Reviewer

Consulting Fee

Adnan Rizvi, MD

Abstract Reviewer

None

Eva M. Rzucidlo, MD

Abstract Reviewer

None

WL Gore, Endologix

*(i.e, course director, moderator, speaker)

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

21


EDUCATION COUNCIL The Education Council has oversight of all SVS programs for continuing education for practicing vascular surgeons.

Name CDA, Financial Relationship Company /Organization

Jean Bismuth, MD

Consulting Fee Contracted Research

Ruth L. Bush, MD, MPH

None

WL Gore WL Gore

Michael Dalsing, MD Ownership Interest Contracted Research Scientific Advisory Board

InterVene Cook, Biomet Biologics, Endologix, WL Gore, eV3 Covidien, InterVene Cook

Mark G. Davies, MD, PhD Research Grants

Medtronic-Simplicy Study-Site Investigator

Ronald M. Fairman, MD

None

Linda M. Harris, MD Contracted Research

Terumo Cardiovascular ev3, Inc Talecris Biotherapeutics, Inc

Sean P. Lyden, MD Consulting Fee Contracted Research Other

Cook Inc, Covidien CoNational PI Illumenate Trial Research trials, WL Gore, Cordis, Aptus, NIH, Cook, Dalichi, Silk Road, Trivascular Aruste Medical Scientific Advisory Board, Medtronic Branch Cessel Advisory Board, Covidien Scientific Advisory Board, Trivascular Scientific Advisory Board, VIVA Physicians 501C3 Board

Jon S. Matsumura, MD Contracted Research

Abbott, Covidien, Gore, Cook, Endologix

Erica L. Mitchell, MD

None

Bruce A. Perler, MD

None

John E. Rectenwald, MD

None

Murray L. Shames, MD

Consulting Fee Speakers Bureau Medical Advisory Board `

Malachi G. Sheahan III, MD

None

Cynthia K. Shortell, MD

None

Gore, Medtronic, Cook Gore, Medtronic, LeMaitre Angiodynamics

2014 COMMITTEE — STAFF DISCLOSURE

Name STAFF

FDA, Financial Relationship

Jason Mui

None

CME Staff

22


SVS BOARD OF DIRECTORS Julie Ann Freischlag, MD Peter F. Lawrence, MD Bruce A. Perler, MD Michel S. Makaroun, MD R. Clement Darling III, MD Peter Gloviczki, MD Ronald M. Fairman, MD Michael S. Conte, MD Elliot L. Chaikof, MD Robert W. Thompson, MD George H. Meier, MD Cynthia K. Shortell, MD Fred A. Weaver, MD Grayson H. Wheatley III, MD Timothy F. Kresowik, MD Vivian Gahtan, MD John W. Hallett, MD Linda M. Harris, MD Joseph L. Mills, MD Lowell S. Kabnick, MD Martin R. Back, MD Robert B. Patterson, MD Jim Dooner, MD Rebecca M. Maron, CAE

President President-Elect Vice President Secretary Treasurer Immediate Past President Program Chair Research Council Chair Fellows Council Chair Fellows Council Vice Chair Clinical Practice Council Chair Education Council Chair Society for Clinical Vascular Surgery International Society of Endovascular Specialists Midwestern Vascular Surgery Society Eastern Vascular Society Southern Association for Vascular Surgery Association of Program Directors in Vascular Surgery Western Vascular Society American Venous Forum Vascular and Endovascular Surgery Society New England Society for Vascular Surgery Canadian Society for Vascular Surgery Executive Director

2014 Vascular Annual Meeting Program Committee Ronald M. Fairman, MD, Chair Ronald L. Dalman, MD, Vice Chair Christopher J. Abularrage, MD Bernadette Aulivola, MD (VESS) Mark F. Conrad, MD, MMSc John A. Curci, MD Ellen D. Dillavou, MD Matthew J. Eagleton, MD Jeffrey E. Indes, MD (VESS) Jeffrey Jim, MD (VESS) Jason T. Lee, MD Joann M. Lohr, MD Mahmoud B. Malas, MD, MHS

Jon S. Matsumura, MD Manish Mehta, MD Mark H. Meissner, MD Firas F. Mussa, MD (VESS) Benjamin J. Pearce, MD (VESS) Iraklis I. Pipinos, MD Amy B. Reed, MD David A. Rigberg, MD (VESS) Eva M. Rzucidlo, MD Murray L. Shames, MD (VESS) Benjamin W. Starnes, MD Ravi K. Veeraswamy, MD

Postgraduate Education Committee Jon S. Matsumura, MD, Chair Kellie R. Brown, MD Daniel G. Clair, MD Steve M. Elias, MD Christopher J. Kwolek, MD

Alan B. Lumsden, MD Robert B. McLafferty, MD Gustavo S. Oderich, MD Peter A. Schneider, MD Michael B. Silva Jr., MD

Niten Singh, MD Jean E. Starr, MD Edward Y. Woo, MD

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

23


Research and Education Committee John A. Curci, MD, Chair Scott A. Berceli, MD, PhD April J. Boyd, MD, PhD Ankur Chandra, MD

Katherine A. Gallagher, MD Peter K. Henke, MD Benjamin M. Jackson, MD, MS Christopher D. Owens, MD, MSc

Kathleen G. Raman, MD Ulka Sachdev, MD Rajabrata Sarkar, MD Christopher L. Skelly, MD

Angela A. Kokkosis, MD Mark D. Morasch, MD

Adnan Z. Rizvi, MD

Video Review Committee Eva M. Rzucidlo, MD, Chair John Blebea, MD

24


PAST MEETINGS Society for Vascular Surgery

American Association for Vascular Surgery

Year City SVS President City

AAVS President

1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992

Emile F. Holman Emile F. Holman Geza de Takats Alton Ochsner Alton Ochsner Harris B. Shumaker Jr. Harris B. Shumaker Jr. Henry Haimovici Henry Haimovici Frank Gerbode Frank Gerbode C. Rollins Hanlon Michael E. DeBakey D. Emerick Szilagyi Ralph A. Deterling Jr. Omand C. Julian Oscar Creech Jr. Andrew Glenn Morrow Edwin J. Wylie Jack Cannon Charles G. Rob Jesse E. Thompson John H. Foster Allan D. Callow Frank C. Spencer John E. Connolly W. Sterling Edwards William S. Blakemore Wiley F. Barker W. Andrew Dale E. Stanley Crawford William J. Fry John L. Ochsner James A. DeWeese George Johnson Jr. Vallee L. Willman Garland Perdue Jr. Ronald J. Baird Norman M. Rich Robert W. Barnes John A. Mannick

Atlantic City Chicago Atlantic City Chicago Atlantic City Chicago New York City San Francisco Atlantic City Chicago New York City San Francisco Atlantic City Miami Beach New York City Chicago Atlantic City San Francisco New York City Chicago Atlantic City San Francisco New York City Chicago Philadelphia Carmel Toronto Chicago Boston Albuquerque Rochester Los Angeles Nashville Chicago Dallas Boston San Francisco Atlanta Baltimore New Orleans Toronto Chicago New York City Los Angeles Boston Chicago

Alton Ochsner Arthur Allen Emile F. Holman Daniel Elkin Ross Veal Alfred Blalock Chicago Geza de Takats New York City Michael E. DeBakey San Francisco Robert Linton Atlantic City George Lilly Chicago Arthur Blakemore New York City Frank Gerbode San Francisco Harris B. Shumaker Jr. Atlantic City Richard Warren Miami Beach Julian Johnson New York City F.A. Simeone Chicago Earle B. Mahoney Atlantic City Richard L. Varco San Francisco John H. Gibbon Jr. New York City Clarence Dennis Chicago William H. Muller Atlantic City Wilfred G. Bigelow San Francisco C. Rollins Hanlon New York City W. Sterling Edwards Chicago F. Henry Ellis Jr. Philadelphia Andrew Glenn Morrow Carmel Wiley F. Barker Toronto W. Andrew Dale Chicago Russell M. Nelson Boston Worthington G. Schenk Albuquerque Jesse E. Thompson Rochester James A. DeWeese Los Angeles F. William Blaisdell Nashville Edwin J. Wylie Chicago John A. Mannick Dallas H. Edward Garrett Boston D. Emerick Szilagyi San Francisco John J. Bergan Atlanta Anthony M. Imparato Baltimore Allan D. Callow New Orleans Wesley S. Moore Toronto E. Stanley Crawford Chicago D. Eugene Strandness Jr. New York City William J. Fry Los Angeles Calvin B. Ernst Boston Malcolm O. Perry Chicago

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

25


Society for Vascular Surgery

American Association for Vascular Surgery

Year City SVS President City

AAVS President

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Lazar J. Greenfield Ronald J. Stoney Robert B. Rutherford Jerry Goldstone Robert B. Smith III William H. Baker Anthony D. Whittemore John M. Porter Robert W. Hobson II William H. Pearce Thomas S. Riles

Washington, D.C. Seattle New Orleans Chicago Boston San Diego Washington, D.C. Toronto Baltimore Boston Chicago

James S.T. Yao Norman R. Hertzer Thomas J. Fogarty Frank J. Veith James C. Stanley William M. Abbott Christopher K. Zarins Jonathan B. Towne Ramon Berguer Thomas F. O’Donnell Jack L. Cronenwett

Vascular Annual Meetings Year City President

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

26

Anaheim Chicago Philadelphia Baltimore San Diego Denver Boston Chicago Washington, D.C. San Francisco Boston

Richard Green Gregorio A. Sicard Enrico Ascher K. Craig Kent K. Wayne Johnston G. Patrick Clagett Anton N. Sidawy Robert M. Zwolak Richard P. Cambria Peter Gloviczki Julie Ann Freischlag

Washington, D.C. Seattle New Orleans Chicago Boston San Diego Washington, D.C. Toronto Baltimore Boston Chicago


SCHEDULE-IN-DETAIL SOCIETY FOR VASCULAR SURGERY AWARDS DAY OF HISTORY WEEK, MONTH 0 DISTINGUISHED SERVICE AWARD 1998 – 2004

1998 1999 2000 2001 2002 2003 2004

Richard Warren, MD Michael E. DeBakey, MD D. Emerick Szilagyi, MD Jesse E. Thompson, MD James A. DeWeese, MD Anthony M. Imparato, MD No recipient

SVS LIFETIME ACHIEVEMENT AWARD 2005 – Present

2005 2006 2007 2008 2009 2010 2011 2012 2013

Robert B. Rutherford, MD Ronald J. Stoney, MD James S.T. Yao, MD No recipient K. Wayne Johnston, MD Frank J. Veith, MD, and David Sumner, MD Wesley S. Moore, MD James C. Stanley, MD Norman M. Rich, MD, and Frank LoGerfo, MD

SVS MEDAL OF INNOVATION IN VASCULAR SURGERY AWARD 2006 – Present

2006 2008 2010 2012 2013

Juan C. Parodi, MD Timothy A.M. Chuter, MD Thomas J. Fogarty, MD Roy Greenberg, MD Edward Diethrich, MD

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

27


WELcOME LETTER FROM MAYOR WALsH

28


SVS Foundation Legacy Program Lifetime Contributors

Thank you to all SVS Foundation donors Founder’s Circle ($500,000 plus) American College of Surgeons Anonymous Donor William J. von Liebig Foundation Chairman’s Circle ($100,000 – $499,999) James R. DeBord, MD Edwards Vascular Foundation President’s Circle ($50,000 – $99,999) Midwestern Vascular Surgical Society Society for Clinical Vascular Surgery Western Vascular Society Director’s Circle ($25,000 – $49,999) George Andros, MD Arthur I. Auer, MD Alexander W. Clowes, MD Michael C. Dalsing, MD Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Richard P. Cambria, MD, Chief Eastern Vascular Society Nicholas D. Garcia, MD Vivienne J. Halpern, MD, FACS Joan L. and Julius H. Jacobson II, MD New England Society for Vascular Surgery William H. Pearce, MD Southern Association for Vascular Surgery Daniel B. Walsh, MD, and Teri Walsh, RN Benefactor’s Circle ($10,000 – $24,999) John Abele, MD Ali F. AbuRahma, MD K. Ramesh Adiga, MD Samuel S. Ahn, MD Dennis F. Bandyk, MD Robert C. Batson, MD Timothy Baxter, MD John J. Bergan, MD Victor M. Bernhard, MD Allan D. Callow, MD Joseph R. Carney, MD

G. Patrick Clagett, MD Jon R. Cohen, MD E. Stanley Crawford, MD Jack L. Cronenwett, MD Ronald L. Dalman, MD Herbert Dardik, MD R. Clement Darling III, MD Mark G. Davies, MD, PhD David Deakins, MD Michael E. DeBakey, MD Dominic A. DeLaurentis, MD Ralph G. DePalma, MD, FACS James A. DeWeese, MD R. Howard Dobbs, MD Magruder C. Donaldson, MD William H. Edwards, MD Calvin B. Ernst, MD Rumi Faizer, MD William R. Flinn, MD Julie Ann Freischlag, MD Bruce L. Gewertz, MD Gary Giangola, MD Peter Gloviczki, MD John F. Golan, MD Richard Green, MD Lazar J. Greenfield, MD Thomas J. Greenfield, MD Roger T. Gregory, MD John (Jeb) W. Hallett, MD Norman R. Hertzer, MD Robert W. Hobson II, MD Glenn C. Hunter, MD Anthony M. Imparato, MD Bengt L. Ivarsson, MD George Johnson Jr., MD Robert L. Kistner, MD Larry W. Kraiss, MD Marvin E. Kuehner, MD Robert P. Leather, MD Frank LoGerfo, MD Joseph G. Magnant, MD William T. Maloney, MD John A. Mannick, MD Rebecca M. Maron, CAE Kenneth E. McIntyre Jr., MD Joseph L. Mills, MD R. Scott Mitchell, MD Gregory L. Moneta, MD

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

29


Benefactor’s Circle ($10,000 – $24,999) (continued) Wesley S. Moore, MD Robert W. Oblath, MD John L. Ochsner, MD Kenneth Ouriel, MD C. Keith Ozaki, MD, FACS Malcolm O. Perry, MD John J. Ricotta, MD, FACS Thomas S. Riles, MD Gary R. Seabrook, MD Alexander D. Shepard, MD Gregorio A. Sicard, MD Robert B. Smith III, MD Ronald J. Stoney, MD David Sumner, MD George T. Sugiyama, MD Vascular and Endovascular Surgery Society Frank J. Veith, MD Fred A. Weaver, MD Jock R. Wheeler, MD Anthony D. Whittemore, MD Samuel J. Williams, MD James S.T. Yao, MD, PhD Robert M. Zwolak, MD, PhD

30


SVS Foundation Individual Contributors (April 1, 2013 through March 31, 2014)

Thank you to all SVS Foundation donors Babak Abai, MD Ali F. AbuRahma, MD Eric Adams, MD Azeez P. Adeduntan, MD Donald L. Akers, MD Suresh Alankar, MD Babatunde H. Almaroof, MD Jose I. Almeida, MD Charles A. Andersen, MD Leonard S. Anderson, MD George E. Anton, MD Shipra Arya, MD Arthur I. Auer, MD Bernadette Aulivola, MD Mario H. Avila, MD Julius W. Babb, MD Sateesh Babu, MD Martin R. Back, MD J. Dennis Baker, MD William H. Baker, MD Jeffery L. Ballard, MD Donald Baril, MD Amanda X. Barroso, MD Timothy Baxter, MD Hernan A. Bazan, MD Carlos Bechara, MD Michael Belkin, MD Eric Berens, MD Thomas M. Bergamini, MD Victor M. Bernhard, MD Edwin G. Beven, MD David H. Bingham, MD John Blebea, MD Clark Brazil, MD Bruce J. Brener, MD Thomas E. Brothers, MD O. William Brown, MD, JD Kevin J. Bruen, MD Jason S. Burgess, MD Jessica B. Campbell, MD Cassius Iyad N. Ochao Chaar, MD, MS Elliot L. Chaikof, MD James G. Chandler, MD Kristofer Charlton-Ouw, MD Giancarlo Cires, MD G. Patrick Clagett, MD

Salomon Cohen, MD Anthony J. Comerota, MD Michael S. Conte, MD Brian W. Coyle, MD John A. Curci, MD Carlo A. Dall’Olmo, MD Ronald L. Dalman, MD Michael C. Dalsing, MD Herbert Dardik, MD R. Clement Darling III, MD Mark G. Davies, MD, PhD Luis R. Davila-Santini, MD Antonio C. De Souza, MD Barry L. Dick, MD Maciej L. Dryjski, MD J. Michael Duncan, MD Joseph R. Durham, MD Matthew J. Eagleton, MD Matthew S. Edwards, MD Ronald M. Fairman, MD Rumi Faizer, MD Tony D. Fang, MD Antoine M. Ferneini, MD Guilherme Maldonado Filho, MD Thomas L. Forbes, MD Randall W. Franz, MD Julie Ann Freischlag, MD Yves A. Gabriel, MD Vivian Gahtan, MD James J. Gallagher, MD Katherine A. Gallagher, MD Nicholas D. Garcia, MD Stephen M. Gemmett, MD Gary Giangola, MD Peter Gloviczki, MD James M. Goff Jr., MD Andrew A. Gonzalez, MD Prem C. Gupta, MD Kevin D. Halow, MD Vivienne J. Halpern, MD Allen D. Hamdan, MD Sachinder S. Hans, MD Joseph P. Hart, MD Thomas S. Hatsukami, MD and Kathy Sie Peter K. Henke, MD Norman R. Hertzer, MD

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

31


Anil P. Hingorani, MD John R. Hoch, MD Robert Hye, MD Mark D. Iafrati, MD Karl A. Illig, MD Eric C. Jaxheimer, MD Fernando L. Joglar, MD William Jordan, MD Alexandre Jurach, MD Pierre B. Karam, MD Vikram S. Kashyap, MD Steven G. Katz, MD Gregory J. Kechejian, MD Melina R. Kibbe, MD Terry A. King, MD Robert L. Kistner, MD Clovis L. Konopka, MD Larry W. Kraiss, MD Gregory J. Landry, MD Robert A. Larson, MD George S. Lavenson, MD Peter F. Lawrence, MD Christopher J. Lecroy, MD Hong-Gi Lee, MD Stephen E. Lee, MD Rhoda F. Leichter, MD Jose Leite, MD Gary W. Lemmon, MD, FACS Paulo R. Da Silva Lima, MD Frank LoGerfo, MD Fedor Lurie, MD Sean P. Lyden, MD Richard A. Lynn, MD, FACS, RPVI Michel S. Makaroun, MD M. Ashraf Mansour, MD Rebecca M. Maron, CAE Gordon H. Martin, MD John H. Matsumura, MD Patrick J. McGovern, MD Robert B. McLafferty, MD George H. Meier, MD, RVT, FACS Donna M. Mendes, MD Nelson S. Menezes, MD Erica Mitchell, MD Nicholas J. Morrissey, MD Satish C. Muluk, MD Ryan D. Nachreiner, MD Gary B. Nackman, MD Massimo M. Napolitano, MD Ramesh C. Narayanagowda, MD Adaalcindo V. Nascimento, MD Michal Nawalany, MD Richard F. Neville, MD Robert E. Noll Jr., MD Obinna Nwobi, MD 32

Patrick J. O’Hara, MD William Oppat, MD C. Keith Ozaki, MD, FACS Frank T. Padberg, MD Robert B. Patterson, MD James J. Patton, MD William H. Pearce, MD Richard C. Pennell, MD Bruce A. Perler, MD William C. Pevec, MD Kevin Raftery, MD Rajesh V. Raikar, MD Seshadri Raju, MD Subhash C. Ramnauth, MD Robert Y. Rhee, MD Norman M. Rich, MD, FACS Thomas S. Riles, MD Andrew B. Roberts, MD Caron B. Rockman, MD Sean P. Roddy, MD L. Richard Roedersheimer, MD Mark S. Rosenbloom, MD Joel C. Rosenfeld, MD David Rosenthal, MD Charles B. Ross, MD Matthew B. Rossi, MD Timothy S. Roush, MD Richard J. Sanders, MD Bhagwan Satiani, MD, MBA Salvatore Scali, MD Marc L. Schermerhorn, MD Darren B. Schneider, MD Gary R. Seabrook, MD Piergiorgio G. Settembrini, MD Susan Shafii, MD Raymond M. Shaheen, MD Maureen K. Sheehan, MD Cynthia K. Shortell, MD Gregorio A. Sicard, MD Michael B. Silva Jr., MD, FACS Alan E. Singer, DPM Mahalingham Sivakumar, MD Sunita D. Srivastava, MD Benjamin W. Starnes, MD David H. Stone, MD Michael D. Sulkin, MD Daniel D. Tamez Jr., MD Gary A. Tannenbaum, MD Robert W. Thompson, MD Dennis I. Toppin, MD, FRCSC Joshua M. Unger, MD Gilbert R. Upchurch Jr., MD Julio C. Vasquez, MD Luiz Marcelo A. Viarengo, MD Christopher K. Vincent, MD, PhD


James S. Wagner, MD Thomas W. Wakefield, MD Daniel B. Walsh, MD, and Teri Walsh, RN Michael T. Watkins, MD Fred A. Weaver, MD Franklin W. West, RN John V. White, MD Douglas B. Wilhite, MD, RVT Karen Woo, MD Timothy Wu, MD Anson A. Yeager, MD Elie J. Zayyat, MD Wayne W. Zhang, MD Robert M. Zwolak, MD, PhD

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

33


NOTES

34


SCHEDULE IN DETAIL

WEDNESDAY, JUNE 4

All events held at Hynes Convention Center unless otherwise noted. VASCULAR ANNUAL MEETING REGISTRATION  6:00 a.m. – 6:30 p.m.  uExhibit Hall C, Foyer, Level 2 POSTGRADUATE COURSES  Separate Registration Required

7:00 a.m. – 5:00 p.m.

Postgraduate Courses Breakfast 

6:00 – 7:00 a.m.

SESSIONS P1 AND P2  Concurrent Tracks

7:00 – 10:00 a.m.

P1: Critical Issues in Managing Lower Extremity PVD  

7:00 – 10:00 a.m. uRoom 302

At the end of this session, participants should be able to: 1. Compare techniques for treating lower extremity PVD. 2. Explain how to build outpatient centers and screen patients for them. 3. Manage costs for peripheral procedures. Moderators: Edward Y. Woo, MD, Medstar Washington Hospital Center, Medstar Georgetown University Hospital, Washington, D.C. Sean P. Lyden, MD, The Cleveland Clinic Foundation, Cleveland, Ohio Peter A. Schneider, MD, Kaiser Permanente Medical Group, Honolulu, Hawaii Establishing and Maintaining a Screening Program  John D. Martin, MD, Cardiology Associates PC, Annapolis, Md.

7:00 a.m.

Strategies for Treating Aortoiliac Occlusions —  Access, Treatment, Outcomes, When to Revert to Open Surgery Daniel G. Clair, MD, The Cleveland Clinic Foundation, Cleveland, Ohio

7:12 a.m.

Strategies for Treating SFA/Pop/BK Occlusions —  Access, Treatment, Outcomes, When to Revert to Open Surgery Cameron M. Akbari, MD, Washington Hospital Center, Washington, D.C.

7:24 a.m.

Alternative Access-Popliteal, Tibial, Pedal, Radial  Firas F. Mussa, MD, New York University, New York City, N.Y.

7:36 a.m.

New Technologies for Lower Extremity Interventions —  7:48 a.m. FDA-Approved in Last 24 Months Excluding DES Adnan Z. Rizvi, MD, Minneapolis Heart Institute/Abbott Northwestern Hospital, Minneapolis, Minn. PANEL DISCUSSION 

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

8:00 a.m.

39


Managing an Outpatient Angio Lab: Set-Up,  Stocking, Accreditation, Issues and Successes Nitin G. Malhotra, MD, Michigan Vascular Center, Flint, Mich.

8:15 a.m.

Update on DEB and DES: New Data and Emerging Trends  8:27 a.m. Patrick Geraghty, MD, Washington University School of Medicine, St Louis, Mo. Controlling Costs in a Hospital-Based System  Sean P. Lyden, MD, The Cleveland Clinic Foundation, Cleveland, Ohio

8:39 a.m.

Closure Devices: What Works and What’s New?  Patrick E. Muck, MD, Good Samaritan Hospital, Cincinnati, Ohio

8:51 a.m.

New Techniques for BK CTO Lesions  9:03 a.m. Dai Yamanouchi, MD, PhD, University of Wisconsin Hospital and Clinics, Madison, Wis. New Changes in Lower Extremity Coding  9:15 a.m. Sunita D. Srivastava, MD, The Cleveland Clinic Foundation, Cleveland, Ohio PANEL DISCUSSION  P2: A  dvanced Chronic Venous Treatment:  Superficial to Deep 

9:27 a.m. 7:00 – 10:00 a.m. uRoom 304

At the end of this session, participants should be able to: 1. Apply techniques of deep vein recannalization to their current practices. 2. Compare principles of endovascular and open venous recannalization to determine best therapy for an individual patient. 3. Evaluate the various quality of life measures and calculate what is most meaningful for their practice. 4. Describe the current therapy for acute VTE and evaluate which treatment is most appropriate for a given clinical setting. 5. Assess the current state of IVC filter use and formulate a strategy to deal with clinical pitfalls. Moderators: Ellen D. Dillavou, MD, University of Pittsburgh Medical Center, Pittsburgh, Pa. Mark H. Meissner, MD, University of Washington, Seattle, Wash. Introduction

7:00 a.m.

Advanced Recanalization Techniques for the Difficult  Iliocaval Occlusion: Sharp Techniques, Fenestrations, Etc. Mark H. Meissner, MD, University of Washington, Seattle, Wash.

7:05 a.m.

Pharmacomechnical Thrombectomy: Which Device to Use,  When — Insights from Recent Trials & Registries Alan M. Dietzek, MD, Danbury Hospital of Western Connecticut Health Network, Danbury, Conn.

7:20 a.m.

Large Bore Suction Devices for Acute IVC Thrombus and/or PE  7:35 a.m. Mark F. Conrad, MD, MMSc, Massachusetts General Hospital, Boston, Mass.

40


DEBATE Compromised Femoral Vein Inflow: Stenting Across the  Inguinal Ligament is the Procedure of Choice Seshadri Raju, MD, The Rane Center, Jackson, Miss.

7:50 a.m.

Compromised Femoral Vein Inflow: Femoral  Endophlebectomy Is the Procedure of Choice Anthony J. Comerota, MD, Jobst Vascular Institute, Toledo, Ohio

8:02 a.m.

Break 

8:15 a.m.

IVC Filter Complications and the Importance of Filter Registries  8:30 a.m. David L. Gillespie, MD, SouthCoast Healthcare System, Fall River, Mass. The Difficult IVC Filter: Tips for Retrieval  Brian G. DeRubertis, MD, UCLA Medical Center, Los Angeles, Calif.

8:45 a.m.

Beyond Thermal Ablation: The Role of Foam,  9:00 a.m. Glue, Steam and MOCHA Steve M. Elias, MD, Columbia University Medical Center, New York City, N.Y. Quality of Life Measures: Why You?  9:15 a.m. Ellen D. Dillavou, MD, University of Pittsburgh Medical Center, Pittsburgh, Pa. Endothermal and Chemically-Induced Deep Venous  9:30 a.m. Thrombosis: Have We Learned Anything Over the Last Decade? Peter F. Lawrence, MD, UCLA Medical Center, Los Angeles, Calif. PANEL DISCUSSION 

9:45 a.m.

Coffee Break 

10:00 – 10:15 a.m. uRoom 306

 SESSIONS P3 AND P4  Concurrent Tracks

10:15 a.m. – 1:15 p.m.

P3: O  pen Surgical Techniques of the Aorta and  Aortic Branches 

10:15 a.m. – 1:15 p.m. uRoom 302

At the end of this session, participants should be able to: 1. Describe the technical aspects of carotid subclavian bypass and transposition. 2. Explain surgical techniques for innominate artery reconstruction. 3. Discuss technical points of proximal vertebral artery reconstruction. 4. Explain the management principles for aneurysms of the great vessels. 5. Describe the most common renal artery reconstructive techniques. 6. Explain the surgical techniques for EVAR explantation and open endoleak repair. 7. Identify the key features in the management of aortoduodenal fistulas and aortic graft infections. 8. Explain the surgical approaches to both occlusive and aneurysmal mesenteric disease. Moderators: Kellie R. Brown, MD, The Medical College of Wisconsin, Milwaukee, Wis. Charles W. Acher, MD, University of Wisconsin, Madison, Wis. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

41


Introduction10:15 a.m. Carotid Subclavian Artery Bypass/Transposition Mark D. Morasch, MD, SVPN Heart & Vascular Center, Billings, Mont.

10:30 a.m.

Innominate Artery Reconstruction: Primary and  10:45 a.m. Hybrid Indications Margaret Clarke Tracci, MD, University of Virginia School of Medicine, Charlottesville, Va. Proximal Vertebral Artery Reconstruction Enrique Criado, MD, PhD, University of Michigan, Ann Arbor, Mich.

11:00 a.m.

Aneurysms of the Great Vessels Thomas C. Bower, MD, Mayo Clinic Rochester, Rochester, Minn.

11:15 a.m.

PANEL DISCUSSION

11:30 a.m.

Break 

11:45 a.m.

Renal Artery Reconstructive Techniques Noon Matthew S. Edwards, MD, Wake Forest School of Medicine, Winston-Salem, N.C. EVAR Explant and Open Repair of Endoleaks Rebecca Kelso, MD, The Cleveland Clinic Foundation, Cleveland, Ohio

12:15 p.m.

Aortoduodenal Fistulas and Aortic Graft Infections Linda M. Reilly, MD, University of California San Francisco, San Francisco, Calif.

12:30 p.m.

Mesenteric Reconstructions for Occlusive and Aneurysmal Disease Bruce L. Gewertz, MD, Cedars-Sinai Medical Center, Los Angeles, Calif.

12:45 p.m.

PANEL DISCUSSION  P4: Innovation and Invention:  A Vascular Surgeon’s Primer 

1:00 p.m. 10:15 a.m. – 1:15 p.m. uRoom 304

At the end of this session, participants should be able to: 1. D  iscuss ideas for innovative technology. 2. Propose the concept, idea or technology to a company to assess interest. 3. Develop ideas, prototypes or concepts. 4. Integrate innovative concepts with a surgical practice to advance care for patients. 5. Construct alternative strategies for moving from surgery to the medical device or business sector. Moderators: Daniel G. Clair, MD, The Cleveland Clinic Foundation, Cleveland, Ohio Steve M. Elias, MD, Columbia University Medical Center, New York City, N.Y.

42


Starting a Physician-Led Company  Timur P. Sarac, MD, Yale University, New Haven, Conn.

10:15 a.m.

Talking to the Big Guys About Your Idea Jose I. Almeida, MD, Miami Vein Center, Miami, Fla.

10:27 a.m.

How to Integrate Academia and Innovation Christopher K. Zarins, MD, Stanford University, Stanford, Calif.

10:39 a.m.

The Transition from Active Surgeon to Surgical Innovator 10:51 a.m. Peter A. Schneider, MD, Kaiser Permanente Medical Group, Honolulu, Hawaii The Role of a CMO with New Technology and Devices Rocco G. Ciocca, MD, Swedish Medical Center, Seattle, Wash.

11:03 a.m.

PANEL DISCUSSION 

11:15 a.m.

How Industry Values Technology James H. Wagner, JD, Cheetah Medical, Newton, MA

11:40 a.m.

How to Protect My Great Idea 11:52 a.m. Richard S. Wesorick, JD, Tarolli, Sundheim, Covell & Tummino LLP, Cleveland, Ohio What Is a Research Organization and  How to Start One? Kenneth Ouriel, MD, Syntactx, New York City, N.Y.

12:04 p.m.

Exit Strategy: Getting the Big Guys to Buy  12:16 p.m. Your Little Company Michael L. Marin, MD, The Mount Sinai Medical Center, New York City, N.Y. Working with Your Institution to Move Your Idea Forward John P. Pigott, MD, ProMedica/Jobst Vascular Institute, Toledo, Ohio

12:28 p.m.

PANEL DISCUSSION 

12:40 p.m.

Postgraduate Courses Lunch  

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

1:15 – 2:00 p.m. uRoom 306

43


SESSIONS P5 AND P6  Concurrent Tracks 

2:00 – 5:00 p.m.

P5: Thoracic  Aortic Disease Management:  From the Aortic Valve to the Bifurcation 

2:00 – 5:00 p.m. uRoom 302

At the end of this session, participants should be able to: 1. Describe the risks, benefits and alternatives associated with different methods used for the repair of aortic arch disease. 2. Understand and explain the rationale for using different endovascular techniques such as stent graft repair and endovascular fenestration for the treatment of acute Type B aortic dissection. 3. Describe the role that vascular surgeons may play in the performance of transaortic valve replacement (TAVR). 4. Understand the role of open repair in the current management of chronic Type B dissection with aneurysmal degeneration. 5. Evaluate the role that endovascular repair with branched endografts will play in the management of chronic Type B dissection with aneurysmal degeneration. Moderators: Christopher J. Kwolek, MD, Massachusetts General Hospital, Boston, Mass. Mark A. Farber, MD, University of North Carolina Hospitals, Chapel Hill, N.C. VALVE TO AORTIC ARCH Update on the Status of TAVR and Why Vascular Surgeons  2:00 p.m. Should Be Involved Marvin D. Atkins Jr., MD, Baylor, Scott & White Hospital and Clinic, Texas A&M Health Science Center, Temple, Texas Arch Debranching: The Best Current Solution for  Arch Disease? Frank R. Arko, MD, Sanger Heart and Vascular Institute, Charlotte, N.C.

2:15 p.m.

Total Endovascular Repair of Arch Aneurysm Disease 2:30 p.m. Matthew J. Eagleton, MD, The Cleveland Clinic Foundation, Cleveland, Ohio What Is the Role of Snorkels, Chimneys and  2:45 p.m. Periscopes in the Arch? Frank J. Criado, MD, FACS, MedStar Union Memorial Hospital, Baltimore, Md. Management of the Aortic Arch:  Hybrid Devices Versus Open Repair Joseph S. Coselli, MD, Baylor College of Medicine, Houston, Texas

3:00 p.m.

PANEL DISCUSSION

3:15 p.m.

Break

3:30 p.m.

MANAGEMENT STRATEGIES FOR DESCENDING THORACIC AORTIC DISSECTION

44


Acute Dissection: Why Most Acute Type B Aortic Dissections  3:45 p.m. Should Be Managed with TEVAR Raghuveer Vallabhaneni, MD, University of North Carolina Hospitals, Chapel Hill, N.C. Acute Dissection: Where Do Fenestrations, Rebuilding the Iliacs  4:00 p.m. and Visceral Vessels Fit In? Mark A. Farber, MD, University of North Carolina Hospitals, Chapel Hill, N.C. Chronic Dissection: Where Will Branched Endografts Fit  4:15 p.m. in the Management of Chronic Aortic Dissection with Aneurysmal Degeneration? W. Anthony Lee, MD, Christine E. Lynn Heart and Vascular Institute, Boca Raton, Fla. Chronic Dissection: What Is the Role of Open Surgical Repair  in the Management of Chronic Aortic Dissection with Aneurysmal Degeneration? Richard P. Cambria, MD, Massachusetts General Hospital, Boston, Mass.

4:30 p.m.

PANEL DISCUSSION

4:45 p.m.

P6: SVS  Leadership Program —  Leadership Styles and Versatility 

2:00 – 5:00 p.m. uRoom 304

At the end of this session, participants should be able to: 1. D  efine leadership, how it differs from management and recognize characteristics of exceptional leaders. 2.  Understand your social style preferences and those of others so that you can leverage the strengths of each style to best benefit your team. 3. Learn how to work with each style to build trust and manage conflict. Moderators: Bhagwan Satiani, MD, MBA, Ohio State University, Columbus, Ohio Douglas L. Wooster, MD, University of Toronto, Toronto, Ontario, Canada Ruth L. Bush, MD, MPH, Texas A&M Health Science Center, College of Medicine, Bryan, Texas Introduction

2:00 p.m.

What Is Leadership? Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif.

2:05 p.m.

Different Types: How Does Leadership Differ  from Management? Douglas L. Wooster, MD, University of Toronto, Toronto, Ontario, Canada

2:10 p.m.

Review of Social Styles Bhagwan Satiani, MD, MBA, Ohio State University, Columbus, Ohio

2:20 p.m.

Different Styles of Leadership:  2:30 p.m. Is One Better than Another? Ruth L. Bush, MD, MPH, Texas A&M Health Science Center, College of Medicine, Bryan, Texas

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

45


Versatility: Leadership in Different Practice/Clinical Settings Robyn A. Macsata, MD, Veteran Affairs Medical Center, Washington, D.C.

2:40 p.m.

Instructions on Group Interactions

2:50 p.m.

Break & Move Session moves to Room 306 for break-out groups

3:00 p.m.

Break-out Groups Break-out groups will focus on your “dominant” or “natural” styles. Group participants will consider: • How has this style served you well? • How has this style created problems?

3:10 p.m.

Discussion of Individual Styles and Versatility

3:40 p.m.

Characteristics of the Best Leaders You’ve Been Associated  with or Have Observed: How to Adapt to Different Styles Thomas S. Huber, MD, University of Florida, Gainesville, Fla.

4:00 p.m.

CASE STUDY

4:10 p.m.

Panel Q & A and Evaluations 4:35 p.m. Vikram S. Kashyap, MD, University Hospitals Case Medical Center, Cleveland, Ohio Bhagwan Satiani, MD, MBA, Ohio State University, Columbus, Ohio Douglas L. Wooster, MD, University of Toronto, Toronto, Ontario, Canada Ruth L. Bush, MD, MPH, Texas A&M Health Science Center, College of Medicine, Bryan, Texas V1: V  ascular and Endovascular Surgery Society (VESS)*  8:30 a.m. – Noon Paper Session I  uRoom 210 *formerly known as PVSS At the end of this session, participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators:  8:30 – 10:30 a.m. Firas F. Mussa, MD, New York University, New York City, N.Y. Malachi G. Sheahan III, MD, Louisiana State University Health Sciences Center, New Orleans, La. Moderators:  10:30 a.m. – Noon Benjamin J. Pearce, MD, University of Alabama at Birmingham, Birmingham, Ala. Bernadette Aulivola, MD, Loyola University Medical Center, Maywood, Ill. Welcome Announcement 

8:30 a.m.

The Norman Rich Military Award Winner  8:35 a.m. Use of the Short Musculoskeletal Function Assessment for Limb-specific Outcomes Following Extremity Vascular Injuries Daniel J. Scott, San Antonio Military Medical Center, Fort Sam Houston, Texas 46


VESS1. A New Aortic Injury Score Predicts Early Rupture  More Accurately Than Clinical Assessment 

8:45 a.m.

Donald G. Harris,1 Joseph Rabin,2 Michelle Ho,1 Gordon A. Crews,1 Bradley S. Taylor,1 Rajabrata Sarkar,1 Joseph A. Kufera,3 Thomas M. Scalea,2 Robert S. Crawford.4 1 University of Maryland School of Medicine, Department of Surgery, Baltimore, Md.; 2R Adams Cowley Shock Trauma Center, Baltimore, Md.; 3National Study Center; Shock, Trauma and Anesthesiology Research Organized Research Center, Baltimore, Md.; 4Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md.

OBJECTIVES: Optimal timing for repair of thoracic aortic injury (TAI) is uncertain. Delayed repair is common, but some injuries may rupture during observation. To help guide management, we describe a risk score to evaluate TAI stability and predict rupture. METHODS: We retrospectively reviewed 49 patients who presented in stable condition with SVS type III or IV TAI. 18 developed rupture within 48 hours defined as active extravasation on CT, or by operative or autopsy findings. 31 patients did not rupture and were repaired 48 hours after admission. There was no difference in age, gender, injury mechanism, non-chest injury severity, blood pressure or Glasgow coma scale on admission between patients who ruptured and those who did not. We generated a model targeting 100% sensitivity for rupture and validated it by boot strap analysis with 1,000 replicates. The model was compared to clinical assessment by surgeons experienced in TAI management who were provided with CT images and clinical data but were blinded to outcome. RESULTS: Multivariate analysis identified lactate >4 mM and mediastinal hematoma >10 mm (major criteria), and lesion: normal aortic diameter ratio >1.4 and pulse >105 bpm (minor criteria) as binary factors associated with rupture. A composite score was generated: (Lactate x4) + (Hematoma x4) + (Ratio x3) + (Pulse x2). A score 8 identified 100% of those who ruptured and 1 (3%) who did not as high-risk (P<0.0001). Sensitivity and negative predictive value were 100%, specificity 97% and the area under the receiver operator curve was 0.98. No patient with score <8 ruptured. The model predicts rupture with 2 major or 1 major + 2 minor criteria. Clinical assessment did not reliably predict rupture (65%, P<0.0001; 73% sensitivity, 61% specificity). CONCLUSIONS: This risk score can be calculated on admission and identifies patients with TAI at high risk for early rupture. Because the model is more accurate than clinical assessment alone, it may help guide appropriate early management. AUTHOR DISCLOSURES: R.S. Crawford: Nothing to disclose; G.A. Crews: Nothing to disclose; D.G. Harris: Nothing to disclose; M. Ho: Nothing to disclose; J.A. Kufera: Nothing to disclose; J. Rabin: Nothing to disclose; R. Sarkar: Nothing to disclose; T.M. Scalea: Nothing to disclose; B.S. Taylor: Nothing to disclose. VESS2. Retrograde Aortic Dissection After  Thoracic Endovascular Aortic Repair

Ludovic Canaud,1 Baris A. Ozdemir,2 Peter Holt,2 Matt Thompson.2

1

9:00 a.m.

A de Villeneuve Hospital, Montpellier, France; St George’s Hospital, London, United Kingdom.

2

OBJECTIVES: To provide data regarding the aetiology and timing of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR).

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

47


METHODS: Details of patients who had RTAD after TEVAR were obtained from the Medtronic Thoracic Endovascular Registry (MOTHER) supplemented by data from a systematic review of the literature (EMBASE, MEDLINE and COCHRANE databases). Univariate analysis and binary logistic regression analysis of patient or technical factors were performed to test for possible associations with RTAD. RESULTS: In MOTHER, RTAD developed in 16 of the 1010 patients (1.6%). Binary logistic regression demonstrated that an indication of TEVAR for aortic dissection (acute p=0.000212; chronic p=0.006) and device oversizing (OR 1.14 per 1% increase in oversizing above 9%, p<0.0001) were significantly more frequent in patients with RTAD. Data from the systematic review was pooled with MOTHER data and demonstrated that RTAD occurred in 1.7% (168/9594). Most of RTAD occurred in the immediate postoperative (58%) period and was associated with a high mortality rate (33.6%). The odds ratio of RTAD for an acute aortic dissection was 7.8 (CI 3.8 to 17.8) and 2.7 (CI 1.04 to 6.9) for chronic aortic dissection. The incidence of RTAD was not significantly different for endografts with proximal bare stent (2.8%) or non-bare stent (2.4%). CONCLUSIONS: Although RTAD after TEVAR is an uncommon complication, it has a high mortality rate. RTAD is significantly more frequent in patients treated for acute and chronic type B dissection, and when the endograft is significantly oversized. The proximal endograft configuration was not associated with any difference in the incidence of RTAD. AUTHOR DISCLOSURES: L. Canaud: Nothing to disclose; P. Holt: Nothing to disclose; B.A. Ozdemir: Nothing to disclose; M. Thompson: Nothing to disclose. VESS3.

Type II Endoleak with or Without Intervention  After Endovascular Aortic Aneurysm Repair (EVAR) Does Not Change Long-Term Outcomes Despite Aneurysm Sac Growth

9:15 a.m.

 Joy Walker,1 Lue-Yen Tucker,2 Philip P. Goodney,3 Hong Hua,4 Steven Okuhn,4 Ann Rhoades,5 Bradley Hill,6 Robert W. Chang.7 1  University of California, San Francisco, Calif.; 2Kaiser Permanente, Division of Research, Oakland, Calif.; 3Dartmouth-Hitchcock Medical Center, Lebanon, N.H.; 4The Permanente Medical Group, San Francisco, Calif.; 5Kaiser Permanente, Oakland, Calif.; 6The Permanente Medical Group, Santa Clara, Calif.; 7The Permanente Medical Group, South San Francisco, Calif.

OBJECTIVES: There is considerable controversy regarding the significance and appropriate treatment of type II endoleaks (T2L) after EVAR. We report our long-term experience with T2L management in a large multicenter registry. METHODS: Between 2000 and 2010, 1736 patients underwent EVAR. The incidence of T2L was observed. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size and reintervention. RESULTS: During the median follow-up of 32.2 months (IQR 14.2-52.8), there were 474 (27.3%) T2L. There were no late AAA ruptures attributable to a T2L. Patients with T2L had no difference in overall mortality (p=.47) or ARM (p=.26) as compared to those without T2L. A median sac growth of 5 mm (IQR 2-10) was seen in 46.1% of patients with T2L. Of these, 11.0% had an additional type of endoleak. Reintervention occurred in 111 (23.4%) of all patients with T2L of which 74% were performed in patients with sac growth and was technically successful in 31.5% of cases. 39 (35.1%) patients underwent lumbar embolization, 31 (27.9%) had adjunctive stents placed, 7 (6.3%) had open surgical revision, and 3 (2.7%) had direct sac injection. 31 (27.9%) patients had multiple

48


interventions. After excluding patients with other types of endoleak, patients with T2L-associated sac growth had no difference in overall mortality (p=.57) or ARM (p=.09) with or without reintervention. CONCLUSIONS: In our multicenter EVAR registry, overall mortality and ARM were unaffected by the presence of a T2L. Moreover, patients who were simply observed for T2L-associated sac growth had similar outcomes compared with those patients who underwent reintervention for same, suggesting that concomitant other endoleak types may be the primary driver of mortality. Our future work will investigate the most cost effective ways to select patients for intervention besides sac growth alone. AUTHOR DISCLOSURES: R.W. Chang: Nothing to disclose; P.P. Goodney: Nothing to disclose; B. Hill: Nothing to disclose; H. Hua: Nothing to disclose; S. Okuhn: Nothing to disclose; A. Rhoades: Nothing to disclose; L. Tucker: Nothing to disclose; J. Walker: Nothing to disclose. VESS4. The Implications of False Lumen Embolization  During TEVAR and EVAR on Thrombosis, Pressurization, Remodeling and Mortality

9:30 a.m.

 Manish Mehta, Medhi J. Teymouri, Philip S.K. Paty, Paul B. Kreienberg, Jeffrey C. Hnath, W. John Byrne, Paul J. Feustel, Sean P. Roddy.  The Institute for Vascular Health and Disease, Albany Medical College/Albany Medical Center Hospital, Albany, N.Y. OBJECTIVES: To evaluate the implications of thoracic and abdominal aortic false lumen embolization (FLE) during TEVAR and EVAR for complicated aortic dissections. METHODS: 96 consecutive patients that presented with complicated acute and chronic Type B thoracic aortic dissections (TAD) that underwent TEVAR with FLE (n=32, 33.3%) and without FLE (n=52, 54.2%), as well as abdominal aortic dissections (AAD) that underwent EVAR with FLE (n=4, 4.2%), and without FLE (n=8, 8.3%). In a subset of 26 patients, prior to FLE a wireless cardioMEMS Endosure® pressure sensor was placed in the false lumen, and used to quantify the false lumen to systemic systolic, diastolic, mean, pulse pressure indices. All data was prospectively collected, and outcomes analyzed. RESULTS: The 30-day mortality in patients with FLE (n=1, 2.3%) was significantly lower than in patients without FLE (mortality, n=5, 9.6%), and none of the patients with FLE developed spinal cord ischemia. Following TEVAR and FLE, 9 (29.0%) patients had persistent retrograde false lumen endoleaks that required repeat embolization procedures. FLE and complete thrombosis was achieved in 100% of EVAR patients. At a mean 18-month follow-up, 88% (23 of 26 patients) had a significant decrease in all false lumen to systemic pressure indices, and 65% (17 of 26 patients) had a false lumen remodeling with > 5 mm maximum diameter reduction. At midterm follow-up, there are no thoracic or abdominal related ruptures, conversions, or deaths. CONCLUSIONS: FLE during TEVAR for complicated acute and chronic TAD and AAD is associated with a lower mortality, and is effective in reducing false lumen pressures, maximum diameter. This adjunctive technique should be considered when managing complicated aortic dissections. AUTHOR DISCLOSURES: W. Byrne: Nothing to disclose; P.J. Feustel: Nothing to disclose; J.C. Hnath: Nothing to disclose; P.B. Kreienberg: Nothing to disclose; M. Mehta: WL Gore; Medtronic; Aptus Endosystems Inc.; EV3 Endovascular Inc.; Cordis Corporation; Trivascular Inc.; Lombard Medical Technologies; Bolton Medical; Abbott Vascular; Terumo Cardiovascular System Corporation; Maquet Cardiovascular; Harvest

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

49


Technologies; Cook Medical, research grants; WL Gore & Associates; Trivascular Inc.; IDEV, honorarium; P.S.K. Paty: Nothing to disclose; S.P. Roddy: Nothing to disclose; M.J. Teymouri: Nothing to disclose. VESS5. The Society for Vascular Surgery Lower  9:45 a.m. Extremity Threatened Limb Classification System Based on Wound, Ischemia, and Foot Infection (WIfI) Correlates with Risk of Major Amputation and Time to Wound Healing  Luke X. Zhan, Bernadino C. Branco, Arash Safavi, David G. Armstrong, Joseph L. Mills.

Surgery, University of Arizona, Tucson, Ariz.

OBJECTIVES: We aimed to evaluate whether the new SVS WIfI classification system correlates with important clinical outcomes for limb salvage and wound healing. METHODS: We analyzed 201 consecutive patients with threatened limbs treated from 2010-2011 in an academic center. We stratified patients into clinical stages 1-4 based on the SVS WIfI classification. We compared the SVS objective performance goals of major amputation, 1-year amputation free survival rate (AFS), and also wound healing time (WHT) according to WIfI clinical stages. RESULTS: The mean age was 59 years; (men - 79%; diabetes - 86%). Forty-two patients required major amputation (21%) while 159 (78%) had limb salvage. The amputation group had a significantly higher prevalence of advanced stage 4 patients (p<0.001), while the limb salvage group presented predominantly as stages 1-3. Patients in clinical stages 3-4 had a significantly higher incidence of amputation (p<0.001), decreased AFS (p<0.001) and delayed WHT (p<0.001) compared to those in stages 1-2. Among patients presenting with stage 3, primarily as a result of wound and ischemia, revascularization resulted in accelerated WHT (p=0.008). CONCLUSIONS: These data support the underlying concept of the SVS WIfI classification. As the clinical stage progresses, the risk of major amputation increases, 1-year AFS declines and wound healing time is prolonged. We further demonstrated the benefit of revascularization to improve WHT in selected patients, especially those in stage 3. Future efforts are warranted to incorporate the SVS WIfI classification into clinical decision-making algorithms in conjunction with a comorbidity index and anatomic classification. AUTHOR DISCLOSURES: D.G. Armstrong: Nothing to disclose; B.C. Branco: Nothing to disclose; J.L. Mills: Nothing to disclose; A. Safavi: Nothing to disclose; L.X. Zhan: Nothing to disclose. Amputation (%)

1-Yr AFS (%)

Mean WHT (days)

Stage 1 (n=39)

0 % (n=0)

100% (n=39)

94

69-119

Stage 2 (n=50)

0 % (n=0)

100% (n=50)

115

92-138

Stage 3 (n=53)

8% (n=4)

92% (n=49)

162

105-220

Stage 4 (n=59)

64% (n=38)

63% (n=38)

263

167-360

50

95% CI for WHT


VESS6. Healthcare Delivery Redesign for EVAR Leads  to Quality Improvement and Cost Reduction

10:00 a.m.

 Courtney J. Warner, Richard J. Powell, Alexander J. Horvath, Jesse A. Columbo, Teri R. Walsh, Philip P. Goodney, Daniel B. Walsh, David H. Stone.

Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

OBJECTIVES: Endovascular aneurysm repair (EVAR) is now a mainstay of therapy for AAA, though it remains associated with significant expense. We performed a comprehensive analysis of EVAR delivery at an academic medical center to identify targets for quality improvement and cost reduction in light of impending healthcare reform. METHODS: All infrarenal EVARs performed from April 2011 to March 2012 were identified (n=127). Procedures were included if they met standard commercial IFU guidelines, used a single manufacturer, and were billed to Medicare DRG 238 (n=49). Using DMAIC quality improvement methodology (define, measure, analyze, improve, control), targets for EVAR quality improvement were identified and high-yield changes were implemented. Procedure technical costs were calculated before and after process redesign. RESULTS: Perioperative services and clinic visits were identified as targets for quality improvement efforts and cost reduction. Mean technical costs prior to the intervention were $31,672, with endograft implants accounting for 52%. Pricing redesign in collaboration with hospital purchasing reduced mean EVAR technical costs to $28,607, a 10% reduction in overall cost, with endograft implants now accounting for 46%. Perioperative implementation of instrument tray redesign reduced instrument use by 32% (184 vs. 132 instruments), saving $50,000 annually. Unnecessary clinic visits were reduced by 39% (1.6 vs. 1.1 clinic visits per patient) through implementation of a pre-clinic imaging protocol. There was no difference in mean length of stay after the intervention (2.85 vs. 2.45 days, p=NS). CONCLUSIONS: Comprehensive EVAR delivery redesign leads to cost reduction and waste elimination, while preserving quality. Future efforts aimed to achieve more competitive and transparent device pricing will make EVAR more cost neutral and enhance its financial sustainability for healthcare systems. AUTHOR DISCLOSURES: J.A. Columbo: Nothing to disclose; P.P. Goodney: Nothing to disclose; A.J. Horvath: Nothing to disclose; R.J. Powell: Nothing to disclose; D.H. Stone: Nothing to disclose; D.B. Walsh: Nothing to disclose; T.R. Walsh: Nothing to disclose; C.J. Warner: Nothing to disclose. VESS7. Prospective Independent Neurologic Evaluation  of Patients Undergoing Carotid Revascularization: Can We Match the CREST Results?

10:15 a.m.

 Christopher J. Kwolek, Guy Rordorf, Virendra I. Patel, Kenneth Rosenfield, Joshua Hirsch, Michael Jaff.  Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass. OBJECTIVES: To prospectively evaluate the neurologic status of all patients (pts) undergoing carotid revascularization in a single institution over a 6 year time period.

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METHODS: Between 1/2007-6/2013 all pts undergoing carotid revascularization underwent independent neurologic evaluation preprocedure, postprocedure and at 30 days. Symptom status (Sx vs. Asx), participation in clinical trials, stroke (S), death (D), and myocardial infarction (MI) were independently reviewed. Chi squared analysis and Fisherâ&#x20AC;&#x2122;s exact test were performed. RESULTS: 2301 interventions were performed: 1969 carotid endarterectomies (CEA) 85.6% and 332 Carotid angioplasty and stent procedures (CAS) 14.4%. S/D/MI was 5.0%. CEA alone was performed in 581/1814 (32%) Sx pts and 1233/1814 (68%) Asx pts. S/D/MI was 4.5% (2.8/0.5/1.2 %) for Sx pts and 4.0% (2.4/0.4/1.1%) for Asx pts. CEA and coronary artery bypass grafting (CABG) was performed in 155 pts (98.7% Asx) S/D/MI of 11.1% (3.9/5.8/1.3%). CAS was performed in 119/332 (36%) Sx pts and 213/332 (64%) Asx pts. 255/332 (77%) patients were treated as part of an FDA approved trial. S/D/MI was 9.2% (4.2/4.2/0.8%) for Sx pts and 5.2% (3.3/1.4/0.4%) for Asx pts. Sx CAS pts treated in a clinical trial (n=64) had 2 events -S/D/MI of 3.1% (3.1%/0/0). Sx pts treated outside a clinical trial (n=55) had 9 events -S/D/MI of 16.4% (5.5/9.1/1.8%). CONCLUSIONS: 1. The prospectively collected, independently verified S/D/MI rates for all CEA and CAS performed within a clinical trial were equivalent to the CREST results. 2. S/D/MI for CAS in Sx pts was significantly higher than CEA 9.2% vs. 4.5% p=.034. 3. S/D/MI for CAS in Sx pts within a clinical trial was equivalent to CEA 3.1% vs. 4.5% p = 0.759. Sx CAS patients who did not qualify for a clinical trial had a 5x increased risk of S/D/MI -16.4%. 4. S/D/MI for CAS in Asx pts was equivalent to CEA 5.2% vs. 4.0% p = 0.42. 5. CEA/CABG in Asx pts is associated with a 3x increased risk of S/D/MI when compared to patients undergoing CEA for Asx disease. AUTHOR DISCLOSURES: J. Hirsch: Nothing to disclose; M. Jaff: Abbott, consulting fees or other remuneration (payment); Silk Road, consulting fees or other remuneration (payment); Boston Scientific, consulting fees or other remuneration (payment); Covidien, consulting fees or other remuneration (payment); Medtronic, consulting fees or other remuneration (payment); C.J. Kwolek: Silk Road, research grants; Cordis, research grants; WL Gore, research grants; Abbott, research grants; V.I. Patel: Nothing to disclose; G. Rordorf: Nothing to disclose; K. Rosenfield: Abbott, research grants; Medtronic, research grants; Lutonix, research grants. VESS8. Kinematics Effectively Delineate Accomplished  Users of Endovascular Robotics Using a Physical Training Model

10:30 a.m.

Cassidy Duran,1 Sean Estrada,2 Marcia Oâ&#x20AC;&#x2122;Malley,2 Jean Bismuth.1 The Methodist DeBakey Heart & Vascular Center, Houston, Texas; Rice University, Houston, Texas.

1

2

OBJECTIVES: Endovascular robotics systems, now approved for clinical use in the US and Europe, are seeing rapid growth in interest. Determining who has sufficient expertise for safe and effective clinical use remains elusive. Our aim was to analyze performance on a robotic platform to determine what defines an expert user. METHODS: Over 3 sessions, 20 subjects with a range of endovascular expertise, and endovascular robotic experience (novices <2hrs to moderate-extensive experience with >20hrs), performed 4 tasks on a training model. All participants completed a 2hr 52


training session on the robot by a certified instructor. Electromagnetic tracking was used to capture and analyze catheter tip motion. Motion analysis was based on derivations of speed and position including spectral arc length and total number of submovements (inversely proportional to proficiency of motion) and duration of submovements (directly proportional to proficiency). RESULTS: There was no significant difference in completion times between novices and experienced users. The experienced users had more efficient motion and performed more consistently. Users with more than 20 hours performed significantly better than those new to the system, independent of standard endovascular experience. (Table) CONCLUSIONS: Expertise in performance of traditional manual endovascular interventions does not translate to performance on the endovascular robot. Efficiency of catheter movement and consistency of performance may help identify users who are sufficiently trained for safe clinical use of the system. This work will help identify the learning curve and specific movements that translate to expert robotic navigation. AUTHOR DISCLOSURES: J. Bismuth: Hansen Medical, consulting fees or other remuneration (payment); C. Duran: Nothing to disclose; S. Estrada: Nothing to disclose; M. O’Malley: Nothing to disclose. Table: Motion Metrics for Robotic Task Performance Competent

Non-Competent

Spectral Arc Length (mm) (mean)

18.18

28.82

p<.0001

Number of Submovements per Sec. (mean)

0.415

0.642

p<0.0001

Duration of Submovements (sec) (mean)

3.27

1.77

p<.0001

VESS9. Surgical Aneurysmorrhaphy to Preserve  Autogenous Arteriovenous Fistula (AAVF) with Aneurysm Related Complications

10:45 a.m.

 Trung Vo, Gloria Tumbaga, Paul Aka, Jeffrey Hsu, Jason Behseresht, Majid Tayyarah.

Kaiser Permanente Fontana, Fontana, Calif.

OBJECTIVES: Aneurysm related complications can result in lost of a functioning aAVF. We reviewed our results with aneurysmorrhaphy to preserve and extend the aAVF use span. METHODS: Over the past 6 year period, we retrospectively reviewed the surgical outcome in patients with an aAVF who presented with aneurysm related bleeding, infection and/or skin erosion. 50 patients were identified of which 36 (72%) underwent aneurysmorrhaphy. The operation involves resecting the redundant aneurysm wall along with compromised skin, and primarily remodeling the remaining vein to create a conduit 6-8 mm in diameter. RESULTS: 34 out of 36 (94%) complicated AVF’s were successfully repaired primarily with aneurysmorrhaphy. Median patient age was 65.5 years, with a range of 29-88 years. Median AVF age was 61.5 months, with a range of 12 to 136 months. Median patient follow-up was 15.5 months, ranging from 1 to 76 months. 75% of patients had at least 9 months of follow-up, and 25% had at least 28 months. Primary patency was 67% and 57%, assisted primary patency was 85% and 80%, and secondary patency was 89% and 89% at one and two years respectively. 67% of the repairs were done under local regional anesthesia compared to 33% done under general anesthesia.

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CONCLUSIONS: This is the largest number of reported case series in patients with aAVF aneurysmal related complications that underwent aneurysmorrhaphy. Surgical aneurysmorrhaphy is a highly successful repair that will preserve the native AVF and extend its functional life with very low complications. Diligence has to be taken to evaluate and treat for central venous stenosis to maintain use of the AVF and prevent recurrence of further aneurysms. AUTHOR DISCLOSURES: P. Aka: Nothing to disclose; J. Behseresht: Nothing to disclose; J. Hsu: Nothing to disclose; M. Tayyarah: Nothing to disclose; G. Tumbaga: Nothing to disclose; T. Vo: Nothing to disclose. VESS10. M  anagement of the Failing AV Access

11:00 a.m.

 Justyna Rzucidlo,1 Christopher Banko,1 Rami Bustami,2 Clifford M. Sales.2 1  The Cardiovascular Care Group, Westfield, N.J.; 2 Overlook Medical Center, Summit, N.J.

OBJECTIVES: Avoidance of stents within the venous circuit of an arteriovenous access is well accepted. The challenge facing the access surgeon in caring for the patient with a failing hemodialysis access is to determine the optimal time to create a new access. We reviewed our data, with our â&#x20AC;&#x153;stent-aversionâ&#x20AC;? policy, in an effort to answer this question. METHODS: Data from consecutive patients treated in our facility from May 2012September 2013 were reviewed. Time to first arteriovenous (AV) access failure was measured as time between date of procedure and failure or last follow-up. Proportion of AV access failure was compared in the two groups using the Chi-square test. A Cox proportional hazards regression model was used to evaluate the risk of failure by group. RESULTS: 170 patients had complete data available for review. 92 patients (54%) were treated with angioplasty alone and the remainder (78) underwent both angioplasty and stent placement (46%). Patency was continually evaluated and all patients underwent a clinical examination at 90 days with fistulography utilized as needed. Average age was 66.9 years (SD =13.9), with 51% males. Median follow-up time was 8.5 months. The overall proportion of failure was 19%: 12% in the angioplasty group vs. 27% in the stent group; p = 0.013. Results from Cox regression showed that patients in the stent group had significantly higher risk of failure [Hazard Ratio (HR) (95% CI): 2.47 (1.15, 5.33); p = 0.021]. Higher risk of failure was also significantly associated with increased number of comorbidities (HR = 1.40, p = 0.020). Kaplan Meier results showed that the 9-month failure rate was 12% in the angioplasty group vs. 33% in the stent group. CONCLUSIONS: This review confirms the inferiority of stents in the management of the failing hemodialysis access. We advocate for the planning of new access creation at the time a stent is placed into the AV Access circuit to reduce the need for further interventions. AUTHOR DISCLOSURES: C. Banko: Nothing to disclose; R. Bustami: Nothing to disclose; J. Rzucidlo: Nothing to disclose; C.M. Sales: Nothing to disclose. VESS11. P  ostoperative Surveillance and Long-Term Outcomes  After Endovascular Aneurysm Repair Among Medicare Beneficiaries

Trit Garg, Laurence C. Baker, Matthew W. Mell.

Vascular Surgery, Stanford University, Stanford, Calif.

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11:15 a.m.


OBJECTIVES: The Society for Vascular Surgery (SVS) recommends annual imaging after endovascular aneurysm repair (EVAR). We sought to describe adherence to these surveillance guidelines and determine the association between adherence and long-term outcomes. METHODS: We analyzed fee-for-service Medicare claims for patients receiving EVAR from 2002 to 2005, collecting all relevant postoperative images through 2011. Allowing for a grace period of 3 months, we defined complete surveillance as at least one CT or ultrasound every 15 months after EVAR. Outcomes included all-cause mortality, late rupture, and complications (conversion to open, proximal or distal extension cuff, angioplasty, or embolization). RESULTS: Our cohort comprised 9503 patients. Median follow-up duration was 5.5 (IQR 2.6 - 7.2) years. Incomplete surveillance was observed in 54.7% of patients, and was observed at 3.2 +/- 1.7 years after EVAR. Patients with incomplete surveillance had lower all-cause mortality (45.8% vs. 68.2%, p<0.001), fewer late ruptures (0.8% vs. 1.4%, p=0.003), and fewer complications (1.6% vs. 6.2%, p<0.001). Aneurysm-related mortality was equivalent (0.7%) for both groups, and was not associated with incomplete surveillance by multivariable logistic regression (Adjusted OR 0.95, 95% CI 0.58 - 1.55, p=0.8). Those with incomplete surveillance had longer intervals from EVAR to late rupture (5.24 vs. 3.48 years, p<0.001), complications (4.10 vs. 1.78 years, p<0.001), and all-cause mortality (5.20 vs. 2.85 years, p<0.001). Incomplete surveillance was associated with a lower total cost ($9,353 ± $9,774 vs. $9,948 ± $12,628, p<0.001) and lower cost per year ($1,471 ± $1,436 vs. $3,043 ± $3,222, p<0.001). CONCLUSIONS: Non-adherence to SVS guidelines for post-EVAR imaging was not associated with poor outcomes. Our findings suggest the need for improved criteria for defining optimal surveillance intervals to achieve desired outcomes while reducing unnecessary cost and resource utilization. AUTHOR DISCLOSURES: L.C. Baker: Nothing to disclose; T. Garg: Nothing to disclose; M.W. Mell: Nothing to disclose. VESS12. A  ssessment of Renal Arterial Anatomy and  11:30 a.m. Implications for Endovascular Repair with Fenestrated, Branched or Parallel Stent-Graft Techniques  Bernardo C. Mendes, Gustavo S. Oderich, Thanila A. Macedo, Randall R. De Martino, Audra A. Duncan, Peter Gloviczki, Manju Kalra, Mark D. Fleming, Thomas C. Bower.

Mayo Clinic, Rochester, Minn.

OBJECTIVES: To evaluate renal artery (RA) and accessory RA (ARA) anatomy and implications for endovascular repair with fenestrated, branched or parallel (chimney, snorkel and periscope) stent-graft techniques. METHODS: Digital computed tomography angiography was analyzed in 520 consecutive patients treated by open or fenestrated endovascular repair for complex abdominal aortic aneurysms (AAAs, 2000-2012). RA/ARA anatomy was assessed using diameter, length, angles and kidney perfusion based on analysis of volumetric kidney parenchyma (VKP, Figure). Endovascular suitability was determined by RA diameter 4 mm, length to RA bifurcation 13 mm and preservation of >60% of one or >75% of both kidneys by VKP analysis. RESULTS: There were 222 juxtarenal (43%), 241 suprarenal (46%) and 57 type IV thoracoabdominal aortic aneurysms (11%). 1009 RAs and 176 ARAs were analyzed. Endovascular incorporation was possible in 884 RAs (88%) and 30 ARAs (17%). Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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Using the proposed criteria, 97 patients (19%) had 1 factor rendering RA incorporation unsuitable, including early bifurcation in 45 (9%), small diameter in 29 (6%) or inability to preserve kidney parenchyma in 28 (5%). 170 patients (33%) had other anatomic issues which would increase technical difficulty to RA incorporation, including excessive downward angulation in 125 (24%), high grade stenosis in 51 (10%) or prior renal stents in 11 (2%). CONCLUSIONS: Independent of the endovascular technique selected to treat a complex AAA, one out of five patients is not a candidate (19%) and one third has anatomic challenges (33%) for RA incorporation. Patients with unsuitable RA anatomy may need open repair to maximize renal artery patency and preserve renal function. AUTHOR DISCLOSURES: T.C. Bower: Nothing to disclose; R.R. De Martino: Nothing to disclose; A.A. Duncan: Nothing to disclose; M.D. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; M. Kalra: Nothing to disclose; T.A. Macedo: Nothing to disclose; B.C. Mendes: Nothing to disclose; G.S. Oderich: Nothing to disclose.

VESS13. N  atural History of Renal Artery Aneurysms —  an 18-Year Single-Institution Experience

11:45 a.m.

 Ziqing Wang, Peter Pak, Caron B. Rockman, Alec Megibow, Neal S. Cayne.

New York University Langone Medical Center, New York City, N.Y.

OBJECTIVES: The natural history of renal artery aneurysms (RAAs) is not well documented. We present an 18-year experience of patients with untreated RAAs. METHODS: A retrospective review was performed for patients with RAAs (1995-2013). Patients that were observed and had at least two studies (CT/MR) were included. Significant aneurysm growth was defined as > 3 mm. RESULTS: Seventy-one aneurysms were analyzed. Mean age on presentation was 69.7±12.3 yrs.; most were female (63.4%). Mean initial diameter was 1.29 ± 0.54 cm (range 0.5-3.7). There was a mean of 2.8 studies per patient; mean follow-up was 33.2 ± 32.4 months. Detailed clinical information was available in 48 patients. The most common comorbidities were hypertension (79%), hyperlipidemia (50%), and a smoking history (48%); 16.7% had renal insufficiency and 17% had other arterial aneurysms. Among the cohort, the mean annual growth rate was 0.077 ± 0.023 cm. Only 4/71 (5.6%) grew more than 3 mm during the study period. By survival analysis, gender was not a risk factor for growth (p=0.08). Only smoking was found to be a significant risk 56


factor for growth; current smokers were significantly more likely to have growth > 3 mm than former smokers or non-smokers (30% incidence of growth among current smokers vs. 8.3% and 0% respectively; p<0.02). Survival analysis demonstrated that larger aneurysms (>1.5 cm at presentation) had significantly less freedom from growth than smaller aneurysms (p=0.009). There were no known ruptures, and no patient required RAA intervention. CONCLUSIONS: Small RAAs exhibit a slow annual growth rate. Active smokers and those with a > 1.5 cm diameter on presentation may have more rapid growth. In particular, current smokers have a high incidence (30%) of clinically meaningful aneurysm growth. Nevertheless, this relatively large and longer term natural history study of observed RAAs supports observation for most small RAAs in patients that do not have a clear indication for surgical repair. AUTHOR DISCLOSURES: N.S. Cayne: Nothing to disclose; A. Megibow: Nothing to disclose; P. Pak: Nothing to disclose; C.B. Rockman: Nothing to disclose; Z. Wang: Nothing to disclose.

V2: Vascular  and Endovascular Surgery Society (VESS)*  1:00 – 4:30 p.m. Paper Session II  uRoom 210 *formerly known as PVSS At the end of this session, participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: 1:00 – 2:30 p.m. David A. Rigberg, MD, UCLA Medical Center, Los Angeles, Calif. Ravi Rajani, MD, Emory University School of Medicine, Atlanta, Ga. Moderators:  2:30 – 4:30 p.m. Venita Chandra, MD, Stanford University Medical Center, Stanford, Calif. Jeffrey E. Indes, MD, Yale University School of Medicine, New Haven, Conn. VESS14. Aggressive Costoclavicular Junction Decompression  in Patients with Threatened AV Access

1:00 p.m.

 Karl A. Illig,1 Wesley Gabbard,2 Aurelia Caler,1 Charles Bailey,1 Murray L. Shames,1 Peter R. Nelson.1 1  Surgery, University of South Florida COM, Tampa, Fla.; 2 Tampa Bay Vascular Center, Tampa, Fla.

OBJECTIVES: A substantial number of patients with threatened AV access are found to have stenoses at the costoclavicular junction (CCJ), which frequently are resistant to angioplasty and stenting. We hypothesized that stenoses in this location will not resolve unless bony decompression is performed to relieve the extrinsic venous compression. METHODS: We reviewed a prospectively maintained database to identify all patients with threatened AV access operated on for stenoses at the CCJ. RESULTS: Between July 2012 and December 2013, 24 patients with threatened access were operated on for CCJ stenoses at our institution. Fifteen had highly dysfunctional Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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AV fistulas otherwise felt to need ligation, 10 had significant arm and/or head swelling, and three required access but had no contralateral options. In six patients the subclavian vein was included and 18 stenotic; five of these had stents in place. Decompression was performed via claviculectomy in three patients, two of whom underwent reconstruction and one who was stented. The other 21 underwent first rib resection, 20 via an infraclavicular exposure; 11 patients underwent post decompression stenting. 30 day morbidity was minimal: there was one significant hematoma and one hemothorax in a patient who underwent on-table thrombolysis and no deaths. At follow-up up to one year (median five months), one patient died of unrelated causes, and one patient undergoing central reconstruction with prosthetic required excision for infection. Assisted primary patency of the fistula was 88%, and of the central bypass, 78%. The index arm continued to be used for access in 93% of patients, and overall survival was 91%. CONCLUSIONS: In this group of patients whose access was judged otherwise non-salvageable, excellent long-term fistula and ipsilateral arm use can be achieved with aggressive decompression of the bony costoclavicular junction. Stents placed after such decompression seem to have good intermediate-term patency in this high flow situation. AUTHOR DISCLOSURES: C. Bailey: Nothing to disclose; A. Calero: Nothing to disclose; W. Gabbard: Nothing to disclose; K.A. Illig: Nothing to disclose; P.R. Nelson: Nothing to disclose; M.L. Shames: Nothing to disclose. VESS15. C  omparison of Endograft Explantation to  Primary Open Aneurysm Repair: A Case-Controlled Study

1:15 p.m.

 Emily Wood, Audra A. Duncan, Thomas C. Bower, Ying Huang, Stephen S. Cha, Manju Kalra, Gustavo S. Oderich, Mark D. Fleming, Randall R. DeMartino, Peter Gloviczki.

Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.

OBJECTIVES: Although rare, EVAR explantation (EX) may be more complex than an initial open repair (OR). We compared EX to primary OR aneurysm repair in a case-controlled manner. METHODS: From 1998-2013, 46 EX (only infrarenal EVAR) and 1624 OR were treated. EX and OR groups were matched (3:1) for age, gender, SVS/AAVS comorbidity score. RESULTS: The 46 cases (EX) and 138 controls (OR) included 164 males (41 EX, 123 OR, mean age 71) and 20 females (5 EX, 15 OR, mean age 73). Mean SVS scores were 4.87 for EX, 4.88 for OR. EX indications were infection (24; 52%), type I endoleak (8; 17%), complex endoleak (5; 11 %), type II endoleak (4; 9%). Aortic clamp was suprarenal in 38 (83%) EX and 43 (31%) OR. Complications were higher for EX compared to OR (early â&#x20AC;&#x201C; 61% EX vs. 20% OR, p<0.001 and late â&#x20AC;&#x201C; 20% EX vs. 6% OR, p=0.008). Mean LOS was 17 (EX), 9.6 (OR) days (p<0.001). Mean follow-up was 1.8 yrs. (EX) and 5.1 yrs. (OR). 30-day overall mortality was similar: 2 (4%) EX vs. 1 (1%) OR (p=0.15). Four EX (9%) and 10 OR (8%) were ruptured; 1 of each group died <30 days. Long-term survival was better for OR vs. EX (non-infected and infected). (Image) CONCLUSIONS: EX, even for non-infected indications, is associated with increased morbidity and reduced long term survival compared to matched primary OR. This data emphasizes the need for careful EVAR patient selection as open reintervention after EVAR is inferior to primary OR.

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AUTHOR DISCLOSURES: T.C. Bower: Nothing to disclose; S.S. Cha: Nothing to disclose; R.R. DeMartino: Nothing to disclose; A.A. Duncan: Nothing to disclose; M.D. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; Y. Huang: Nothing to disclose; M. Kalra: Nothing to disclose; G.S. Oderich: Nothing to disclose; E. Wood: Nothing to disclose.

VESS16. Impact of Renal Artery Angulation on Procedural Complexity During Fenestrated and Snorkel EVAR

1:30 p.m.

Brant W. Ullery, Venita Chandra, Ronald L. Dalman, Jason T. Lee. Stanford University Medical Center, Stanford, Calif. OBJECTIVES: To determine the relationship of renal artery angulation (RAA) on time to target branch vessel catheterization and procedural efficiency during fenestrated (f-EVAR) and snorkel (sn-EVAR) endovascular aortic repair. METHODS: We reviewed imaging and procedural logs of 77 patients undergoing complex EVAR (53 sn-EVAR, 24 f-EVAR) from 2010-2013. RAA was measured on preop CT-A, with positive or negative orientation based upon the relative position above or below the plane perpendicular to the lateral aortic wall at the level of each renal ostium. Intra-procedural time to renal artery catheterization was recorded and compared to preop RAA as well as peri-procedural metrics. RESULTS: 111 renal artery catheterizations were included (72 sn-EVAR, 39 f-EVAR). Mean RAA was -28°±21° (range +37° to -60°) for f-EVAR and -30°±19° (range +22° to -65°) for sn-EVAR (p=.66). Comparative analysis using median RAA (-30° for both f-EVAR and sn-EVAR) demonstrated that less downward angulated renals were associated with longer catheterization times for sn-EVAR (18.1 vs. 12.3 min, p=.04), and more downward angulated renals were associated with longer times for f-EVAR (31.4 vs. 15.7 min, p=.05). The quartile of patients with the longest renal catheterization times was associated with increased operative time (303 vs. 214 min, p<.001), fluoro time (125 vs. 84 min, p=.01), and blood loss (767 vs. 473 mL, p=.01) in the f-EVAR cohort, and increased fluoro time (86 vs. 69 min, p=.05) in the sn-EVAR group. CONCLUSIONS: Preop renal artery angulation directly impacts the time to renal catheterization and sheath placement, which is the key step in f-EVAR and sn-EVAR. Angles steeper than -30° favor the snorkel approach, while less angulated renal arteries Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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favor the fenestrated strategy. Furthermore, renal artery catheterization time is related to procedural metrics of efficiency during complex EVAR; therefore, operative strategies and device/technique selection should take into account significant variations in renal artery angulation. AUTHOR DISCLOSURES: V. Chandra: Nothing to disclose; R.L. Dalman: Nothing to disclose; J.T. Lee: Nothing to disclose; B.W. Ullery: Nothing to disclose. VESS17. R  e-Admissions After Complex Aneurysm Repair:  Frequent, Costly, and Primarily at Non-Index Hospitals

1:45 p.m.

 N atalia O. Glebova,1 Caitlin W. Hicks,1 Ryan Taylor,2 Dean J. Arnaoutakis,1 George J. Arnaoutakis,1 James H. Black.1 Johns Hopkins Hospital, Baltimore, Md.; 2Johns Hopkins Health System, Baltimore, Md.

1

OBJECTIVES: Readmissions after complex vascular surgery are not well studied. We hypothesized that the rate of readmission after thoracic and thoracoabdominal aortic aneurysm repair (TAA/TAAAR) is underestimated by our single center results and sought to analyze the risk factors and costs of these readmissions. METHODS: Using our institutional database in conjunction with Maryland (MD) Health Services Cost Review Commission, we reviewed index admissions and all state-wide readmissions of MD patients who underwent TAA/TAAAR between 2002 and 2013 at our hospital. RESULTS: 115 MD residents were identified (mean age 65±1.2 years; 58% men; 57% open repair). Readmissions occurred in 29% of cases. Most readmitted patients (79%; p<.001) were NOT readmitted to the index hospital where their procedure was performed. Readmitted patients were not significantly different from non-readmitted patients in preoperative comorbidities, aneurysm extent; or postoperative neurologic, renal, or cardiovascular complications. On multivariate analysis, significant risk factors for readmission were open repair (OR 3.1, p=.03) and post-operative pneumonia (OR 4.3, p=.02). Striking differences were seen between patients readmitted to JHH (R-JHH) vs. OSH (R-OSH): R-JHH were readmitted mainly for aneurysm-related surgical issues, and R-OSH for medical morbidities. 75% of R-JHH required aneurysm-related intervention vs. 9% of R-OSH. R-OSH also had significantly higher total index hospitalization charges ($100,729±12,772 vs. $43,225±24,615, p=.05). CONCLUSIONS: Readmissions after TAA/TAAAR are frequent and occur at hospitals other than the index institution in the majority of cases. Risk factors for readmission include open repair and post-operative pneumonia, but not preexisting patient comorbidities. Our study suggests preoperative assessment of patients for targeted interventions to reduce readmission is not likely to be efficacious. Minimizing non-operative complications may reduce readmissions and the high costs associated with repeat care. AUTHOR DISCLOSURES: D.J. Arnaoutakis: Nothing to disclose; G.J. Arnaoutakis: Nothing to disclose; J.H. Black: Cook Medical, consulting fees or other remuneration (payment); N.O. Glebova: Nothing to disclose; C.W. Hicks: Nothing to disclose; R. Taylor: Nothing to disclose.

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VESS18. Arteriovenous Graft (AVG) Is Associated with Increased Secondary Procedures but Lower Catheter Use than Arteriovenous Fistula (AVF)

2:00 p.m.

Andrew E. Leake, Theodore H. Yuo, Timothy Wu, Larry Fish, Ellen D. Dillavou, Rabih A. Chaer, Steven A. Leers, Michel S. Makaroun.

University of Pittsburgh Medical Center, Pittsburgh, Pa.

OBJECTIVES: AVF is associated with improved long-term outcomes but longer maturation periods than AVG. The Fistula First Breakthrough Initiative has recently emphasized TDC avoidance. We sought to characterize the relationship of AVF and AVG to the utilization of TDCs as well as secondary procedures, defined as surgical revision, fistulogram and thrombectomy. METHODS: Using the US Renal Data System (USRDS) database, we identified incident HD patients in 2005 who started HD with a TDC and survived at least one year. Access creation, TDC placement and secondary procedures were identified by CPT codes. Multivariate logistic regression was used to identify risk factors for TDC placement or secondary procedures. RESULTS: 56,839 patients started HD in 2005, 73% with a TDC. Of those patients, 6,286 had an access procedure within 3 months and had at least one year of follow-up available (AVF 4,634; AVG 1,652). Mean age was 67.7 years (AVF 67.4, AVG 68.7; P<.001), 53.3% were male (AVF 57.9%, AVG 40.5%; P<.001), and 33.9% were obese (AVF 33.6%, AVG 34.6%; P=NS). Multivariate logistic regression demonstrates that AVG is associated with more secondary procedures (OR 1.403, P<.001) but significantly lower TDC use (OR 0.845, P=.006). Lower BMI, white race, older age, and male gender also protect against TDC placement (Table). Lower BMI, male gender, white race and younger age are protective against secondary procedures. CONCLUSIONS: In patients starting dialysis with TDC, AVG is associated with increased secondary procedures but lower TDC placement at one year. AUTHOR DISCLOSURES: R.A. Chaer: Nothing to disclose; E.D. Dillavou: Nothing to disclose; L. Fish: Nothing to disclose; A.E. Leake: Nothing to disclose; S.A. Leers: Nothing to disclose; M.S. Makaroun: Nothing to disclose; T. Wu: Nothing to disclose; T.H. Yuo: Nothing to disclose. One-Year Predictors of TDC Placement and Secondary Procedures Predictor

TDC Placement

Secondary Procedures

AV Graft

0.845 (.006)

1.403 (<.001)

Age (per decade)

0.949 (.020)

1.057 (.014)

White Race

0.864 (.012)

0.731 (<.001)

Male Gender

0.0831 (.001)

0.945 (.298)

BMI (per 5 units)

1.046 (.015)

1.06 (.002)

Odds Ratio (P-value)

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VESS19. Agency for Healthcare Research and  Quality (AHRQ) Inpatient Quality Indicator #11 Fails to Provide Accurate Assessment of Mortality After Abdominal Aortic Aneurysm Repair

2:15 p.m.

William P. Robinson,1 Wei Huang,2 Amy Rosen,4 Andres Schanzer,1 Hua Fang,3 Frederick Anderson,2 Louis M. Messina.1 Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.; 2Center for Outcomes Research, University of Massachusetts Medical School, Worcester, Mass.; 3Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Mass.; 4VA Boston Healthcare System, Boston, Mass.

1

OBJECTIVES: AHRQ Inpatient Quality Indicator (IQI) #11, abdominal aortic aneurysm (AAA) repair inpatient mortality rate, is a measure of hospital quality which is publicly reported but has not been externally validated. Because the measure includes both intact and ruptured aneurysms and open and endovascular repair, we hypothesized that IQI #11 does not provide accurate assessment of mortality risk after AAA repair. METHODS: Using AHRQ IQI software version 4.2, we calculated observed (O) and expected (E) mortality rates for IQI #11 for all hospitals performing AAA repair in the Nationwide Inpatient Sample 2007-2011. We assessed the correlation between expected rates as determined by IQI #11 risk-adjustment methodology and observed rates for all AAA repairs and in four cohorts stratified by aneurysm stability (ruptured vs. intact) and method of repair (open vs. endovascular). RESULTS: Among 187,773 AAA repairs performed at 1,268 U.S. hospitals, hospitals’ IQI #11 expected rates correlated poorly with their observed rates (E: 5.0±4.4% vs. O: 6.0±9.8%; r=.49). For ruptured AAA, IQI #11 methodology underestimated the mortality risk of open repair (E: 34±7.2% vs. 0: 40.1±38.2%; r=0.20) and endovascular repair (E: 24.8±9% vs. 0: 27.3±37.9%; r=0.08). For intact AAA repair, IQI #11 methodology underestimated the mortality risk of open repair (E:4.3±2.4% vs. O:6.3±16.1%; r=.24) but overestimated the mortality risk of endovascular repair (E:1.3±.8% vs. O:1.1±3.7%; r=0.25). Hospitals’ observed mortality rates after intact AAA repair were not correlated with their mortality rates after ruptured AAA repair (r=0.03). CONCLUSIONS: Inpatient Quality Indicator #11 fails to provide accurate assessment of inpatient mortality risk after AAA repair. Our results suggest that due to its poor validity, it is premature to use IQI #11 for quality reporting. Separate quality measures which assess mortality risk after repair of ruptured and intact AAAs, stratified by the use of open or endovascular repair, should be developed. AUTHOR DISCLOSURES: F. Anderson: Nothing to disclose; H. Fang: Nothing to disclose; W. Huang: Nothing to disclose; L.M. Messina: Nothing to disclose; W.P. Robinson: Nothing to disclose; A. Rosen: Nothing to disclose; A. Schanzer: Nothing to disclose. VESS20. F  ive-Year Stroke Rate After CEA Versus CAS  in the Vascular Quality Initiative

2:30 p.m.

 Philip P. Goodney,1 Brian W. Nolan,1 David H. Stone,1 Benjamin S. Brooke,2 Randall R. De Martino,3 Jessica Wallaert,1 Thomas Curran,4 Marc L. Schermerhorn,4 Jack L. Cronenwett.1 1  Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, N.H.; 2University of Utah, Salt Lake City, Utah; 3Mayo Clinic, Rochester, Minn.; 4 Beth Israel Deaconess, Boston, Mass.

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OBJECTIVES: The goal of carotid endarterectomy (CEA) and carotid stenting (CAS) is to limit future stroke during a patient’s lifetime. We linked data from the Vascular Quality Initiative (VQI) with Medicare claims to compare long-term stroke rate and 5-year stroke-free survival after CEA and CAS. METHODS: We linked 6,188 unique patients who underwent primary CEA or CAS in VQI (2005-2011) to their Medicare claims. We used VQI for perioperative and 1 year data, and added long-term follow-up from Medicare for stroke or death. We compared five-year freedom from stroke and stroke or death in crude and inverse propensityweighted (IPW) cohorts. RESULTS: Patients selected for CEA (n=5,792) or CAS (n=396) were similar in age (73 years), and 56% were asymptomatic in both groups. However, patients selected for CAS were more likely to have diabetes, coronary disease, CHF, and renal insufficiency. In-hospital stroke rate was similar for CEA and CAS, in both asymptomatic (1.5% versus 2.2%, p=0.34) and symptomatic (2.3% versus 3.5%, p=0.29) patients. However, the incidence of any stroke at 3 years was significantly higher after CAS compared with CEA (23% versus 13%, log-rank p<0.001, Figure). Further, failure to achieve 5-year stroke-free survival was worse for CAS patients, both asymptomatic (adjusted HR=1.9, 95% 1.5-2.6, p<0.001) and symptomatic (adjusted HR=1.6, 95% CI 1.3-2.0, p<0.001). CONCLUSIONS: Patients selected for CAS in VQI have worse long-term stroke rate and stroke-free survival when compared to patients treated with CEA, even when controlling for symptom status and patient-level comorbidities. AUTHOR DISCLOSURES: B.S. Brooke: Nothing to disclose; J.L. Cronenwett: Nothing to disclose; T. Curran: Nothing to disclose; R.R. De Martino: Nothing to disclose; P.P. Goodney: Nothing to disclose; B.W. Nolan: Nothing to disclose; M.L. Schermerhorn: Nothing to disclose; D.H. Stone: Nothing to disclose; J. Wallaert: Nothing to disclose.

VESS21. Endovascular Simulation Leads to Efficiency  and Competence in TEVAR Procedures

2:45 p.m.

Andre F. Gosling, Anil Nagavalli, Daniel Kendrick, Vikram S. Kashyap, John C. Wang.

Vascular Surgery, University Hospitals Case Medical Center, Cleveland, Ohio.

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OBJECTIVES: We assessed the effects of TEVAR rehearsal with an endovascular surgical simulator in surgical trainees at different levels in training. METHODS: 12 trainees in 3 cohorts (student; PGY 1-3; PGY 4-7) were oriented to using the Simbionix AngioMentorâ&#x201E;˘ simulator over four sessions. Likert scale qualitative analysis evaluated participant proficiency. Analysis of data included one-way ANOVA and paired t-tests. RESULTS: All groups had reduction of total procedure (mean 537s +/- 148 vs. 269s +/- 66, 1st session vs. 4th, p<0.05, CI 195-341) and fluoroscopy (201s +/- 74 vs. 110s +/- 37, p<0.05, CI 51-132) times with case progression. Students (551s +/- 84 vs. 313s +/- 65, p<0.05, CI 189-287) and PGYâ&#x20AC;&#x2122;s 1-3 (591s +/- 149 vs. 264s +/- 29, p<0.02, CI 113-541) had a significant decrease in procedure time. Fluoroscopy times were brief overall between individuals and groups, and did not change significantly with case progression. Participants acquired proficiency after a few runs in almost every step of the procedure. Endograft sizing appeared to be the most challenging task by qualitative analysis. PGY 4-7 trainees had higher technical scores but this was not statistically significant. CONCLUSIONS: Practice on endovascular surgical simulators can reduce overall procedure and fluoroscopy time, independent of trainee skill level or experience. Endovascular simulators can be effective tools in residency training and maintenance of proficiency. Further studies are needed to compare simulator performance with outcomes in real cases. AUTHOR DISCLOSURES: A.F. Gosling: Nothing to disclose; V.S. Kashyap: Nothing to disclose; D. Kendrick: Nothing to disclose; A. Nagavalli: Nothing to disclose; J.C. Wang: Nothing to disclose.

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VESS22. T  wenty-Four-Month Data from Bravissimo:  A Large-Scale Prospective Trial on Self-Expanding and Balloon-Expandable Stents for Tasc A&B and Tasc C&D Aorto-Iliac Lesions

3:00 p.m.

 Gianmarco de Donato,1 Marc Bosiers,2 Francesco Setacci,3 Koen Deloose,2 Jürgen Verbsit,4 Giuseppe Galzerano,1 Patrick Peeters,4 Carlo Setacci.1 1  Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy; 2 Department of Vascular Surgery, Algemeen Ziekenhuis Sint-Blasius, Dendermonde, Belgium; 3P. Valdoni Department of Surgery, La Sapienza University, Rome, Italy; 4Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium.

OBJECTIVES: To evaluate the long-term (up to 24 months) outcome of stenting in TASC A&B and TASC C&D iliac lesions in a controlled setting. METHODS: The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial including 325 patients with aorto-iliac lesions. The endpoint is the primary patency at 24 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio >2.0). A separate analysis for TASC A&B vs. TASC C&D population is performed. RESULTS: Between July 2009 and September 2010, 190 patients with TASC A or B, and 135 patients with TASC C or D aorto-iliac lesions were included. The demographic data were comparable for TASC A/B cohort and TASC C/D cohort. Technical success was 100%. Significantly more balloon-expandable stents were deployed in TASC A&B lesions, and considerably more self-expanding stents were placed in TASC C&D (p=0.01). The long-term primary patency rate after 24 months for the total population was 87.9% (88.0% for TASC A, 88.5% for TASC B, 91.9% for TASC C and 83.1% for TASC D, no statistically significant difference was shown when comparing these groups). The 24-month primary patency rates were 92.1% for patients treated with the self-expanding stent, 85.2% for patients treated with the balloon-expandable stent and 75.3% for patients treated with a combination of both stents (p=0.06). Univariate and multivariable regression analyses using Cox proportional hazards model identified only kissing stent configuration (p=0.0012) and obesity (p=0.0109) as independent predictors of restenosis (primary patency failure). Interestingly, as all TASC groups enjoyed high levels of patency, neither TASC category nor lesion length was predictive of restenosis. CONCLUSIONS: The 24-month data from this large, prospective, multi-center study confirm that endovascular therapy may be considered the preferred first-line treatment option of aorto-iliac lesions, irrespectively of TASC lesion category. AUTHOR DISCLOSURES: M. Bosiers: Nothing to disclose; G. de Donato: Nothing to disclose; K. Deloose: Nothing to disclose; G. Galzerano: Nothing to disclose; P. Peeters: Nothing to disclose; C. Setacci: Nothing to disclose; F. Setacci: Nothing to disclose; J. Verbsit: Nothing to disclose.

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VESS23. Open Repair of Asymptomatic Popliteal Artery Aneurysms Is Associated with Better Outcomes than Endovascular Repair: A Review of the VQI Database

3:15 p.m.

Mohammad H. Eslami,1 Denis Rybin,2 Gheorghe Doros,2 Alik Farber.1 Division of Vascular Surgery, Boston University School of Medicine, Boston, Mass.; 2Division of Biostatistics, Boston School of Public Health, Boston, Mass.

1

OBJECTIVES: Both open (OPAR) and endovascular (EPAR) repair are used to treat popliteal artery aneurysms (PAA). We assessed outcomes of both modalities in the treatment of asymptomatic PAA. METHODS: VQI databases (2010-2013) were queried for patients undergoing asymptomatic PAA repair using OPAR and EPAR. The groups were compared with respect to demographics, medical history and procedural characteristics. Outcomes included major adverse limb events (MALE), MALE and post-operative death (MALE-POD), popliteal artery patency loss, and length of stay (LOS). Proportional hazard Cox regression was used to compare the outcomes across the treatment groups and multivariate regression with backward elimination procedure (alpha=0.5) was used to construct parsimonious models. RESULTS: 390 patients (221 OPAR, 169 EPAR) were identified. Pre-operative comorbidities were similar between the two groups except for a higher rate of congestive heart failure (11.8% vs. 5.9%, P=0.043) and chronic obstructive pulmonary disease (19.5% vs. 11.8%, p=0.045) in the EPAR group. No in-hospital mortality was observed. LOS was longer in the OPAR group (3.8Âą2.5 vs. 1.4Âą1.9 days; p<0.001). OPAR was associated with lower hazard of MALE (0.35, 95% confidence interval (CI): 0.14-0.86), MALE-POD (0.28, 95% CI: 0.13-0.63) and popliteal artery patency loss (0.35, 95% CI: 0.16-0.75). OPAR patients had a significantly better MALE free survival (Figure). CONCLUSIONS: This retrospective analysis suggests that OPAR is associated with better outcomes than EPAR. Ultimately, the ongoing, adequately powered open vs. endovascular repair of PAA (OVERPAR) trial will definitively compare these procedures. AUTHOR DISCLOSURES: G. Doros: Nothing to disclose; M.H. Eslami: Nothing to disclose; A. Farber: Nothing to disclose; D. Rybin: Nothing to disclose.

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VESS24. Drug-Eluting Balloons (DEB) for Femoropopliteal  Lesions: Better Performance in De-Novo Stenosis or Occlusion Versus Restenosis

3:30 p.m.

 Monika Herten,1 Stefan Stahlhoff,2 Eva Schoenefeld,1 Giovanni B. Torsello.1 1  Department of Vascular and Endovascular Surgery, University-Hospital Muenster, University of Muenster, Muenster, Germany; 2Department of Vascular Surgery, St. Franziskus-Hospital Muenster, Muenster, Germany.

OBJECTIVES: The use of drug-eluting balloon (DEB) in treating de-novo arteriosclerotic lesions is well established. However, the effectiveness of this technology in femoropopliteal restenosis has to be demonstrated. The purpose of the study was to assess the efficacy of paclitaxel-DEB in restenotic (stented=ISR and non-stented) vs. de-novo stenotic femoropopliteal arteries. METHODS: Patients undergoing femoropopliteal endovascular intervention with DEB for restenosis (RE) or de-novo stenosis (DN) were prospectively enrolled. Excluded were patients with additional atherectomy. Clinical parameters (age, risk, risk factors) were comparable within the groups apart from the treated lesion lengths (RE 130 ±65 mm; DN 115 ± 71 mm; p=0.041). Primary endpoint was the primary patency rate (PP) at 12 months. Secondary endpoints were secondary sustained clinical improvement measured by Rutherford classification and clinically driven target lesion revascularization (TLR). RESULTS: 97 limbs were treated with DEB for intermittent claudication (IC, n=8, 8%) or critical limb ischemia (CLI, n=89, 92%) in 88 patients. Lesions were either de-novo (n=37, 38%) or restenosis (n=60, 64% with n=41, 68% ISR). Overall PP was 77.2% and 57.8% at 6 and 12 months. PP of de-novo group was significantly (p< 0.05) higher compared to restenosis group after 6 (94.5% vs. 77.2%) and 12 months (85.1% vs. 57.8%). After 12 months secondary TLR was significantly higher in RE (23.7% vs. 4.1% in DN; p<0.001). Sustained clinical improvement was 79.4% in RE and 66.7% in DE (p=0.34). CONCLUSIONS: DEB is an effective therapy for femoropopliteal lesions. The results of DEB for restenosis are inferior compared to de-novo stenosis. Nevertheless, outcomes after DEB for restenosis seem to be comparable with technically more demanding ISR strategies. AUTHOR DISCLOSURES: M. Herten: Nothing to disclose; E. Schoenefeld: Nothing to disclose; S. Stahlhoff: Nothing to disclose; G.B. Torsello: Nothing to disclose. VESS25. Use of Intravascular Ultrasound (IVUS) and  Catheter Venography in the Evaluation of Patients with Venous Thoracic Outlet Syndrome

3:45 p.m.

 Sharon C. Kiang, Hugh A. Gelabert, Brian G. DeRubertis, Steven M. Farley, David A. Rigberg, Juan C. Jimenez, Jane Yang, Jessica B. O’Connell.

Ronald Reagan UCLA Medical Center, Los Angeles, Calif.

OBJECTIVES: There are no defined criteria for the degree of venous compression leading to venous Thoracic Outlet Syndrome (vTOS). Our goal is to evaluate the relationships between subclavian vein stenosis and symptoms in vTOS using contrast venography and IVUS. METHODS: Subclavian veins of consecutive patients presenting with vTOS were evaluated by venography and IVUS in the index and contralateral limbs. Venograms

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were classified as normal, stenotic, or occluded. Venogram and IVUS measurements were made at two locations: lateral margin of the first rib (S1) and site of maximal compression (S2). Venography provided cranial-caudal (CC) dimensions. IVUS measurements included: anterior-posterior (AP), cranial-caudal (CC) dimensions (mm) and cross sectional area (mm2). The ratio of these determined percent stenosis. Post-operatively, limbs were re-evaluated by both venography and IVUS. RESULTS: Forty-five limbs from 23 patients were evaluated. Twenty-three limbs underwent TOS decompression and were evaluated post-op. IVUS and venogram data are presented in Table. CONCLUSIONS: vTOS symptoms are related to the presence of high-grade stenosis and best defined by IVUS. Asymptomatic patients demonstrate unexpected luminal reduction, which appears non-pathologic. Compared to venography, IVUS provides a more detailed evaluation of the subclavian vein. The greatest change in venous dimension by IVUS is in the AP plane and is not seen on venography. IVUS offers the potential to refine criteria identifying critical stenosis at the thoracic outlet. AUTHOR DISCLOSURES: B.G. DeRubertis: Nothing to disclose; S.M. Farley: Nothing to disclose; H.A. Gelabert: Nothing to disclose; J.C. Jimenez: Nothing to disclose; S.C. Kiang: Nothing to disclose; J.B. O’Connell: Nothing to disclose; D.A. Rigberg: Nothing to disclose; J. Yang: Nothing to disclose. Venogram and IVUS Data for All Subjects Presenting with vTOS Symptoms Number of Patients Symptomatic

Asymptomatic

Pre-Op Venogram (Reading)

Pre-Op Venogram (% cc stenosis)

Pre-Op IVUS (% area stenosis)

Post-Op Venogram (% cc stenosis)

Post-Op IVUS (% area stenosis)

3

Normal

24.1

54.0

n/a

n/a

12

Stenotic

39.0

81.1

31.2

40.3

11

Occluded

100

100

34.9

57.1

11

Normal

8.4

59.0

n/a

n/a

8

Stenotic

48.7

72.6

n/a

n/a

VESS26. EVAR Candidacy Impacts 30-Day Mortality  for REVAR but NOT for Open Repair of Ruptured Abdominal Aortic Aneurysms

4:00 p.m.

 Benjamin W. Starnes, Brandon T. Garland, Sarasi Desikan, Nam T. Tran, Elina Quiroga, Niten Singh.

University of Washington, Seattle, Wash.

OBJECTIVES: The impact of anatomic suitability for EVAR as it relates to mortality for ruptured AAA (rAAA) is unknown. We reviewed our experience managing rAAA patients with emphasis on EVAR candidacy as it relates to 30-day mortality. METHODS: This study included all patients with rAAA between Jan 1, 2002 and Oct 31, 2013 from a single institution. All images were reviewed by a physician blinded to outcome/procedure with specific notation made on EVAR candidacy (aortic neck D and L). Data were compared using Pearson Chi-Square with significance set at p<0.05. RESULTS: Of 303 patients with rAAA, 235 patients had a CT scan (78%) and 215 were “evaluable.” 156 (73%) were considered EVAR candidates. Mean aneurysm diameter, aortic neck diameter and length were 82.4 mm (r 37-182), 26.7 mm (r 15-65) and 17.2 mm (r 0-105). Table shows 30-day mortality based on procedure and EVAR candidacy. 68


For patients undergoing EVAR, EVAR candidates had a significant survival advantage (77.6% vs. 0%), p=0.0001. For patients undergoing open repair, there was no difference in mortality based on EVAR candidacy (49.2% vs. 46.9%), p= 0.82. CONCLUSIONS: Candidates for EVAR who undergo EVAR for rAAA have a significant survival advantage over those undergoing open repair and those undergoing EVAR without suitable anatomy. Mortality for ANY open repair is high and does not differ based on EVAR candidacy. Those patients with anatomy unsuitable for EVAR should not undergo an attempt at endovascular repair as the result is uniformly fatal at 30 days. AUTHOR DISCLOSURES: S. Desikan: Nothing to disclose; B.T. Garland: Nothing to disclose; E. Quiroga: Nothing to disclose; N. Singh: Nothing to disclose; B.W. Starnes: Nothing to disclose; N.T. Tran: Nothing to disclose.

rAAA and Candidacy for EVAR Candidates for EVAR

Number (%)

30-Day Mortality

EVAR

85 (54%)

22.4%

Open

71 (46%)

49.2%

Total/p-value

156

p=0.0007

Not Candidates for EVAR

Number (%)

30-Day Mortality

EVAR

5 (9%)

100%

Open

49 (91%)

46.9%

Total/p-value

54

p=0.024

15 patients died before OR.  

VESS27. L essons Learned from a Single Center’s Experience  Developing a Complex Endovascular Fenestrated/Branched Aortic Program and Obtaining a Physician-Sponsored FDA Investigational Device Exemption (IDE)

4:15 p.m.

 Andres Schanzer,1 Patrick Thompson,1 Donald Baril,2 William P. Robinson,1 Jessica P. Simons,1 Francesco A. Aiello,1 Danielle Doucet,1 Elias Arous,1 Louis M. Messina.1 University of Massachusetts Medical School, Worcester, Mass.; University of Pittsburgh Medical Center, Pittsburgh, Pa.

1 2

OBJECTIVES: In 2008, our division’s five-year strategic plan prioritized three programs. The top priority was, “To become an internationally recognized center of excellence for endovascular treatment of complex aortic pathology extending from aortic valve to external iliac artery.” METHODS: We identified 4 key components to achieve this strategic priority: 1) training at centers of excellence (COE) in complex endovascular repair, 2) industry partnership to improve access to developing technologies, 3) prospective data collection, 4) development and implementation of a physician-sponsored IDE for juxtarenal, pararenal, and thoracoabdominal aneurysms. RESULTS: After completing training at COEs and developing industry partnerships, our first complex endovascular aortic repair (definition: including 1 fenestration/branch) was done in 2010. We have now performed 45 repairs (15 commercially-manufactured Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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devices, 30 physician-modified devices) for 3 common iliac, 20 juxtarenal, 8 pararenal, and 14 thoracoabdominal aneurysms. The repairs incorporated 112 fenestrations/16 scallops; 94 (73%) were bridged to a target vessel with a stentgraft. All patients had complete 30-day follow-up for calculation of 30-day event rates: 2 (4.4%) mortality, 2 (4.4%) progression to dialysis, 8 (18%) access complications, 2 (4.4%) type 1 or 3 endoleaks, and no instances of myocardial infarction, bowel ischemia, paraplegia, paralysis, or stroke. With this experience, we submitted a physician-sponsored IDE to the FDA to evaluate safety/efficacy of physician-modified endografts for complex aortic aneurysms in the fall of 2013 and obtained approval on 30-day review. CONCLUSIONS: In 5 years, we developed a successful complex endovascular aortic program that utilizes both fenestrated and branch repair techniques. Focused strategic planning and a team approach to program development is an effective way for vascular surgery divisions to gain experience and expertise with new complex technologies while ensuring acceptable patient outcomes. AUTHOR DISCLOSURES: F.A. Aiello: Nothing to disclose; E. Arous: Nothing to disclose; D. Baril: Nothing to disclose; D. Doucet: Nothing to disclose; L.M. Messina: Nothing to disclose; W.P. Robinson: Nothing to disclose; A. Schanzer: Cook Medical, consulting fees or other remuneration (payment); Bolton Medical, consulting fees or other remuneration (payment); J.P. Simons: Nothing to disclose; P. Thompson: Nothing to disclose. General Surgery Resident/Medical Student  Scholarship Program —  OpEN AND ENDOVASCULAR TRAINING Scholarship Recipients Only See Fellow/Resident/Student Programs Tab.

C1: International Forum  At the end of this session, participants should be able to:

2:00 – 6:00 p.m. uExhibit Hall B, Level 1

4:00 – 6:00 p.m. uRoom 312

1. Discuss the methodology, results and conclusions of clinical research on vascular disease and vascular health presented in the forum. 2. Identify new methodologies for the diagnosis and treatment of vascular disease as it relates to aortic aneurysm disease. Moderators: Piergiorgio Cao, MD, Azienda Ospedaliera S.Camillo-Forlanini, Rome, Italy and University of Perugia, Perugia, Italy Sebastian Debus, MD, PhD, University Heart Center, Hamburg, Germany Glenn M. LaMuraglia, MD, Massachusetts General Hospital, Boston, Mass. Juan C. Parodi, MD, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina Kumud M. Rai, MD, Max Devki Devi Heart and Vascular Insitute, New Delhi, India, Frank J. Veith, MD, New York University Medical Center, New York City, N.Y. and The Cleveland Clinic Foundation, Cleveland, Ohio

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IF1. Predicting Mortality After Abdominal Aortic  Aneurysm Repair: The United Kingdom Aneurysm Risk Model

4:00 p.m.

 Graeme K. Ambler,1 Manjit S. Gohel,1 David C. Mitchell,2 Jonathan R. Boyle.1 1  Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; 2Southmead Hospital, Bristol, United Kingdom.

Discussant: Philip P. Goodney, MD, MS, Dartmouth-Hitchcock Medical Center, Lebanon, N.H. OBJECTIVES: Current risk-prediction models for abdominal aortic aneurysm (AAA) repair are suboptimal and infrequently used. This study aimed to develop a reliable model for in-hospital mortality after AAA intervention using data from the United Kingdom National Vascular Database (UK NVD), applying rigorous and contemporary statistical techniques to handle missing data. METHODS: UK NVD data for AAA interventions over a 15-month period (Feb 2010Apr 2011) were analyzed. Multiple imputation methodology was applied to handle missing data, and stepwise minimization of the Schwarz-Bayes criterion was used to select optimal models of in-hospital mortality following AAA repair using pre-operative variables only (A) or pre and peri-operative variables (B). Two-thirds of the data were used as the ‘modeling set’, with the remaining third used as the ‘validation set’. Model performance was assessed using receiver operating characteristic (ROC) curve analysis, and compared to existing risk-prediction models. RESULTS: 8088 AAA procedures were recorded in the NVD during the study period, of which 5872/8088 (72.6%) were elective. Model A (9 variables) and B (10 variables) showed excellent discrimination, with areas under the ROC curve (AUC) of 0.89 and 0.92 respectively for all AAA procedures. Separate models for endovascular/open or elective/emergency interventions were not necessary, as a single model (with type of repair and mode of admission as input variables) performed better. Discrimination remained excellent when considering only elective procedures (AUC 0.82 and 0.85) and was significantly better than existing models (p<0.001 & p=0.001, for models A and B respectively). CONCLUSIONS: The United Kingdom Aneurysm Risk Model appears accurate and outperformed all existing tools in this study. After further validation, the model could be invaluable both for pre-operative patient counseling and accurate risk adjustment of published outcome data. AUTHOR DISCLOSURES: G.K. Ambler: Nothing to disclose; J.R. Boyle: Nothing to disclose; M.S. Gohel: Nothing to disclose; D.C. Mitchell: Nothing to disclose. IF2. Clinical Outcome and Morphological  Determinants of Mural Thrombus in Abdominal Aortic Endografts

4:10 p.m.

Nelson Oliveira,1 Frederico Bastos Gonçalves,1 Sanne Hoeks,1 Sander Ten Raa,1 Ellen Rouwet,1 Johanna Hendriks,1 Frans L. Moll,2 Hence Verhagen.1 Erasmus University Medical Center, Rotterdam, Netherlands; Utrecht University Medical Center, Rotterdam, Netherlands.

1 2

Discussant: Christopher J. Abularrage, MD, Johns Hopkins Hospital, Baltimore, Md.

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OBJECTIVES: Determine the clinical impact and predictors of ingraft thrombus formation after EVAR. METHODS: A prospective EVAR database with 473 patients treated from 2000-2012 was searched. All postoperative CTAs were scrutinized for ingraft thrombus using 3D dedicated software. Patients with main body thrombus thickness >2 mm in >25% of the graft circumference were selected for the study group and compared to controls. Primary endpoint was freedom from thromboembolic events. Estimates were obtained using Kaplan-Meier plots. Secondary endpoints included clinical, morphological and device-related characteristics and were tested using a multivariable model. RESULTS: Sixty-eight patients (16.4%) were included in the study group. Median follow-up was 3.5 years (IQR: 2.0-5.5 years). Mural thrombus was identified on the 30-day CTA in 22 patients (32.4%) and up to 1 year in 25 (36.7%). In total, 17 patients (4.1%) suffered endograft or limb occlusions, 3 in the thrombus group (4.4%, P=0.89). Freedom from thromboembolic events at 5 years was 95% for the study group and 94% for controls (P=0.97-Figure). Smoking (HR 2.9, 95%CI 1.6-5.2), polyester-based endografts (HR 3.8, 1.8-8.0), AUI (HR 5.1, 2.0-13.1), and barrel configuration (HR 3.3, 1.7-6.4) were associated with thrombus accumulation. CONCLUSIONS: Mural thrombus formation within the main-body of the endograft is related to smoking, AUI design, main-body barrel configuration and polyester graft fabric but has no impact on thromboembolic events over time. AUTHOR DISCLOSURES: F. Bastos Gonรงalves: Nothing to disclose; J. Hendriks: Nothing to disclose; S. Hoeks: Nothing to disclose; F.L. Moll: Nothing to disclose; N. Oliveira: Nothing to disclose; E. Rouwet: Nothing to disclose; S. Ten Raa: Nothing to disclose; H. Verhagen: Nothing to disclose.

IF3. Contemporary Comparison of Aortic Arch Repair  by Endovascular and Open Surgery

4:20 p.m.

Paola De Rango,3 Piergiorgio Cao,1 Francesco Musumeci,2 Ciro Ferrer,1 Fabio Verzini,3 Carlo Coscarella,1 Gabriele Pogany,1 Andrea Montalto.1 Department of Vascular Surgery, Hospital S. Camillo Forlanini, Rome, Italy; Department of Cardiac Surgery, Hospital S. Camillo Forlanini, Rome, Italy; 3 Vascular and Endovascular Surgery; University of Perugia, Perugia, Italy.

1 2

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Discussant: Frank R. Arko, MD, Sanger Heart and Vascular Institute, Charlotte, N.C. OBJECTIVES: To analyze total aortic arch reconstruction in a contemporary comparison of current open and endovascular repair. METHODS: Open (group 1) and endovascular procedures (group 2) during 2007-2013 were reviewed. Endovascular repair (only landing zone 0-1), with or without hybrid adjunct, was selected for patients at high comorbidity and fit anatomy. Early and mid term mortality and major complications were assessed. RESULTS: There were overall 100 (78 males; mean age 68y) consecutive procedures performed; 29 were in group 1. Among the 71 in group 2, 7 were treated with branched or chimney endograft, 64 with partial or total debranching and straight endograft. Patients in group 1 were younger (mean age 61.9 vs. 70.8; p=0.03), more frequently females (48.2% vs. 11,3; p<0.001) with less cardiac (6.9% vs. 38.2%; p=0.001), hypertensive (58.5% vs. 88.4%; p=0.002) and peripheral arterial (0% vs. 16%; p=0.031) disease. At 30 days there were 4 deaths in group 1 and 6 in group 2 (13.8% vs. 8.5%; OR 1.7; 95% CI 0.45-6.66; p=0.47) and 1 stroke in group 1 and 4 in group 2 (OR 0.59; 95% CI 0.06-5.59; p=1). No spinal cord ischemia occurred in group 1 and 2 in group 2. Two perioperative bleedings (1 fatal) and one renal failure leading to death after 2 months occurred in group 1. Three retrograde dissections (1 fatal) were detected in group 2. According to Kaplan Meier estimates survival at 48 months was 69.8% in group 1 and 78.7% in group 2 (p=0.60). 4 reinterventions and 4 endoleaks were recorded in group 2 at mean follow-up of 26.2 months. CONCLUSIONS: Despite the higher comorbidity in patients undergoing endovascular aortic arch repair, no differences were detected in perioperative mortality, neurological complications and 48-month survival in the 2 groups. Endovascular approach may be a valid alternative to open surgery when morphologically feasible also in average risk patients. However a larger concurrent comparison and longer follow-up is needed to confirm this information. AUTHOR DISCLOSURES: P. Cao: Nothing to disclose; C. Coscarella: Nothing to disclose; P. De Rango: Nothing to disclose; C. Ferrer: Nothing to disclose; A. Montalto: Nothing to disclose; F. Musumeci: Nothing to disclose; G. Pogany: Nothing to disclose; F. Verzini: Nothing to disclose. International Scholars Recognition

4:30 p.m.

Scholar: Jo Krysa, MD, New Zealand Mentor: Wei Zhou, MD, Stanford University Medical Center, Stanford, Calif. Scholar: Jose Leite, MD, Brazil Mentor: Sateesh Babu, MD, Westchester Medical Center, Hawthorne, N.Y. Scholar: Mentor:

Yamume Tshomba, MD, Italy Manju Kalra, MD, Mayo Clinic, Rochester, Minn.

Scholar: Ilkka Uurto, MD, Finland Mentor: Rabih A. Chaer, MD, University of Pittsburgh, Pittsburgh, Pa.

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IF4. Finite Element Models with Patient  Specific Wall Strength Estimations Improve Growth Predictions of Abdominal Aortic Aneurysms

4:40 p.m.

Joy Roy,1 Moritz Lindquist Liljeqvist,1 Christian Gasser,2 Rebecka Hultgren.1 Karolinska Institutet/Hospital, Stockholm, Sweden; Royal Institute of Technology, Stockholm, Sweden.

1 2

Discussant: Mark F. Fillinger, MD, Dartmouth-Hitchcock Medical Center, Lebanon, N.H. OBJECTIVES: Abdominal aortic aneurysms (AAA) grow in a discontinuous manner and there is no reliable way to predict the growth rate of a specific aneurysm. In this study, we used finite element modeling (FEM) with estimations of patient specific parameters including wall strength and wall thickness to find a biomechanical parameter that predicted AAA growth. METHODS: 41 patients (9 women, 32 men) who had undergone two computed tomography angiographies (CT-A) within 9-18 months were included. Two FEM were made per CT-A; one (standard) with and one (matched) without modeling influence of patient specific age, sex, mean arterial pressure and family history. Annual increases in volume and diameter were compared to baseline AAA volume, diameter, intraluminal thrombus (ILT) volume, mean wall stress (MWS), mean ILT stress (MIS), peak wall stress (PWS) and peak wall rupture risk (PWRR = maximal wall stress/wall strength ratio). Linear and non-linear correlation was tested with Pearson product-moment and Spearman’s rank correlation coefficients. RESULTS: Standard baseline PWRR correlated with diameter growth (r = 0.32 P = 0.040). Baseline AAA volume (r = 0.57 P = 0.0001), diameter (r = 0.53 P = 0.0003), ILT volume (r = 0.50, P = 0.0009), standard (r = 0.44 P = 0.0087) and matched (r = 0.32 P = 0,043) PWRR and matched MIS (r = 0.39 P = 0.013) correlated with volume growth. PWS and MWS did not correlate with AAA growth. CONCLUSIONS: PWRR, based on patient specific wall stress and strength estimations, can predict both diameter and volume growth in our small sample. As this parameter previously has been shown to predict rupture, it is promising as a future clinical predictor for AAA progression and outcome. Our results also suggest a role for the ILT in AAA expansion since both the mean stress and volume of the ILT correlated with AAA volume growth. AUTHOR DISCLOSURES: C. Gasser: Nothing to disclose; R. Hultgren: Nothing to disclose; M. Lindquist Liljeqvist: Nothing to disclose; J. Roy: Nothing to disclose. IF5. Renal Volume Analysis Following Endovascular  and Open Aneurysm Repair

4:50 p.m.

 Teresa Martin Gonzalez, Adrien Hertault, Blandine Maurel-Desanlis, Jonathan Sobocinski, Marielle Le Roux, Rafaëlle Spear, Richard Azzaoui, Stéphan Haulon.

Hôpital Cardiologique, CHRU Lille, Lille CEDEX, France.

Discussant: Virendra I. Patel, MD, Massachusetts General Hospital/Harvard Medical School, Boston, Mass. OBJECTIVES: The purpose of this study was to compare renal outcomes (glomerular filtration rate (GFR) and renal volume) after endovascular (EVAR) and open AAA repair.

74


METHODS: All AAA repairs performed between November 2009 and July 2011 were included in this retrospective study. Patients requiring suprarenal clamping and renal bypass or re-implantation, and requiring fenestrated endografting, were excluded from the open and EVAR groups respectively. All EVAR were performed with transrenal proximal fixation. Renal volume (calculated with a 3D workstation), and GFR (estimated with the MDRD formula) were evaluated before the procedure, 12 months after and yearly thereafter. RESULTS: 91 patients (41 Open and 50 EVAR) were included. Both groups were comparable except for peripheral artery disease, arrhythmia and vitamin K antagonist treatment. Median follow-up was 35.8 months (29.8-36.7). In both groups, a similar significant decrease in right renal volume (9,41 cm3; 95% CI, 3,55-15,27), left renal volume (12,67 cm3; 95% CI, 6,81-18,54) and GFR (9,94 ml/min per 1,73 m2; 95% CI, 3,93-15,95) were observed during follow-up (p<0,002), despite no significant decrease in serum creatinine level during follow-up (p=0.056). CONCLUSIONS: Renal function impairment is similar after open and endovascular AAA repair. It is associated with a decrease in renal volume, which is a better marker of renal dysfunction than serum creatinine level. AUTHOR DISCLOSURES: R. Azzaoui: Nothing to disclose; S. Haulon: Cook Medical, consulting fees or other remuneration (payment); General Electrics, consulting fees or other remuneration (payment); A. Hertault: Nothing to disclose; M. Le Roux: Nothing to disclose; T. Martin Gonzalez: Nothing to disclose; B. Maurel-Desanlis: Nothing to disclose; J. Sobocinski: Nothing to disclose; R. Spear: Nothing to disclose. IF6. Inflammatory Response and Renal Function Following TEVAR

5:00 p.m.

 Konstantinos G. Moulakakis,1 Constantine N. Antonopoulos,1 George S. Sfyroeras,1, John Kakisis,1 Anastasios Papapetrou,1 Maria Alepaki,2 Petros Karakitsos,2 Christos D. Liapis.1 Department of Vascular Surgery, University of Athens, Attikon Hospital, Athens, Greece; 2Department of Cytopathology, University of Athens, Attikon Hospital, Athens, Greece.

1

Discussant: Rodney A. White, MD, Harbor UCLA, Los Angeles, Calif. OBJECTIVES: Endovascular treatment of abdominal and thoracic aortic aneurysms (EVAR, TEVAR) may induce a systemic inflammatory response characterized as the post-implantation syndrome (PIS). It has been suggested that this inflammatory response may influence renal function. The purpose of this study was to evaluate the inflammatory response and the renal function after TEVAR. METHODS: Thirty-two consecutive patients treated with TEVAR from January 2010 were enrolled in this prospective study. Temperature and serum levels of white blood cells (WBC), C-Reactive Protein (CRP), interleukin-10 (IL-10), interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor a (TNF-a), creatinine, urea and cystatin-c were measured preoperatively, and at 24 hours (h) and 48 h postoperatively. RESULTS: A statistically significant increase in temperature and serum levels of WBC, CRP, IL-10, IL-6 was observed 24h and 48h postoperatively, compared to baseline (all p-values < 0.05). The number of endografts and the coverage of the celiac or the subclavian artery did not affect the magnitude of the inflammatory response. No significant differences were observed concerning serum levels of IL-8, TNF-a, creatinine and cystatin-c from baseline to 24h and 48h postoperatively.

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CONCLUSIONS: TEVAR may propagate the inflammatory response during the early postoperative period. No clinical adverse events related to postimplantation syndrome were observed. Renal function does not seem to be influenced by the inflammatory response. Close surveillance is recommended for patients developing an excessive inflammation response postoperatively. AUTHOR DISCLOSURES: M. Alepaki: Nothing to disclose; C.N. Antonopoulos: Nothing to disclose; J. Kakisis: Nothing to disclose; P. Karakitsos: Nothing to disclose; C.D. Liapis: Nothing to disclose; K.G. Moulakakis: Nothing to disclose; A. Papapetrou: Nothing to disclose; G.S. Sfyroeras: Nothing to disclose.

Values of urea, creatinine, cytokines (IL-10, IL-8, IL-6, TNF-a), cystatin-C, WBC, PTL and temperature in baseline, 24h and 48h. IF7. Custom-Made Versus Off-the-Shelf  Multi-Branched Endografts for Endovascular Repair of Thoracoabdominal Aortic Aneurysms

5:10 p.m.

 Theodosios Bisdas, Konstantinos P. Donas, Michel Bosiers, Giovanni B. Torsello, Martin Austermann.

St. Franziskus Hospital and University Clinic of Muenster, Muenster, Germany.

Discussant: Benjamin W. Starnes, MD, University of Washington, Seattle, Wash. OBJECTIVES: To compare the early outcomes between the custom-made 4-branched endografts (4bEVARs) and the new off-the-shelf 4bEVAR (t-branch) for the endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). METHODS: Between January 2010 and December 2013, 42 consecutive patients with TAAAs underwent endovascular aortic repair with 4bEVARs. Twenty-two patients (group A, 53%) received a custom-made (Crawford classification type I: 2 [9%], type II: 4 [18%], type III: 9 [41%], type IV: 7 [32%]) and 20 patients (group B, 47%) a t-branch device (type II: 8 [40%], type III: 12 [60%]). Main outcome measure was the technical success defined as successful target revascularization without occlusion of the bridging endografts at the completion angiography. Secondary endpoints were mortality, reintervention, and paraplegia or paraparesis. RESULTS: Technical success amounted to 100% in both groups. Thirty-day mortality was 9% in group A (n=2) and 0% in group B (P= .51). Survival rates at 6 months amounted to 77% in group A [mean follow-up: 14Âą12 months] and 95% in group B (7Âą3 months) (P= .09). Reintervention-free survival rates at 6 months were also comparable between 76


the groups [group A: 100% versus group B: 95% (n=2), P= .31]. Paraplegia was observed in one patient in each group (5%) and persistent (after discharge) paraparesis in 2 patients in group A (9%) and one patient (5%) in group B (P= .99). CONCLUSIONS: The t-branch device with the unique advantage of direct implantation without any delay for manufacturing, showed excellent technical success and comparable clinical outcomes to the traditional custom-made 4bEVARs. AUTHOR DISCLOSURES: M. Austermann: Cook Medical, honorarium; Cook Medical, consulting fees or other remuneration (payment); T. Bisdas: Nothing to disclose; M. Bosiers: Nothing to disclose; K.P. Donas: Nothing to disclose; G.B. Torsello: Nothing to disclose. IF8. Endovascular Repair of Aortoiliac Aneurysms:  5:20 p.m. Concurrent Comparison Between Hypogastric Artery Interruption, Bell-Bottom and Sandwich Techniques Armando C. Lobato,1 Luciana Camacho-Lobato,1 Dino F. Colli,2 Robert G. Nascimento,3 Fausto Miranda,3 Guilherme V. Meirelles,4 Marcelo P. Cury.5 Vascular Surgery, Sao Paulo Vascular & Endovascular Surgery Institute, Sao Paulo, Brazil; 2Santa Catarina Hospital, Sao Paulo, Brazil; 3Escola Paulista de Medicina, Sao Paulo, Brazil; 4PUC Campinas University, Campinas, Brazil; 5 Sao Luiz Hospital, Sao Paulo, Brazil.

1

Discussant: Carlos H. Timaran, MD, University of Texas Southwestern Medical Center, Dallas, Texas OBJECTIVES: AAA with concomitant bilateral common iliac artery aneurysms (BCIAA) remains a challenge for endovascular aneurysm repair (EVAR). The current study aims at comparing the results of Hypogastric Artery Interruption (HAI), Bell-Bottom (BBT) and Sandwich techniques (ST) to address complex aortoiliac aneurysms. METHODS: From Jan 2000 to Dec 2012, 122 patients with asymptomatic AAA (mean Ø: 56 mm) associated with BCIAA (mean Ø: 32 mm) underwent elective EVAR at our Institution. A total of 244 CIAA were treated using either the same technique bilaterally or a different technique in each side. G1 comprised 52 HA endorevascularizations by ST; G2: 141 HAI by coil embolization followed by positioning of a limb extension to the external iliac artery and G3: 51 HA preservation by BBT [iliac limb endograft (ILE) 20 mm in Ø]. RESULTS: Median follow-up was 54m (33/99/75m) and the technical success rate 100%. Early (0/0.7/0%) and late (0/1.4/2%) related mortality rates as well as postoperative aneurysm rupture (0/0.7/2%) rates were similar among the 3 groups (p= NS). Permanent buttock claudication (PBC) (1.9/13.5/2%; p=.0006) as well as late type II endoleak rates (1.9/17/2%; p<.0004) were significantly higher in G2. Iliac limb migration (ILM) (1.9/0/9.8%; p<.0001) and late type IB endoleak rates (0/0/7.8%; p<.0001) were significantly higher in G3. Type III endoleak rates did not differ among the groups (1.9/4.3/2.0%; p: NS). Iliac limb occlusion (5.7/7.1/3.9) as well as reintervention rates (7.7/11/15.9%) failed to reach statistical significance (p:NS). Most complications and reinterventions occurred within a median follow-up of 18m. According to multivariate statistical analysis (Cox regression model), bilateral HAE was associated with PBC (p=.03) and late type II endoleak (p=.04). BBT (ILE24mm in Ø) was associated with ILM (p=.01) and late type IB endoleak (p=.01). CONCLUSIONS: HAI and BBT are associated with greater complication rates in comparison to the ST for the treatment of complex aortoiliac aneurysms. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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AUTHOR DISCLOSURES: L. Camacho-Lobato: Nothing to disclose; D.F. Colli: Nothing to disclose; M.P. Cury: Nothing to disclose; A.C. Lobato: Nothing to disclose; G.V. Meirelles: Nothing to disclose; F. Miranda: Nothing to disclose; R.G. Nascimento: Nothing to disclose. IF9. Fenestrated and Branched Stent-Grafting for  Post-Dissection Thoracoabdominal Aortic Aneurysms

5:30 p.m.

Eric L. Verhoeven,1 Kyriakos Oikonomou,1 Athanasios Katsargyris,1 Wolfgang Ritter.2 Department of Vascular and Endovascular Surgery, Klinikum Nürnberg Süd, Nuremberg, Germany; 2Department of Radiology, Klinikum Nürnberg Süd, Nuremberg, Germany.

1

Discussant: Tara M. Mastracci, MD, The Cleveland Clinic Foundation, Cleveland, Ohio OBJECTIVES: Secondary aneurismal degeneration of the thoracoabdominal aorta following acute aortic dissection is a complex scenario. Open repair carries a high surgical risk, and thoracic endovascular repair (TEVAR) is only feasible when the aneurysm is limited to the thoracic aorta. We present our experience with fenestrated/ branched TEVAR (F/Br-TEVAR) in the treatment of post-dissection thoracoabdominal aortic aneurysms (TAAAs). METHODS: A prospectively maintained database including all patients with postdissection TAAAs that underwent F/Br-TEVAR within the period January 2010 – December 2013. Evaluated outcomes included initial technical success, operative mortality and morbidity, late survival, endoleak, aneurysm diameter regression, renal function and reintervention during follow-up (FU). RESULTS: A total of 19 patients (15 male, mean age 65.2 ± 7.6 years) were treated. Technical success was 100%. Two (10.5%) patients died within 30-days postoperatively, one due to multiple organ failure and one due to cardiac de-compensation. Temporary spinal cord ischaemia occurred in two (10.5%) patients, with no case of permanent paraplegia. Mean FU was 10 ± 8 months. There was one late death, aneurysm unrelated. Renal function impairment occurred in one (5.3%) patient. Endoleak was diagnosed in eight (42%) patients during FU, including three type Ib side-branch endoleaks and five type II endoleaks. Three out of five type II endoleaks resolved spontaneously. Reintervention was required in three (15.8%) patients, all for type Ib endoleak. Mean aneurysm sac regression was 7.2 ± 8 mm, with a false lumen thrombosis rate of 65%. CONCLUSIONS: F/Br-TEVAR is feasible for patients with a post-dissection TAAA. It is associated with additional technical challenges and need for reintervention. F/Br-TEVAR seems to lead to favorable aneurysm remodeling. AUTHOR DISCLOSURES: A. Katsargyris: Nothing to disclose; K. Oikonomou: Nothing to disclose; W. Ritter: Nothing to disclose; E.L. Verhoeven: W.L. Gore & Associates, consulting fees or other remuneration (payment); Cook, consulting fees or other remuneration (payment); Siemens, consulting fees or other remuneration (payment); Atrium, consulting fees or other remuneration (payment); Medtronic, consulting fees or other remuneration (payment).

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IF10. Aortic Diameter Changes After Thoracic  Endovascular Aortic Repair for Stanford Type B Dissections Midterm Results of Single Center

Wei Guo

PLA General Hospital, Beijing, China.

5:40 p.m.

Discussant: Mark A. Farber, MD, University of North Carolina Hospitals, Chapel Hill, N.C. OBJECTIVES: This study assessed midterm results of aortic diameter changes of type B aortic dissection after thoracic endovascular aortic repair (TEVAR). METHODS: Between January 2002 and June 2008, 91 patients with type B aortic dissection underwent TEVAR and were followed up by computer tomography angiography (CTA) in our center. The CTA images were used to measure the diameters of aortic, TL and FL. Three measurement levels, including A, B and C, were established for the entire aorta in advance. Level A represented the point located at pulmonary artery bifurcate. Level B was located by projecting the first axial section passing through the diaphragm, and Level C was located by projecting the first section passing under the left main renal artery. False lumen thrombosis was analyzed according to the same three levels. RESULTS: After TEVAR, diameters of aortic and FL decreased, while TL diameters increased on level A and B significantly. During the follow-up, aortic segments with a thrombosed false lumen manifested no substantial diameter changes on these two levels. Patent FL caused the increase of substantial diameter on level C. Aneurysmal dilatation was developed on abdominal aorta 2 years after TEVAR. CONCLUSIONS: The midterm results of endovascular repair of acute type B dissection are encouraging. FL diameter decreases and TL diameter increases were noted in thoracic aorta in most patients. Persistent flowing into the false lumen, mainly due to entry tears at the abdominal level, was the cause of increasing of aortic, TL and FL diameters. Close follow-up is mandatory for patients whose false lumina were patent. AUTHOR DISCLOSURES: W. Guo: Nothing to disclose. IF11. Results of Aberrant Right Subclavian Artery  Aneurysms Repair: A Contemporary Multi-Center Experience

5:50 p.m.

Fabio Verzini,1 Giacomo Isernia,1 Gioele Simonte,1 Ciro Ferrer,2 Santi Trimarchi,3 Vincenzo Rampoldi,3 Nicola Tusini,7 Enrico Vecchiati,7 Mauro Gargiulo,6 Enrico Gallitto,6 Michelangelo Ferri,5 Emanuele Ferrero,5 Gabriele Piffaretti,4 Diletta Loschi,1 Paola De Rango,1 Piergiorgio Cao.2 Vascular Surgery, University of Perugia, Perugia, Italy; 2Department of Vascular Surgery, Hospital S. Camillo Forlanini, Rome, Italy; 3Thoracic Aortic Research Center, IRCCS Policlinico San Donato, University of Milan, Milan, Italy; 4 Vascular Surgery, Dept of Surgical Sciences, University of Insubria, Circolo University Teaching Hospital, Varese, Italy; 5Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy; 6Department of Vascular Surgery, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum, Bologna University, Bologna, Italy; 7Vascular Surgery, Azienda Ospedaliera di Reggio Emilia, Reggio Emilia, Italy.

 1

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Discussant: Timothy A.M. Chuter, MD, University of California, San Francisco, Calif. OBJECTIVES: To review current choices and late results of Aberrant Right Subclavian Artery Aneurysms (ARSAA) repair. METHODS: All consecutive ARSAA repairs from 2006 to 2013 in 7 centers were reviewed. Endpoints were 30-day and late mortality, reintervention rates and ARSAA related deaths. RESULTS: 21 ARSAA repairs were included (57% males, mean age 67 years); 3 ruptures (14%) required emergent treatment; 12 (57%) were symptomatic for dysphagia (33%), dysphonia (24%), pain (19%). 8 cases presented thoracic aortic aneurysm, 2 intramural hematoma, 1 acute type B aortic dissection. Mean ARSAA diameter was 42 mm; a single bi-carotid common trunk was present in 38% of cases. Majority of patients received hybrid procedures (71%), consisting of single (2 cases), bilateral (12) subclavian-to-carotid transposition or bypass, or ascending aorta to subclavian bypass (1 case) plus thoracic endografting (TEVAR); 19% of cases underwent open repair and 9% simple TEVAR with ARSA overstenting. Peri-operative death occurred in 2 patients (9%): in 1 case after TEVAR in ruptured ARSAA, requiring secondary sternotomy and aortic bending, and due to multi-organ failure after hybrid procedure in an elective case. Mean follow-up was 31+/-20 months. Estimates Kaplan Meier 36-month survival was 90%. Late ARSAA related death occurred in 1 case due to aorto-bronchial fistula with continuing back-flow from distal ARSAA and previous TEVAR. At CT controls, 1 type I and 1 type II endoleak were detected; the latter required a sacotomy re-intervention. ARSAA-related-death was statistically more frequent after TEVAR, a procedure reserved for ruptures, compared to open or hybrid repairs (p=0.01). CONCLUSIONS: Hybrid repair is the preferred therapeutic option for patients presenting with ARSAA. Mid term results show high rates of clinical success with low risk of re-intervention. Simple endografting presents high risk of related death; these findings underline the importance of achieving complete sealing, to avoid treatment failures. AUTHOR DISCLOSURES: P. Cao: Nothing to disclose; P. De Rango: Nothing to disclose; C. Ferrer: Nothing to disclose; E. Ferrero: Nothing to disclose; M. Ferri: Nothing to disclose; E. Gallitto: Nothing to disclose; M. Gargiulo: Nothing to disclose; G. Isernia: Nothing to disclose; D. Loschi: Nothing to disclose; G. Piffaretti: Nothing to disclose; V. Rampoldi: Nothing to disclose; G. Simonte: Nothing to disclose; S. Trimarchi: Nothing to disclose; N. Tusini: Nothing to disclose; E. Vecchiati: Nothing to disclose; F. Verzini: Nothing to disclose.

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CONCURRENT BREAKOUT SESSIONS  C2, C3 and C4

5:00 – 6:30 p.m.

C2: V  ascular Surgery in the VA: Issues for VA Surgeons  5:00 – 6:30 p.m. and What Can We All Learn?  uRoom 311 At the end of this session, participants should be able to: 1. Identify opportunities for career development in the VA. 2. Discuss common barriers to effective clinical practice and research. 3. Develop a network of colleagues to continue the dialogue. Moderators: Alan Dardik, MD, PhD, Yale University, New Haven, Conn. and VA Connecticut Healthcare Systems, West Haven, Conn. Jessie M. Jean-Claude, MD, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio Vascular Surgery Practice in the VA Thomas G. Lynch, MD, Veterans Health Administration, Washington, D.C.

5:00 p.m.

Leadership and the Academic Pathway at the VA Peter K. Henke, MD, University of Michigan, Ann Arbor, Mich.

5:08 p.m.

Creating and Maintaining a Robust Vascular Center Panos Kougias, MD, Baylor College of Medicine, Houston, Texas

5:16 p.m.

How Does the VA Enable Coding and Payment for  5:24 p.m. Vascular Procedures? Robert M. Zwolak, MD, PhD, Dartmouth-Hitchcock Medical Center, Lebanon, N.H. The Value of the VA in Running Multicenter Clinical Trials Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif.

5:32 p.m.

How Do We Fund Research at the VA? Melina R. Kibbe, MD, Northwestern University, Chicago, Ill.

5:40 p.m.

Collaborative Opportunities for VA Research 5:48 p.m. Ralph G. DePalma, MD, FACS, Veterans Health Administration, Washington, D.C. Moving Your Career to the VA Vivienne J. Halpern, MD, FACS, Carl T. Hayden Phoenix Medical Center, Phoenix, Ariz.

5:56 p.m.

PANEL DISCUSSION

6:04 p.m.

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C3: S  VS Young Surgeons Committee/VESS Session:  Preparing Young Surgeons for the Future 

5:00 â&#x20AC;&#x201C; 6:30 p.m. uRoom 310

At the end of this session, participants should be able to: 1. Identify the evolving vascular surgery employment models. 2. Employ methods to manage turf battles. 3. Review ways to build your promotion portfolio. 4. Evaluate job advancement opportunities. 5. Develop ways to prepare for contract negotiations. 6. Describe the differences in academic and private practice contracts. Moderators: Rabih A. Chaer, MD, University of Pittsburgh, Pittsburgh, Pa. Grace J. Wang, MD, Hospital of the University of Pennsylvania, Philadelphia, Pa. Vikram S. Kashyap, MD, University Hospitals Case Medical Center, Cleveland, Ohio Evolving Employment Models  K. Craig Kent, MD, University of Wisconsin, Madison, Wis.

5:00 p.m.

Managing Turf Battles 5:10 p.m. Gilbert R. Upchurch Jr., MD, University of Virginia Medical Center, Charlottesville, Va. Advancement Opportunities: Promotions Joseph L. Mills, MD, Arizona Health Sciences Center, Phoenix, Ariz.

5:20 p.m.

Advancement Opportunities: Switching Jobs  Michael J. Singh, MD, University of Pittsburgh, Pittsburgh, Pa.

5:30 p.m.

Contract Negotiations: How to Prepare and Recognize You Are Negotiating 5:40 p.m. O. William Brown, MD, JD, William Beaumont Hospital, Bingham Farms, Mich. Contract Negotiations: Academic Practice C. Keith Ozaki, MD, Brigham and Womenâ&#x20AC;&#x2122;s Hospital/Harvard Medical School, Boston, Mass.

5:50 p.m.

Contract Negotiations: Private Practice Russell H. Samson, MD, Mote Vascular Foundation and Sarasota Vascular Specialists, Sarasota, Fla.

6:00 p.m.

PANEL DISCUSSION

6:10 p.m.

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C4: R  oles and Controversies Surrounding Technology,  Policy and Clinical Practice in Vascular Surgery 

5:00 – 6:30 p.m. uRoom 309

At the end of this session, participants should be able to: 1. Discuss basic strategies in comparative effectiveness research in vascular practice. 2. Describe how Medicare determines coverage policies. 3. Define basic principles surrounding the development of investigational device exemption. 4. Identify basic cost effectiveness measurement for patients with critical limb ischemia. 5. Describe the design and measures used in the BEST trial. Moderators: Philip P. Goodney, MD, MS, Dartmouth-Hitchcock Medical Center, Lebanon, N.H. Wei Zhou, MD, Stanford University Medical Center, Stanford, Calif. Comparative Effectiveness in Vascular Practice 5:00 p.m. Marc L. Schermerhorn, MD, Beth Israel Deaconess Medical Center, Boston, Mass. CMS Coverage Decisions: How Does CMS Decide? Louis Jacques, MD, ADVI, Washington, D.C.

5:18 p.m.

IDEs Versus IRB Rodney A. White, MD, Harbor UCLA, Los Angeles, Calif.

5:36 p.m.

Cost Effective Approach to CLI Treatments Spence M. Taylor, MD, Greenville Health Systems, Greenville, S.C.

5:54 p.m.

BEST Trial: Design and Measures Alik Farber, MD, Boston University Medical Center, Boston University School of Medicine, Boston, Mass.

6:12 p.m.

Welcome Reception for Medical Students  6:45 – 8:15 p.m. and General Surgery Residents uSheraton Boston Hotel,  Commonwealth Room, Third Floor Cosponsored by the SVS Young Surgeons Committee and the Vascular and Endovascular Surgery Society See Fellow/Resident/Student Programs Tab.

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NOTES

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SCHEDULE IN DETAIL

THURSDAY, JUNE 5

All events held at Hynes Convention Center unless otherwise noted. REGISTRATION 

6:00 a.m. – 6:00 p.m. uExhibit Hall C Lobby, Level 2

BREAKFAST SESSIONS B1: H  emodialysis Access: Challenges  and Breakthroughs

6:30 – 8:00 a.m. 6:30 – 8:00 a.m. uBallroom C, Level 3

At the end of this session, participants should be able to: 1. Identify the factors affecting vein diameter on ultrasound. 2. Describe endovascular options for fistula salvage. 3. Describe how aneurysmal degeneration of AVFs can be treated. 4. Identify the utility of ultrasound in fistula maintenance. 5. Explain the options of dialysis access available for the morbidly obese. 6. Describe new technology for dialysis access. Moderators: Niten Singh, MD, University of Washington, Seattle, Wash. Eric K. Peden, MD, The Methodist Hospital, Houston, Texas Fistula First — When is the Vein Too Small for an AVF?  Niten Singh, MD, University of Washington, Seattle, Wash.

6:30 a.m.

Endovascular Salvage of the Failing Fistula George H. Meier, MD, RVT, FACS, University of Cincinnati School of Medicine, Cincinnati, Ohio

6:40 a.m.

Treatment of Fistula Aneurysms Eric K. Peden, MD, The Methodist Hospital, Houston, Texas

6:50 a.m.

Point of Care Ultrasound — How I Use This in My Practice  Gale L. Tang, MD, FACS, University of Washington, Seattle, Wash.

7:00 a.m.

Dialysis Access in the Morbidly Obese Patient William C. Jennings, MD, University of Oklahoma College of Medicine, Tulsa, Okla.

7:10 a.m.

Emerging Technology Beyond the Conventional Graft Jeffery H. Lawson, MD, Duke University Medical Center, Durham, N.C.

7:20 a.m.

PANEL DISCUSSION AND QUESTIONS

7:30 a.m.

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B2: C  hanging Paradigms in Asymptomatic  Carotid Disease 

6:30 – 8:00 a.m. uRoom 304/06

At the end of this session, participants should be able to: 1. Distinguish features on carotid imaging that can help select patients for intervention. 2. Describe the management of asymptomatic proximal common carotid and innominate lesions during intervention for bifurcation carotid disease. 3. Identify important technical steps during performance of carotid endarterectomy. 4. Estimate the potential advantages and disadvantages of transcervical carotid stenting with flow reversal. 5. Describe current management of patients with asymptomatic carotid dissection. 6. Distinguish available information on carotid artery disease and the rationale behind future trials. Moderators: Manish Mehta, MD, Institute for Vascular Health and Disease, Albany Medical College, Albany, N.Y. Mark K. Eskandari, MD, Northwestern University Feinberg School of Medicine, Chicago, Ill. William J. Quinones-Baldrich, MD, University of California, Los Angeles, Calif. How Advanced Imaging Might Shape Our Ability to  Manage Asymptomatic Carotid Stenosis Patients Patrick A. Stone MD, West Virginia University, Charleston, W.Va.

6:30 a.m.

Tandem Asymptomatic Proximal Common Carotid or  Innominate Lesions during CEA or CAS — When to Treat and How? Saum A. Rahimi, MD, Rutgers – Robert Wood Johnson Medical School, New Brunswick, N.J.

6:38 a.m.

CEA Techniques That Matter Philip S.K. Paty, MD, The Vascular Group, Albany, N.Y.

6:46 a.m.

Transcervical Carotid Stenting with Flow Reversal  6:54 a.m. for Cerebral Protection Enrique Criado, MD, PhD, Vascular Surgery, University of Michigan, Ann Arbor, Mich. Asymptomatic Carotid Dissections — Imaging and Treatment  Robert Y. Rhee, MD, Maimonides Medical Center, Brooklyn, N.Y.

7:02 a.m.

ACT 1 Update  7:10 a.m. Jon S. Matsumura, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wis. Crest 2 Design — Will It Find the Answers? 7:18 a.m. Wesley S. Moore, MD, Division of Vascular Surgery, UCLA, Los Angeles, Calif. PANEL DISCUSSION

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7:26 a.m.


B3: P  ost-EVAR Management: Surveillance Endoleaks  and When to Intervene 

6:30 – 8:00 a.m. uRoom302

At the end of this session, participants should be able to: 1. Evaluate the risk of rupture after EVAR. 2. Assess and apply different strategies of follow-up after EVAR according to preoperative, operative and postoperative risk factors and imaging findings. 3. Develop methods for surveillance after EVAR. 4. Identify endovascular treatment modalities for different types of endoleaks. 5. Explain how to approach and treat persistent type II endoleaks and type I endoleaks. Moderators: Peter A. Schneider, MD, Kaiser Permanente Medical Group, Honolulu, Hawaii Carlos H. Timaran, MD, University of Texas Southwestern Medical School, Dallas, Texas Introduction

6:30 a.m.

What Do We Know So Far About Post-EVAR Rupture?  Can It Be Prevented? W. Charles Sternbergh, MD, Ochsner Clinic Foundation, New Orleans, La.

6:35 a.m.

Post-EVAR Surveillance: How Often, By What Modality,  Is It Forever and Tips for Following High-Risk Groups Rabih A. Chaer, MD, University of Pittsburg, Pittsburg, Pa.

6:47 a.m.

Which Endoleaks to Worry About and When to Intervene Bart E. Muhs, MD, Yale University School of Medicine, New Haven, Conn.

6:59 a.m.

Procedures for Treating Type II Endoleaks Carlos H. Timaran, MD, University of Texas Southwestern Medical School, Dallas, Texas

7:11 a.m.

Endovascular Treatment for Type I Endoleaks Gustavo S. Oderich, MD, Mayo Clinic, Rochester, Minn.

7:23 a.m.

PANEL DISCUSSION

7:33 a.m.

GENERAL SURGERY RESIDENT PROGRAM BREAKFAST  See Fellow/Resident/Student Programs Tab. 

6:30 – 8:00 a.m. uRoom 210

MEDICAL STUDENT PROGRAM BREAKFASTS  See Fellow/Resident/Student Programs Tab. MS1/MS2  MS3/MS4 

6:30 – 8:00 a.m. uRoom 202 uRoom 203

OPENING CEREMONY 8:00 – 8:30 a.m. Presiding:  uBallroom A/B, Level 3 Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif.

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S1: William J. von Liebig Forum  

8:30 – 10:00 a.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif. Ronald M. Fairman, MD, Hospital of the University of Pennsylvania, Philadelphia, Pa.

SS1. Predictors and Outcomes of Endoleaks  in the OVER Trial

8:30 a.m.

 Wei Zhou,1 Brajesh K. Lal,2 Ziyi Li,3 Tassos Kyriakides,3 Jon S. Matsumura,4 Frank A. Lederle,5 Julie Ann Freischlag.6 1  Surgery, Stanford University, Stanford, Calif., VA Palo Alto Health Care System, Palo Alto, Calif.; 2University of Maryland, School of Medicine, Baltimore, Md., VA Medical Center, Baltimore, Md.; 3VA Cooperative Studies Program Coordinating Center, Veterans Affairs Medical Center, West Haven, Conn.; 4 University of Wisconsin, Madison, Wis.; 5Minneapolis VA Medical Center, Minneapolis, Minn.; 6University of California – Davis, Sacramento, Calif.

OBJECTIVES: The VA Open Versus Endovascular Repair of AAA (OVER) study is the only federally funded randomized control trial in the U.S. comparing open versus EVAR in standard-risk patients with infra-renal AAA. This sub-analysis is to identify risk factors and long-term outcome of endoleaks in patients treated with EVAR in OVER cohort. METHODS: The OVER trial randomized 881 patients and 439 received successful EVAR. Logistic regression analysis was used to identify predictors for endoleaks and secondary interventions. Kaplan Meier survival analysis, longitudinal plots and generalized linear mixed models methods were used to describe time to endoleak detection, resolution, or death. RESULTS: 135 (31%) patients developed 187 endoleaks over a mean follow-up of 6.2±2.4 years. 5 aneurysms went on to rupture. There was no difference in survival between the patients who developed endoleaks and those who did not. The 187 endoleaks included 76% type II, 12% type I, 3% type III, 3% type IV, and 6% indeterminate. Initial aneurysm size and age >75 years predicted the presence of endoleaks (P<0.001), while neck length and angulation were not associated with endoleak development. The presence of endoleaks is associated with lack of aneurysm shrinkage (P<0.001). 53% of endoleaks resolved spontaneously and 31% received secondary interventions. The initial aneurysm size independently predicted a need for secondary intervention (P<0.001). Delayed type II endoleaks (detected >1 year following EVAR) was associated with aneurysm enlargement compared to the early counterpart. There was no difference in aneurysm size or length of survival between type II and other types of endoleaks. CONCLUSIONS: We present one of the most comprehensive and longest follow-up analyses of patients treated with aortic endografts in a randomized control trial. Endoleaks are common and the presence of endoleaks negatively impacts sac shrinkage. Delayed Type II endoleaks are associated with late sac enlargement.

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AUTHOR DISCLOSURES: J.A. Freischlag: Nothing to disclose; T. Kyriakides: VA Cooperative Studies Program, research grants; B.K. Lal: National Institutes of Health; VA, research grants; F.A. Lederle: Nothing to disclose; Z. Li: Nothing to disclose; J.S. Matsumura: Abbott; Cook; Covidien; Endologix; Gore; National Institutes of Health, research grants; W. Zhou: Life Cell; Silk Road Medical, consulting fees or other remuneration (payment); National Institutes of Health; VA Merit, research grants. SS2. Staged Endovascular Repair of Thoraco-Abdominal  Aneurysms (TAA) Protects Against Spinal Cord Injury

8:44 a.m.

Adrian O’Callaghan,1 Matthew J. Eagleton,1 Tara M. Mastracci,1 James Bena.2 1  Vascular Surgery, Cleveland Clinic, Cleveland, Ohio; 2 Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.

OBJECTIVES: Spinal cord ischemia (SCI) devastatingly complicates extensive aortic repair owing to disruption of spinal perfusion. We hypothesized that staged repair might provide time for collateral development and lessen the surgical insult, thus mitigating the incidence and severity of SCI. METHODS: We conducted a retrospective cohort study of patients undergoing endovascular type II TAAA repair. Staged repair was defined as intentional completion of the endovascular repair as two temporally separate procedures. Extent of aortic cover was calculated using 3D imaging. Primary outcome measures were incidence and severity of SCI and mortality. RESULTS: 91 patients underwent type II repair between January 2008 and July 2013. 34 patients with prior aortic surgery were excluded. 32 non-staged (NSR) and 27 staged (SR) repairs were performed. Both groups were equivalent in terms of demographics and risk factors. The SR group had significantly greater percentage of the aorta covered (94% vs. 86%, p=.001). Median time to the second stage repair was 4 months (1-60). Rates of SCI were 37.5% (NSR) and 11.1% (SR, P=.03). All neurological injuries in SR were temporary, but resolved in only 58% of the NSR group. 30-day mortality rates were 18.8% (NSR) and 0% (SR), and these differences persisted during follow-up (Figure, P=.03). CONCLUSIONS: Primary staged repair is protective against SCI development and severity. In addition, the staged approach lowers 30-day and long-term mortality. Further investigations will be directed towards understanding the physiology of this benefit. AUTHOR DISCLOSURES: J. Bena: Nothing to disclose; M.J. Eagleton: Cook Medical, consulting fees or other remuneration (payment); Bolton Medical, consulting fees or other remuneration (payment); T.M. Mastracci: Cook Medical, consulting fees or other remuneration (payment); A. O’Callaghan: Nothing to disclose.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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Survival, Staged vs. Non-Staged VS1. 3D Fusion Overlay Imaging Is an Important  8:58 a.m. Adjunct for Reducing Radiation Dose, Contrast Volume, and Surgery Time When Performing Fenestrated Endovascular Aneurysm Repair

Andres Schanzer, Manuela Schuksz.

University of Massachusetts Medical School, Worcester, Mass.

BACKGROUND: Fenestrated endovascular aneurysm repair is now an FDA-approved treatment in the United States for short neck infrarenal aortic aneurysms and for juxtarenal aortic aneurysms. These complex endovascular aortic aneurysm repairs necessitate larger doses of radiation, increased volumes of contrast, and increased operative time. This video provides a step-by-step description of how 3D fusion overlay imaging can be utilized to reduce radiation dose, contrast volume, and surgery time during fenestrated endovascular aortic aneurysm repair. TECHNICAL DESCRIPTION: This is an 85-year-old man who presented for a commercially available fenestrated endovascular repair of a 6.1 cm abdominal aortic aneurysm with a 4 mm infrarenal neck. Since August of 2013, all endovascular aortic aneurysm repairs performed at the University of Massachusetts Medical School utilize 3D fusion imaging. The patient underwent successful percutaneous fenestrated endovascular repair of his aortic aneurysm with complete exclusion of the aneurysm and preservation of branch artery circulation with stent grafted bilateral renal artery fenestrations and an unstented scallop for the SMA. The total radiation dose administered was 987 Gray, total contrast use was 18 ml, and total operative time was 111 minutes. With the recent approval of a fenestrated endovascular device in the United States, and with several more devices in the pipeline, the number of complex endovascular aortic aneurysm repairs will continue to increase. These complex procedures generally require increased radiation dose, contrast volume, and operative time. The use of 3D fusion overlay imaging is an important modality to reduce radiation dose, contrast volume, and surgery time during endovascular aortic aneurysm repair.

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AUTHOR DISCLOSURES: A. Schanzer: Cook Medical, consulting fees or other remuneration (payment); Bolton Medical, consulting fees or other remuneration (payment); M. Schuksz: Nothing to disclose. SS3. Factors Associated with Spinal Cord  Ischemia After Multi-Branched Endovascular Thoracoabdominal Aneurysm Repair

9:08 a.m.

Julia D. Sobel,1 Shant M. Vartanian,1 Warren J. Gasper,1 Marlene Grenon,2 Joseph H. Rapp,2 Jade S. Hiramoto,1 Timothy A.M. Chuter,1 Linda M. Reilly.1 Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif.; 2San Francisco VA Medical Center, San Francisco, Calif.

1

OBJECTIVES: Spinal cord ischemia (SCI) after open or endovascular thoracoabdominal aortic aneurysm (TAAA) repairs is a serious complication with adverse effects on quality of life and long term survival. Many risk factors for SCI after open surgery have been identified; however the pathophysiology of SCI after endovascular repair is less understood. Our aim was to identify factors associated with postoperative SCI following multi-branched endovascular aneurysm repair (MBEVAR) for TAAA. METHODS: From July 2005 to October 2013, 116 patients with TAAA (30 women; mean age 73.4+/- 7.7y) were treated in a prospective, single center trial for MBEVAR. Symptomatic patients and those with dissection were excluded. SCI was classified into lower extremity paralysis (LEP), permanent lower extremity weakness (pLEW) and transient lower extremity weakness (tLEW). Perioperative spinal cord protection measures included cerebrospinal fluid (CSF) drainage and permissive hypertension. RESULTS: Postoperative SCI occurred in 24/116 (20.6%) patients. Most patients had tLEW (15/116, 12.9%) with full recovery and less frequently pLEW (n=3/116, 2.6%) or LEP (n=6/116, 5.2%). Most SCI events (79% 19/24) had a delayed onset (>6h postop), were transient (15/24, 62.5%), and symptoms resolved within a median 1d (IQR 1-3.5d). Prolonged postoperative hypotension was associated with SCI (OR 5.0, 95% CI [1.6-16.1] p<.01). Aneurysm extent or the presence of a postoperative endoleak was not associated with SCI events. The change in C-reactive protein levels from baseline to peak was 1.8 times greater in patients with SCI than those without (p=.03). CONCLUSIONS: Most episodes of SCI after MBEVAR are transient and do not occur in the operating room. Increased systemic inflammation may have an adverse effect on spinal cord perfusion and play a role in the delayed onset of SCI. Current adjunct strategies to maintain spinal cord perfusion, including permissive hypertension and CSF drainage, may help prevent permanent SCI. AUTHOR DISCLOSURES: T.A.M. Chuter: Cook Medical, consulting fees or other remuneration (payment); Cook Medical, research grants; W.J. Gasper: Nothing to disclose; M. Grenon: Nothing to disclose; J.S. Hiramoto: Cook Medical, consulting fees or other remuneration (payment); Cook Medical, research grants; J.H. Rapp: Nothing to disclose; L.M. Reilly: Nothing to disclose; J.D. Sobel: Nothing to disclose; S.M. Vartanian: Nothing to disclose. SS4. In Patients Stratified by Preoperative Risk,  Endovascular Repair of Ruptured Abdominal Aortic Aneurysms Has a Lower In-Hospital Mortality and Morbidity than Does Open Repair

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

9:22 a.m.

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Mujtaba Ali,1 Julie Flahive,2 Andres Schanzer,1 Jessica P. Simons,1 Francesco A. Aiello,1 Danielle Doucet,1 Louis M. Messina,1 William P. Robinson.1 Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.; 2Center for Outcomes Research, University of Massachusetts Medical School, Worcester, Mass.

1

OBJECTIVES: Endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAA) is reported to have a lower postoperative mortality than open repair (OR). However, comparisons have involved heterogeneous populations that lack adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR. METHODS: In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England (VSGNE) RAAA Risk Score into low (Score 0-1), moderate (Score 2-3), and high (Score 4-6) risk groups. RESULTS: Among 592 patients who underwent EVAR and 703 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (23% vs. 36%, p<0.001). In risk-stratified patients, EVAR trended towards a lower mortality in the low risk group (n=631; EVAR 11% vs. OR 16%, p=.07), had a significantly lower mortality in the moderate risk group (n=460; EVAR 37% vs. OR 48%, p=.02), and no advantage in the high risk group (n=84; EVAR 95% vs. OR 80%, p=.17). Across all risk groups, cardiac complications (EVAR: 28% vs. OR: 38%, p=0.0003), respiratory complications (EVAR: 27% vs. OR: 46%, p<0.0001), renal insufficiency (EVAR: 23% vs. OR: 37%, p<0.0001), and bowel ischemia (EVAR: 4% vs. OR: 10%, p<0.0001) were reduced significantly after EVAR. Across all risk groups, ICU LOS (EVAR: 2 days (IQR 1-5) vs. OR: 6 days (IQR 4-13); p<0.0001) and hospital LOS (EVAR: 5 days (IQR 3-11) vs. OR: 13 days (IQR 8-22); p<0.0001) were lower after EVAR than OR. CONCLUSIONS: Based on this first risk-stratified comparison using a national clinical database, EVAR of RAAA has a lower mortality and morbidity compared to OR in patients of low and moderate risk, and EVAR should be utilized to treat these patients when feasible. For RAAA patients at highest preoperative risk, there is no benefit to utilizing EVAR in comparison to OR. AUTHOR DISCLOSURES: F.A. Aiello: Nothing to disclose; M. Ali: Nothing to disclose; D. Doucet: Nothing to disclose; J. Flahive: Nothing to disclose; L.M. Messina: Nothing to disclose; W.P. Robinson: Nothing to disclose; A. Schanzer: Nothing to disclose; J.P. Simons: Nothing to disclose. SVS Foundation Resident Research Prize Paper SS5. Antibodies Against Malondialdehyde-Acetaldehyde  Adducts Can Identify Patients with Abdominal Aortic Aneurysm

9:36 a.m.

 Jeffrey S. Carson,1 Wanfen Xiong,1 Jennifer M. Worth,2 Trevor Meisinger,1 Matthew Dale,1 Fang Yu,3 Lynell W. Klassen,5 Michael J. Duryee,5 Carlos D. Hunter,4 Daniel R. Anderson,6 Geoffrey M. Thiele,4 Timothy Baxter.1  1Department of Surgery, University of Nebraska Medical Center, Omaha, Neb.; 2 Cardiothoracic Surgery, Lancaster General Health Physicians, Lancaster, Pa.; 3 Department of Biostatistics, University of Nebraska Medical Center, Omaha, Neb.; 4Experimental Immunology Laboratory, Veterans Affairs NebraskaWestern Iowa Health Care System (VA NWIHCS), Omaha, Neb.; 5Experimental

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Immunology Laboratory, University of Nebraska Medical Center, Department of Internal Medicine, Division of Rheumatology, Omaha, Neb.; 6Experimental Immunology, Research in Cardiovascular Disease Laboratory at the University of Nebraska Medical Center, Department of Internal Medicine, Division of Cardiology, Omaha, Neb. OBJECTIVES: Abdominal aortic aneurysm (AAA) is a pathologic dilation of the aorta. Inflammation of the aortic wall has been shown to be involved in AAA formation. Malondialdehyde-acetaldehyde (MAA) adducts are MAA/protein hybrids with immunogenic, proinflammatory and profibrotic properties. Levels of MAA adducts are elevated in patients with coronary artery disease; however, the role of MAA adducts in AAA is unclear. We hypothesize that levels of circulating antibodies against MAA adducts are increased in patients with AAA. METHODS: Plasma samples were collected from mice and patients with and without AAA. AAA was induced in mice by a standard CaCl2 protocol, with matching sham mice. Plasma levels of anti-MAA antibodies were quantified by ELISA. RESULTS: Patients with AAA exhibited higher levels of IgG and IgA anti-MAA antibody subtypes (P = .049 and .026 respectively) compared to control patients. Conversely, IgM anti-MAA antibodies in AAA patients were lower compared to control patients (P = .018). In CaCl2 treated mice IgG anti-MAA antibodies were elevated after AAA formation (P = .006). CONCLUSIONS: The pattern of anti-MAA antibodies is able to distinguish between patients with AAA and patients with atherosclerosis but no AAA. These results demonstrate that MAA adducts are associated with AAA and suggest they may play a role in either initiating or propagating chronic inflammation in AAA. AUTHOR DISCLOSURES: D.R. Anderson: Nothing to disclose; T. Baxter: Nothing to disclose; J.S. Carson: Nothing to disclose; M. Dale: Nothing to disclose; M.J. Duryee: Nothing to disclose; C.D. Hunter: Nothing to disclose; L.W. Klassen: Nothing to disclose; T. Meisinger: Nothing to disclose; G.M. Thiele: Nothing to disclose; J.M. Worth: Nothing to disclose; W. Xiong: Nothing to disclose; F. Yu: Nothing to disclose. E1: John Homans Lecture: Carotid Surgery —  Trials and Tribulations

10:00 – 10:30 a.m. uBallroom A/B, Level 3

At the end of this lecture, participants should be able to: 1. Describe the history of events leading up to carotid endarterectomy. 2. Outline the progressive improvement of results following carotid endarterectomy. 3. Compare the results of best medical management alone with carotid endarterectomy, plus best medical management for both symptomatic and asymptomatic carotid stenosis. 4. Discuss the rationale for the new CREST II trial.

Introduction  10:00 a.m. Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif. Lecture  10:05 a.m. Wesley S. Moore, MD, Division of Vascular Surgery, UCLA, Los Angeles, Calif.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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F1: E.  Stanley Crawford Critical Issues Forum  Appropriate Use of Vascular Surgery  Procedures: Do We Have a Problem?

10:30 a.m. – Noon uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Distinguish regional variations in vascular surgery procedures. 2. Explain the impact of industry on appropriateness of procedures and volume. 3. Determine who should perform vascular procedures by controlling variations in quality. 4. Explain how guidelines impact appropriateness and establish enforceable professional standards. 5. Compare ethical breaches in community practice and academic practice. Moderator: Peter F. Lawrence, MD, UCLA Medical Center, Los Angeles, Calif. Introduction  Peter F. Lawrence, MD, UCLA Medical Center, Los Angeles, Calif.

10:30 a.m.

Data on Vascular Surgery Procedures  10:35 a.m. Robert M. Zwolak, MD, PhD, Dartmouth-Hitchcock Medical Center, Lebanon, N.H. Optimizing Multi-Specialty Involvement in  Vascular Procedures Michael D. Dake, MD, Stanford University Medical Center, Stanford, Calif.

10:45 a.m.

Hospital/Physician Practice Organization Impact  on Appropriateness Timothy Ferris, MD, Partners Health Care, Boston, Mass.

10:55 a.m.

Practice Guidelines  Peter Gloviczki, MD, Mayo Clinic, Rochester, Minn.

11:05 a.m.

Ethical Issues Related to Frequency of Procedures  11:15 a.m. Russell H. Samson, MD, Mote Vascular Foundation and Sarasota Vascular Specialists, Sarasota, Fla. PANEL DISCUSSION 

11:25 a.m.

EXHIBIT HALL OPEN 

Noon – 6:30 p.m. uExhibit Halls C & D, Level 2

 LUNCH IN EXHIBIT HALL AND VASCULAR LIVE PRESENTATIONS

POSTER SET-UP 

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Noon – 1:20 p.m. uExhibit Halls C & D, Level 2

Noon – 6:30 p.m. uAuditorium, Level 2 (enter through Exhibit Hall C)


 S2: SVS Plenary Session II  

Room to Come 1:20 – 2:30 p.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: Peter F. Lawrence, MD, UCLA Medical Center, Los Angeles, Calif. Manish Mehta, MD, The Institute for Vascular Health and Disease, Albany Medical College, Albany, N.Y.

SS6. Natural History of Medically-Managed  Acute Type B Aortic Dissections

1:20 p.m.

Christopher A. Durham, Linda Wang, Emel A. Ergul, Nathan J. Aranson, Virendra I. Patel, Richard P. Cambria, Mark F. Conrad. Massachusetts General Hospital, Boston, Mass. OBJECTIVES: Although medical management of uncomplicated acute Type B aortic dissections remains the standard of care, contemporary data regarding the natural history of medically treated patients are sparse. The goal of this study is to evaluate the ability of medical therapy to prevent long-term complications in patients with acute Type B aortic dissection. METHODS: All patients with acute uncomplicated Type B aortic dissection that were initially managed medically between March 1999-March 2011 were included. Failure of medical therapy was defined as any death or aortic-related intervention. Early failure occurred within 15 days of presentation and late failure occurred thereafter. Predictors of long-term outcomes were determined using Cox Proportional hazards models. RESULTS: A total of 298 patients with medically managed acute Type B dissections were identified. The cohort had an average age of 65.9 years at presentation and was 61.7% male. There were 37 (12%) early failures including 12 deaths and 25 interventions (10 TEVAR/15 open). Aneurysmal degeneration was the indication for intervention in 6 (24%). Mean follow-up was 4.2 years (range 0.1-14.7 years). There were 174 (58.4%) failures including 87 deaths and 87 interventions (24 TEVAR/63 open). 57 (66%) interventions were for aneurysmal degeneration. Freedom from intervention was 77.3%+/0.024 at 3 years and 74.2%+/-0.025 at 6 years. There were no predictors of freedom from intervention. The intervention free survival was 55.0%+/-0.030 at 3 years and 41.0%+/-0.032 at 6 years. Age >70 years was protective against failure (HR .97, CI .95-.98, p<.01). Survival was higher in patients who required intervention at both 3 years (78% vs. 73%) and 6 years (76% vs. 58%)(p=0.018). CONCLUSIONS: Medical therapy of acute uncomplicated type B dissections is successful in the short term. However, the overall 6-year intervention free survival is low, and survival is significantly higher in patients who underwent intervention. AUTHOR DISCLOSURES: N.J. Aranson: Nothing to disclose; R.P. Cambria: Nothing to disclose; M.F. Conrad: Nothing to disclose; C.A. Durham: Nothing to disclose; E.A. Ergul: Nothing to disclose; V.I. Patel: Nothing to disclose; L. Wang: Nothing to disclose.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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SS7. The Contemporary Guidelines for Asymptomatic  Renal Artery Aneurysms Are Too Aggressive: A North American Experience

1:34 p.m.

 Peter F. Lawrence,1 Jill Q. Klausner,1 Michael P. Harlander-Locke,1 Dawn M. Coleman,2 James C. Stanley,2 Gustavo S. Oderich,3 Tazo S. Inui,4 Matthew W. Mell,5 Misty Humphries,6 Paul G. Bove,7 Christopher J. Abularrage,8 Robert J. Feezor,9 Amir F. Azarbal,10 Matthew R. Smeds,11 Joseph M. Ladowski,12 York N. Hsiang,13 Josefina A. Dominguez,14 Mark D. Morasch,15 for the Vascular Low-Frequency Disease Consortium. 1  Division of Vascular Surgery, University of California Los Angeles, Los Angeles, Calif.; 2Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich.; 3Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.; 4Kaiser Permanente, San Diego, Calif.; 5Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif.; 6 Division of Vascular and Endovascular Surgery, University of California Davis Health System, Sacramento, Calif.; 7Division of Vascular Surgery, Department of Surgery, William Beaumont Hospital, Royal Oak, Mich.; 8Division of Vascular Surgery, Johns Hopkins Hospital, Baltimore, Md.; 9Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.; 10Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, Ore.; 11Division of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, Ark.; 12The Cardiothoracic and Vascular Surgeons and Nurses of Lutheran Health Network, Fort Wayne, Ind.; 13Division of Vascular Surgery, University of British Columbia, Vancouver, British Columbia, Canada; 14Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California, Los Angeles, Calif.; 15St. Vincent Heart and Vascular, Billings, Mont.

OBJECTIVES: Most prior single-center series have recommended repair of asymptomatic renal artery aneurysms (RAA) > 2 cm. This study evaluates the contemporary management of a large series of RAA. METHODS: Patients with RAA were analyzed using a standardized database by a research consortium of 15 institutions. RESULTS: Six hundred and fourteen RAA were identified in 525 patients at 15 institutions (age = 61; M: F = 1:2). Seventy-one percent of patients were asymptomatic; symptomatic patients had severe hypertension (12%), flank pain (7%), abdominal pain (6%), and hematuria (4%). Aneurysm location included the main renal artery bifurcation (40%), main trunk (28%), primary branch (18%), secondary branch (7%), and pole artery (7%). Most RAA were saccular (86%) and calcified (64%). Diameter of symptomatic RAA was 1.8 ± .1 cm and asymptomatic RAA was 1.5 ± .1 cm (P < .001). Aneurysms were observed (67%; diameter 1.3 ± .1 cm) or surgically treated with open repair (OR) (28%; diameter 2.1 ± .1 cm), or endovascularly (EV) (5%; diameter 2.3 ± .2 cm). OR vs. EV minor complications were 26% and 10%, respectively (P < .001). OR vs. EV major complications were 1% and 3%, respectively (P = .014). Only one mortality occurred, in an EV patient. Conservatively managed patients were observed for 41 ± 4 months with no ruptures. Fifty-nine RAA > 2 cm were treated non-operatively (diameter 2.8 ± .1 cm) with a mean follow-up time of 42 ± 10 months; there were no ruptures. The growth rate for asymptomatic RAA, based on serial imaging, was .16 ± .01 cm/yr (calcified = .16 ± .01 cm/yr; non-calcified = .17 ± .01 cm/yr; P = .913).

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CONCLUSIONS: This largest study of RAA demonstrates that: 1. Asymptomatic RAA rarely rupture, even when > 2 cm and not calcified; 2. Open repair is associated with significant minor morbidity but rarely a major morbidity or mortality; 3. RAA growth rate is .16 ± .01 cm/yr and calcification does not protect against growth; 4. The current guideline of repairing asymptomatic RAA > 2 cm is too aggressive. AUTHOR DISCLOSURES: C.J. Abularrage: Nothing to disclose; A.F. Azarbal: Nothing to disclose; P.G. Bove: Nothing to disclose; D.M. Coleman: Nothing to disclose; J.A. Dominguez: Nothing to disclose; R.J. Feezor: Nothing to disclose; M.P. Harlander-Locke: Nothing to disclose; Y.N. Hsiang: Nothing to disclose; M. Humphries: Nothing to disclose; T.S Inui: Nothing to disclose; J.Q. Klausner: Nothing to disclose; J.M. Ladowski: Nothing to disclose; P.F. Lawrence: Nothing to disclose; M.W. Mell: Nothing to disclose; M.D. Morasch: Nothing to disclose; G.S. Oderich: Nothing to disclose; M.R. Smeds: Nothing to disclose; J.C. Stanley: Nothing to disclose; The Vascular Low-Frequency Disease Consortium: Nothing to disclose. SS8. Contemporary Outcomes of Intact (iVAA)  and Ruptured (rVAA) Visceral Artery Aneurysm Repair

1:48 p.m.

Ankur J. Shukla, Raymond Eid, Larry Fish, Efthimios Avgerinos, Luke K. Marone, Michel S. Makaroun, Rabih A. Chaer.

UPMC, Pittsburgh, Pa.

OBJECTIVES: To review the outcomes of open and endovascular intervention for intact and ruptured VAA. METHODS: Retrospective review of treated VAA at one institution from 2003–2013. RESULTS: 261 patients with VAA were identified; 155 were repaired (69 ruptured, Table; 86 intact). Pseudoaneurysms were more common in rVAA (80% vs. 35% iVAA, p<0.001). rVAA were smaller than iVAA (20.5 vs. 27.5 mm, p=0.018) at repair, and their most common presentation was abdominal pain; 18% were hemodynamically unstable. Endo intervention was the initial treatment for 70% (78% for rVAA, 63% for iVAA). Perioperative complication rate was higher for rVAA (19% vs. 4% iVAA, p=0.003), as well as 30-day mortality (12% vs. 0% iVAA, p=0.001), 1-yr (26% vs. 4% iVAA, p<0.001) and 3-yrs (30% vs. 7% iVAA, p<0.001). Lower 30-day mortality was noted with endo repair for rVAA (7% vs. 28% open, p=0.06). Predictors of mortality for rVAA included age (HR=1.098, p=0.006) while endo repair was protective (HR=0.231, p=0.035). Mean follow-up was 26 months, and KM estimates of survival were higher for iVAA at 3 yrs (88% vs. 62% iVAA, p=0.045). 30-day reintervention rate was higher for rVAA (9% vs. 1% iVAA, p=0.045), but was similar between open and endo repair (8.5% vs. 15%, p=NS). CONCLUSIONS: rVAAs have significant mortality. Open or endo interventions are equally durable, but endo interventions for rVAA result in lower morbidity and mortality. Aggressive treatment of pseudoaneurysms is electively recommended at diagnosis regardless of size. AUTHOR DISCLOSURES: E. Avgerinos: Nothing to disclose; R.A. Chaer: Nothing to disclose; R. Eid: Nothing to disclose; L. Fish: Nothing to disclose; M.S. Makaroun: Nothing to disclose; L.K. Marone: Nothing to disclose; A.J. Shukla: Nothing to disclose.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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VS2. TEVAR, EVAR, Endovascular Septectomy,  and Chimneys for Managing Complex Thoracoabdominal Aortic Dissection & Aneurysms

2:02 p.m.

 Manish Mehta,1 Pierre Galvagni Silviera,2 Medhi J. Teymouri,1 Philip S.K. Paty,1 Lewis Britton,1 Chin Chin Yeh,1 Paul B. Kreienberg,1 Benjamin B. Chang.1 1  The Institute for Vascular Health and Disease, Albany Medical College/Albany Medical Center Hospital, Albany, N.Y.; 2Universidade Federal de Santa Catarina, Florianopolis, Brazil.

BACKGROUND: Endovascular therapy for treating complex throacoabdominal aortic dissections with aneurysmal degeneration is riddled with challenges of inadequate false lumen exclusion and thrombosis, inadequate proximal and distal landing zones with septum dividing the true and false lumen, and the potential for visceral malperfusion. This movie presentation will focus on a stepwise approach to managing complex thoracoabdominal dissections and aneurysms with advanced imaging, TEVAR, EVAR, in-situ fenestrations, endovascular septectomy, and Chimneys as necessary adjunctive techniques for successful thoracoabdominal dissection and aneurysm exclusion and visceral perfusion. TECHNICAL DESCRIPTION: Patient presented with chronic thoracoabdominal aortic dissection from left subclavian to iliac bifurcation with 6.5 cm thoracic aneurysm and 6 cm abdominal aortic aneurysm. Underwent TEVAR and false lumen coil embolization for complete false lumen exclusion. EVAR was planned several months later. The juxta-renal and infrarenal aorta had a chronic aortic septum with distinct separation of true and false lumens, prohibiting an adequate proximal stentgraft landing zone at

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the intrarenal aortic neck. True and false lumens were accessed, and an endovascular septectomy was performed across a fenestration at the level of the infrarenal aortic neck to create an adequate proximal stentgraft landing zone for successful EVAR. Patient subsequently presented with juxtarenal 7.8 cm AAA with a true lumen pedicle perfusing all visceral vessels. Patient underwent TEVAR bridging the thoracic and abdominal aortic stentgrafts and a chimney to the pedicle perfusing all visceral vessels, and complete aneurysm exclusion. At 1 year postop, patient is doing well with complete throacoabdominal aortic aneurysms exclusion. AUTHOR DISCLOSURES: L. Britton: Nothing to disclose; B.B. Chang: Nothing to disclose; P.B. Kreienberg: Nothing to disclose; M. Mehta: WL Gore; Medtronic; Aptus Endosystems Inc.; EV3 Endovascular Inc.; Cordis Corporation; Trivascular Inc.; Lombard Medical Technologies; Bolton Medical; Abbott Vascular; Terumo Cardiovascular System Corporation; Maquet Cardiovascular; Harvest Technologies; Cook Medical, research grants; WL Gore & Associates; Trivascular Inc.; IDEV, honorarium; P.S.K. Paty: Nothing to disclose; P. Silviera: Nothing to disclose; M.J. Teymouri: Nothing to disclose; C. Yeh: Nothing to disclose. SS9. Vascular Reconstruction Plays an Important Role  in the Treatment of Pancreatic Adenocarcinoma

2:12 p.m.

Michael D. Sgroi, Raja S. Narayan, John S. Lane, Aram N. Demirjian, Roy M. Fujitani, David K. Imagawa. University of California, Irvine, Orange, Calif. OBJECTIVES: Previous studies have proven the feasibility of performing a pancreaticoduodenecotomy (Whipple) in patients with portal/superior mesenteric vein (PV/SMV) or arterial invasion. We report our institutional experience with the use of a variety of vascular reconstructive methods during pancreatic resections for adenocarcinoma. METHODS: A retrospective review was performed identifying all Whipple and total pancreatectomy patients from January 2003 through February 2013. All venous (PV/SMV) and arterial (SMA/hepatic) reconstructions were extracted and reviewed to determine survival and perioperative complications. RESULTS: 270 Whipple and total pancreatectomy procedures were performed during the 10-year study period, of which 183 were for adenocarcinoma of the pancreas. A total of 60/183 (32.8%) vascular reconstructions were found, 49 venous and 11 arterial. Venous reconstruction included 37 (61.7%) primary repairs, 4 (6.7%) reconstructions with cryovein, 3 (5.0%) repairs with autologous vein patch, 3 (5.0%) autologous saphenous reconstructions, and 2 (3.33%) porto-caval shunts. Additionally, there were 11 (18.3%) arterial reconstructions (7 hepatic artery and 4 superior mesenteric artery). There was one peri-operative death (1.7%). 1-year survival for all reconstructions was 70.3%, which is equivalent to T3 lesions that did not receive vascular reconstruction (72.6%), with a median survival time 515 days and 12 patients still alive. Survival time was comparable with each type of venous reconstruction, averaging 528 days (11/49 patients still alive). Of the venous reconstructions, 4/49 (8.2%) resulted in PV thrombosis, 3 within the primary repair group and 1 delayed thrombosis within the cryovein group. There was no thrombosis in any patients after arterial reconstruction. CONCLUSIONS: An aggressive approach for stage II pancreatic cancers with venous or arterial invasion can be performed with comparable results when executed by an experienced institution with skilled oncologic and vascular surgeons.

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AUTHOR DISCLOSURES: A.N. Demirjian: Nothing to disclose; R.M. Fujitani: Nothing to disclose; D.K. Imagawa: Nothing to disclose; J.S. Lane: Nothing to disclose; R.S. Narayan: Nothing to disclose; M.D. Sgroi: Nothing to disclose. E2: R  oy Greenberg Distinguished Lecture:  New Horizons in Aortic Disease —  The Lasting Legacy of a Visionary Innovator

2:30 – 3:00 p.m. uBallroom A/B, Level 3

T his lecture will summarize key concepts and major contributions of Dr. Roy Greenberg in the development of endovascular aortic side branch incorporation, and how these contributions have affected the development of a new, advanced aortic research program at the speaker’s institution. At the end of this session, participants should be able to: 1. Define novel concepts of aortic disease progression and how it has affected stent design and extent of aortic repair. 2. Describe current applications of fusion imaging technology for complex aortic repair. 3. Analyze development of institutional investigational device exemption protocols and single-institution outcomes of fenestrated and branched repair.

In Memoriam and Introduction Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif.

2:30 p.m.

Lecture Gustavo S. Oderich, MD, Mayo Clinic, Rochester, MN

2:40 p.m.

AWARDS PRESENTATION  COFFEE BREAK AND VASCULAR LIVE PRESENTATIONS

S3: SVS Plenary Session III 

3:00 – 3:30 p.m. uBallroom A/B, Level 3 3:30 – 4:00 p.m. uExhibit Halls C & D, Level 2

4:00 – 5:30 p.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. D  iscuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: Peter Gloviczki, MD, Mayo Clinic, Rochester, Minn. Amy B. Reed, MD, Penn State Heart and Vascular Institute, Hershey, Pa.

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SS10. Why Discordance of the Treatment Received  4:00 p.m. Compared with the Treatment Recommended Results in Worse Outcomes for Peripheral Arterial Disease

Thomas E. Brothers.

 Surgery, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, S.C. OBJECTIVES: Strategies available to facilitate decision-making for patients with peripheral arterial disease (PAD) include a Markov-based decision analysis (DA) model and the Lower Extremity Grading System (LEGS) score, both of which have suggested that outcomes may be inferior when the actual treatment received does not follow that recommended. The purpose of the current study is to examine this discordance and why patients fared worse with discordance. METHODS: Patients referred for symptomatic lower extremity PAD over a 3-year period were evaluated using the DA model and LEGS score. Calculated quality of life (cQOL) values were assigned preoperatively and at follow-up according to symptoms and treatment results (.00 [death] - 1.00 [perfect health]). Outcomes were compared according to whether the treatment provided matched that initially proposed by the surgeon or predicted by the models. RESULTS: Among 375 consecutively enrolled patients (median follow-up 16 months), the cQOL at last follow-up improved from baseline with endovascular (.23+/-.16) or open (.21+/-.17) revascularization more than with amputation (.10+/-.07) or medical therapy (.04+/-.09). The magnitude in cQOL improvement was greatest when the treatment received was concordant with the initial plan of the surgeon (k=.84, .18 vs. .08, P<.01), the DA model (k=.53, .19 vs. .13, P<0.01), or the LEGS score (k=.32, .23 vs. .10, P<.01). Patient refusal to follow the surgeon’s recommendations and on-going tobacco use were associated with minimal improvement in cQOL (ranges .05 to .07 and .00 to .02, respectively), while the decision to pursue a less morbid therapy was associated with substantial improvement in cQOL (range .28 to .38). CONCLUSIONS: Mean cQOL improved most when the treatment received matched that proposed by the surgeon or predicted by the models. Patient refusal to follow the therapy recommended as well as the strategy not to revascularize claudicants in patients who persist in smoking were associated with significantly less patient benefit. AUTHOR DISCLOSURES: T.E. Brothers: Nothing to disclose. SS11. Geometric Remodeling of Vein Bypass Grafts  and the Impact on Graft Failure

4:14 p.m.

Yong He,1 Kenneth Desart,1 Khayree Butler,1 Anne Irwin,2 Peter R. Nelson,3 Scott A. Berceli.2 University of Florida, Gainesville, Fla.; 2Malcom Randall VAMC, Gainesville, Fla.; 3University of South Florida, Tampa, Fla.

1

OBJECTIVES: The risk factors for vein graft (VG) failure are well established but the underlying mechanisms are poorly understood. This study uses high-resolution, sequential mapping to identify factors controlling VG remodeling. METHODS: VG patients (n=56) were prospectively recruited and underwent CT imaging at 1 week, and 1/6/12 months postoperatively. VGs were digitally reconstructed and lumen areas were calculated at 1-mm intervals, followed by segmental analysis.

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RESULTS: VG remodeling was highly dynamic with substantial spatial and patient-topatient heterogeneity (Fig). Distinct temporal phases in the remodeling response were observed (change in lumen cross-sectional area: -5.5% (early) versus +1.3% (late), P=0.03). Small diameter VGs (area<15 mm2) demonstrated enhanced outward remodeling (P=0.002), consistent with a shear driven adaptation response. 12/56 (21%) VGs failed within 12 months, and maladaptive early (1wk-1mo) remodeling in regions of stenosis was predictive of VG failure (P=0.03). Impaired remodeling was observed in the anastomotic regions of composite VGs (P<0.001); no remodeling differences were noted in arm versus leg VGs or outflow location. Cilostazol use was associated with marked outward remodeling in all phases of VG adaptation (P=0.005); warfarin and Plavix had no effect on this response. Race (black versus non-black) was a significant factor in both impaired outward remodeling (p=0.03) and VG survival (P=0.02). CONCLUSIONS: VGs demonstrate distinct temporal patterns in remodeling. Anatomic, pharmacologic, and racial factors control adaptation and impact VG survival. AUTHOR DISCLOSURES: S.A. Berceli: Nothing to disclose; K. Butler: Nothing to disclose; K. Desart: Nothing to disclose; Y. He: Nothing to disclose; A. Irwin: Nothing to disclose; P.R. Nelson: Nothing to disclose.

Dynamics of vein graft cross-sectional area changes following implantation. Graphs of individual and cumulative patients demonstrate the significant temporal and spatial heterogeneity in these remodeling events.

SS12. Prospective Analysis of Wound Characteristics  4:28 p.m. and Degree of Ischemia on Time to Wound Healing and Limb Salvage: An Early Validation of the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System David L. Cull, Ginger Manos, Michael Hartley, Spence M. Taylor, Eugene M. Langan, John F. Eidt, Brent L. Johnson. Surgery, Greenville Health System, Greenville, S.C. OBJECTIVES: The Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic/Ischemia/foot Infection (WIfI) to stratify the risk of limb amputation at one year. Though intuitive in nature, the new system has not been validated. The purpose of this study is to determine whether the WIfI system is predictive of limb loss/wound healing.

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METHODS: Between 2008 and 2010, we prospectively scored 139 patients with foot wounds (158 revascularizations) at the time of the revascularization procedure using a novel wound classification grading system similar to WIfI. The ischemic component of the grading system was obtained immediately post-procedure. Adapting our data to the WIfI classification, the influence of grading system factors on time to wound healing was analyzed. Empirical Kaplan Meier survival curves were compared to theoretical outcomes predicted by WIfI expert consensus opinion. RESULTS: Seventy-nine percent (125/158) of the foot wounds healed. The median time to wound healing was 4 months (range 1 - 18 months). Factors associated with wound healing included presence of diabetes mellitus (p=0.013), wound location (p=0.049), wound size (p=0.007), wound depth (p=0.004), and degree of ischemia (p<0.001). A comparison of observed versus theoretical outcomes is shown in Table. CONCLUSIONS: The theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified. AUTHOR DISCLOSURES: D.L. Cull: Nothing to disclose; J.F. Eidt: Nothing to disclose; M. Hartley: Nothing to disclose; B.L. Johnson: Nothing to disclose; E.M. Langan: Nothing to disclose; G. Manos: Nothing to disclose; S.M. Taylor: Nothing to disclose. 1-Year Outcomes (Predicted and Observed) of Revascularized Foot Wounds by Estimated WIfI Classification Predicted Outcome

Observed Outcome

Estimated WIfI Classification

Limb Loss

Limb Loss

Class 0 - Very Low Risk (n=40)

~3%

3 ± 3%

Non-Healing Wound 8 ± 4%

Class 1 - Low Risk (n=63)

~8%

10 ± 4%

19 ± 5%

Class 2 - Moderate Risk (n=46)

~25%

23 ± 6%

30 ± 7%

Class 3 - High Risk (n=6)

~50%

40 ± 22%

63 ± 21%

SS13. Inflammation and Vascular Healing Invited Research Summary Christopher D. Owens, MD, MSc, University of California San Francisco, San Francisco, Calif.

4:42 p.m.

VS3. Popliteal Venous Pseudoaneurysm and  Associated Arteriovenous Fistula Following Knee Arthroscopy

4:56 p.m.

Sachinder Singh Hans, Marika Y. Gassner.

Vascular Surgery, Henry Ford Hospital System, Detroit, Mich.

BACKGROUND: Vascular trauma following knee arthroscopy is rare with a reported incidence of 0.03%-0.5%. Injuries most commonly involve direct injury to the popliteal artery. We present the case of a 67-year-old female who developed a venous pseudoaneurysm and arteriovenous fistula 3 weeks following knee arthroscopy. TECHNICAL DESCRIPTION: Duplex ultrasound finds pulsatile flow in the common femoral vein and a pseudoaneurysm is observed in the popliteal fossa. Arteriography is then performed demonstrating early venous opacification of the popliteal and femoral vein; 2 vessels can be seen feeding a large venous pseudoaneurysm. CTA demonstrates Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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simultaneous opacification of femoral artery and vein in the thigh. At the level of popliteal fossa a large contrast opacified pseudoaneurysm is identified; distally no venous opacification is seen and two vessel runoff to the foot is identified. In the operating room the patient is positioned supine, sutures are seen in place on the anterior knee from recent arthroscopy. Patient is re-positioned prone and a lazy-s skin incision is made over the popliteal fossa. During dissection a large hematoma is noted between the two heads of the gastrocnemius muscle. The proximal popliteal artery is then controlled with a blue Silastic vessel loop. A yellow Silastic vessel loop is passed around the proximal popliteal vein. The tibial nerve is identified and sural nerve dissected out. A debakey points to the peroneal N, tibial N and hematoma overlying the pseudoaneurysm. Bleeding is then seen from the venous pseudoaneurysm as it ruptures. The distal popliteal vein is encircled with a yellow vessel loop and a blue vessel loop is placed around the posterior tibial A. Dissection of popliteal artery below geniculate neurovascular bundle reveals multiple venous tributaries with are suture ligated. Ligation of the arteriovenous fistula follows. Identification of the tibial nerve, popliteal vein and popliteral artery. The skin and subcutaneous tissue is re-approximated in layers. AUTHOR DISCLOSURES: M.Y. Gassner: Nothing to disclose; S. Hans: Nothing to disclose. SS14. Endovascular Treatment of Common  Femoral Artery Occlusive Disease in 167 Consecutive Patients: Midterm Analysis

5:06 p.m.

 Manish Mehta,2 Max Kahn,1 Philip S.K. Paty,2 Jeffrey C. Hnath,2 Paul B. Kreienberg,2 Melissa Shah,2 W. John Byrne,2 Paul J. Feustel.1 1  Albany Medical College, Albany, N.Y.; 2 The Vascular Group at Albany Medical Center, Albany, N.Y.

OBJECTIVES: This study evaluates the feasibility, safety, and effectiveness of endovascular interventions for common femoral artery (CFA) occlusive disease. METHODS: Using a prospectively maintained multicenter database, we analyzed outcomes in 167 consecutive patients that underwent percutaneous CFA interventions for Rutherford (R) 3-6 classification. The standardized treatment approach included primary PTA-only for non-calcified lesions with <50% residual stenosis, atherectomy ± PTA for calcified lesions or PTA-only failures, and provisional stenting. RESULTS: Over a 7-year period, 167 patients with R3 (n=91, 54.5%), R4 (n=37, 22.2%) or R5-6 (n=39, 23.4%) underwent isolated CFA interventions that included PTA-only (n=114, 68.2%), atherectomy ± PTA (n=38, 22.8%), or stent (n=15, 9.0%) for failed atherectomy ± PTA. Procedure related complications included pseudoaneurysm (n=1, 0.6%), thrombosis (n=1, 0.6%), distal embolization (n=1, 0.6%), and death (R6, n=1, 0.06%). At a mean follow-up of 17 months, CFA restenosis was observed in 29 (17.4%) patients; these underwent further percutaneous (n=13, 7.8%) or surgical (n=16, 9.6%) revascularization that included femoral endarterectomy (n=4, 2.4%) or femoral-popliteal/ tibial bypass (n=12, 7.2%). Major or minor amputations were observed in none of the R3 patients, and in only 3 (3.9%) and 5 (6.6%) of the R4-6 patients, respectively. When compared to the atherectomy ± PTA group, patients in the PTA-only group had a significantly higher incidence of female gender (43% vs. 24%), DM (49% vs. 29%), HTN (89% vs. 76%), and restenosis requiring secondary interventions (21.9% vs. 5.3%), p<0.01.

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CONCLUSIONS: Data from this largest study to date would suggest that percutaneous CFA interventions in select patients appear to be relatively safe, and effective. Female gender, diabetes, and hypertension negatively impact risk of re-stenosis, while atherectomy ± PTA reduces re-stenosis risks significantly. A randomized controlled trial is warranted. AUTHOR DISCLOSURES: W. Byrne: Nothing to disclose; P.J. Feustel: Nothing to disclose; J.C. Hnath: Nothing to disclose; M. Kahn: Nothing to disclose; P.B. Kreienberg: Nothing to disclose; M. Mehta: WL Gore; Medtronic; Aptus Endosystems Inc.; EV3 Endovascular Inc.; Cordis Corporation; Trivascular Inc.; Lombard Medical Technologies; Bolton Medical; Abbott Vascular; Terumo Cardiovascular System Corporation; Maquet Cardiovascular; Harvest Technologies; Cook Medical, research grants; WL Gore & Associates; Trivascular Inc.; IDEV, honorarium; P.S.K. Paty: Nothing to disclose; M. Shah: Nothing to disclose. OPENING RECEPTION  

5:30 – 6:30 p.m. uExhibit Halls C & D, Level 2

Individual Alumni and Committee Receptions  Beth Israel Deaconess Alumni Reception  

7:00 – 10:00 p.m. uSheraton Boston 7:00 – 8:30 p.m. uSheraton Boston, Fairfax A Room, Third Floor

Brigham & Women’s Hospital Alumni Reception 7:00 – 8:30 p.m.  uSheraton Boston,  Fairfax A Room, Third Floor Cleveland Clinic Alumni Reception   Henry Ford Health Systems Alumni Reception  

7:00 – 8:30 p.m. uSheraton Boston, Fairfax B Room, Third Floor 7:00 – 8:30 p.m. uSheraton Boston, Exeter Room, Third Floor

Harvard Vascular Surgeons’ Alumni Reception 7:00 – 8:30 p.m.  uSheraton Boston,  Fairfax A Room, Third Floor Massachusetts General Hospital Alumni Reception 7:00 – 8:30 p.m.  uSheraton Boston,  Fairfax A Room, Third Floor

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Mayo Clinic Alumni Reception  

7:00 – 9:00 p.m. uSheraton Boston, Beacon D Room, Third Floor

NYU Langone Medical Center Alumni Reception 7:00 – 10:00 p.m.  uSheraton Boston,  Commonwealth, Third Floor OHSU Alumni and Friends Reception   

7:00 – 9:00 p.m. uSheraton Boston, Beacon E, Third Floor

Penn Vascular Surgery Alumni Reception 7:00 – 9:00 p.m.  uSheraton Boston,  Independence West Ballroom, Second Floor Stanford University Alumni Reception  

7:00 – 10:00 p.m. uSheraton Boston, Hampton Room, Third Floor

UCLA Division of Vascular Surgery Alumni Reception 7:00 – 8:30 p.m.  uSheraton Boston,  Dalton Room, Third Floor University of Washington Alumni Reception 7:00 – 8:30 p.m.  uSheraton Boston,  Clarendon Room, Third Floor Washington University St. Louis Alumni Reception 7:00 – 9:00 p.m.  uSheraton Boston,  Beacon A Room, Second Floor

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SCHEDULE IN DETAIL

FRIDAY, JUNE 6

All events held at Hynes Convention Center unless otherwise noted. REGISTRATION   

6:00 a.m. – 5:30 p.m. uExhibit Hall C Lobby, Level 2

BREAKFAST SESSIONS

6:30 – 8:00 a.m.

B4: C  urrent Management of Vascular Graft Infections 6:30 – 8:00 a.m. from Head to Toe uBallroom C, Level 3 At the end of this session, participants should be able to: 1. Identify clinical presentation and risk factors for most common vascular infections. 2. Describe technical aspects of vascular reconstructive techniques using extra-anatomic or in situ arterial reconstruction with autologous vein, cryopreserved arterial allografts and rifampin-soaked grafts. 3. Analyze outcomes of contemporary reports dealing with infected aortic stent-grafts, lower extremity and carotid reconstructions. Moderators: Gustavo S. Oderich, MD, Mayo Clinic, Rochester, Minn. Amy B. Reed, MD, Penn State Heart and Vascular Institute, Hershey, Pa. Treatment Challenges and Outcomes in Patients with  Infected Aortic Stent-Grafts Manju Kalra, MD, Mayo Clinic, Rochester, Minn.

6:30 a.m.

Techniques and How to Minimize Complications When  Using Femoral Vein Grafts to Treat Vascular Infections R. James Valentine, MD, University of Texas South Western, Dallas, Texas

6:45 a.m.

Tips and Tricks to Deal with Infected Groin  Joseph S. Giglia, MD, University of Cincinnati, Cincinnati, Ohio

7:00 a.m.

Update on Management of Infected Carotid Patch  Patrick A. Stone, MD, West Virginia University, Charleston, W.V.

7:15 a.m.

PANEL DISCUSSION

7:30 a.m.

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B5: Optimizing  Wound Care and Amputation Management 

6:30 â&#x20AC;&#x201C; 8:00 a.m. uRoom 304/06

At the end of this session, participants should be able to: 1. Identify useful adjunctive methods that will assist in healing chronic wounds associated with PAD. 2. Analyze opportunities for system improvement in managing patients with vascular disease and chronic wounds to improve limb preservation. 3. Assess patients at high risk for amputation complications and employ strategies for prevention to increase healing and preserve function. Moderators: William A. Marston, MD, University of North Carolina School of Medicine, Chapel Hill, N.C. Marc A. Passman, MD, University of Alabama at Birmingham, Birmingham, Ala. Importance of Optimal Wound Care in Maximizing Outcomes  in Patients with Peripheral Vascular Disease William A. Marston, MD, University of North Carolina School of Medicine, Chapel Hill, N.C.

6:30 a.m.

Understanding the Advantages of a Wound Care Center  William J. Ennis, MD, University of Illinois Hospital & Health Sciences System, Chicago, Ill.

6:45 a.m.

Amputation Complications: How to Prevent Them Amir F. Azarbal, MD, Oregon Health & Science University, Portland, Ore.

7:00 a.m.

Evidence-Based Guidelines for Wound Care and  7:15 a.m. Vascular Surgeons Marc A. Passman, MD, University of Alabama at Birmingham, Birmingham, Ala. PANEL DISCUSSION B6: The Role of Vascular Surgery During  Multispecialty Operations

7:30 a.m. 6:30 â&#x20AC;&#x201C; 8:00 a.m. uRoom 312

At the end of this session, participants should be able to: 1. Formulate management plans to repair traumatic injuries to the popliteal artery. 2. Describe techniques for exposure and repair of vascular injuries incurred during spine and hip surgery. 3. Demonstrate methods of management of infrainguinal vascular injuries. 4. Illustrate methods of exposure of the IVC and portal vein for repair of iatrogenic injury. 5. Explain the concepts for choosing open versus endovascular repair of common femoral and profunda femoral injuries. 6. Measure the impact of the vascular surgeon as a master surgeon on the complexity of procedures performed at your hospital. Moderators: Michael B. Silva Jr., MD, The University of Texas Medical Branch, Galveston, Texas Mark F. Conrad, MD, MMSc, Massachusetts General Hospital, Boston, Mass.

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Management of Popliteal Injury After Iatrogenic/  6:30 a.m. Accidental Trauma Charlie C. Cheng, MD, The University of Texas Medical Branch, Galveston, Texas Management of Major Vessel Injury During Spinal/Hip Surgery 6:40 a.m. Virendra I. Patel, MD, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Management of Infrainguinal Vascular Trauma,  Vein and Artery W. Darrin Clouse, MD, UC Davis Vascular Center, Sacramento, Calif.

6:50 a.m.

Management of Portal/IVC Injuries During  7:00 a.m. Non-Vascular Procedures Louis M. Messina, MD, University of Massachusetts Medical School, Worcester, Mass. Management of Common/Profunda Femoral Injuries  7:10 a.m. (Infected, Iatrogenic, Trauma) — Is There an Endovascular Role? David H. Stone, MD, Dartmouth-Hitchcock Medical Center, Lebanon, N.H. Vascular Surgeons, Rescue, and Concept of Master Surgeon 7:20 a.m. Michael B. Silva Jr., MD, The University of Texas Medical Branch, Galveston, Texas PANEL DISCUSSION

7:30 a.m.

B10: Population-Based Health Services Research: When,  6:30 – 8:00 a.m. Where, How and Why  uRoom 302 At the end of this session, participants should be able to: 1. Describe the characteristics of large, population-based datasets and attributes of studies where they can be used effectively. 2. Understand the complexities of obtaining access to large national datasets. 3. Illustrate basic and advanced analytic methods commonly used in outcomes research. 4. Explain the added value in health policy related to vascular disease that can be garnered by research using large, population-based datasets. Moderators: Philip P. Goodney, MD, MS, Dartmouth-Hitchcock Clinic, Lebanon, N.H. Marc L. Schermerhorn, MD, Beth Israel Deaconess Medical Center, Boston, Mass. WHEN Is It Best to Study a Research Question Using Large,  6:30 a.m. Population-Based Datasets Such as Administrative Claims or NIS? Jason Wiseman, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wis. WHERE Can Researchers Get Access to Population-Based  6:45 a.m. Resources for Research? Todd R. Vogel, MD, MPH, University of Missouri Hospital & Clinics, Columbia, Mo. HOW Should Surgical Investigators Design Their Analyses  and Execute Their Research? Matthew A. Corriere, MD, MS, Wake Forest University School of Medicine, Winston-Salem, N.C. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

7:00 a.m.

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WHY Can Population-Based Datasets Be a Good Resource  to Influence Health Policy for Patients with Vascular Disease? Matthew W. Mell, MD, Stanford University, Stanford, Calif.

7:15 a.m.

PANEL DISCUSSION

7:30 a.m.

GENERAL SURGERY RESIDENT/MEDICAL STUDENT  6:30 – 8:00 a.m. PROGRAM BREAKFAST — SURGICAL  uExhibit Hall B, Level 1 SKILLS COMPETITION See Fellow/Resident/Student Programs Tab.

S4: SVS Plenary Session IV 

8:00 – 9:30 a.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: R. Clement Darling III, MD, The Vascular Group, Albany, N.Y. Jon S. Matsumura, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wis.

SS15. A Randomized Controlled Trial of Domain-Specific  Cognitive Function After Carotid Endarterectomy and Stenting

8:00 a.m.

 Panos Kougias,1 Nicholas Pastorek,1 Robert Collins,1 Sally A. McCoy,2 Sherene Sharath,2 Briauna Lowery,2 Shalinie Mukhi,2 Katie McCulloch,3 Carlos Bechara,1 Neal R. Barshes,1 George Pisimisis,1 David Berger.1

Baylor College of Medicine, Houston, Texas; 2Michael E. DeBakey VAMC, Houston, Texas; 3University of Houston, Houston, Texas. 1

OBJECTIVES: Observational data indicate that carotid artery stenting (CAS) is associated with higher incidence of subclinical cerebral microemboli than carotid endarterectomy (CEA). We hypothesized that CEA would be associated with superior performance on cognitive domain-specific testing compared to CAS. METHODS: Patients with greater than 80% asymptomatic carotid artery stenosis were randomized to CEA or CAS. A robust battery of tests was used to assess the cognitive domains of attention, memory, mood, visual-spatial skills, motor ability, processing speed and executive functioning within 10 days preoperatively and at 6 weeks and 6 months postoperatively. Patients without contra-indications to magnetic resonance imaging underwent assessment of cerebral micro-infarcts (CMI), mean transit time (MTT), cerebral blood flow (CBF) and cerebral blood volume (CBV) at the same time points. RESULTS: Baseline cognitive performance was similar between CAS (n=29) and CEA (n=31) groups (p>0.05). Relative to baseline, verbal and visual memory and attention functions improved in both CAS and CEA groups at six months (multiple cognitive tests achieved statistical significance). Compared to CEA, cognitive processing speed (Stroop Color test: 9.0 vs. 7.3, p=0.04; and Stroop Word test: 9.0 vs. 7.4, p=0.05) and executive 110


functioning (Trail Making Test: 49.4 vs. 44, p=0.06) were superior in CAS at 6 weeks. Executive functioning (Phonemic verbal fluency: 10.6 vs. 8.4, p=0.01) and motor function (Grooved Pegboard of non-dominant extremity: 45.7 vs. 38.9, p=0.01) were also superior in CAS at 6 months. Tests of attention, memory and visual-spatial skills were similar between CAS and CEA at 6 weeks and 6 months. CMI, CBV, CBF, and MTT were similar between the groups at all time points. CONCLUSIONS: Memory and attention improve within the first six postoperative months with both CAS and CEA. Compared to CEA, CAS results in improved cognitive processing speed, executive functioning, and motor function. AUTHOR DISCLOSURES: N.R. Barshes: Nothing to disclose; C. Bechara: Nothing to disclose; D. Berger: Nothing to disclose; R. Collins: Nothing to disclose; P. Kougias: Nothing to disclose; B. Lowery: Nothing to disclose; S.A. McCoy: Nothing to disclose; K. McCulloch: Nothing to disclose; S. Mukhi: Nothing to disclose; N. Pastorek: Nothing to disclose; G. Pisimisis: Nothing to disclose; S. Sharath: Nothing to disclose. SS16. Potential of Preoperative Frailty Risk Analysis  Index to Stratify Patients Undergoing Carotid Endarterectomy

8:14 a.m.

 Alyson Melin,2 Kendra K. Schmid,2 Thomas G. Lynch,1 Steven Kappes,3 Iraklis I. Pipinos,1 Matthew G. Longo,2 Prateek K. Gupta,4 Jason M. Johanning.1 1  NWI VA Medical Center, Omaha, Neb.; 2University of Nebraska Medical Center, Omaha, Neb.; 3Aurora Healthcare System, Milwaukee, Wis.; 4 University of Wisconsin, Madison, Wis.

OBJECTIVES: Rapid and objective preoperative assessment of patients undergoing carotid endarterectomy remains problematic. Preoperative variables correlate with increased morbidity and mortality, yet no easily implemented tool exists to stratify patients. We determined the relationship between our fully implemented frailty based bedside Risk Analysis Index (RAI) and complications after CEA. METHODS: Patients undergoing CEA in American College of Surgeons National Quality Improvement Project (NSQIP) database (2005-2011). Variables of frailty RAI were matched to preoperative NSQIP variables and outcomes including mortality, stroke, and length of stay were analyzed. We further analyzed patients who were symptomatic and asymptomatic prior to CEA. RESULTS: 44,832 patients undergoing CEA were analyzed (27,136/60.5% asymptomatic; 17,696/39.5% symptomatic). RAI demonstrated increasing risk of stroke and death based on risk stratification. (Low Risk (0-10): 1.9%/High Risk (>10): 5.2%). Increasing frailty RAI score correlated with increasing mortality, stroke and LOS (P<.01:Figure1). The majority of patients undergoing CEA scored low on the RAI (87.5% Symptomatic/94.4% Asymptomatic). CONCLUSIONS: Frailty is an independent predictor of increased mortality, stroke and LOS after CEA. An easily implemented RAI holds the potential to identify a limited subset of patients who are at higher risk for postoperative complications and may not benefit from CEA. AUTHOR DISCLOSURES: P.K. Gupta: Nothing to disclose; J.M. Johanning: Nothing to disclose; S. Kappes: Nothing to disclose; M.G. Longo: Nothing to disclose; T.G. Lynch: Nothing to disclose; A. Melin: Nothing to disclose; I.I. Pipinos: Nothing to disclose; K.K. Schmid: Nothing to disclose.

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Stroke and Death Rate for Total NSQIP CEA Group based on frailty RAI score.

VS4.

Anatomical Exposure of Thoracic Outlet with Supraclavicular Approach and Resection of Cervical Rib

8:28 a.m.

Himanshu Verma, Ramesh K. Tripathi. Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bangalore, India. BACKGROUND: Thoracic outlet syndrome is known for complex anatomy of this region. Scalene triangle is a narrow space with neurovascular bundle emerging from it with multiple anatomical variations described. Depending on requirement, rib resection (cervical, 1st or both), scalenectomy and various degrees of neurolysis is performed in different patients. Various approaches had been described for this anatomical region, e.g., supraclavicular, para-clavicular and trans-axillary. TECHNICAL DESCRIPTION: This patient had sign symptoms consistent with arterial and neurogenic thoracic outlet syndrome. Preoperative CT showed complete right cervical rib causing arterial and neural compression. Video view has been adjusted as per view to the main operator standing on right side of patient. Operation was performed in following steps: 1. Supraclavicular incision 2. Raising superior and inferior sub-platysmal flaps 3. Dissection of scalene pad of fat 4. Dissection of phrenic nerve 5. Anterior scalenectomy 6. Dissection of subclavian artery, neurolysis including resection of multiple muscle slips interdigitating between brachial plexus 7. Resection of cervical rib 8. Hemostasis and wound closure In our experience 42 thoracic outlet syndrome decompressions have been performed between January 2011 to September 2013 (18 arterial, 12 arterial and neurological, 8 neurological + venous and 4 venous TOS). In 25 cases supraclavicular approach was

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used whereas 17 cases involved paraclavicular approach. There was 7% perioperative morbidity with no mortality. Though operative steps are familiar for most surgeons who regularly participate in this surgery, video demonstration would be useful for trainees to understand principles of surgery. AUTHOR DISCLOSURES: R.K. Tripathi: Nothing to disclose; H. Verma: Nothing to disclose. SS17. Cognitive Effects of Carotid Disease and  8:38 a.m. Carotid Interventions Invited Research Summary Wei Zhou, MD, Stanford University Medical Center, Stanford, Calif. SS18. The Effect of Beta Blockade on Operative Mortality:  Harmful or Helpful?

8:52 a.m.

Mark Friedell,1 Charles VanWay,1 Ronald Freyberg,3 Peter Almenoff.2

1

Surgery, University of Missouri-Kansas City, Kansas City, Mo.; 2 VA Medical Center - Kansas City, Kansas City, Mo.; 3 VA Medical Center - Cincinnati, Cincinnati, Ohio.

OBJECTIVES: The use of perioperative pharmacologic beta blockade (BB) in patients with low risk of myocardial ischemic events undergoing non-cardiac surgery (NCS) is controversial because of the risk of stroke and hypotension. Published studies have not shown consistent benefit in this cohort. The present investigation was undertaken to determine the perioperative effect of BB on NCS patients. METHODS: This is a retrospective observational analysis of operative patients in Veterans Affairs (VA) hospitals from October 2009 through September 2013. BB was started 8 hours before surgery and continued postoperatively. Data from the VA electronic database included demographics, diagnosis/procedure codes, medications, perioperative laboratory values, and date of death. A 4-point cardiac risk score was calculated by assigning one point each for: renal failure, coronary disease, diabetes, and surgery in a major body cavity. End points were death in-hospital and within 30 days. Previously validated linear regression models for all hospitalized acute care medical/ surgical patients were used to calculate predicted mortality and then to calculate odds ratios (OR). RESULTS: There were 343,645 patients in this cohort: 331,217 underwent NCS and 12,428 underwent cardiac surgery. BB lowered the odds ratio for mortality significantly on NCS patients with 3-4 cardiac risk factors (OR 0.64, 0.46-0.90). It had no effect on patients with 1-2 risk factors. However, BB resulted in a significantly higher chance of death in NCS patients (OR 1.17, 1.04-1.31) with no risk factors. CONCLUSIONS: In this large series, BB appears to be beneficial perioperatively in NCS patients with high cardiac risk. However, the use of BB in NCS patients with no cardiac risk factors should be avoided because of the increased chance of death seen in this patient cohort. AUTHOR DISCLOSURES: P. Almenoff: Nothing to disclose; R. Freyberg: Nothing to disclose; M. Friedell: Nothing to disclose; C. VanWay: Nothing to disclose.

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SS19. Prospective, Randomized, Multi-Institutional  Clinical Trial of a Silver Alginate Dressing to Reduce Lower Extremity Vascular Surgery Wound Complications

9:06 a.m.

C. Keith Ozaki,1 Allen D. Hamdan,2 Neal R. Barshes,3 Mark C. Wyers,2 Nathanael D. Hevelone,1 Michael Belkin,1 Louis L. Nguyen.1

1 Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass.; 2Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass.; 3Michael E. DeBakey Veterans Affairs Medical Center/Baylor College of Medicine, Houston, Texas.

OBJECTIVES: Wound complications (WC) negatively impact lower extremity (LE) arterial reconstruction outcomes. Acticoat Absorbent® (Smith & Nephew, Inc.) is a moisture absorbing alginate coated with nanocrystalline silver that delivers a sustained (3 day) dose of broadly antimicrobial silver ions. Via an investigator initiated clinical trial we tested the hypothesis that this silver eluting topical surgical dressing would lower WC rates in patients undergoing open arterial LE procedures. METHODS: 500 patients at 3 institutions were block-randomized to either standard gauze or silver alginate dressings placed over incisions after LE arterial surgery. This original OR dressing remained until gross soiling, clinical need to remove, or POD #3 (whichever first); subsequent care was at provider discretion. The primary endpoint was 30-day WC incidence based on NSQIP guidelines. Demographic/clinical/quality of life/economic endpoints were also collected. RESULTS: Participants (70% male, 84% white; 45% DM; 31% claudicants [remainder CLI/aneurysm/revision]) had an overall 30-day WC incidence of 28%, with superficial surgical site infection as the most common. In intent-to-treat analysis, silver alginate had no impact on WC. In multivariable analysis, female sex (OR 1.6, 95% CI 1.04-2.58, P=0.034), ipsilateral incision length (cm) (OR 1.02, 95% CI 1.01-1.03, P=0.002) and coumadin (OR 1.7, 95% CI 1.02-2.85, P=0.043) were significantly associated with WC. CONCLUSIONS: The incidence of WCs remains high in contemporary open LE arterial surgery. Under the study conditions, a silver eluting dressing had no effect on WC incidence. AUTHOR DISCLOSURES: N.R. Barshes: Nothing to disclose; M. Belkin: Nothing to disclose; A.D. Hamdan: Nothing to disclose; N.D. Hevelone: Nothing to disclose; L.L. Nguyen: Nothing to disclose; C. Ozaki: Smith & Nephew, research grants; Novartis Institutes for Biomedical Research, research grants; M.C. Wyers: Nothing to disclose. Worst Wound Complication by Assigned Dressing Wound Status

Sterile Gauze

Silver Alginate

Total

No Wound Complication

179 (72%)

181 (72%)

360 (72%)

Hematoma, Seroma, Lymphatic Complication

15 (6%)

10 (4%)

25 (5%)

Dehiscence Requiring Local Wound Care

18 (7%)

22 (9%)

40 (8%)

Superficial Surgical Site Infection

30 (12%)

28 (11%)

58 (12%)

Deep Surgical Site Infection

8 (3%)

9 (4%)

17 (3%)

Total

250

250

500

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EXHIBIT HALL OPEN 

9:30 a.m. – 4:30 p.m. uExhibit Halls C & D, Level 2

COFFEE BREAK AND VASCULAR LIVE PRESENTATIONS

9:30 – 10:00 a.m. uExhibit Halls C & D, Level 2

 F2: P  rojects and Reports from the  Vascular Quality Initiative

10:00 – 11:05 a.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Identify opportunities for regional quality improvement initiatives. 2. Identify the regional and patient-specific variations in use of completion imaging for lower extremity bypass. 3. Distinguish which patient subgroups may benefit or be harmed from perioperative beta blocker exposure before major elective vascular surgery in the VQI. 4. Discuss the controversy surrounding the use of perioperative beta blockers in non-cardiac vascular surgery. Moderators: Richard P. Cambria, MD, Massachusetts General Hospital, Boston, Mass. Jack L. Cronenwett, MD, Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

Annual Report  Richard P. Cambria, MD, Massachusetts General Hospital, Boston, Mass.

10:00 a.m.

Regional Differences in Patient Selection and  Treatment of AAA, Lower Extremity and Carotid Artery Disease in the SVS Vascular Quality Initiative

10:10 a.m.

Marc L. Schermerhorn,1 Thomas Curran,1 Dominique Buck,1 John C. McCallum,1 Philip P. Goodney,2 Jason T. Lee,3 Joseph R. Schneider,4 Jack L. Cronenwett.2 1  Beth Israel Deaconess Medical Center, Boston, Mass; 2Dartmouth-Hitchcock Medical Center, Lebanon, N.H.; 3Stanford University Medical Center, Stanford, Calif.; 4 Vascular and Interventional Program of Central DuPage Hospital, Winfield, Ill.

OBJECTIVES: Regional variation in patient selection and treatment type could identify targets for quality improvement initiatives. We used the SVS VQI to evaluate regional variation in patient characteristics, and management of AAA, lower extremity and carotid artery disease. METHODS: All EVAR, open AAA, infra-inguinal bypass (Bypass) or endovascular intervention (PVI), carotid endarterectomy (CEA), or carotid stent (CAS) from 2009 to 2012 in VQI were analyzed. Each of 14 de-identified regional quality groups was compared. Indications and surgical approach were compared between groups. RESULTS: We identified 52,742 procedures [20,987 PVI, 8,144 Bypass, 12,971 CEA, 1,900 CAS, 6,608 EVAR, and 2,132 Open AAA] from 14 regions. Substantial regional differences in patient comorbidities (e.g. diabetes, dialysis), indication for procedures (e.g., symptom status for carotids, limb threat for LE revascularization, AAA diameter), Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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technical approach (e.g., open surgery vs. stent) and utilization of evidence-based process measures (e.g., chlorhexidine skin prep for bypass, antiplatelet and statin use) were identified. (Table 1. p<.001 for all listed parameters) CONCLUSIONS: The VQI database demonstrates significant regional variation in the management of peripheral arterial disorders. The natural variation in patient selection and management that occurs between regions can identify the most effective practice when combined with future studies of risk-adjusted outcomes. AUTHOR DISCLOSURES: D. Buck: Nothing to disclose; J.L. Cronenwett: Nothing to disclose; T. Curran: Nothing to disclose; P.P. Goodney: Nothing to disclose; J.T. Lee: Nothing to disclose; J.C. McCallum: Nothing to disclose; M.L. Schermerhorn: Endologix Inc, consulting fees or other remuneration (payment); Medtronic, Inc, consulting fees or other remuneration (payment); J.R. Schneider: Nothing to disclose. Factors that Increase Length of Stay After EVAR  in the Vascular Quality Initiative

10:20 a.m.

V  irendra I. Patel,1 Salvatore T. Scali,2 Marc L. Schermerhorn,3 David H. Stone,4 Karen Homa,4 Yuanyuan Zhao,4 Richard P. Cambria,1 Jack L. Cronenwett.4 1  Massachusetts General Hospital, Boston, Mass.; 2Shands Hospital at the University of Florida, Gainesville, Fla.; 3Beth Israel Deaconess Medical Center, Boston, Mass.; 4 Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

OBJECTIVE: Increased length of stay (iLOS) following elective EVAR repair of AAA is associated with increased costs and serves as an important quality metric. We developed a model to identify factors resulting in iLOS following EVAR. METHODS: All non-ruptured EVAR procedures recorded in the Vascular Quality Initiative Registry (VQI) were evaluated for iLOS, defined as > 2 days. Predictors of iLOS were identified by univariate and multivariable methods and validated using random validation cohorts. RESULTS: This study included 5,143 EVAR procedures performed at 196 institutions from 2010 to 2013. 1261 (25%) patients had iLOS. Univariate and clinically relevant variables were evaluated using a risk adjusted regression model with excellent discrimination AUC=0.813. We identified clinical features (female gender, race, age category), technical features (estimated blood loss, procedure time, complicated procedure, post-op vasopressor requirement), cardiac complications (MI, CHF, arrhythmia), respiratory complications, renal complications, procedural complications (leg embolization, return to OR), and practice variations (discharge to facility, Mon. or Fri. operation) that significantly (P<0.001 for nearly all) impacted iLOS. Chi-pie analysis shows the relative impact of each category on iLOS (Figure 1). The model was validated in 50 random derivation and validation subsets with no statistical difference in AUC (P=0.47). CONCLUSIONS: Modeling of VQI registry data highlights important clinical, technical and complication variables associated with iLOS. These results may be utilized to establish national quality benchmarks and enact process improvement measures to improve patient care and reduce hospital costs. AUTHOR DISCLOSURES: R.P. Cambria: Nothing to disclose; J.L. Cronenwett: Nothing to disclose; K. Homa: Nothing to disclose; V.I. Patel: Nothing to disclose; S.T. Scali: Nothing to disclose; M.L. Schermerhorn: Endologix Inc, consulting fees or other remuneration (payment); Medtronic, Inc, consulting fees or other remuneration (payment); D.H. Stone: Nothing to disclose; Y. Zhao: Nothing to disclose. 116


Variations in the Practice Patterns of Intra-Operative  Completion Imaging for Lower Extremity Bypass in the Vascular Quality Initiative

10:30 a.m.

Karen Woo, Owen P. Palmer, Vincent L. Rowe, Fred A. Weaver.

Vascular Surgery, University of Southern California, Los Angeles, Calif.

OBJECTIVES: To examine the practice patterns of intra-operative completion imaging (CI) for infrainguinal lower extremity bypass (LEB) among regional quality groups in the Vascular Quality Initiative (VQI). METHODS: A retrospective review of all LEB in the VQI database from January 2003 to October 2013 was performed. Regional groups with less than 200 LEB procedures were excluded from the regional analysis. The modality of CI was defined as duplex ultrasound, angiogram or both. RESULTS: A total of 14,140 LEB were captured with the rate of CI being 43%. After excluding three regions for insufficient volume, 13,945 LEB operations across 13 regions were available for regional analysis. Use of any type of intra-operative CI varied across regions from a low of 8% to a high of 70%, with angiography being performed most frequently. When performed, the type of imaging modality varied between regions from a high of 99% angiography to a high of 75% duplex ultrasound. CI was more common in males (male 44% vs. female 42%, p=0.032), diabetics (diabetic 44% vs. non-diabetic 42%, P=0.026), and patients with coronary artery disease (CAD 45% vs. no CAD 42%, P=0.0015). CI was performed in 31% of cases where a prosthetic conduit was used and 49% of cases where a venous conduit was used (P<0.0001). CI was performed less frequently in LEB using single segment greater saphenous vein vs. LEB using lesser saphenous, arm or composite vein (48% vs. 57%, P<0.0001). CI was used in 51% of

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LEB with a tibial or pedal target vessel vs. 38% of LEB with a more proximal target vessel (p < 0.0001). Patients with an indication of critical limb ischemia underwent CI in 45% of LEB vs. 39% with an indication other than critical limb ischemia (p<0.0001). CONCLUSIONS: Within the VQI database, considerable practice pattern variation exists in the use of completion imaging. Currently, completion imaging is most commonly employed for patients with critical limb ischemia, infrageniculate target vessel and disadvantaged venous conduit. Further study is required to standardize and define the appropriate use of completion imaging for lower extremity bypasses. AUTHOR DISCLOSURES: O.P. Palmer: Nothing to disclose; V.L. Rowe: Nothing to disclose; F.A. Weaver: Nothing to disclose; K. Woo: Nothing to disclose. A Comparison of Superficial Femoral Artery Treatment  Strategies for Critical Limb Ischemia in the Vascular Quality Initiative

10:40 a.m.

Alik Farber,1 Mohammad H. Eslami,2 Denis V. Rybin,3 Gheorghe Doros,3, Allen D. Hamdan,4 William P. Robinson,5 Ahmed M. Abou-Zamzam Jr.,6 Matthew T. Menard.7 1Boston Medical Center, Boston, Mass.; 2Boston University School of Medicine, Boston, Mass.; 3Boston University School of Public Health, Boston, Mass.; 4Beth Israel Deaconess Medical Center, Boston, Mass.; 5University of Massachusetts Memorial Medical Center, Worcester, Mass.; 6Loma Linda University Medical Center, Loma Linda, Calif.; 7 Brigham and Womenâ&#x20AC;&#x2122;s Hospital, Boston, Mass. OBJECTIVES: There is substantial equipoise between lower extremity bypass (LEB) and peripheral vascular intervention (PVI) for treating CLI due to superficial femoral artery (SFA) disease. We compared outcomes of LEB and PVI using the Vascular Quality Initiative (VQI). METHODS: Patients undergoing first-time LEB and PVI of SFA occlusive disease for CLI were analyzed in the VQI database. For LEB, only femoral-above knee popliteal bypass procedures were included. Patients with hybrid procedures were excluded. The PVI cohort was limited to those with TASC C and D disease. Outcomes included mortality, re-intervention, major amputation, graft/lesion primary and secondary patency. Mean follow-up was 12+10 months. Cox proportional hazard regression was used for unadjusted and adjusted analyses controlling for confounding variables. RESULTS: Between 2010 and 2013, a total of 1,028 procedures were identified (502 LEB, 526 PVI). In the LEB cohort, 40% of procedures were performed using great saphenous vein conduit. In the PVI cohort, angioplasty alone, atherectomy alone and stenting were utilized in 20%, 7%, and 62% of cases, respectively. Patients with LEB were younger (67+11 vs. 71+12, p<.001), more likely to have smoked (90% vs. 73%, p<.001), less likely to be diabetic (53% vs. 60%, p=.03), less likely to be on dialysis (5% vs. 10%, p=.002) and less likely to have a history of congestive heart failure (18% vs. 25%, p=.009). Patients treated with LEB were more likely to be ambulatory without assistance (76% vs. 66%, p<.001), more likely to be on a statin (69% vs. 62%, p=.02) and more likely to have ischemic rest pain (vs. tissue loss, 45% vs. 33%, p<.001). In unadjusted analysis, LEB was associated with increased 1-year survival, freedom from re-intervention, freedom from major amputation and higher primary and secondary patency. After multivariable adjustment for differences in patient characteristics, however, mortality, re-intervention, and primary and secondary patency loss were similar between LEB and PVI. LEB remained associated with decreased amputation after adjustment for other variables. (Table). CONCLUSION: In VQI patients with severe SFA disease and CLI, LEB and PVI have similar outcomes at one year after treatment. LEB is associated with improved limb salvage.

118


AUTHOR DISCLOSURES: A.M. Abou-Zamzam: Nothing to disclose; G. Doros: Nothing to disclose; M.H. Eslami: Nothing to disclose; A. Farber: Nothing to disclose; A.D. Hamdan: Nothing to disclose; M.T. Menard: Nothing to disclose; W.P. Robinson: Nothing to disclose; D.V. Rybin: Nothing to disclose.

Survival

Freedom from ReIntervention

Freedom from Major Amputation

Primary Patency

Secondary Patency

LEB, 1-year Outcomes (SE)

92% + 1%

78% + 3%

95% + 2%

76% + 3%

78% + 3%

PVI, 1-year Outcomes (SE)

85% + 2%

71% + 4%

91% + 2%

69% + 4%

71% + 4%

Adj. HR (95%CI) LEB vs. PVI

0.82 (0.57,1.18)

0.97 (0.64,1.48)

0.41 (0.20,0.85)

0.83 (0.56,1.21)

0.68 (0.39,1.21)

p-value

0.283

0.894

0.016

0.330

0.190

Pre-Operative Beta-Blockers Prior to Major Elective  Vascular Surgery Do Not Improve Cardiac Outcomes and May Be Harmful

10:50 a.m.

Salvatore T. Scali,1 Daniel W. Neal,2 Daniel J. Bertges,3 Karen J. Ho,4 Virendra I. Patel,5 Jens Eldrup-Jorgensen,6 Jack L. Cronenwett,7 Adam W. Beck.8 1  Shands Hospital at University of Florida, Gainesville, Fla.; 2University of Florida College of Medicine, Gainesville, Fla.; 3University of Vermont/FAHC, Burlington, Vt.; 4 Northwestern University Feinberg School of Medicine, Chicago, Ill.; 5Massachusetts General Hospital, Boston, Mass.; 6Maine Medical Partners Surgical Care, Portland, Maine; 7Dartmouth-Hitchcock Medical Center, Lebanon, N.H.; 8University of Florida, Gainesville, Fla.

OBJECTIVE: Pre-operative -blocker (pBB) initiation is controversial due to conflicting data in the literature. The purpose of this analysis was to determine whether pBB started before major elective vascular surgery decreased postoperative cardiac events or mortality. METHODS: Using the VQI dataset, a retrospective cohort analysis was performed of patients undergoing infrainguinal bypass (IIB), suprainguinal bypass (SIB) and open AAA repair (oAAA). Patients on chronic BB (>30 days) were excluded. Comparisons were made between pBB (0-30 day) and no BB (nBB) groups. Patients were risk stratified and multiple iterative analytic methods were performed. End-points included in-hospital major adverse cardiac events [MACE: MI, dysrhythmia (DYS), CHF] and 30-day mortality. RESULTS: A total of 5,957 patients (pBB, N=1,797;30%; nBB, N=4,160;70%) were analyzed. A propensity-matched pairs analysis revealed higher rates of DYS (IIB, SIB, oAAA) with pBB, but no difference in MI, CHF or mortality in any group. When stratified into low, medium and high-risk groups within each procedure, all groups treated with pBB had either no difference or higher rates of MACE and 30-day mortality, with the exception of high-risk oAAA patients, who had a lower rate of MI when treated with pBB (Figure). CONCLUSIONS: Exclusive of high-risk oAAA patients, pBB did not decrease rates of MACE after elective IIB, SIB or oAAA, and in fact increased the rate of some adverse events. The data in VQI do not support the practice of routine pBB before major vascular surgery in most patients.

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AUTHOR DISCLOSURES: A.W. Beck: Nothing to disclose; D.J. Bertges: Nothing to disclose; J.L. Cronenwett: Nothing to disclose; J. Eldrup-Jorgensen: Nothing to disclose; K.J. Ho: Nothing to disclose; D.W. Neal: Nothing to disclose; V.I. Patel: Nothing to disclose; S.T. Scali: Nothing to disclose. SVS PRESIDENTIAL ADDRESS 

11:05 a.m. – 12:15 p.m. uBallroom A/B, Level 3

Introduction Peter F. Lawrence, MD, UCLA Medical Center, Los Angeles, Calif.

11:05 a.m.

Presidential Address: Of Strategies and Chances 11:20 a.m. Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif.

SVS MEMBER BUSINESS LUNCHEON   NON-MEMBER LUNCH IN EXHIBIT HALL AND VASCULAR LIVE PRESENTATIONS

S5: SVS Plenary Session V  At the end of this session, participants should be able to:

12:15 – 1:30 p.m. uBallroom C, Level 3

12:15 – 1:30 p.m. uExhibit Halls C & D, Level 2

1:30 – 3:00 p.m. uBallroom A/B, Level 3

1. D  iscuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: Ronald L. Dalman, MD, Stanford University School of Medicine, Stanford, Calif. Ravi K. Veeraswamy, MD, Emory University School of Medicine, Atlanta, Ga.

SS20. Mortality Benefits of Different Hemodialysis  Access Types Are Age-Dependent

1:30 p.m.

Caitlin W. Hicks,1 Joseph K. Canner,1 Isibor Arhuidese,2 Umair Qazi,2 Natalia O. Glebova,1 Julie Ann Freischlag,1 Mahmoud B. Malas.2

1Johns Hopkins Hospital, Baltimore, Md.; 2 Johns Hopkins Bayview Medical Center, Baltimore, Md.

OBJECTIVES: Risk of death in dialysis patients is lowest with arteriovenous fistulas (AVF), followed by arteriovenous grafts (AVG) and then intravenous hemodialysis catheters (IHC). Our aim was to analyze the effect of age on first dialysis access outcomes. METHODS: All patients 18 years in the United States Renal Data System (2006-2010) were analyzed. Spline modeling and risk-adjusted Cox proportional hazard models were used to analyze the effect of age on mortality for first dialysis access with AVF vs. AVG vs. IHC.

120


RESULTS: 502,380 patients (63±15 years, 57% male, 41% mortality, followup 1.6±1.4 years) were analyzed. Increasing age was a significant predictor of overall mortality (adjusted HR 1.03, p<0.001). Compared to patients with IHC (N=419,009), overall risk-adjusted mortality was lowest in patients with AVF (N=71,328; HR 0.65, p<0.001) followed by AVG (N=17,544; HR 0.83, p<0.001). AVF was superior to both IHC and AVG for all age groups (p<0.001; Fig 1). However, there was a significant change in the relative efficacy of AVG at age 45 based on spline modeling: there were no differences comparing AVG to IHC for patients aged 18-44 years (adjusted HR 0.90, p=0.12), but AVG was superior to IHC for patients 45 years of age (adjusted HR 0.82, p<0.001). CONCLUSIONS: Contrary to previous reports, our data suggest that AVF is superior to AVG and IHC regardless of patient age, including in octogenarians. In contrast, the mortality benefit of AVG over IHC may not apply to younger age groups. All patients <45 years should receive AVF for dialysis access whenever possible. AUTHOR DISCLOSURES: I. Arhuidese: Nothing to disclose; J.K. Canner: Nothing to disclose; J.A. Freischlag: Nothing to disclose; N.O. Glebova: Nothing to disclose; C.W. Hicks: Nothing to disclose; M.B. Malas: Nothing to disclose; U. Qazi: Nothing to disclose.

Fig 1. Risk-adjusted mortality based on age and first dialysis access.

SS21.

Dialysis Access-Associated Steal Syndrome Management and Outcomes: A 10-Year Experience

1:44 p.m.

Andrew E. Leake1, Daniel G. Winger2, Steven A. Leers1, NavYash Gupta3, Michel S. Makaroun1, Ellen D. Dillavou.1 1 University of Pittsburgh Medical Center, Pittsburgh, Pa.; 2University of Pittsburgh, Pittsburgh, Pa.; 3North Shore University Health System, Evanston, Ill.

OBJECTIVES: Dialysis access-associated steal syndrome (DASS) complicates arteriovenous (AV) access surgery. We describe our ten-year experience with DASS. METHODS: DASS operations were retrospectively reviewed from July 2003-July 2013. Demographics, symptoms, surgical details and outcomes were collected. IRB approval was secured and a P< .05 was considered significant.

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RESULTS: 201 patients had 218 episodes of DASS. Mean age was 65 years, 62% were female. 175 AV fistulas (80%), 41 prosthetic grafts (19%) and 2 thigh grafts (1%) caused DASS; 87% were brachial artery based. 22% were referred for DASS from outside practices. All patients had grade 2 (48%) or 3 (52%) DASS. 92% (185) were available for follow-up, with a median follow-up of 23 days. There were no differences in pre-op co-morbidities. Surgical managements, omitting thigh grafts due to low numbers, were compared (Table 1). 30 day complications included continued steal, thrombosis, bleeding, infections or mortality. Over the study period, access volume has increased (2003-2008: 1,312 access creations vs. 2008-2013: 1,975). Percentage of fistulas (79% vs. 86%), incidence of steal (4% vs. 6%), and percentage of DRILs (25% vs. 28%) was consistent across study periods. CONCLUSIONS: DRIL and ligation were performed in the most severe patients. Compared to ligation, DRIL has equal symptom resolution, no increase in complications and fistula preservation. Compared to banding, DRIL resulted in superior fistula preservation and fewer complications. DRIL should be considered the gold standard management for DASS. AUTHOR DISCLOSURES: E.D. Dillavou: Nothing to disclose; N. Gupta: Nothing to disclose; A.E. Leake: Nothing to disclose; S.A. Leers: Nothing to disclose; M.S. Makaroun: Nothing to disclose; D.G. Winger: Nothing to disclose. DASS Surgical Outcomes Procedure (N)

Grade 3 Steal (%)

Time to Intervention (days)

Native AVF (%)

Fistula Preserved (%)

Improvement of Steal Symptoms (%)

30d Complications (%)

Ligation (73)

67

39*

64*

0*

93

10

Distal Revascularization & Interval Ligation (DRIL, 59)

64

210

97

100

98

14

Revision Using Distal Inflow (RUDI, 21)

19*

72

100

95

89

37

Banding (38)

32*

24*

71*

89

75*

49*

Proximalization of Arterial Inflow (PAI, 12)

33

92

83

100

100

44

Radial Artery Ligation (RAL, 13)

39

199

100

100

100

0

Total (216)

52

72

80

64

90

22

* P< 0.05 vs. DRIL

SS22. AV Fistula for Hemodialysis: Benchtop to Bedside Invited Research Summary Eric T. Choi, MD, Temple University Hospital, Philadelphia, Pa.

1:58 p.m.

VS5.

2:12 p.m.

Human Tissue-Engineered Grafts for  Hemodialysis: Development, Preclinical Data, and Early Investigational Human Implant Experience

Jeffrey H. Lawson,1 Shannon Dahl,2 Heather Prichard,2 Roberto Manson,1 Shawn Gage,1 Alan Kypson,3 Juliana Blum,2 Alison Pilgrim,2 William Tente,2 Laura Niklason.4

122

1Duke University, Durham, N.C.; 2Humacyte, Inc., Durham, N.C.; 3East Carolina University, Greenville, N.C.; 4Yale University, New Haven, Conn.


BACKGROUND: Current synthetic grafts have high rates of failure, due primarily to thrombosis and intimal hyperplasia. We have developed a tissue engineered vascular graft that is comprised of human extracellular matrix and is similar in strength to native human vein and artery. This investigational graft is currently in clinical studies for evaluation of safety and efficacy in hemodialysis vascular access in patients with end stage renal disease. In this presentation, we describe the development, preclinical experience, and early human implant experience for these tissue-engineered vascular grafts. TECHNICAL DESCRIPTION: A video is presented on the first case in the United States, in which a human tissue engineered vascular graft was implanted into a patient for hemodialysis access. Perspective is presented on the key developmental milestones that led to the first clinical implantation. These milestones include graft growth, animal studies, and clinical implantation of the graft. Banked human aortic smooth muscle cells were cultured in bioreactors in vitro to produce vascular tissue grafts, and a decellularization process was subsequently employed to remove immunogenic cellular antigens. Arteriovenous grafts were implanted into non-human primates for up to 6 months, and were evaluated for patency, durability, cannulation, rejection, and cellular repopulation. In addition, these grafts were evaluated for long-term arterial reconstruction in a canine model, using canine-derived grafts. In animal studies, histologic analysis demonstrated evidence of host vascular cell migration into grafts and endothelialization. Little intimal hyperplasia was observed in animal studies. These preclinical studies supported initiation of clinical trials. AUTHOR DISCLOSURES: J. Blum: Humacyte, Inc., employment (full or part-time); S. Dahl: Humacyte, Inc., employment (full or part-time); S. Gage: Cryolife, Inc., consulting fees or other remuneration (payment); Cryolife, Inc., honorarium; A. Kypson: Humacyte, Inc., consulting fees or other remuneration (payment); Pioneer, research grants; Humacyte, Inc., research grants; J.H. Lawson: Humacyte, Inc., consulting fees or other remuneration (payment); Department of Defense via Humacyte, Inc., research grants; R. Manson: Department of Defense via Humacyte, Inc., research grants; L. Niklason: Humacyte, Inc., ownership or partnership; United Therapeutics, research grants; various universities for speaking, honorarium; A. Pilgrim: Humacyte, Inc., employment (full or part-time); H. Prichard: Humacyte, Inc., employment (full or part-time); W. Tente: Humacyte, Inc., employment (full or part-time). SS23. Clinical Outcomes and Cost Effectiveness of  Initial Treatment Strategies for Non-Embolic Acute Limb Ischemia in Real-Life Clinical Settings

2:22 p.m.

Anthony J. Comerota,1 Varun Vaidya,2 Fedor Lurie.1

Jobst Vascular Institute, Toledo, Ohio; University of Toledo College of Pharmacy, Toledo, Ohio.

1 2

OBJECTIVES: Optimal initial treatment for patients with acute limb ischemia (ALI) remains undefined. Although clinical outcome data are inconsistent, catheter-directed thrombolysis (CDT) with tissue plasminogen activator is increasingly used. Patient-level analysis combining clinical and economic data in a real-life setting is lacking. This study compares clinical outcomes and cost effectiveness of initial treatment strategies for non-embolic ALI using real-life patient-level data. METHODS: Medical records and hospital cost data were analyzed for non-embolic ALI patients treated in four hospitals over 3 years. A cost-effectiveness analysis was

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performed using a decision tree analytical model. All costs were valued based on cost-to-charge ratios. RESULTS: In 205 patients, initial treatments were CDT alone (68) or with angioplasty (16), open surgery (60), endovascular (33), and hybrid (28). Clinical and economic outcomes are summarized in Table 1. Although clinical outcomes did not differ significantly between groups, re-intervention rates during hospital stay, readmission rates, and cost were highest in the CDT group. 16% of patients in CDT group needed more than one re-intervention. CONCLUSIONS: In this real-life study, initial treatment of non-embolic limb ALI with currently available CDT options was associated with greater healthcare resource consumption and cost compared to other initial treatment options. AUTHOR DISCLOSURES: A.J. Comerota: Nothing to disclose; F. Lurie: Nothing to disclose; V. Vaidya: Nothing to disclose. CDT (N=68)

CDT + A (N=16)

Open Surg. (N-60)

Endovasc (N=33)

Hybrid (N28)

P

Amp. Free Surv. (%/N)

94/64

87/14

95/57

100/33

100/28

NS

Readmissions (%/N)

16/11

31/5

7/4

6/2

3/1

< .05

Mortality (%/N)

0

6/1

1/1

0

0

NS

Major Bleed (%/N)

3/2

0

1/1

0

0

NS

Reinterventions (%/N)

62/42

33/5

7/4

12/4

18/5

<.00001

Initial Hosp. Costs ($)

M

31,804

27,779

16,636

20,751

21,134

SE

2,436

5,035

2,595

3,494

3,850

Readmission Cost ($)

M

20,441

26,844

7,434

24,409

4,156

SE

4,684

7,306

9,847

11,235

18,117

M

34,840

37,002

17,758

21,916

21,220

SE

2,725

5,628

2,921

3,911

4,309

Total Cost

SS24. Lessons Learned in the Surgical Treatment of    Neurogenic Thoracic Outlet Syndrome over 10 Years

.01 .05 .0001

2:36 p.m.

Kendall Likes, Megan S. Orlando, Serene Mirza, Quinn Salditch, Anne Cohen, Ying W. Lum, Thomas Reifsnyder, Julie Ann Freischlag.

Johns Hopkins Medical Institutions, Baltimore, Md.

OBJECTIVES: To evaluate our extensive experience in the treatment of patients with Neurogenic Thoracic Outlet Syndrome (NTOS) who underwent first rib resection and scalenectomy (FRRS) over a decade. METHODS: Patients treated with FRRS for NTOS from 2003 to 2013 were retrospectively reviewed using a prospectively maintained database. RESULTS: Over the ten years, 286 patients underwent 308 FRRS. During the first 5 year period, 127 FRRS were performed (96F, 31M), with an average age of 36.9 years. During the second 5 year period, 181 FRRS were performed (143F, 38M), with an average age of 33 years. 24 children (age â&#x2030;¤18 years) underwent FRRS; 9 during the first 5 years and 15 during the second 5 years. When comparing the second five year period to the first five year period, patients were younger (p=0.066), reported a significantly shorter length of preoperative symptoms 124


(35.4 vs. 52.1 months, p<0.01), prior narcotic use decreased from 31.5% to 23.8% (p<0.05) and a history of prior surgical intervention on the ipsilateral side (head, neck, shoulder) increased from 30.1% to 51.9% (p<0.01). Use of Lidocaine blocks as a diagnostic tool (57% to 35.4%, p=0.06) and Botox blocks as a therapeutic tool (29.1% to 12.7%, p<0.01) decreased in the second 5 years with similar positive results. Improved or fully resolved symptoms following FRRS increased from 89% in the first 5 years to 92.8% in the second 5 years. Average length of follow-up over the 10 year period was 13.4 months. CONCLUSIONS: 1. Excellent results were seen in this largest surgical series reported for Neurogenic TOS. 2. Younger patients with shorter duration of symptoms with less narcotic use led to even better FRRS results in the second 5 years of surgical intervention. 3. An established vascular practice for referrals for NTOS resulted in an increased number of appropriate patients for surgical intervention, requiring less Lidocaine and/or Botox injections preoperatively. AUTHOR DISCLOSURES: A. Cohen: Nothing to disclose; J.A. Freischlag: Nothing to disclose; K. Likes: Nothing to disclose; Y.W. Lum: Nothing to disclose; S. Mirza: Nothing to disclose; M.S. Orlando: Nothing to disclose; T. Reifsnyder: Nothing to disclose; Q. Salditch: Nothing to disclose. COFFEE BREAK AND VASCULAR LIVE PRESENTATIONS

3:00 – 3:30 p.m. uExhibit Halls C & D, Level 2

CONCURRENT BREAKOUT SESSIONS 

3:30 – 5:00 p.m.

C5: SVS/ESVS Joint Debate Session  

3:30 – 5:00 p.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Compare conventional and endovascular treatment methods and outcomes for patients with thoracoabdominal aortic aneurysms. 2. Evaluate the methodology and outcomes of the randomized clinical trials of percutaneous renal artery intervention to determine whether the conclusions are relevant to treatment of renal artery occlusive disease. 3. Assess the differences of open surgical and endovascular approaches to popliteal artery aneurysms and determine whether successful treatment requires surgical bypass. Moderators: Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif. (SVS) Philippe Kolh, MD, PhD, University Hospital of Liège, Liège, Belgium (ESVS) Bruce A. Perler, MD, Johns Hopkins Hospital, Baltimore, Md. (SVS) Jean-Baptiste Ricco, MD, PhD, University Hospital of Poitiers, Poitiers, France (ESVS)

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DEBATE 1: Thoracoabdominal Aneurysms “Fenestrated and branched grafts are the optimal way to treat  thoracoabdominal aortic aneurysms.” Stéphan Haulon, MD, PhD, Hospital Cardiologique, Lille, France (ESVS)

3:30 p.m.

“Open surgical repair is still the best way to treat thoracoabdominal  3:45 p.m. aortic aneurysms.” Richard P. Cambria, MD, Massachusetts General Hospital, Boston, Mass. (SVS) DEBATE 2: Renal Artery Stenosis “With the results of the ASTRAL and the CORAL trials, there is no  4:00 p.m. indication to percutaneously treat renal artery occlusive disease.” George Hamilton, MD, University College London, London, United Kingdom (ESVS) “These trials do not answer the important questions; there are still  indications to treat renal artery occlusive disease.” Matthew A. Corriere, MD, Wake Forest University School of Medicine, Winston-Salem, N.C. (SVS)

4:15 p.m.

DEBATE 3: Popliteal Artery Aneurysm 4:30 p.m.

“Popliteal artery aneurysms can be successfully treated by endograft  exclusion of the aneurysm.” Luke K. Marone, MD, University of Pittsburgh, Pittsburgh, Pa. (SVS)

“Surgical repair remains the gold standard and the optimal method to  4:45 p.m. treat a popliteal artery aneurysm.” Jean-Baptiste Ricco, MD, PhD, University Hospital of Poitiers, Poitiers, France (ESVS)  C6: SVS/STS Joint Session  

3:30 – 5:00 p.m. uRoom 312

At the end of this session, participants should be able to: 1. Formulate a plan based on published data for management of patients with severe carotid stenosis undergoing CABG surgery. 2. Identify treatment options for patients with acute and chronic type B dissection. 3. Describe the advantages and disadvantages of best medical management versus endovascular intervention in type B dissection. Moderators: Keith B. Allen, MD, Mid America Heart & Lung Surgeons, Kansas City, Mo. Jeffery B. Dattilo, MD, The Surgical Clinic, St. Thomas Health, Nashville, Tenn. Contemporary Management of Type B Aortic Dissection  3:30 p.m. STS: Alan B. Lumsden, MD, The Methodist DeBakey Heart & Vascular Center, Houston, Texas SVS: Christopher J. Kwolek, MD, Massachusetts General Hospital, Boston, Mass. Discussion 

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4:00 p.m.


Management of Severe Carotid Stenosis in  4:15 p.m. Patients Undergoing CABG Surgery STS: Keith B. Allen, MD, Mid America Heart & Lung Surgeons, Kansas City, Mo. SVS: Jeffery B. Dattilo, MD, The Surgical Clinic, St. Thomas Health, Nashville, Tenn. Discussion  C7: C  ollaborating on Resident/Student Education:  Opportunities for Education Abroad and  in North America

4:45 p.m. 3:30 – 5:00 p.m. uRoom 311

At the end of this session, participants should be able to: 1. Examine the reasons for participating in supplemental resident/student training opportunities abroad or in the U.S. 2. Identify barriers and solutions for participating in supplemental resident/student training opportunities abroad or in the U.S. Moderators: John E. Rectenwald, MD, University of Michigan Health System, Ann Arbor, Mich. Gustavo S. Oderich, MD, Mayo Clinic, Rochester, Minn. Introduction  3:30 p.m. John E. Rectenwald, MD, University of Michigan Health System, Ann Arbor, Mich. INTERNATIONAL OPPORTUNITIES FOR U.S. TRAINEES Why Go Abroad During Your Training?  Peter Gloviczki, MD, Mayo Clinic, Rochester, Minn.

3:35 p.m.

What You Need to Know from ACGME  Linda M. Harris, MD, University of Buffalo, Buffalo, N.Y.

3:45 p.m.

What You Need to Know from the ABS  Vivian Gahtan, MD, SUNY Upstate Medical University, Syracuse, N.Y.

3:55 p.m.

My International Training Experience  Adam W. Beck, MD, University of Florida, Gainesville, Fla.

4:05 p.m.

U.S. OPPORTUNITIES FOR INTERNATIONAL TRAINEES Opportunities for International Trainees Igor L. Banzic, MD, Surgery Clinical Center of Serbia, Belgrade, Serbia

4:15 p.m.

How to Structure a Program for International Trainees  Matthew J. Eagleton, MD, Cleveland Clinic, Cleveland, Ohio

4:25 p.m.

My U.S. Training Experience  4:35 p.m. Nirvana Sadaghianloo, MD, University of Nice – Sophia Antipolis, Nice, France PANEL DISCUSSION 

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4:45 p.m.

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C8: POSTER SESSION — See Next Tab  3:30 – 5:00 p.m.  uAuditorium, Level 2  (enter through Exhibit Hall C) At the end of this session, participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: Peter F. Lawrence, MD, UCLA Medical Center, Los Angeles, Calif. Melina R. Kibbe, MD, Northwestern University, Chicago, Ill. C8a: Aortic Disease (1) Moderator: Christopher J. Abularrage, MD, Johns Hopkins Hospital, Baltimore, Md. C8b: Aortic Disease (2) Moderator: Joann M. Lohr MD, Lohr Surgical Specialists, Cincinnati, Ohio C8c: Complications Moderator: Jason T. Lee, MD, Stanford University Medical Center, Stanford, Calif. C8d: Vascular Laboratory and Imaging • Renal/Visceral • Educational/ Training Credentialing Moderator: Benjamin W. Starnes, MD, University of Washington, Seattle, Wash. C8e: Dialysis Access • Cerebrovascular Including Great Vessels Moderator: Ravi K. Veeraswamy, MD, Emory University School of Medicine, Atlanta, Ga. C8f: Vascular Medicine • Practice Management • Other Moderator: John A. Curci, MD, Washington University School of Medicine, St Louis, Mo. C8g: Peripheral Arterial Disease Moderator: Ellen D. Dillavou, MD, University of Pittsburgh Medical Center, Pittsburgh, Pa. C8h: Vascular Trauma • Venous Disease Moderator: Mahmoud B. Malas, MD, MHS, Johns Hopkins Hospital, Baltimore, Md. C8i: Research (1) Moderator: Peter K. Henke, MD, University of Michigan, Ann Arbor, Mich. C8j: Research (2) Moderator: Benjamin M. Jackson, MD, MS, University of Pennsylvania, Philadelphia, Pa.

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GENERAL SURGERY RESIDENT/MEDICAL STUDENT  5:00 – 6:00 p.m. PROGRAM — RESIDENCY FAIR  uAuditorium, Level 2 See Fellow/Resident/Student Programs Tab. (enter through Exhibit Hall C)

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NOTES

130


POSTER SESSION

FRIDAY, JUNE 6

All events held at Hynes Convention Center unless otherwise noted. C8: POSTER SESSION  

3:30 – 5:00 p.m. „Auditorium, Level 2 (enter through Exhibit Hall C)

At the end of this session participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: Peter F. Lawrence, MD, UCLA Medical Center, Los Angeles, Calif. Melina R. Kibbe, MD, Northwestern University, Chicago, Ill.

Introduction and Rules

C8a: Aortic Disease (1)   

3:30 p.m.

3:30 – 5:00 p.m. uAuditorium, Level 2 (enter through Exhibit Hall C)

Moderator: Christopher J. Abularrage, MD, Johns Hopkins Hospital, Baltimore, Md.

PS2. Type Ia Endoleaks Following Fenestrated and  Branched Endografts May Lead to Component Instability and Increased Mortality

3:40 p.m.

Adrian O’Callaghan,1 Tara M. Mastracci,1 Roy K. Greenberg,1 Matthew J. Eagleton,1 Shona Bathurst,1 Yuki Kuramochi,1 James Bena.2 1  Vascular Surgery, Cleveland Clinic, Cleveland, Ohio; 2Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.

OBJECTIVES: Fenestrated and branched endografts facilitate sealing in the visceral aorta to extend the landing zone for complex aneurysms. We describe the causes and implications of proximal endoleak in our experience. METHODS: Data on all patients undergoing fenestrated/branched repair were entered into a prospective database. Inclusion criteria necessitated the availability of at least one post-operative contrast CT scan. 3-D imaging was used to characterize morphology and correlated with outcome. Blinded assessors resized the repairs in the endoleak group to assess the change in practice from early repairs to current practice. Outcome measures were mortality and a composite of stent fracture, type III and Ic endoleak, as an indicator of device stability.

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RESULTS: 969 patients underwent fenestrated/branched repair up to July 2013. Emergency repairs (n=24) and patients without requisite imaging (n=21) were excluded, leaving 924 available for analysis. A type Ia endoleak was identified in 23 patients (2.5%). Landing zone choice was implicated as cause of endoleak development, as sealing in the visceral aorta was associated with endoleak development (52.2% vs. 24.5%, p=.006). Aortic related mortality was higher in the endoleak group, 30% vs. 7%, respectively (p=.001) and they experienced a higher incidence of component instability, 34.8 vs. 9.5% (p=.001). CONCLUSIONS: Fenestrated/branched endovascular repair has a low incidence of sealing zone failure despite the increased complexity. Choice of proximal landing zone may predict occurrence of endoleak. Development of a proximal endoleak seems to destabilize the repair and may lead to increased mortality. AUTHOR DISCLOSURES: S. Bathurst: Nothing to disclose; J. Bena: Nothing to disclose; M.J. Eagleton: Cook Medical, consulting fees or other remuneration (payment); Bolton Medical, consulting fees or other remuneration (payment); R.K. Greenberg: Nothing to disclose; Y. Kuramochi: Nothing to disclose; T.M. Mastracci: Cook Medical, consulting fees or other remuneration (payment); A. Oâ&#x20AC;&#x2122;Callaghan: Nothing to disclose. PS4. Re-Intervention After Abdominal Aortic Aneurysm  Repair in the Vascular Study Group of New England (VSGNE)

3:45 p.m.

Christina Feng, Rodney Bensley, Marc Schermerhorn.

Beth Israel Deaconess Medical Center, Boston, Mass.

OBJECTIVES: Endovascular repair (EVAR) has become the primary treatment for AAA but is associated with more late re-interventions compared to open repair. This study compares the outcomes from EVAR and open repair in the VSGNE. METHODS: We reviewed all elective, non-ruptured symptomatic, and ruptured endovascular and open repairs of AAA from 2003-2012. Post-operative re-interventions, morbidity, and mortality were compared at 30-days, 30-day to 1-year, and overall 1-year follow-ups. RESULTS: We identified 3347 EVARs and 2251 open repairs. At 30-days and 1-year, overall re-intervention rates were higher after open repair compared to EVAR (Table). Between 30-days and 1-year, re-interventions were less after elective open repair compared to EVAR (2.6% vs. 3.8%, p=0.03) but were similar after open repair and EVAR for symptomatic (4.5% vs. 4.6%, p=0.97) and ruptured (5.5% vs. 4.3%, p=0.58) AAA. Mortality was lower after elective EVAR compared to open repair at 30 days (1.6% vs. 2.6%, p=0.01) but was similar at 1 year (7.2% vs. 7.3%, p=0.88). CONCLUSIONS: Re-intervention was more common after open repair compared to EVAR across all AAA repair in the perioperative period. Between 30-days to 1-year, EVAR had higher re-intervention rates for elective AAA repair but was similar to open repair for symptomatic and ruptured AAA. AUTHOR DISCLOSURES: R. Bensley: Nothing to disclose; C. Feng: Nothing to disclose; M. Schermerhorn: Nothing to disclose.

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Re-Intervention Rates for All Patients Undergoing EVAR vs. Open AAA Repair Re-Interventions

EVAR (n=3347)

Open (n=2251)

p-value

30-Day Re-Interventions

1.9%

11.5%

<0.01

Multiple Re-Interventions

0.3%

2.2%

<0.01

Leg Embolization

0.8%

1.6%

<0.01

Bowel Ischemia

0.5%

2.5%

<0.01

Wound Complication

0.4%

3.1%

<0.01

Hemorrhage

0.6%

2.7%

<0.01

Return to OR

10.8%

10.9%

<0.01

EVAR (n=3002)

Open (n=2140)

p-value

30-day to 1-year Re-Interventions

3.8%

3.3%

0.29

Multiple Re-Interventions

1.3%

0.6%

<0.01

Total 1-Year Re-Interventions

5.5%

13.2%

<0.01

PS6. Effectiveness and Cost of Different Intravenous  Drugs Used for Patients Presenting with Acute Stanford Type B Aortic Dissection

3:50 p.m.

Adam Richter, Calvin Sheng, Kathleen Maxfield, Thomas Naslund.

Dept. of Vascular Surgery, Vanderbilt University Medical Center, Nashville, Tenn.

OBJECTIVES: The purpose of this study is to determine the cost differences associated with different intravenous (IV) blood pressure medications used in the treatment of acute Stanford Type B aortic dissections. METHODS: A retrospective chart review was conducted on patients treated for an acute Type B aortic dissection between June 2006 and September 2013 to determine the IV blood pressure medication regimen (a combination of labetalol, esmolol, nitroprusside, and/or nicardipine). Patients receiving each IV infusion were compared to patients not receiving that drug with regards to the total cost of the infusion, mortality, the complication rate associated with the dissection, and the need for operation. RESULTS: 90 patients were treated with IV blood pressure medications for an acute Type B dissection. In-hospital mortality rate was 11.1%, and 33.3% experienced a complication of their dissection. 14.4% had an operation after an initial attempt at medical therapy. 53% of patients received an esmolol infusion, 46% a nicardipine infusion, 41% a labetalol infusion, and 54% a nitroprusside infusion. Median cost of admission was $66.355 (interquartile range $41,372-160,176), and median cost of the infusions was $4,837 (interquartile range $1,922-13,240). Esmolol was associated with increased total drug cost (median $10,545 vs. $1,947, p<.001) and longer ICU stays (median 5 vs. 3 days, p=.025). Nicardipine carried increased cost ($11,195 vs. $3,365, p<.001) and longer ICU stay (5 vs. 3 days, p=.058). Labetalol carried decreased cost (median $3,931 vs. $9,136, p=.004) with no difference in ICU stay (3 vs. 3 days, p=.175). Nitroprusside carried no difference in cost ($5,095 vs. $4,038, p=.182). No drug was associated with increased mortality, need for operation, or complication of the dissection. CONCLUSIONS: Labetalol and nitroprusside are significantly cheaper medications to treat acute Type B aortic dissections, and they are not associated with increased risk of death, complication of the dissection, or need for operation.

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AUTHOR DISCLOSURES: K. Maxfield: Nothing to disclose; T. Naslund: W.L. Gore, consulting fees or other remuneration (payment); Aptus Endosystems, consulting fees or other remuneration (payment); CVRx, consulting fees or other remuneration (payment); A. Richter: Nothing to disclose; C. Sheng: Nothing to disclose. PS8. Flap Thickness in Type B Aortic Dissection  Predicts Aneurysmal Expansion

3:55 p.m.

Mohsen Bannazadeh, Andrew Forsyth, Bradley Wilson, Christina Jenkins, Marc Sakwa, Jeffrey Altshuler, Kostaki Bis, O.W. Brown.

William Beaumont Hospital, Royal Oak, Mich.

OBJECTIVES: We sought to demonstrate the prognostic implication of flap thickness (FT) in Type B aortic dissection (TBAD). METHODS: A retrospective review was undertaken of all patients with TBAD from June 2006 to June 2012. Demographics, hospital course, imaging, and follow-up visits were analyzed. FT on Computed Tomographic Angiography (CTA) was measured using full width at half maximum technique. Survival rates and predictors of outcome were determined using the Kaplan-Meier method with Cox proportional hazards. RESULTS: Of 134 patients with TBAD, 101 (75%) had a classical dissection and 33 (24%) had atypical dissection (no dissection flap). FT analysis was available in 63 patients. Thirty-eight were male and the mean age was 64 Âą 15 years. Median follow-up was 33 (0-135) months. Sixteen patients underwent surgical interventions and 47 were managed non-operatively. Patients with FT >2.5 mm had higher rates of aneurysmal growth (2.7 vs. 0.3 mm/year, p=0.01). In addition, patients with FT greater than 2.5 mm had worse survival (median survival 61 vs. 100 months, p=0.03). However, multivariate analysis showed that only age (hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.06-1.2; p<0.000) and growth rate greater than 2 mm were independent predictors of survival (HR 0.1, 95% CI 0.02-0.5; p<0.004) (Figure). CONCLUSIONS: Flap thickness in Type B aortic dissection predicts aneurysmal expansion. AUTHOR DISCLOSURES: J. Altshuler: Nothing to disclose; M. Bannazadeh: Nothing to disclose; K. Bis: Nothing to disclose; O.W. Brown: Nothing to disclose; A. Forsyth: Nothing to disclose; C. Jenkins: Nothing to disclose; M. Sakwa: Nothing to disclose; B. Wilson: Nothing to disclose.

Figure: Comparison of Survival 134


PS10. Adherence to EVAR Device Instructions-for-Use (IFU)  Guidelines Has No Impact on Long-Term Outcomes

4:00 p.m.

Joy Walker,1 Lue-Yen Tucker,2 Philip P. Goodney,3 Hong Hua,4 Steven Okuhn,4 Ann Rhoades,5 Bradley Hill,6 Robert W. Chang.

1 University of California, San Francisco, Calif.; 2Kaiser Permanente Division of Research, Oakland, Calif.; 3Dartmouth-Hitchcock Medical Center, Lebanon, N.H.; 4The Permanente Medical Group, San Francisco, Calif.; 5Kaiser Permanente, Oakland, Calif.; 6The Permanente Medical Group, Santa Clara, Calif.; 7The Permanente Medical Group, South San Francisco, Calif.

OBJECTIVES: Prior reports have suggested unfavorable outcomes after EVAR performed outside of the recommended IFU. We report our long-term EVAR experience with regard to IFU in a large multicenter registry. METHODS: Between 2000 and 2010, 1736 patients underwent EVAR, with 92% follow-up. Baseline anatomic measurements obtained from the M2S, Inc. imaging database were compared with device-specific IFU. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were endoleak status, adverse events and reintervention. RESULTS: During the median follow-up of 2.7 years, 489 (28.2%) patients had preoperative anatomic data available. Overall, 58% had EVAR performed within and 42% outside of IFU guidelines. 62.4% of outside-IFU cases had short neck length, 10.2% had greater angulation, 7.3% did not meet neck diameter criteria, and 20% had multiple anatomic issues. There was no difference in any of the primary or secondary outcomes between the two groups (Table). Percent change in aneurysm sac size over time appeared similar (-12.1% vs. -14.1% at 5 years), with no significant difference in sac increase at any time point during follow-up. Cox proportional hazard models showed that IFU non-adherence was not predictive of overall mortality (HR 1.06, p=.80), ARM (HR .17, p=.07) or adverse events (HR .84, p=.61). CONCLUSIONS: In our cohort of EVAR patients with detailed preoperative anatomic information and long-term follow-up, overall mortality and ARM are unaffected by IFU adherence, despite a higher proportion of females and larger aneurysms in the nonadherent group. In addition, rates of late endoleak and reintervention are similar, suggesting that operator experience and patient selection influence outcomes despite lack of IFU-based anatomic suitability. AUTHOR DISCLOSURES: R.W. Chang: Nothing to disclose; P.P. Goodney: Nothing to disclose; B. Hill: Nothing to disclose; H. Hua: Nothing to disclose; S. Okuhn: Nothing to disclose; A. Rhoades: Nothing to disclose; L. Tucker: Nothing to disclose; J. Walker: Nothing to disclose. IFU Adherent (n=284)

IFU Non-Adherent (n=205)

p-value

Female Baseline AAA Size

6.7% 56.6 mm

14.6% 59.7 mm

<.01 <.01

Overall Mortality ARM

21.1% 2.8%

21.5% 1.0%

.93 .20

Type I/III Leak Adverse Events Reintervention

3.5% 8.8% 13.4%

4.4% 11.2% 17.6%

.62 .38 .20

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PS12. Influence of Gender on Abdominal Aortic Aneurysm  Repair in the Community

4:05 p.m.

Daiva Nevidomskyte,1 Mark H. Meissner,1 Nam Tran,1 Steve Murray,3 Ellen Farrokhi.2

Department of Vascular Surgery, University of Washington, Seattle, Wash.; Providence Regional Medical Center, Everett, Wash.; 3Providence Vascular Institute, Spokane, Wash.

1 2

OBJECTIVES: Although much of the management of abdominal aortic aneurysms (AAAs) has been based on outcomes in men, there may be important gender differences in outcomes. The goal of this study was to evaluate the management and outcomes after AAA repair in women. METHODS: We utilized the Washington Surgical Care and Outcomes Assessment Program (VI-SCOAP) data that includes details and outcomes of vascular procedures as part of a statewide quality improvement initiative. We compared demographics, presentation, procedural data, and outcomes between men and women undergoing AAA repair at 19 VI-SCOAP hospitals from July 2010 to September 2013. RESULTS: We identified 1233 patients (19.5% women) who underwent repair of an intact (n = 1065, 86.5%) or ruptured AAA (n = 142, 13.5%). Endovascular repair was performed in 969 (78.6%) of these patients. Men and women were of equivalent age (73.1 vs. 73.4, p < .001), although women had smaller aneurysm diameters (6.4 ± 4.2 vs. 5.8 ± 1.1 cm, p = .03) at the time of presentation. Men were more likely to present with leak or rupture (14.3% vs. 10.4%, p< .001) and more likely to have EVAR (80.0% vs. 73.0%, p<.001). Overall, women had higher hospital mortality (6.2% vs. 3.2%, p<.001) and were less likely to be discharged to home after longer hospital stays (6.0 ± 9.1 days vs. 4.6 ± 6.5 days, p=.029). Mortality was significantly higher in women having elective repair (4.2% vs. 0.8%, p=.01), but not undergoing ruptured repair (24.0% vs. 18.0%, p = .4). CONCLUSIONS: Despite presentation at a similar age, with a smaller aneurysm diameter, and lower incidence of rupture, hospital outcomes in women are substantially worse than in men. Although utilization of endovascular techniques in women was high, it remained significantly lower than in men. Improved outcomes likely depend not only on technical improvements in repair techniques, but also on patient stratification and management strategies that may differ in men and women. AUTHOR DISCLOSURES: E. Farrokhi: Nothing to disclose; M.H. Meissner: Nothing to disclose; S. Murray: Nothing to disclose; D. Nevidomskyte: Nothing to disclose; N. Tran: Nothing to disclose. PS14. Does CTA Surveillance After EVAR Accelerate  Age-Related Decline in Renal Function?

4:10 p.m.

Vincent Kirkpatrick, Khoi N. Trinh, Russell A. Williams, Ian L. Gordon, Samuel E. Wilson.

Surgery, University of California Irvine, Orange, Calif.

OBJECTIVES: Intravenous contrast used for computed tomographic angiography (CTA) can adversely affect renal function in certain clinical contexts, and this is often cited as a reason for modification of standard surveillance imaging after endovascular repair of abdominal aortic aneurysms (EVAR). We examined renal function after EVAR and compared this to the expected age-related renal function decline from historic controls.

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METHODS: Of 140 consecutive male patients who underwent EVAR, 27 were excluded from analysis due to follow-up of less than one year. Using serum creatinine values we calculated the change in estimated glomerular filtration rate (GFR) over the postoperative period. RESULTS: The 113 patients examined had an average of 4.1 CTAs (range 1-12) over mean follow-up of 3.8 years (range 1-12). Mean yearly decline in GFR after EVAR was 1.20 mL/min/1.73 m2, compared to the rate from age-matched historical controls of 1.4 mL/ min/1.73 m2. The 29 patients who had baseline chronic kidney disease (CKD), or GFR < 60 mL/min/1.73 m2, had yearly GFR decline comparable to the 84 patients without CKD; 1.26 mL/min/1.73 m2/year vs. 1.19 mL/min/1.73 m2/year, respectively (P=0.94). Two patients progressed to dialysis, which was related to remote nephrectomy in one and diabetic nephropathy in the other. CONCLUSIONS: Patients receiving on average four CTAs after EVAR exhibited a gradual GFR decline over four years of follow-up, which compared closely with the expected age-related decline. Standard post-EVAR CTA surveillance does not accelerate renal function decline to a degree that is detectable by serum creatinine-based calculations of estimated GFR. AUTHOR DISCLOSURES: I.L. Gordon: Nothing to disclose; V. Kirkpatrick: Nothing to disclose; K.N. Trinh: Nothing to disclose; R.A. Williams: Nothing to disclose; S.E. Wilson: Nothing to disclose. PS16. Ambulatory Endovascular Abdominal Aortic  Aneurysm (AAA) Repair in the National Surgical Quality Improvement Project (NSQIP)

4:15 p.m.

Sarah J. Carlson, Thomas Curran, Dominique B. Buck, John C. McCallum, Jeremy D. Darling, Michelle Martin, Mark Wyers, Marc L. Schermerhorn.

Beth Israel Deaconess Medical Center, Boston, Mass.

OBJECTIVES: Length of stay after AAA repair has decreased with endovascular repair (EVAR) though reports of ambulatory EVAR (aEVAR) are limited. We compared the safety and cost of aEVAR versus inpatient EVAR (iEVAR) using clinical and administrative databases. METHODS: All patients undergoing non-emergent EVAR in the NSQIP 2005-2012 were identified. Patients with non-death, same-calendar-day discharge after EVAR had aEVAR while others had iEVAR. Demographics and outcomes were compared. Charges for aEVAR and iEVAR (1-2 day stay only) were compared using the Florida Inpatient and Ambulatory Surgery Databases from 2006-2009. RESULTS: 16,420 patients received EVAR; 53 aEVAR, 16,367 iEVAR. aEVAR patients were younger (69 vs. 74 years; p=.003), more often female (32 vs. 18%; p=.011) and less likely to have creatinine > 1.2 g/dL (14 vs. 28%; p=.027). Femoral cutdown rate did not differ between aEVAR and iEVAR (45 vs. 50%; p=.495). Pre-discharge complications after aEVAR included DVT (1), return to the OR (2) and transfusion (2). Post-discharge complications included transfusion (2) and DVT (1). Administrative data showed median total charges of $59,100 for aEVAR (N=36) as compared to $81,724 for iEVAR (N=5,725). CONCLUSIONS: Though aEVAR sample size is limited, this multi-center, national database shows aEVAR to have acceptable morbidity in select patients. Further studies may delineate aEVAR candidate selection criteria and explore differential resource utilization between aEVAR and iEVAR.

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AUTHOR DISCLOSURES: S.J. Carlson: Nothing to disclose; D.B. Buck: Nothing to disclose; T. Curran: Nothing to disclose; J.D. Darling: Nothing to disclose; M. Martin: Nothing to disclose; J.C. McCallum: Nothing to disclose; M. L. Schermerhorn: Endologix, consulting fees or other remuneration (payment); M. Wyers: Endologix, consulting fees or other remuneration (payment). Overall N = 16,420 N (%)

aEVAR N = 53 N (%)

iEVAR N = 16,637 N (%)

p-value (aEVAR vs. iEVAR)

Length of Postoperative Stay, Days; Mean (SD)

2.5 (3.8)

0

2.5 (3.8)

<.01

Any Complication

2,262 (13.8)

5 (9.4)

2,257 (13.8)

.43

- Pre-Discharge

1,756 (10.7)

4 (7.5)

1,752 (10.7)

.66

- Post-Discharge

714 (4.3)

2 (3.8)

712 (4.4)

1.00

Mortality

168 (1.0)

0

168 (1.0)

1.00

- Pre-Discharge

97 (0.6)

x

97 (0.6)

1.00

- Post-Discharge

54 (0.3)

0

54 (0.3)

1.00

Readmission

205 (8.3)

0

205 (8.3)

1.00

Return to OR

612 (3.7)

2 (3.8)

610 (3.7)

1.00

PS18. Endovascular Occlusion of False Lumen in  Chronic Aortic Dissection — A Novel Approach

4:20 p.m.

Eric E. Roselli, Jahanzaib Idrees, Joshua Reside, Susan Shafii, Timur Sarac.

Cleveland Clinic, Cleveland, Ohio.

OBJECTIVES: Persistent retrograde false lumen (FL) perfusion is a common mode of failure after TEVAR for chronic dissection. Objectives were to describe a novel endovascular approach for false lumen occlusion and assess outcomes. METHODS: From 2009 to 2013, 20 patients with chronic thoracoabdominal dissection, underwent adjunctive FL embolization using covered stent devices (Figure) for persistent retrograde perfusion. Mean age was 63±11 years. Eight patients had type B dissection, 12 had prior type A repair and were deemed high-risk for open operation. Three patients had patent FL after previous TEVAR coverage sparing celiac artery and underwent FL embolization as an isolated procedure. In the remaining 17, embolization was performed adjunctively at the time of initial TEVAR or extension (n= 15) and elephant trunk completion (n= 2). Covered stent devices included: iliac plugs (n=17), nitinol embolization plugs (n=2) and occluded stent graft (n=1). Multiple devices were used in 14 patients. RESULTS: There was 1 hospital death due to left subclavian artery aneurysm rupture, but no stroke, paraplegia, MI or renal failure. Mean follow-up was 25±19 months. During surveillance CT imaging FL thrombosis was noted in all patients (Figure), but 3 required further embolization as the thrombosis was incomplete. Mean maximum aortic diameter decreased from 64±14 to 59±15 mm. There was one late death from intracranial hemorrhage and no aortic ruptures. 138


CONCLUSIONS: Adjunctive false lumen embolization with a covered stent device promotes thrombosis and remodeling after stent-grafting the true lumen for chronic dissection. Further study of this strategy is warranted. AUTHOR DISCLOSURES: J. Idrees: Nothing to disclose; J. Reside: Nothing to disclose; E.E. Roselli: Medtronic, speakers bureau; Cook, speakers bureau; Vascuteck, speakers bureau; Medtronic, honorarium; Cook, honorarium; Vascuteck, honorarium; T. Sarac: Nothing to disclose; S. Shafii: Nothing to disclose.

PS20.  Outcomes of Fenestrated and Branched Aortic  Arch Endografts for Patients Unfit for Open Surgery

4:25 p.m.

Nikolaos Tsilimparis, E. Sebastian Debus, Sabine Wipper, Sebastian Carpenter, Axel Larena, Tilo Kölbel.

Department of Vascular Medicine, University Heart Center, Hamburg, Germany.

OBJECTIVES: Evaluate the outcomes of high-risk patients receiving elective repair of aortic arch pathologies with customized fenestrated or branched stent grafts (FBSG). METHODS: Single-center, prospective, non-comparative study using customized fenestrated grafts or the Zenith Arch-branch® endograft (Cook Medical). All patients were denied open surgical therapy. RESULTS: During a 2-year period, 14 patients (10 , age 66±8 years) received FBSG involving the aortic arch (6 customized fenestrated, 8 Zenith A-branch). Six patients had previous thoracic aortic repair. The maximal aortic diameter was 6±1 cm and indication for surgery included aortic arch aneurysms (n=5, 36%), penetrating arch ulcers (n=2, 14%), type B dissection with aneurismal arch involvement (n=3, 21%), residual arch dissections after ascending aortic repair (n=2, 14%) post-traumatic aneurysm (n=1, 7%) and type II TAAA with arch involvement (n=1, 7%). A total of 22 aortic arch vessels (brachiocephalic trunk=7, left common carotid artery=11, bovine arch=2, left subclavian artery (LSA)=2) were targeted. The left LSA was intentionally covered in 12 cases and preoperatively revascularized in 9. Successful endograft implantation was achieved in all cases. Two early postoperative deaths occurred (retroperitoneal hematoma and stroke=1, unclear cause=1). Further major complications included a major stroke with significant early clinical improvement, one delayed transient paraplegia and one vascular plug dislocation. The mean ICU and hospital stay was 3±2 and 11±8 days, respectively. At 8±7 months of follow-up the cumulative survival was 79% with no aneurysm-related death or re-

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interventions. One type II endoleak was managed conservatively and one patient with persistent false lumen perfusion was planned to undergo endograft extension. CONCLUSIONS: FBSG present a feasible and safe therapeutic alternative for repair of aortic arch pathologies in high-risk patients. AUTHOR DISCLOSURES: S. Carpenter: Nothing to disclose; E. Debus: Nothing to disclose; T. KĂślbel: Cook Medical, consulting fees or other remuneration (payment); A. Larena: Nothing to disclose; N. Tsilimparis: Nothing to disclose; S. Wipper: Nothing to disclose. PS22. Endovascular Repair of Ruptured Abdominal  Aortic Aneurysm: Are Outcomes Improving?

4:30 p.m.

Khanjan H. Nagarsheth, Ariful Alam, Jonathan Schor, Kuldeep Singh, Saqib Zia, Jonathan Deitch.

Vascular Surgery, Staten Island University Hospital, Staten Island, N.Y.

OBJECTIVES: To evaluate if increased experience with endovascular repair of abdominal aortic aneurysm (EVAR) for ruptured abdominal aortic aneurysm (rAAA) has improved patient outcomes. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried, from the years 2005 to 2011, to identify patients who underwent EVAR for rAAA. There were a total of 803 EVAR procedures performed for rAAA. Procedures performed between 2005 and 2007 were placed into the early EVAR (E-EVAR) group and those performed between 2008 and 2011 were placed into the late EVAR (L-EVAR) group. Patient demographics, comorbidities, perioperative data, and outcomes were compared. RESULTS: There were more EVAR procedures performed for rAAA in the L-EVAR group than the E-EVAR group (n=124 vs. 679, p<0.01). The groups were similar with regards to demographics and preoperative comorbid conditions. There was a lower rate of acute renal failure (9% vs. 15%, p=0.03), pneumonia (11% vs. 18%, p=0.03), deep venous thrombosis (0% vs. 2%, p<0.01) and urinary tract infections (4% vs. 8%, p=0.03) for L-EVAR compared to E-EVAR. In addition, L-EVAR patients were more likely to be hemodynamically unstable requiring large volume blood transfusions (>4 units) (16% vs. 4%, p<0.01). The L-EVAR group had shorter operative times (173 min vs. 187 min, p<0.01) despite the trend toward hemodynamic instability. Mortality on the day of surgery (10% vs. 10%, p=0.82) and 30-day mortality (26% vs. 24%, p=0.69) was not significantly different between E-EVAR and L-EVAR. CONCLUSIONS: There has been an increase in the use of EVAR for hemodynamically unstable patients with rAAA with acceptable immediate and 30-day mortality rates. The findings may be attributed to an improvement in EVAR devices and/or the surgeonsâ&#x20AC;&#x2122; comfort level with the use of EVAR for rAAA. These data suggest that EVAR is an effective treatment for rAAA even in the setting of an unstable patient. AUTHOR DISCLOSURES: A. Alam: Nothing to disclose; J. Deitch: Nothing to disclose; K.H. Nagarsheth: Nothing to disclose; J. Schor: Nothing to disclose; K. Singh: Nothing to disclose; S. Zia: Nothing to disclose.

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PS24. Endovascular Repair of Ruptured Abdominal  Aortic Aneurysm Is Associated with Lower Perioperative Mortality and Morbidity than Open Repair in Elderly Patients

4:35 p.m.

Tze-Woei Tan,1 Mohammad Eslami,2 Wayne W. Zhang,1 Amy Coulter,1 Denis Rybin,2 Gheorghe Doros,2 Alik Farber.2

Louisiana State University Health Shreveport, Shreveport, La.; 2 Boston University Medical Center, Boston, Mass. 1

OBJECTIVES: Endovascular repair (EVAR) is becoming the preferred treatment modality for patients with ruptured abdominal aortic aneurysm (rAAA). Although survival advantage of EVAR over open repair (OAR) has been shown in some studies it is unclear whether this benefit extends to elderly patients. We evaluated the outcomes of rAAA repair in octogenarians. METHODS: We reviewed the American College of Surgeons National Surgical Quality Initiative Project dataset (2005 to 2011) to identify patients 80 years treated with EVAR and OAR for rAAA. Procedural trends were evaluated over the study period. Perioperative outcomes including mortality, morbidity and hospital length of stay (LOS) were compared. Multivariable logistic regression was used to compare perioperative mortality, adjusting for possible confounders. RESULTS: Among 591 octogenarians who had rAAA repair, 207 (35%) had EVAR and 384 (65%) had OAR. Endovascular repair rates to treat rAAA have significantly increased in this patient population (0 in 2005 vs. 53% in 2011, p=.001). Overall mortality rate among octogenarians was 42%, which was significantly higher among the OAR patients (48.2% vs. 30.9%, p<.001). Pneumonia (24% vs. 10.6%, p<.001), unplanned intubation (14.6% vs. 8.2%, p=.03), renal failure (8.3% vs. 3.4%, p=.02), and LOS (13.8 vs. 10.1 days, p<.001) were also significantly higher with OAR than EVAR. Compared to EVAR, OAR was independently predictive of mortality among this cohort (Odds ratio 2.7, 95% confidence interval 1.5-4.8, p<.001). CONCLUSIONS: Elderly patients have significant perioperative mortality after repair of rupture abdominal aortic aneurysm. Endovascular repair is associated with better perioperative outcomes in octogenarians and should be the preferred modality of treatment if feasible. AUTHOR DISCLOSURES: A. Coulter: Nothing to disclose; G. Doros: Nothing to disclose; M. Eslami: Nothing to disclose; A. Farber: Nothing to disclose; D. Rybin: Nothing to disclose; T. Tan: Nothing to disclose; W.W. Zhang: Nothing to disclose. C8b: Aortic Disease (2) 3:30 – 5:00 p.m.  uAuditorium, Level 2  (enter through Exhibit Hall C) Moderator: Joann M. Lohr MD, Lohr Surgical Specialists, Cincinnati, Ohio

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PS26. Frailty Increases Risk of Mortality After  Elective Abdominal Aortic Aneurysm (AAA) Repair Independent of Age and Comorbidity Status

3:40 p.m.

Sung I. Kim,1 Yazan Duwayri,2 Luke P. Brewster,2 Ravi Veeraswamy,2 Atef Salam,3 Thomas Dodson,2 Shipra Arya.2

Emory University Rollins School of Public Health, Atlanta, Ga.; Emory University School of Medicine Division of Vascular Surgery, Atlanta, Ga.; 3Atlanta VA Medical Center, Decatur, Ga.

1

2

OBJECTIVES: Frailty is a syndrome of decreased physiological reserve which increases vulnerability to adverse health outcomes. We evaluated the effect of frailty on 30-day mortality after elective AAA repair and compared endovascular (EVAR) and open (OAR) repair for patients with similar frailty burden. METHODS: We identified patients undergoing elective AAA repair using the National Surgical Quality Improvement Program (NSQIP) database. Frailty was quantified using the modified frailty index (mFI; Ann Vasc Surg 2013;27,904-8) and categorized into tertiles. Univariate and multivariate regression was performed to assess mortality in EVAR and OAR groups. RESULTS: Of 18,594 patients undergoing elective AAA repair, 299 (1.6% overall; 1.1% in EVAR and 3.0% in OAR) died within 30 days of repair. Mortality risk was consistently more than twofold higher for OAR across all mFI subgroups (Figure 1). In the multivariate analysis, higher mFI correlated to higher mortality risk [EVAR OR=1.7(95% CI 1.0-2.9); OAR OR=3.3(95% CI 1.9-5.6)]. Contrastingly, age had minimal effect on mortality [EVAR OR=1.1(95% CI 1.04, 1.10); OAR OR=1.1(95% CI 1.06, 1.13)]. ASA class, recent weight loss, and transfer status were independent risk factors in the EVAR but not in the OAR group. CONCLUSIONS: Frailty (mFI) is a stronger predictor of mortality after elective aneurysm repair than existing clinical criteria for both EVAR and OAR. For patients with similar frailty indices, mortality risk was higher with OAR. AUTHOR DISCLOSURES: S. Arya: Nothing to disclose; L.P. Brewster: Nothing to disclose; T. Dodson: Nothing to disclose; Y. Duwayri: Nothing to disclose; S.I. Kim: Nothing to disclose; A. Salam: Nothing to disclose; R. Veeraswamy: Nothing to disclose.

Figure 1. Thirty-day mortality rate after AAA repair by ascending tertiles of frailty (mFI).

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PS28. Isolated Infrarenal Aortic Dissection and  Penetrating Aortic Ulcer: A Nonmorbid Condition

3:45 p.m.

David A. Nation, Yana Etkin, Harold I. Litt, Grace J. Wang, Benjamin M. Jackson, Ronald M. Fairman, Edward Y. Woo.  University of Pennsylvania, Philadelphia, Pa. OBJECTIVES: Isolated infrarenal aortic dissection is uncommon. The natural history and optimal management are unclear. We hypothesize that many of these dissections can be managed expectantly. METHODS: The radiology database at a single institution was queried to identify all imaging between 7/2003 and 8/2013 that included aortic dissections. A retrospective chart review identified baseline patient characteristics, anatomic characteristics of the dissections, symptoms, management, and outcomes. RESULTS: Twenty-nine infrarenal dissections were identified. Most started below the inferior mesenteric artery (18/29) and extended to either the iliac bifurcation (13/29) or only into the common iliac arteries (10/29). Average dissection length was 77 ± 65 mm (15-204 mm). Many of these dissections had a component of penetrating aortic ulcer. Only 21% (6/29) of patients presented with symptoms (abdominal or back pain). Eighty-three percent (24/29) were managed with observation alone, including all six symptomatic patients. Five patients were treated with EVAR, all on an elective basis. Indications for intervention were concomitant aneurysm (4) and claudication (1). Technical success was 100%. Average follow-up was 26 ± 37 months (0-138 mo). Factors that were associated with isolated infrarenal aortic dissection included HTN (20/29), male gender (19/29), significant aortic ulcerated plaque (15/29), and smoking history (12/29). Family history (3/29) and Marfan’s disease (2/29) were less common. Forty-five percent (13/29) of patients had other evidence of aortic pathology, with nearly one third found to have a AAA at some point during follow up period. CONCLUSIONS: Isolated infrarenal aortic dissections can be treated successfully with observation even in symptomatic patients. When treatment is required, it is generally for an associated AAA and can often be managed successfully electively using endovascular techniques. Many of these dissections are likely part of the spectrum of evolution of penetrating aortic ulcer. AUTHOR DISCLOSURES: Y. Etkin: Nothing to disclose; R.M. Fairman: Nothing to disclose; B.M. Jackson: Nothing to disclose; H.I. Litt: Nothing to disclose; D.A. Nation: Nothing to disclose; G.J. Wang: Nothing to disclose; E.Y. Woo: Nothing to disclose. PS30. The Implications of Increasing Tortuosity  on EVAR Outcomes

3:50 p.m.

Paymon Sanati-Mehrizy, Rami O. Tadros, Peter L. Faries, Elizabeth Weissler, Robert Lookstein, Marvin V. Weaver, Ageliki Vouyouka, Rajesh Malik, Sharif Ellozy, Michael Marin.

Surgery, The Icahn School of Medicine at Mount Sinai, New York City, N.Y.

OBJECTIVES: Tortuosity increases the challenges of Endovascular Aneurysm Repair (EVAR). This study assesses the impact of increasing tortuosity indices on EVAR outcomes. METHODS: 501 of 1380 patients met inclusion criteria and were analyzed using 3D reconstructions of CT angiograms. Tortuosity indices (TI) were calculated, and the impact of increasing tortuosity on endoleaks, reinterventions, and AAA-related and all-cause

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mortality were assessed. Hazard ratios (HR) were calculated based on 0.01 incremental increases of TI. RESULTS: Increased TI of the left common iliac artery (LCIA) resulted in 17% increased risk of AAA-Related Mortality (p=0.001) and 7% increased risk of all-cause mortality (table, p=0.02). Increased TI from the lowest renal artery to the right iliac bifurcation was associated with a 63% increased risk for AAA-related mortality (p=0.01) and 22% increased risk for all-cause mortality (p=0.01). Patients with increased TI from the lowest renal artery through the LCIA had significantly increased risk of adverse events, including an 83% increased risk for AAA-related mortality (p=0.02), 20% increased risk for all-cause mortality (p=0.006), 18% increased risk for the development of an endoleak (p=0.002), and 27% increased risk for reintervention (p=0.01). CONCLUSIONS: Increased TI is associated with increased post-operative complications, including endoleaks, reinterventions, and both AAA-related and all-cause mortality after EVAR. Greater caution is recommended when performing EVAR in patients with increased TI. AUTHOR DISCLOSURES: S. Ellozy: Nothing to disclose; P.L. Faries: Nothing to disclose; R. Lookstein: Nothing to disclose; R. Malik: Nothing to disclose; M. Marin: Nothing to disclose; P. Sanati-Mehrizy: Nothing to disclose; R.O. Tadros: Nothing to disclose; A. Vouyouka: Nothing to disclose; M.V. Weaver: Nothing to disclose; E. Weissler: Nothing to disclose. Table 1: Adverse Outcomes by Tortuosity Index TI: Lowest Renal A to Total n=501 TI: LCIA RCIA Bifurcation Adverse HR(95%CI), p HR(95%CI), p Outcome

TI: Lowest Renal A to LCIA Bifurcation HR(95%CI), p

AAA-Related Mortality

1.17(1.06-1.29), 0.001

1.63(1.12-2.37), 0.01

1.83(1.09-3.05), 0.02

All-Cause Mortality

1.07(1.01-1.13), 0.02

1.22(1.05-1.42), 0.01

1.2(1.05-1.36), 0.006

1.10(0.97-1.25), 0.15

1.18(1.06-1.30), 0.002

1.11(0.87-1.42), 0.39

1.27(1.06-1.53), 0.01

Endoleak (Any) Reintervention

0.98(0.91-1.05), 0.53 0.98(0.86-1.12), 0.76

TI: Tortuosity Index. LCIA: Left Common Iliac Artery. RCIA: Right Common Iliac Artery.

PS32. Assessing the Designation of “Unfit for  Open Repair” and the Difference in Outcomes Among Open Surgery Patients

Lindsay Gates, Jeffrey Indes.

Vascular Surgery, Yale New Haven Hospital, East Haven, Conn.

3:55 p.m.

OBJECTIVES: Recently patients who were subjectively deemed to be “unfit for open aneurysm repair” were evaluated and found more likely to have advanced age, cardiac disease, chronic obstructive pulmonary disease and larger aneurysms. The objective of this study was to analyze patients who underwent open repair with these characteristics and to determine if they had worse outcomes after surgery, justifying a designation of “unfit.” 144


METHODS: Data on 2320 open aneurysm repairs between 2003-2013 at 20 VSGNE centers were used for this study. All aneurysm repairs were included. Patients were separated into risk factor groups based on the number of “unfit” risk factors they had. End points included in-hospital major adverse events. RESULTS: Of 2329 patients 15.4% had 0 risk factors, 34.3% had 1 risk factor, 33.1% had 2 risk factors, 15.3% had 3 risk factors and 2.3% had all four defined risk factors. Patients with 2 or more risk factors had more post op cardiac complications including: post op MI (p=.01), dysrhythmia (p=.003), and new CHF (p=.02). They also had more post operative renal dysfunction (p=.02), higher rate of returning to the OR (p<.001), bowel ischemia (p=.04) and higher in-hospital mortality (p=.01). Patients with one or more risk factors were found to have higher rates of respiratory complications (p<.001). There did not appear to be a significant difference between post operative wound infection rates (4.01% in the 0 RF group vs. 5.7% in the 4 RF group, p=.31) and incidence of distal limb ischemia (2.0% in the 0 RF groups vs. 5.7% in the 4 RF group, p=.10) among the different risk factor groups. CONCLUSIONS: This study supports that the factors of advanced age, cardiac disease, COPD and larger aneurysm size can be used to categorize patients as fit vs. unfit for open repair. Also it shows that patients with increasing number of “unfit” characteristics tend to have worse outcomes after open aneurysm repair. AUTHOR DISCLOSURES: L. Gates: Nothing to disclose; J. Indes: Nothing to disclose. PS34. Comparison of Renal Perfusion Solutions  During Suprarenal Aortic Aneurysm Repair

4:00 p.m.

Yamume Tshomba,1 Denise Ferrari,1 Germano Melissano,1 Laura Pasin,2 Andrea Kahlberg,1 Luca Apruzzi,1 Enrico M. Marone,1 Roberto Chiesa.1

1 Vascular Surgery, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy; 2Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy.

OBJECTIVES: To determine whether renal perfusion with cold crystalloid solution enriched with Histidine-Tryptophan-Ketoglutarate (Custodiol®) provides better protection against renal ischemic injury than cold lactated Ringer’s solution in patients undergoing suprarenal aortic aneurysm (sAAA) open repair. METHODS: We reviewed 256 consecutive patients undergoing sAAA open repair between 1993 and 2013. In 181 cases direct perfusion of at least one renal artery was performed. Among these patients, 87 had cold renal perfusion with Ringer’s lactate solution and 94 with Custodiol solution. Propensity score matching based on baseline clinical variables which were expected to influence renal outcomes was performed to correct for any bias that may have been associated with the use of Custodiol. Postoperative acute renal dysfunction (ARD) stratified in five classes according to postoperative serum creatinine elevation and need for dialysis was compared in the two groups and independent predictors of ARD were identified at multivariate analysis. RESULTS: After propensity score matching we were able to match 74 Custodiol cases one-to-one to those receiving perfusion with lactated Ringer’s solution. Overall 30-day mortality was 3.4%, temporary hemodialysis or continuous veno-venous hemofiltration 4.7%, and dialysis at discharge 2.7%. Freedom from ARD>2 (>100% elevation in baseline creatinine level) and from the need for dialysis were significantly increased in the Custodiol group (P=.007; and P=.04 respectively). At multivariate analysis Custodiol perfusion and clamping time were the independent predictors of non-ARD>2.

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CONCLUSIONS: In this series of sAAA repairs, perfusion with (4°C) Custodiol offered superior renal protection when compared with (4°C) Ringer’s lactate. Larger series and/ or randomized trials are needed to confirm this finding. AUTHOR DISCLOSURES: L. Apruzzi: Nothing to disclose; R. Chiesa: Nothing to disclose; D. Ferrari: Nothing to disclose; A. Kahlberg: Nothing to disclose; E.M. Marone: Nothing to disclose; G. Melissano: Nothing to disclose; L. Pasin: Nothing to disclose; Y. Tshomba: Nothing to disclose. PS36. Type II Endoleak Prevention with Coil  Embolization During Endovascular Aneurysm Repair for At-Risk Patients: Does the Benefit Warrant the Price?

4:05 p.m.

Dominique Fabre,1 Philippe Brenot,1 Olivier Planché,1 Frederic Cochennec,2 Elie Fadel,1 Sacha Mussot,1 Claude Angel.1

1Vascular Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France; 2 Henri Mondor Hospital, Creteil, France.

OBJECTIVES: To evaluate the level of Endoleak and the decrease in size of infrarenal Abdominal Aortic Aneurysm (AAA) after Coil Embolization during EVAR for at-risk patients for type II endoleak. METHODS: Between 2009 and 2013, 80 patients with AAA and a high risk for type II endoleak were treated with coil embolization of the aneurysm sac during EVAR. Embolization was performed using a microcatheter placed between the stentgraft and the aortic aneurysm wall. Follow-up using computed tomography (CT) scans (first month, six months, one year, and two years) was obtained to evaluate presence of endoleaks and the size of the aneurysm sac. RESULTS: The mean number of coils used for embolization was 11 (range 8-14). Technical success was achieved in all patients. Only 1 patient of 80 (1.2%) presented a type II endoleak on follow-up CT scans. Statistical analysis (T paired test) showed a significant decrease of the aneurysm diameter at 6 months (p=0,036), one year (p=0,004) and two years (p=0,001). The mean follow-up period after treatment was 13 months (range 1-29 months). There were no procedure related complications and two secondary interventions. CONCLUSIONS: Coil embolization of the aneurysm sac during EVAR for at-risk patients for type II endoleak is technically feasible and clinically effective in preventing type II endoleak. This leads to a rapid decrease in size of AAA and low level of secondary intervention. AUTHOR DISCLOSURES: C. Angel: Nothing to disclose; P. Brenot: Nothing to disclose; F. Cochennec: Nothing to disclose; D. Fabre: Nothing to disclose; E. Fadel: Nothing to disclose; S. Mussot: Nothing to disclose; O. Planché: Nothing to disclose.

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PS38. The Incidence of Ischemic Colitis After  Repair of Ruptured Abdominal Aortic Aneurysms Is Decreasing in the Endovascular Era

4:10 p.m.

Sarasijhaa Desikan,1 Niten Singh,1 Scott R. Steele,2 Nam Tran,1 Elina Quiroga,1 Ty Garland,1 Benjamin W. Starnes.1

University of Washington, Seattle, Wash.; 2 Madigan Army Medical Center, Tacoma, Wash. 1

OBJECTIVES: Ischemic colitis (IC) is a well-described complication of ruptured AAA (rAAA). The objective of this study was to compare the incidence of IC in patients with rAAA undergoing open or endovascular aneurysm repair (EVAR) comparing the pre- and post- implementation of a formal rupture AAA protocol with modern methods of resuscitation to include permissive hypotension. METHODS: Data on all patients presenting with rAAA to our institution between Jan 1, 2002 and Oct 31, 2013 were collected. Data analyzed included pre-hospital records, anesthesia reports, operative notes, pre- and intra-operative imaging, and outcomes. A database with over 37,000 variables was created and analyzed. The incidence of IC with open when compared to endovascular repair was determined using Pearson Chi-Square Statistic with significance set at p<0.05. RESULTS: 303 patients with rAAA presented over the study period. Of these, 191 patients underwent open repair and 89 patients underwent endovascular repair. 23 patients died either in the emergency department, en route to the operating room, or after choosing comfort care. The overall incidence of IC in this cohort was 16.4% (46/280). Of the patients undergoing open repair versus EVAR, the rate of IC was 44% (40/191) vs. 6.7% (6/89) (p=0.03). Over the study period, no statistical difference was noted in 30-day mortality for patients with IC between the open (55%, 22/40) and EVAR groups (33%, 2/6) p=0.32. Rates of IC prior to and following implementation of our formal rupture protocol in 2007 were compared. Prior to July 2007, the rate of IC was 37.1% (36/97). With the protocol in place, the rate of IC decreased to 6.4% (10/157), p=0.000.

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CONCLUSIONS: With the emergence of EVAR for rAAA, the incidence of ischemic colitis has decreased significantly. However, ischemic colitis continues to portend a poor prognosis after any type of repair. We believe that modern methods of resuscitation to include permissive hypotension are related to this decreased rate of ischemic colitis. AUTHOR DISCLOSURES: S. Desikan: Nothing to disclose; T. Garland: Nothing to disclose; E. Quiroga: Nothing to disclose; N. Singh: Nothing to disclose; B.W. Starnes: Nothing to disclose; S.R. Steele: Nothing to disclose; N. Tran: Nothing to disclose. PS40. Region, Hospital Size, and Case Volume  Influence on Mortality from AAA Repair

Sapan S. Desai,1 Anahita Dua.2

1

4:15 p.m.

Duke University, Durham, N.C.; University of Texas at Houston, Houston, Texas.

2

OBJECTIVES: The aim of this paper is to use a national inpatient database to identify variables that impact mortality following elective and ruptured abdominal aortic aneurysm (AAA) repair. METHODS: The National Inpatient Sample was utilized from 2000 to 2010, and ICD-9 codes for AAA repair utilized for elective and ruptured cases. Clinical covariates included type of repair, in-hospital mortality, total charges converted to 2010 US dollars. Hospital covariates included hospital ownership, size, location (rural vs. urban), teaching status, and region. RESULTS: Mortality from all AAA repair is up to 50% greater in Western states with up to a 39% increase in total charges; this is associated with a 6% greater DRG mortality score and a higher proportion of ruptured aneurysms. Small hospitals (< 100 beds) need to complete an average of 5 AAA repairs annually or see a 200% increase in mortality, while larger hospitals need to complete at least 10 AAA repairs before seeing the same benefit. CONCLUSIONS: Western region, small hospital size, and completing fewer than 5-10 AAA repairs annually influence mortality following AAA repair. Some of the variation may be due to increased ruptured AAAs and more ill patients in the Western hospitals sampled. Overall mortality from ruptured AAA is greatest for hospitals in the Western United States, and has increased 12% over the past 10 years. AUTHOR DISCLOSURES: S.S. Desai: Nothing to disclose; A. Dua: Nothing to disclose.

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Demographics and outcomes for patients who underwent AAA repair in the NIS from 2000-2010.

PS42. National Trends of Operative Approach and  Mortality for Ruptured Abdominal Aortic Aneurysms from 2002 to 2011

Trit Garg, Laurence C. Baker, Matthew W. Mell.

Vascular Surgery, Stanford University, Stanford, Calif.

4:20 p.m.

OBJECTIVES: We sought to determine if trends of declining rates of ruptured abdominal aortic aneurysm (rAAA) were sustained through the most recent available data. We also examined factors associated with use of EVAR and survival after rAAA. METHODS: We analyzed fee-for-service Medicare claims for patients diagnosed with a rAAA from 2002 through 2011. Data included patient demographics, hospital characteristics, treatment type (EVAR or open surgical repair; OSR), and perioperative mortality (death upon discharge or within 30 days of repair). Statistical analysis included X2 or non-parametric tests for trends, and multivariable logistic regression. RESULTS: The cohort of rAAA comprised 4,996 patients. Repair for rAAA

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hospitalizations declined from 11.3 per 100,000 Medicare beneficiaries in 2002 to a nadir of 7.84 in 2007. From 2007 the rates have increased to a rate 8.84 in 2011 (p<0.001 for trend). The use of EVAR increased for each subsequent year (7.84% in 2002 to 51.4% in 2011; p<0.001). Mortality was lower for EVAR compared with OSR (30.0% vs. 46.6%, p<0.001). Improved mortality (52% in 2002 to 33% in 2011, p<0.001) was observed for both EVAR (44% in 2002 to 26% in 2011, p=0.014) and OSR (53% in 2002 to 41% in 2011, p=0.001). After adjusting for patient factors, EVAR was more commonly performed for men (OR 1.68 95% CI 1.60-1.77, p<0.001), in metropolitan hospitals (OR 1.15, 95% CI 1.10-1.20, p<0.001) and at high volume hospitals (OR 1.23, 95% CI 1.17-1.30, p<0.001). Improved operative mortality was independently associated with EVAR (OR 0.26; 95% CI 0.23-0.28, p<0.001), male sex (OR 0.69; 95% CI 0.64-0.75, p<0.001) and treatment in high-volume centers (OR 0.73; 95% CI 0.66-0.82, p<0.001). CONCLUSIONS: Repair for rAAA has increased since 2007. Although survival has increased for both OSR and EVAR, it has improved the most for those undergoing EVAR for rAAA. Systems that improve access to EVAR and expertise for rAAA may improve population-level outcomes. AUTHOR DISCLOSURES: L.C. Baker: Nothing to disclose; T. Garg: Nothing to disclose; M.W. Mell: Nothing to disclose. PS44. Functional Status as a Predictor of Mortality  in Open and Endovascular Abdominal Aortic Aneurysm Repair in Octogenarians

Dominic Emerson,1 Richard Amdur,2 Robyn A. Macsata.2

1

4:25 p.m.

Georgetown University Hospital, Washington, D.C.; Veterans Affairs Medical Center, Washington, D.C.

2

OBJECTIVES: The frequency at which patients greater than 80 years old are presenting for abdominal aortic aneurysm (AAA) repair is increasing; here we examine the value of functional status in predicting outcomes in endovascular (EVAR) and open (OR) abdominal aortic aneurysm repair within this population. METHODS: All patients who underwent EVAR or OR from 2002-2010 in the Veterans Affairs National Quality Improvement Program (VASQIP) database were identified. Functional status (F), defined as an ordinal scale from 1-3 (1-independent, 2-partially dependent, 3-totally dependent), was examined using multivariate regression models, with 30-day mortality as the primary outcome; morbidity was examined as a secondary end point. Statistical analysis was performed using a student’s t-test, or X2 test, where appropriate. RESULTS: In total, 9030 patients underwent AAA repair (4822 EVAR, 4208 OR); mortality was 2.8% (1.7% vs. 4.2%, respectively, p<0.001). 1340 patients were 80 (902 EVAR, 438 OR); mortality was 4.9% (2.9% vs. 9.1%, respectively, p<0.001). Functional status was abnormal (2-3) in 9.5% of all patients and in 5.1% of those 80. See table. CONCLUSIONS: Functional status is an independent predictor of mortality for EVAR and OR; it is generally not associated with increased morbidity, however, does correlate to a longer LOS. This trend is more pronounced among those 80 years old. AUTHOR DISCLOSURES: R. Amdur: Nothing to disclose; D. Emerson: Nothing to disclose; R.A. Macsata: Nothing to disclose.

150


All AAA (n=9030)

≥80 Years Old (n=1340)

F=1

F=2-3

P (OR)

F=1

F=2-3

P (OR)

30d Mortality

2.5%

8.0%

P<0.001 (3.3)

3.9%

14.8%

P<0.001 (4.4)

LOS

7.1 d

10.5 d

P<0.001

7.9 d

12.2 d

P<0.001

Neurologic

4.3%

1.1%

P=0.068 (2.4)

0.5%

0.8%

P=0.505 (1.6) P=0.210 (1.9)

Cardiac

1.4%

1.9%

P=0.321 (1.4)

2.1%

3.9%

Pulmonary

5.7%

10.3%

P<0.001 (1.9)

6.5%

10.9%

P=0.068 (1.8)

Renal

1.7%

2.5%

P=0.202 (1.5)

2.6%

3.9%

P=0.382 (1.5)

PS48. McGill University Sheath-Shunt Technique  (MUSST) for Avoiding Lower Limb Ischemia During Complex Endovascular Aneurysm Repair

4:30 p.m.

Simon Neequaye,1 Stephen C. Hanley,2 Kent Mackenzie,2 Oren Steinmetz,2 Daniel I. Obrand,3 Marc-Michel Corriveau,2 Cherrie Z. Abraham.3 1  Royal Liverpool and Broadgreen University Hospitals, Liverpool, United Kingdom; 2McGill University Health Centre, Montreal, Quebec, Canada; 3Jewish General Hospital, Montreal, Quebec, Canada.

OBJECTIVES: Complex aortic aneurysms are being repaired by endovascular techniques with increasing frequency. While EVAR is generally associated with a reduction in complications as compared to open repair, complex EVAR requires the use of a large diameter introducer sheath that can occlude arterial flow to the lower limb. This fact, along with longer procedure times, suggests that complex EVAR techniques may increase the risk of lower limb ischemia and reperfusion injury. METHODS: We have adopted a technique (McGill University sheath-shunt technique; MUSST) whereby an additional 6 or 7 Fr introducer sheath is placed distal to the stent-graft introduction site in antegrade fashion. This sheath is then connected to the side-arm of one of the introducer sheaths placed in the contralateral limb, allowing continuous perfusion of the limb distal to the stent-graft introduction site. Arterial perfusion distal to the stent-graft introduction site, both before and during shunting, was assessed by duplex ultrasonography, while shunt flow was measured by transit-time flow measurement. RESULTS: In our initial experience with seven patients undergoing complex EVAR, with confirmed occlusion of the native arterial system by the stent-graft introduction site, occlusion time was 169 ± 55 minutes. Use of the sheath-shunt technique resulted in pulsatile flow in all cases, with an average flow of 45 ± 10 mL/min. There were no complications related to the use of this technique. CONCLUSIONS: In patients undergoing complex EVAR who are at increased risk of lower limb ischemia and reperfusion injury, the MUSST technique results in continued perfusion of a limb that would otherwise be ischemic for a significant amount of time. Given the limited risk of this technique coupled with the potential benefit, we propose its use in all patients undergoing complex EVAR. AUTHOR DISCLOSURES: C.Z. Abraham: Nothing to disclose; M. Corriveau: Nothing to disclose; S.C. Hanley: Nothing to disclose; K. Mackenzie: Nothing to disclose; S. Neequaye: Nothing to disclose; D.I. Obrand: Nothing to disclose; O. Steinmetz: Nothing to disclose.

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C8c: Complications   

3:30 – 5:00 p.m. uAuditorium, Level 2 (enter through Exhibit Hall C)

Moderator: Jason T. Lee, MD, Stanford University Medical Center, Stanford, Calif.

PS50. Management of Thoracic Aortic Endograft Infection 

3:40 p.m.

Andrea Kahlberg, Efrem Civilini, Germano Melissano, Roberto Chiesa.

 ascular Surgery, Vita-Salute University, San Raffaele Scientific Institute, V Milan, Italy.

OBJECTIVES: Most surveillance after thoracic endovascular aortic repair (TEVAR) concentrates on the technical aspects of the procedure, including endoleak, device migration and endoprosthesis rupture; so far, the knowledge on endoprosthesis infective complications is quite limited. METHODS: From 1999 to 2013, 478 TEVAR were performed at our institution. In the same period, thoracic endograft infection (TEI) was identified in 12 patients (10 males, mean age 61.5 years) initially treated for non-infectious disease. RESULTS: Initial TEVAR was performed at outside institutions in 5 patients, and at our institution in 7 patients, for an in-house prevalence of TEI of 1.5%. The mean time from the index procedure to the diagnosis of TEI was 14.9 months (range 1-75). Associated aortoesophageal (AEF) or aortobronchial (ABF) fistula was found in 7 and 1 case(s), respectively. Overall, 3 patients died before any surgical treatment could be performed, 8 patients were operated, and 1 patient was medically treated. In case of surgical treatment, stent-graft explantation was performed in all cases, with extra-anatomical revascularization (2 cases) or “in situ” reconstruction (6 cases). Associated tracheal or esophageal repair was performed in all AEF/ABF cases with different techniques. In-hospital mortality in the surgical cohort was 25% (2/8). Another patient died 4 months after intervention due to sepsis and bleeding. An AEF or an ABF was present in 100% of deceased patients. The other 6 patients, including the one medically treated, are alive at a mean follow-up of 43 months (range 12-108). CONCLUSIONS: TEI represents a not negligible late complication of TEVAR, and is associated with an AEF or ABF in the majority of cases. Surgical treatment includes several technical options, and it is still burdened with high mortality rates. AUTHOR DISCLOSURES: R. Chiesa: Nothing to disclose; E. Civilini: Nothing to disclose; A. Kahlberg: Nothing to disclose; G. Melissano: Nothing to disclose. PS52. Paraplegia Rates After Branched and  Fenestrated Endograft Repair of over 1000 Thoracoabdominal Aneurysms

Travis L. Engelbert, Prateek K. Gupta, Charles W. Acher.

Surgery, University of Wisconsin, Madison, Wis.

3:45 p.m.

OBJECTIVES: Open repair has long been considered the gold standard treatment for thoracoabdominal aortic aneurysms (TAAA), with paraplegia rates at centers of excellence being 3.5 to 7% (O/E 0.11-0.55). In the last decade, endograft repair (TEVAR) 152


has largely replaced open repair for thoracic aneurysms. While endovascular TAAA repair with branched and fenestrated endografts (B/FEVAR) is less common than TEVAR, data on more than 1000 repairs have been published. Our objective was to review the published literature on B/FEVAR for TAAAs to assess perioperative and long-term spinal cord ischemia (SCI) and mortality rates. METHODS: A systematic review was performed from 2003 to 2013 with a query of PubMed and EBSCOHost databases. Eleven articles fitting specified criteria were published assessing outcomes associated with elective B/FEVAR for TAAA (n=1,006 patients). Data for 30-day and long-term mortality, technical success, complications, and morbidity were gathered. SCI and protective strategies, as well as Crawford classification of extent of coverage were also collected and pooled for categorical analysis. RESULTS: Crawford classification included type I (n=44), type II (n=110), type III (n=228), and type IV (n=624) aneurysms. The 30-day mortality was 5.4% (n=54). The 1- and 2-year reported survival were 74.9% and 57.4%, respectively. SCI occurred in 7.1% (O/E 1.41) and acute renal failure was reported in 13.4% of patients. Technical success was 96.8% with endoleaks occurring in 18.8%, and reintervention during follow-up required in 19.0%. Branch patency rates ranged from 76.9% in early experiences to 98.0% in late experiences. CONCLUSIONS: When compared to open centers of excellence, B/FEVAR for TAAA has similar perioperative mortality rates but worse SCI rates. This data suggests the branched graft TAAA repair carries a greater risk of paraplegia or less effective spinal cord protective measures are used because of the misperception of less risk. AUTHOR DISCLOSURES: C.W. Acher: Nothing to disclose; T.L. Engelbert: Nothing to disclose; P.K. Gupta: Nothing to disclose. PS54. Clostridium Difficile Infections in Vascular  Surgery Patients: Evaluation of Incidence, Risk Factors and Costs

3:50 p.m.

Roman Nowygrod,1 Natalia N. Egorova,2 Jeffrey J. Siracuse,1 James F. McKinsey.1 1  Columbia University Medical Center, New York City, N.Y.; 2 Icahn School of Medicine at Mount Sinai, New York City, N.Y.

OBJECTIVES: Starting in December 2013, the Hospital Inpatient Quality Reporting Program includes Clostridium difficile (C. diff) infection rates as a new publicly reported quality measure. Our goal was to review the incidence, trend, and hospital variability in C. diff rates as well as associated risk factors and costs in vascular surgery. METHODS: The incidence of C. diff diagnoses after major vascular procedures of AAA repair, carotid and lower extremities revascularization (LER), and LE amputation was identified using Nationwide Inpatient Sample database for 2000-2010. Costs were assessed using cost-to-charge ratio. Risk factors associated with C. diff were analyzed with hierarchical multivariate logistic regression. RESULTS: During the past decade the rates of C. diff after vascular procedures had steadily increased by 66% from 0.6 to 0.99%. In 2010, the highest rates were after ruptured AAA repair (2.7%), while the lowest rates were after carotid endarterectomy (0.1%). The incidence of C. diff increased after open AAA, endo-LER and CEA by 141%, 115%, and 40% respectively. In 2010, patients who had experienced C. diff had median length of stay of 15 days (IQR 9, 26 days), in-hospital mortality 9.8%, and $20,600 extra cost per hospitalization. The national cost associated with C. diff treatment was ~$86.7

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million. Hospital incidence of C. diff varied from 0-50% with 3.5% of hospitals having infection rates 5%. Factors associated with C. diff included patient advanced age, female gender, renal insufficiency, multiple chronic conditions, emergent and weekend hospitalizations, hospital transfers, surgery type, and hospital characteristics (large, urban, public, and smaller RN FTEs rates). CONCLUSIONS: Despite potential reduction of infection rates as evidenced by the experience of hospitals with effective interventions, C. diff incidence is increasing among vascular patients and is associated with prolonged length of stay, increased mortality and higher costs. AUTHOR DISCLOSURES: N.N. Egorova: Nothing to disclose; J.F. McKinsey: Nothing to disclose; R. Nowygrod: Nothing to disclose; J.J. Siracuse: Nothing to disclose. PS56. Acute Kidney Injury in Critically Ill Vascular  Surgery Patients Is Associated with Increased Mortality Regardless of Severity and Type of Index Procedure

3:55 p.m.

Donald G. Harris,1 Grace Koo,1 Michelle P. McCrone,1 Rajabrata Sarkar,1 William C. Chiu,2 Thomas M. Scalea,2 Jose J. Diaz,2 Matthew E. Lissauer,2 Robert S. Crawford.1 1  Department of Surgery, University of Maryland School of Medicine, Baltimore, Md.; 2R Adams Cowley Shock Trauma Center; University of Maryland School of Medicine, Baltimore, Md.

OBJECTIVES: Perioperative acute kidney injury (AKI) is common, but has only been studied in select vascular surgery subgroups. We studied the incidence, risk factors and outcomes of AKI in a broad vascular surgery cohort. METHODS: This was a retrospective analysis of vascular patients from a 1-year cohort of surgical ICU admissions at a tertiary hospital. Patients were identified from a prospective APACHE IV database. The endpoint was AKI by RIFLE creatinine (Cr, mg/dL) criteria (increase vs. baseline: Risk, 1.5x; Injury, 2x; Failure, 3x). Outcomes were: inpatient & 1-year mortality, SICU & hospital lengths of stay and discharge. Cr. AKI and non-AKI groups were compared by univariate analysis, and AKI risk factors assessed by multivariate regression. RESULTS: Of 628 SICU admissions, 136 (22%) were vascular patients (28% of all vascular patients). 65 (48%) developed AKI, a rate similar to non-vascular patients (234/492, 48%; P=1.0). AKI and non-AKI patients had similar baseline Cr (0.90±0.44 vs. 0.96±0.46; P=0.73). Independent risk factors for AKI were increasing illness severity (APACHE III >50: OR 1.3, 1.1-1.6; P=0.01) and diabetes (OR 1.2, 1.1-1.5; P<0.05). Admission urgency and surgery class (aortic, peripheral vascular, carotid or endovascular) did not predict AKI. AKI patients had higher mortality (inpatient: 20% vs. 1%, 1-year: 34% vs. 14%; P<0.01 both). Among AKI patients, mortality was increased even for mild renal dysfunction (1-year mortality: Risk 33% vs. Injury/Failure 36%; P=0.79). With AKI, lengths of stay were longer (SICU: 8±8 vs. 4±2, hospital: 20±15 vs. 11±8 days; P<0.001) and discharge Cr higher (1.47±1.15 vs. 0.92±0.49; P<0.001). CONCLUSIONS: AKI is common among vascular surgery patients requiring SICU admission, regardless of admission status or surgery class. All severities of renal dysfunction are associated with significantly worse outcomes. Further study with identification of early, modifiable risk factors, particularly in elective surgery patients, may prevent AKI and improve outcomes.

154


AUTHOR DISCLOSURES: W.C. Chiu: Nothing to disclose; R.S. Crawford: Nothing to disclose; J.J. Diaz: Nothing to disclose; D.G. Harris: Nothing to disclose; G. Koo: Nothing to disclose; M.E. Lissauer: Nothing to disclose; M.P. McCrone: Nothing to disclose; R. Sarkar: Nothing to disclose; T.M. Scalea: Nothing to disclose. PS58. Changes in and Factors Affecting Failure  to Rescue Mortality After Elective Abdominal Aortic Aneurysm Repair: 1995-2011

4:00 p.m.

Nicole Ilonzo,1 Natalia N. Egorova,2 Eugene A. Sosunov,2 James F. McKinsey,1 Roman Nowygrod.1

Columbia University Medical Center, New York City, N.Y.; 2 Icahn School of Medicine at Mount Sinai, New York City, N.Y. 1

OBJECTIVES: Factors affecting mortality after abdominal aortic aneurysm (AAA) repair have been extensively studied, but little is known about the effects of the shift to endovascular (EVAR) vs. open repair (OAR) and of interhospital transfers on failure to rescue (FTR). This study examines the impact of these factors on FTR after elective AAA surgery from 1995-2011. METHODS: Patient demographics, comorbidities, hospital volume, repair type, and patient transfer status for 491,658 patients undergoing elective AAA surgery were collected using Medicare files. Primary outcome was FTR: the percentage of deaths in patients who had a complication within 30 days of surgery. Data was analyzed using univariate and multivariate analysis. RESULTS: In parallel with shifts from OAR to EVAR, overall FTR after AAA surgery decreased from 4.5 in 1995 to 2.2% in 2011 (P<.001), while FTR for OAR increased from 4.4 to 5.7% (P<.001) and for EVAR decreased from 2.1 to 1.3% (P<.001). FTR rates were higher in low (1-2 procedures/yr) vs. high (>20 procedures/yr) volume hospitals after either OAR (6.1 vs. 3.4%) or EVAR (2.4 vs. 1.1%). FTR for patients who underwent AAA surgery and management of their complication at their primary institution decreased from 4.5 to 2.1% (P<.001) over the study time. Patients were more likely to be transferred if they had coronary artery disease, renal failure, pulmonary disease, or needed OAR. Transferred patients experienced more postoperative cardiac (9.0 vs. 4.7%, P<.001), respiratory (18.1 vs. 12.7%, P<.001), and arterial complications (8.1 vs. 4.3%, P<.001). Transfer into high volume hospitals of clinically complex patients was associated with decreased FTR (RR .83, CI .72-.96, P=.003). CONCLUSIONS: The success in AAA surgery of rescuing patients from 30-day mortality after complications has significantly improved over the last 12 years as a result of the increased volume of EVAR. Clinically complex patients were less likely to incur complications and mortality if they were treated in high volume centers. AUTHOR DISCLOSURES: N.N. Egorova: Nothing to disclose; N. Ilonzo: Nothing to disclose; J.F. McKinsey: Nothing to disclose; R. Nowygrod: Nothing to disclose; E.A. Sosunov: Nothing to disclose. PS60. Predicting Cerebral Hyperperfusion Syndrome  with Velocity Systolic Blood Pressure Index

Zhichao Lai, Bao Liu, Changwei Liu.

Peking Union Medical College Hospital, Beijing, China.

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4:05 p.m.

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OBJECTIVES: Cerebral hyperperfusion syndrome (CHS) is a life-threatening complication of carotid endarterectomy (CEA); the changes in the middle cerebral artery velocity (MCAV) are used to predict the occurrence of CHS, but the accuracy of this measurement is limited. Therefore, we aimed to identify the relationship between the increase in BP in the early stage after surgery and CHS occurrence. Additionally, we aimed to combine the change in MCAV and the increase in BP in the early stage after surgery to create a more precise parameter to predict the patients that are at risk for CHS. METHODS: A prospective study was held from October 2010 to January 2013. A total of 185 patients were recruited. Patients were classified according to the occurrence or absence of CHS. The velocity systolic blood pressure index (VSI) was calculated from the post-operative increase ratio of the MCAV and systematic blood pressure crossing CEA. The post-operative increase ratios of MCAV (VR), for predicting CHS occurrence were also calculated. The prediction powers of these different calculations for CHS were compared. The sensitivities, specificities, positive predictive values, and negative predictive values of these measurements were calculated. A receiver operating characteristic analysis (ROC) was performed. RESULTS: Eleven cases of CHS were diagnosed. A best-fit cutoff point of 1.7 for VSI was identified, which had 100% sensitivity, 84% specificity. This result is significantly better than the traditional parameter, VR. The sensitivity of VSI is four times higher than that of VR. The area under the curve (AUC) of ROC of VSI was 0.934, AUC of VR =0.872, p=0.008. CONCLUSIONS: VSI can be a useful new parameter to diagnose CHS in patients after undergoing CEA under general anesthesia. However, this observation needs to be validated by other larger studies. AUTHOR DISCLOSURES: Z. Lai: Nothing to disclose; B. Liu: Nothing to disclose; C. Liu: Nothing to disclose. PS62. Vascular Surgery Readmissions After  Common Vascular Procedures: Risk Factors and Cost Analysis

4:10 p.m.

Nathan T. Orr, Shady El-Maraghi, Daniel L. Davenport, Eleftherios S. Xenos.

University of Kentucky, Lexington, Ky.

OBJECTIVES: The aim of this study is to analyze readmissions and their associated hospital costs after common vascular surgeries at a single institution. METHODS: Patients undergoing open or endovascular abdominal aortic aneurysm repair (oAAA/eAAA), aorto-iliac revascularization (oAIR/eAIR), or infrainguinal revascularization (oIIR/eIIR) from 2010 through 2012 were retrospectively evaluated. We compared 30- and 90-day readmission rates and costs by procedure group, tabulated reasons for readmission and identified preoperative and perioperative risk factors by univariate analysis. Parametric or non-parametric methods were used as appropriate. RESULTS: 219 cases were analyzed which had a 30-day readmission rate of 16.9% and 90-day readmission rate of 27.4% (Table). Median readmission costs were $10,700. The most frequent reasons for readmissions related to the procedure were surgical wound complications (60%), graft occlusion (14%), and renal insufficiency/failure (8%), bleeding (5%) and endoleak (5%). Risk factors for readmission included hyperglycemia on discharge, perioperative transfusion, preoperative open wound, dialysis, COPD, and functional dependency.

156


CONCLUSIONS: Vascular surgery readmissions occur at a rate of 27.4% at 90-days and have an associated median cost of $10,700 per readmission comprising an additional 38.6% beyond the index admission cost. Prevention of surgical wound complications and vigilance to ensure that open wounds and chronic comorbidities are well managed as patients leave the hospital should be the focus of interventions aiming at reducing readmissions. AUTHOR DISCLOSURES: D.L. Davenport: Nothing to disclose; S. El-Maraghi: Nothing to disclose; N.T. Orr: Nothing to disclose; E.S. Xenos: Nothing to disclose. Table: Readmission rates and costs by procedure Procedure

Median Index Costs $000's

≤30 Day Readmission %

≤90 Day Readmission %

Median Readmission Costs $000's

eAAA

38

14

21

18

oAAA

42

13

13

1.4

eAIR

18

19

25

23

oAIR

29

29

29

3.3 9.7

eIIR

18

9

32

oIIR

25

24

41

10

Total

27.7

16.9

27.4

10.7

 

PS64. Iliac Injury During Abdominal and Thoracic  Aortic Endovascular Intervention

4:15 p.m.

Samir K. Shah, James F. Bena, Federico E. Parodi, Alisha Moreno, Daniel G. Clair.

Vascular Surgery, Cleveland Clinic, Cleveland, Ohio.

OBJECTIVES: Iliac injury is a devastating and potentially avoidable complication of endovascular aortic intervention. To our knowledge, this study is the first investigation of demographic, anatomic, and device factors related to injury in vascular surgery patients. METHODS: We retrospectively examined 1859 endovascular aortic interventions and found 42 iliac injuries, including 21 ruptures. Demographic, anatomic, and device data were extracted from these patients and a cohort of 200 case-matched control patients derived from the group of uninjured patients. Anatomic data includes centerline and straight distance measurement of the iliac system from the aortic bifurcation to the inguinal ligament. The ratio of the two (“tortuosity index”) was calculated. Additional data includes midpoint and narrowest diameters in the iliac system along with the most acute angle. Each measurement was taken for the side through which the main body was introduced (“device side”) and the contralateral side. RESULTS: Demographic factors associated with injury were female gender (p<0.001) and non-Caucasian race (p=0.028). None of the examined comorbidities were associated with iliac injury. Increasing sheath size was associated with injury (p<0.001). Device-side anatomic factors associated with injury are decreasing iliac midpoint (p=0.002) and narrowest diameters (p<0.001). Contralateral-side anatomic variables associated with injury are iliac centerline distance (p=0.030), decreasing midpoint (p<0.001) and narrowest diameters (p<0.001), and angularity (p=0.036). Injury is associated with inpatient death (p<0.001) with iliac rupture conferring an OR of 15.3 (p<0.001).

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CONCLUSIONS: Iliac injury is associated with death on the index admission. Female gender, non-Caucasian race, large sheath sizes, and iliac occlusive disease and angularity are associated with iliac injury. These findings should be prospectively evaluated along with interventions to reduce injury. AUTHOR DISCLOSURES: J.F. Bena: Nothing to disclose; D.G. Clair: Nothing to disclose; A. Moreno: Nothing to disclose; F.E. Parodi: Nothing to disclose; S.K. Shah: Nothing to disclose. PS66. National Trends in Surgical Site Infections  in Open Vascular Procedures: Has SCIP Made an Impact?

4:20 p.m.

Anahita Dua,1 Sapan S. Desai,2 SreyRam Kuy,3 Charles E. Edmiston,4 Cheong J. Lee.3

1 Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas-Houston, Houston, Texas; 2Department of Surgery, Duke University Medical Center, Durham, N.C.; 3Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis.; 4Department of Infectious Disease, Medical College of Wisconsin, Milwaukee, Wis.

OBJECTIVES: The Surgical Care Improvement Project (SCIP) is a national initiative to reduce surgical complications including post-operative surgical site infection (SSI) through protocol driven antibiotic usage. This study aimed to determine the impact SCIP guidelines had on SSIs after open vascular procedures. METHODS: A retrospective analysis was completed using the National Inpatient Sample (NIS) utilizing ICD-9 diagnosis codes to capture patients who underwent elective carotid endarterectomy (CEA), elective open repair of abdominal aortic aneurysms (AAA), and peripheral bypass who developed surgical site infections (SSIs). The pre-SCIP era was defined as 2000-2005 and post-SCIP was defined as 2007-2010. The year 2006 was excluded as it was the transition year in which the SCIP guidelines were implemented. ANOVA and chi-square testing were utilized for statistical analysis. RESULTS: The incidence of SSI was higher in the post-SCIP era for open AAA repairs. For those who underwent CEA or peripheral bypass, there was no difference in SSI rates in the pre to post SCIP era (Table 1). There were no significant differences between demographics or in-hospital mortality between groups. CONCLUSIONS: Implementation of SCIP guidelines has made no significant impact on the incidence of SSI in open vascular operations; rather an increase in SSI rates in open AAA repairs was observed. AUTHOR DISCLOSURES: S.S. Desai: Nothing to disclose; A. Dua: Nothing to disclose; C.E. Edmiston: Nothing to disclose; S. Kuy: Nothing to disclose; C.J. Lee: Nothing to disclose.

158


SSI CEA

2000

2001

2002

2003

2004

2005

2007

2008

2009

2010

446

384

435

412

369

340

364

328

300

251

Total 20,230 19,700 19,539 18,062 16,558 15,183 13,999 14,193 13,354 12,311 %

2.2

1.9

2.2

2.3

2.2

2.2

2.6

2.3

2.2

SSI

51

52

60

57

50

41

45

20

42

27

5,563

4,958

4,698

4,156

3,570

2,616

2,597

2,302

1,782

AAA (p<0.05) Total 7,572

Bypass

2.0

%

0.7

0.9

1.2

1.2

1.2

1.1

1.7

0.8

1.8

1.5

SSI

42

35

48

44

37

48

36

39

29

19

Total 30,277 30,190 30,979 29,440 26,285 25,188 24,628 24,541 22,592 19,665 %

0.1

0.1

0.2

0.1

0.1

0.2

0.1

0.2

PS68. Post-Procedural Pseudo-Aneurysms:  Experience in 170 Patients

0.1

0.1

4:25 p.m.

Loay Kabbani, Farah Mohammad, Praveen Balraj, Judith Lin, Efstathios Karamanos, Fatema Esmael, Alexander Shepard.

Henry Ford Hospital, Detroit, Mich.

OBJECTIVES: Pseudo-aneurysms (PA) are a well-recognized complication of percutaneous angiographic procedures. Ultrasound-guided thrombin injection is currently the preferred treatment modality. This study was undertaken to evaluate our experience with post procedure PA (PPPA). METHODS: A retrospective study was performed of all patients who developed a PPPA between March 2004 and January 2013. Data was obtained from our prospectively maintained non-invasive vascular lab data bank. RESULTS: 167 patients (80 men) with PPPA were identified. Mean age was 66 years. PPPA developed following diagnostic coronary angiography [65 (38%)], coronary angioplasty [63 (37%)], peripheral vascular interventions [25 (14.7%)], and other access procedures [13 (7.6%)]. Mean PPAA diameter was 2.8 ± 1.8 cm. One hundred and forty-two PPPA were injected with thrombin under ultrasound guidance. There were 12 failures (8.5%) of which 10 (83%) responded to re-injection and 2 (17%) required operative management. Failures were associated with increasing aneurysm diameter (p=0.006; OR 2.23, 95% CI 1.25 to 3.96) and ESRD (p=0.013; OR 1.15, 95% CI 1.09 to 1.78). There were two episodes of thrombus formation in the femoral artery - one resolved with anticoagulation alone and the other required thrombectomy. Treatment of the 25 PPPA not injected included ultrasound-guided compression [7 (25%)], surgical repair [10 (46.5%)], and observation [8 (28.5%)]. CONCLUSIONS: Percutaneous ultrasound-guided thrombin injection is an effective and safe treatment for PPPA. Failure rates are low and associated with larger aneurysm size and ESRD. AUTHOR DISCLOSURES: P. Balraj: Nothing to disclose; F. Esmael: Nothing to disclose; L. Kabbani: Nothing to disclose; E. Karamanos: Nothing to disclose; J. Lin: Nothing to disclose; F. Mohammad: Nothing to disclose; A. Shepard: Nothing to disclose.

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PS70. Patient Age Is an Independent Predictor of  Mortality After Emergency Vascular Surgery

4:30 p.m.

John E. Scarborough, Sandhya A. Lagoo-Deenadayalan, Theodore N. Pappas, Kyla M. Bennett, Cynthia K. Shortell.

Duke University Medical Center, Durham, N.C.

OBJECTIVES: To determine the association between patient age and 30-day postoperative outcomes for patients undergoing emergency vascular surgery. METHODS: The 2005-2011 ACS-NSQIP database was used for this analysis. Procedure- and age-specific postoperative outcomes were determined for patients undergoing operation for AAA, lower extremity arterial thromboembolism, or of an existing vascular graft. Multivariate logistic regression was used to determine the association between patient age outcomes after adjustment for a comprehensive array of patient- and procedure-related variables. The frequency of postoperative complications, and the subsequent mortality associated with those complications, was also determined. RESULTS: Elderly emergency patients accounted for only 6.6% of the 154,851 vascular operations included in ACS-NSQIP, but 34.7% of the 1,908 postoperative deaths. After emergency vascular surgery, patient age is an independent predictor of 30-day mortality but not major morbidity (see Figure). Older patients who sustain major complications are less likely to undergo reoperation, and are more likely to die, than younger patients who experience similar complications (see Figure). CONCLUSIONS: Elderly emergency patients account for a disproportionate number of deaths after vascular surgery, and therefore represent an ideal target for quality improvement initiatives. Our findings suggest that the excess mortality experienced by elderly patients is due in part to a lower likelihood of receiving aggressive management of postoperative complications. AUTHOR DISCLOSURES: K.M. Bennett: Nothing to disclose; S.A. Lagoo-Deenadayalan: Nothing to disclose; T.N. Pappas: Nothing to disclose; J.E. Scarborough: Nothing to disclose; C.K. Shortell: Nothing to disclose.

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PS72. The Incidence and Risk Factors for Graft Infection  of Chronically Occluded Prosthetic Grafts After Major Lower Extremity Amputation

4:35 p.m.

Adriana Gamboa Ayala, Neal R. Barshes, George Pisimisis, Peter Lin, Panos Kougias, Carlos F. Bechara.

Baylor College of Medicine, Houston, Texas.

OBJECTIVES: The data on incidence of graft infection after major amputation in chronically occluded prosthetic grafts are scarce. We elected to look at the short-term and long-term incidence as well as risk factors for prosthetic graft infection after major amputation. METHODS: This is a single center retrospective study. The amputation records to identify patients that suffered graft infection after a major amputation were reviewed between 1/1/2009-12/30/2012. We included patients that had a failed lower extremity prosthetic bypass and required an amputation at least 3 months after the bypass. We performed univariate and multivariate analysis. RESULTS: We reviewed 234 major amputations, average age was 66.2 years, 33 patients had at least one occluded prosthetic graft at the time of the amputation. The incidence of graft infection among those with a history of previous prosthetic bypass was 18% (6 of 33 patients). All 6 cases required graft removal with a median time of 24 months and 36 days after the bypass operation and the amputation, respectively. Univariate and multivariate analysis showed that history of DVT (odds ratio=17.3, p=0.04) was associated with post-amputation graft infection, while hypertension was protective (odds ratio=0.038, p=0.013). Stump revision was not a risk factor for graft infection. CONCLUSIONS: Incidence of chronically occluded prosthetic graft infection after a major amputation is significant. Based on this study and other data in the literature, complete graft removal might be justified in patients with history of DVT undergoing a major lower extremity amputation. AUTHOR DISCLOSURES: N.R. Barshes: Nothing to disclose; C.F. Bechara: Nothing to disclose; A. Gamboa Ayala: Nothing to disclose; P. Kougias: Nothing to disclose; P. Lin: Nothing to disclose; G. Pisimisis: Nothing to disclose. C8d: V  ascular Laboratory and Imaging •  Renal/Visceral • Educational/ Training Credentialing

3:30 – 5:00 p.m. uAuditorium, Level 2 (enter through Exhibit Hall C)

Moderator: Benjamin W. Starnes, MD, University of Washington, Seattle, Wash.

PS74. Obesity Is Associated with Elevated  Radiation Exposure During Endovascular Aortic Aneurysm Repair

3:40 p.m.

Michael Amendola,1 John Pfeifer,1 Luke Wolfe,2 Marcela Woogen-Fisher,1 Mark Levy.2

McGuire Veterans Affairs Medical Center, Richmond, Va.; 2 Virginia Commonwealth University Health System, Richmond, Va. 1

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OBJECTIVES: Endovascular aortic aneurysm repair (EVAR) is the preferred method for treating infrarenal aortic aneurysms. Limited data is available correlating elevated body mass index (BMI) to radiation exposure during EVAR procedures. METHODS: Serially encountered patients who underwent EVAR from September 2011 to December 2013 were identified. The population was divided into a high BMI group (≤ 26 kg/m2) and a low BMI group (< 26 kg/m2). Patient demographics, operative times, number of EVAR components utilized, adjunctive open/endovascular procedures, contrast utilized, fluoroscopy time and radiation exposure data were collected and analyzed. RESULTS: Sixty-two EVAR procedures were performed. The high BMI group was significantly younger than the low BMI group (67 ± 6 years vs. 73 ± 7 years, p = 0.0015; Wilcoxon Two-Sample Rank Test). Patient factors including diabetes, hypertension and smoking history were not significantly different between the two cohorts. All patients were male. Multiple linear regression models with step-wise selection of all variables identified four factors (operative time, contrast utilized, fluoroscopy time and BMI) as significant predictors of increased radiation exposure levels. CONCLUSIONS: Retrospective analysis of EVAR demonstrates that patients with modestly elevated BMI had markedly increased radiation exposure. This finding has patient safety implications but also serves as a warning to providers who are conducting EVARs in patients with elevated BMI. AUTHOR DISCLOSURES: M. Amendola: Nothing to disclose; M. Levy: Nothing to disclose; J. Pfeifer: Nothing to disclose; L. Wolfe: Nothing to disclose; M. Woogen-Fisher: Nothing to disclose. Low BMI (n=24)

High BMI (n=36)

p value‡

Body Mass Index (mean +/- SD)

23.1 +/- 2.0 kg/m2 31.4 +/- 4.5 kg/m2 <0.0001

Operative Time (mean +/- SD)

144 +/- 30 minutes 155 +/- 30 minutes

0.1365

Number of EVAR Components Used (mean +/- SD)

2.8 +/- 0.7 components

2.8 +/- 0.8 components

0.8823

Fluoroscopy Time (mean +/- SD)

19.5 +/- 8.2 minutes

19.7 +/- 10.4 minutes

0.9194

Radiation Exposure (mean +/- SD)

380.6 +/- 240.4 mGy

670.7 +/- 430.3 mGy

0.0007

‡Wilcoxon Two-Sample Rank Test

PS76. Expanded Screening for Mesenteric Ischemia  Improves Diagnosis and Decreases Mortality

Sapan S. Desai,1 Anahita Dua.2

1

3:45 p.m.

Department of Surgery, Duke University, Durham, N.C.; 2 Medical College of Wisconsin, Milwaukee, Wis.

OBJECTIVES: The aim of this study was to evaluate national trends in screening for mesenteric ischemia and its impact on the diagnosis and mortality. METHODS: A retrospective analysis of the cross-sectional National Inpatient Sample (2000-2011) was used to evaluate patients who underwent screening evaluation for acute and chronic mesenteric ischemia, and this was correlated with the number of open and endovascular interventions, in-hospital mortality, length of stay, and total charges (2011 USD). 162


RESULTS: The number of open interventions for mesenteric ischemia increased 33%, while endovascular interventions increased by 468% over the study period. Earlier diagnosis led to a decrease in acute mesenteric ischemia from 62% in 2000 to 43% in 2011 (P<0.05). This was associated with a 64% decline in in-hospital mortality (28.3% to 17.3%), and a decrease in median length of stay from 11 to 8 days. During this period, noninvasive screening for mesenteric ischemia increased by 73%. The rate of bowel resection remained constant at 8.7%. Total charges increased by 34% during the study period. CONCLUSIONS: Increased utilization of noninvasive screening for mesenteric ischemia is associated with earlier diagnosis, an increase in open and endovascular interventions, decreased length of stay, and decreased in-hospital mortality. However, the utilization of screening does not affect the rate of complications following intervention. AUTHOR DISCLOSURES: S.S. Desai: Nothing to disclose; A. Dua: Nothing to disclose.

Trends in open and endovascular interventions for acute and chronic mesenteric ischemia utilization the National Inpatient Sample (2000-2011).

PS78. The OPTIMISE Trial: Intravascular Optical  Coherence Tomography in Lower Extremity Arteries

3:50 p.m.

Daniel Kendrick,1 Matthew T. Allemang,1 Nathaniel Liu,1 Andre Gosling,1 Anil Nagavalli,2 Elizabeth Kudlaty,2 Henry Baele,1 Hiram Bezerra,1 Vikram S. Kashyap.1

University Hospital-Case Medical Center, Harrington Heart and Vascular Institute, Cleveland, Ohio; 2Case Western Reserve University, Dept. of Physiology and Biophysics, Cleveland, Ohio. 1

OBJECTIVES: Intravascular Optical Coherence Tomography (OCT) utilizes a fiberoptic catheter to generate a high-resolution, cross-sectional image of small blood vessels but Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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requires blood clearing. OCT is used in coronary vessels to generate axial images superior to IVUS or conventional angiography for morphology assessment. This firstin-man trial examines OCT and determines the optimum flush medium in lower extremity OCT image capture. METHODS: OPTical Imaging Measurement of Intravascular Solution Efficacy (OPTIMISE) Trial is a single-center, prospective study. 28 patients were recruited undergoing elective endovascular intervention in a patent superficial femoral artery. A 54-mm segment was imaged using an OCT system with automated pullback over 2-3 seconds. Successive flush media were injected in random order to generate imaging segments. Adequate vessel clearance was defined as a >270° visualization of all vessel wall layers from the imaged segment. Analysis included one-way ANOVA with Tukey test. RESULTS: 19 patients (mean age 68.2 years; 52.6% male) had ≥1 OCT images generated from 106 total runs. The average diameter vessel imaged was (3.99 mm +/- 1.01). OCT imaging allowed 15 μm resolution of the luminal border in vessels <5 mm. High quality image capture for each medium are as follows with 95% CI: heparin saline 63.7%; [51.3-76.3], dextran 54.9%; [34.9-54.9], contrast 47.0%; [32.4-61.5] and CO2 14.5%; [0.0-50.0] with a significant difference of means by one-way ANOVA (p=.038). Saline was significantly better in image quality than CO2, CI difference of means [0.02-0.97]. There were 9 technical exclusions, but no procedural related complications. CONCLUSIONS: In this initial sample, OCT is feasible in large caliber peripheral vessels less than 5 mm. CO2 does not provide adequate clearance for OCT imaging. Clearance via heparin saline is promising, can be used for multiple pullbacks and avoids iodinated contrast. Axial imaging identifies plaque morphology and may aid in endovascular interventions. AUTHOR DISCLOSURES: M.T. Allemang: Nothing to disclose; H. Baele: Nothing to disclose; H. Bezerra: Nothing to disclose; A. Gosling: Nothing to disclose; V.S. Kashyap: Nothing to disclose; D. Kendrick: Nothing to disclose; E. Kudlaty: Nothing to disclose; N. Liu: Nothing to disclose; A. Nagavalli: Nothing to disclose. PS80. Safety and Feasibility of Intravascular  Optical Coherence Tomography to Evaluate Lesions of Femoro-Popliteal Arterial Segment Before and After Endovascular Treatment

3:55 p.m.

Gianmarco de Donato,1 Francesco Setacci,2 Giuseppe Galzerano,1 Maria Pia Borrelli,1 Umberto Ruzzi,1 Carlo Setacci.1

Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy; P. Valdoni Department of Surgery, La Sapienza University, Rome, Italy.

1 2

OBJECTIVES: To evaluate the feasibility and image quality assessment of optical coherence tomography (OCT) for the in-vivo examination of de-novo lesions or restenosis of lower limb arteries, before and after endovascular treatment. METHODS: OCT was performed in 15 consecutive patients with peripheral arterial obstructive disease (PAD) of femoro-popliteal segments, undergoing endovascular treatment. Images were acquired before treatment, immediately after balloon angioplasty, and following bail-out stenting and post-dilatation, if necessary (range 2-6 scans/patient). Two independent physicians judged blinded sets of OCT images for image quality, artifact frequency, discriminability of the vessel wall layers and plaques on a pre-defined 1-10 scale. The proportions of specific agreement and kappa values (k) were calculated. 164


RESULTS: Twenty-two arterial lesions of the femoro-poplitel arterial segment were studied, for a total of 58 OCT acquisitions. No procedural or in-hospital complications related to OCT images acquisition occurred. The technical success of OCT pullbacks was 94.8% (55/58). The images obtained were of high quality (mean value 8.3/10), both with good interand intra-observer agreement (respectively k=0.85 and k=0.94). OCT image quality improved with decreasing vessel diameter, and decreased with the presence of multiple collateral vessels. OCT images after endovascular treatment revealed innovative features such as intimal tears, flaps and residual dissection, intimal or subintimal guidewire passage, as well as plaque prolapse through the stent cell and malapposition in case of stenting. CONCLUSIONS: Intravascular OCT appears to be feasible and safe in femoropopliteal arterial segments, permitting the acquisition of high quality images that might increase our understanding in the application of endovascular technique to the femoropopliteal arterial segments, as well as influencing our clinical policies. AUTHOR DISCLOSURES: M. Borrelli: Nothing to disclose; G. de Donato: Nothing to disclose; G. Galzerano: Nothing to disclose; U. Ruzzi: Nothing to disclose; C. Setacci: Nothing to disclose; F. Setacci: Nothing to disclose. PS82. Measurement of Carotid Plaque Volume  by 3D Ultrasound

4:00 p.m.

Khalid Al-Muhanna,2 Murad Hossain,2 Abtin Khosravi,1 Limin Zhao,1 Jonathan Fischell,1 Gregory Kowalowski,1 Siddhartha Sikdar,2 Brajesh K. Lal.1 1  University of Maryland School of Medicine, Baltimore, Md.; 2 George Mason University, Fairfax, Va.

OBJECTIVES: As investigations into nonsurgical treatment for atherosclerosis expand, the measurement of plaque regression and progression has become an important endpoint to study. Carotid plaque progression does not occur in only one or two dimensions. Therefore measurements of plaque volume are more sensitive to change than are traditional estimates of stenosis severity or cross-sectional area. 3D-ultrasound (US) may allow monitoring of plaque volume changes, but has not been used routinely due to cumbersome motorized units required to drive transducers. We investigated the reliability of plaque volume measurement by a novel freehand 3D US system that can be applied in a clinical environment. METHODS: Ten patients with carotid stenosis underwent 3D US imaging using a linear transducer integrated with a magnetic position tracker. Plaque boundaries were outlined in serial cross-sectional images 1 mm apart. Plaque volumes were measured by 4 observers and repeated by them 4 weeks later. This allowed measurement of inter- and intra-observer variability of 6 pairs of observations. We measured Bland-Altman statistics, intra-class correlation, coefficient of reliability and the minimum detectable plaque volume change. RESULTS: The mean plaque volume of carotid lesions in the study was 1276.8 mm3 (range 620.6 to 1956.3 mm3). Bland Altman plots demonstrated low inter- and intraobserver variability; variability of volume measurements as a function of mean volume was 10.8%. Reliability, quantified by the intraclass correlation coefficient was 85.5%. The least detectable change in plaque volume was 21.1% (range 14.1 to 27.6%).

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CONCLUSIONS: Carotid plaque volume can be measured accurately and reliably with this novel 3D ultrasound technique. The volumetric change that must be observed to establish with 95% confidence that a plaque has undergone growth or regression is approximately 20%. AUTHOR DISCLOSURES: K. Al-Muhanna: Nothing to disclose; J. Fischell: Nothing to disclose; M. Hossain: Nothing to disclose; A. Khosravi: Nothing to disclose; G. Kowalowski: Nothing to disclose; B.K. Lal: National Institutes of Health; VA Research and Development Department, research grants; S. Sikdar: Nothing to disclose; L. Zhao: Nothing to disclose. PS84. Intravenous Catheter Remains the Primary Access  Type of Incident Hemodialysis a Decade After the Fistula First Breakthrough Initiative

4:05 p.m.

Mahmoud B. Malas,1 Joseph Canner,1 Devin S. Zarkowski,2 Isibor Arhuidese,1 Umair Qazi,1 Eric Schneider,1 Dorry Segev,1 Bruce A. Perler.1

Surgery, Johns Hopkins University, Baltimore, Md.; 2 Dartmouth-Hitchcock Medical Center, Dartmouth, Mass. 1

OBJECTIVES: Based on evidence of survival benefit when initiating hemodialysis (HD) via an arteriovenous fistula (AVF) or graft (AVG) versus intravenous hemodialysis catheter (IHC), the National Kidney Foundation-Kidney Dialysis Outcomes Quality Initiative (NKF-KDOQI) published practice guidelines in 1997 recommending î&#x192;Ą50% AVF rates in incident HD patients. We evaluated whether this goal has been achieved and its effect on HD outcomes. METHODS: Dialysis initiates (2006-10) captured by United States Renal Database System were included. Relative mortality quantified by multivariable Cox proportional hazard models, adjusting for demographics and comorbidities, with coarsened-exact and propensity score matching used as sensitivity analyses to account for confounding by indication. RESULTS: Among 510,000 patients, 82.6% initiated HD via IHC, 14.0% via AVF, and 3.4% via AVG. HD initiation with IHC remained consistent at 82.5% between 2006 and 2010 (figure 1). Patients initiating HD with AVF had 35% lower mortality than patients with IHC (aHR 0.65, 95% CI: 0.64-0.66, p<0.001). Patients initiating HD with AVF had 23% lower mortality than those initiating with IHC while awaiting AVF maturation (aHR 0.73, 95% CI 0.76-0.79, p<0.001). CONCLUSIONS: Current access practice has failed to satisfy the NKF-KDOQI recommendations of 50% incident AVF. Functioning permanent access at initiation of HD is strongly associated with lower mortality, even compared to patients temporized with IHC while awaiting maturation of permanent access. Multi-disciplinary efforts should focus on achieving HD access to allow ample time for fistula maturation to ameliorate this deficit in delivering care. AUTHOR DISCLOSURES: I. Arhuidese: Nothing to disclose; J. Canner: Nothing to disclose; M.B. Malas: Nothing to disclose; B.A. Perler: Nothing to disclose; U. Qazi: Nothing to disclose; E. Schneider: Nothing to disclose; D. Segev: Nothing to disclose; D.S. Zarkowski: Nothing to disclose.

166


PS86. Isolated Renal Artery Aneurysms: Management  and Outcomes in the Endovascular Era

4:10 p.m.

Dominique B. Buck,1 Thomas Curran,1 John C. McCallum,1 Jeremy D. Darling,1 Joost A. van Herwaarden,2 Frans L. Moll,2 Marc L. Schermerhorn.2

BIDMC, Boston, Mass.; 2UMCU, Utrecht, Netherlands.

1

OBJECTIVES: Isolated renal artery aneurysms (iRAA) are rare, but potentially fatal. The impact of endovascular therapy on RAA treatment and perioperative mortality is unknown. METHODS: We identified all patients undergoing open or endovascular repair of isolated RAA in the NIS from 1988 to 2011. A primary diagnosis of RAA and open (nephrectomy or reconstruction) or endovascular repair (coil or stent) were required. Patients with a diagnosis or repair of aortic aneurysms/dissection were excluded. Patient characteristics and in-hospital outcomes were compared between open and endovascular repair from 2000 to 2011. RESULTS: We identified 6,234 RAA repairs between 1988 to 2011; 2,086 (78% for reconstruction) open and 1,082 endovascular from 2000 to 2011. Total repairs increased after the introduction of endovascular repair (p=0.03), though open repairs did not decrease (P=0.20). Patients undergoing endovascular repair had more CAD (17.5 vs. 10.6%, <0.001), prior MI (5.2 vs. 1.8%, <0.001) and CRF (7.7 vs. 3.3%, <0.001). In-hospital mortality was 1.8% for endovascular, 0.9% for open reconstruction and 5.4% for nephrectomy (P=<.001). Complication rates were 12.4% for open reconstruction vs. 10.5% for endovascular repair (p=0.134). Open repair had a significantly longer length of stay (6.0 vs. 4.6 days, <0.001). CONCLUSIONS: More renal artery aneurysms are getting treated due to endovascular repair without a reduction in operative mortality. Indications of repair of RAA should be evaluated. AUTHOR DISCLOSURES: D.B. Buck: Nothing to disclose; T. Curran: Nothing to disclose; J.D. Darling: Nothing to disclose; J.C. McCallum: Nothing to disclose; F.L. Moll: Medtronic, consulting fees or other remuneration (payment); M.L. Schermerhorn: Endologix, consulting fees or other remuneration (payment); Medtronic, consulting fees or other remuneration (payment); J.A. van Herwaarden: Medtronic, consulting fees or other remuneration (payment); Philips, consulting fees or other remuneration (payment).

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PS88. Failures and Lessons in Endovascular Treatment  of Symptomatic Isolated Dissection of Superior Mesenteric Artery

4:15 p.m.

Zhi Hui Dong, Jun Jie Ning, Wei Guo Fu, Yu Qi Wang, Da Qiao Guo, Xin Xu, Bin Chen, Jun Hao Jiang, Jue Yang, Zhen Yu Shi, Ting Zhu, Yun Shi.  Department of Vascular Surgery, Zhongshan Hospital, Fudan University; Institute of Vascular Surgery, Fudan University, Shanghai, China. OBJECTIVES: To discuss the technical failures and lessons in endovascular treatment of symptomatic isolated dissection of superior mesenteric artery (SIDSMA). METHODS: 33 patients with SIDSMA treated between July 2007 and September 2013 were retrospectively collected. The technical failures and lessons in the endovascular management were analysed in terms of their causes and prophylaxis. RESULTS: 18 patients were successfully treated medically, 13 underwent stent placement, 1 received a hybrid procedure, and 1 had open fenestration. Full follow-up (3 to 72 months, mean 29Âą19 months) was achieved in 28 patients. The failure in cannulating the true lumen developed in 7 patients. Of them, the femoral and brachial approaches were taken in 5 and 2 patients, respectively, and there was no significance between them (1-sided Fisherâ&#x20AC;&#x2122;s exact=0.572). Among the 5 femoral failures, the true lumen was ultimately cannulated after conversion to the brachial approach in 2 cases. The perfusion of distal SMA was not improved until the second stent was placed distally covering the whole expanded false lumen in 1 case. Quite a few branches originating from the false lumen were overlooked in 1 patient, which were apparently compromised after stenting. Consequently, the patient died of intestinal necrosis. In a patient with a huge dissecting aneurysm, the stent was misplaced across the false lumen. Fortunately, remarkable aneurismal thrombosis formed at 3 months. In the patient receiving the hybrid procedure including thrombectomy, distal fenestration and proximal stenting, the stent was occluded at 2 weeks probably because the thrombus protruded into the stent. CONCLUSIONS: Difficulty in cannulating the true lumen was not uncommon in endovascular treatment of SIDSMA, and the brachial approach might be helpful. The length and branches involvement of the false lumen would better be evaluated beforehand. Should the lumen contain thrombus, a covered stent would be a reasonable option. 168


AUTHOR DISCLOSURES: B. Chen: Nothing to disclose; Z. Dong: Nothing to disclose; W. Fu: Nothing to disclose; D. Guo: Nothing to disclose; J. Jiang: Nothing to disclose; J. Ning: Nothing to disclose; Y. Shi: Nothing to disclose; Z. Shi: Nothing to disclose; Y. Wang: Nothing to disclose; X. Xu: Nothing to disclose; J. Yang: Nothing to disclose; T. Zhu: Nothing to disclose. PS90. Inexperienced Vascular Surgeons and  Abdominal Vascular Cases Disproportionately Contribute to Malpractice Lawsuits

Sapan S. Desai,1 John Eidt.2

1

4:20 p.m.

Department of Surgery, Duke University, Durham, N.C.; University of South Carolina, Greenville, S.C.

2

OBJECTIVES: Open abdominal cases have declined steadily over the past ten years. The purpose of this study is to evaluate trends in malpractice lawsuits and determine if an inverse correlation exists with the decline in open abdominal vascular cases. METHODS: A review of all legal cases filed between 1996 and 2013 against vascular surgeons for malpractice was completed using Westlaw and Google Scholar. Board certification was verified using the American Board of Surgery. Each legal case was characterized with regard to the ACGME category of the procedure, complication, and outcome. Interval between initial vascular certification and the year of incident was determined to characterize vascular surgeon experience. ACGME case logs were reviewed from 2001-2012 and trends in open abdominal vascular cases determined. RESULTS: 25 legal proceedings against vascular surgeons were identified over the ten-year period. 19/25 surgeons were boarded in vascular surgery at the time of the incident. 15 patients died and 10 experienced major disability. 10/20 (50%) completed cases were decided in favor of the defendant. Litigation for major abdominal vascular procedures increased by 50% over the past ten years, and 39% (7/18) of cases were among boarded vascular surgeons within the first 3 years of practice. The number of open abdominal vascular cases has decreased by 45% during this interval. CONCLUSIONS: A disproportionate number of legal proceedings are initiated against vascular surgeons within their first three years of practice, and the majority of these lawsuits deal with major abdominal vascular procedures. Litigation for major abdominal vascular procedures is increasing, and this is inversely correlated with the declining number of open abdominal cases performed by ACGME trainees. The declining open abdominal volume may contribute to an increase in lawsuits against graduating vascular surgeons in the coming years. AUTHOR DISCLOSURES: S.S. Desai: Nothing to disclose; J. Eidt: Nothing to disclose. PS92. Challenges in Vascular Surgery Training:  Open Aneurysm Repair in 2020

Sapan S. Desai,1 Anahita Dua,2 John Eidt.3

1

4:25 p.m.

Department of Surgery, Duke University, Durham, N.C.; 2Medical College of Wisconsin, Milwaukee, Wis.; 3University of South Carolina, Greenville, S.C.

OBJECTIVES: The aim of this study was to evaluate trends in open aneurysm repair (OAR) by vascular surgery trainees and make predictions on the impact that decreasing volume will have on outcomes. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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METHODS: A retrospective analysis of the National Inpatient Sample (2000-2010) and ACGME case logs (2001-2012) was completed to ascertain trends in OAR. This was correlated with a survey sent to all graduating vascular trainees (0+5 and 5+2) asking them to identify their confidence completing index open and endovascular procedures. Trends in malpractice litigation from 2000-2013 were identified using Westlaw and Google Scholar. Associations between these variables were identified, and a mathematical model created to project trends in OAR into 2020. RESULTS: 5.2% of AAAs were repaired by EVAR in 2000 compared to 74% in 2010. As the volume of OAR has been constant at 45,000 cases annually, the increase in EVAR has led to a 34% drop in OAR. This national decline in OAR is paralleled by a 33% decline in OAR completed by vascular trainees since 2001. Trainees report (N=41) low confidence in independently performing open aneurysm cases, with nearly 40% of 2014 graduating vascular trainees having low confidence (1.4) on a three point Likert scale (1-not confident, 2-somewhat confident, 3-very confident). Over the past decade, there has been a 3X increase in adjudicated cases against vascular surgeons due to complications arising from open AAA cases, along with an increase in litigation against vascular surgeons in practice for fewer than three years. A mathematical model predicts that trainees will complete less than 25% OAR cases in 2020 than they complete today. CONCLUSIONS: Based on prediction models, vascular trainees will complete only five OAR cases by 2020. In conjunction with decreasing trainee confidence completing OAR and increased malpractice litigation in this area, a new paradigm in vascular surgery education will be necessary to maintain high standards for patients who undergo OAR. AUTHOR DISCLOSURES: S.S. Desai: Nothing to disclose; A. Dua: Nothing to disclose; J. Eidt: Nothing to disclose. PS94. U.S. Vascular Fellowsâ&#x20AC;&#x2122; Assessment of Their Training 

Syed Ali Rizvi, Anil Hingorani, Enrico Ascher, Natalie Marks.

Lutheran Medical Center, Brooklyn, NY.

4:30 p.m.

OBJECTIVES: In an attempt to assess their perception of their training, we conducted an annual survey consisting of 22 questions at an annual national meeting in March from 2004 to 2012 METHODS: 496 of the 683 fellows responded (73%). In order to obtain accurate data, all surveys were kept anonymous. The fellows were asked to assess various aspects of their training as excellent, satisfactory, or mixed. RESULTS: Males made up 83% of those surveyed, and 57% were between the ages of 31 and 35 years. Second-year fellows made up 56% of those surveyed. Those expecting to join a private, academic, or mixed practice made up 30%, 26%, and 25% of the respondents, respectively, with 75% anticipating entering a 100% vascular practice. 80% were satisfied with their endovascular experience during their fellowship while 81% were satisfied with their experience with open cases. Vascular surgeons were the primary source of endovascular training in 85%. The distribution of non-learning cases was felt to be excellent, satisfactory, or required some or much improvement in 46%, 41%, and 11%, respectively. However, only 65% felt that their vascular laboratory experience was excellent or satisfactory. Only 37% actually performed the vascular duplex exam, and only 47% felt that they would feel comfortable in managing a vascular laboratory. Over the years, an increasing number of trainees are receiving their endovascular training under vascular surgeons only. Other areas of the survey did not change significantly over the years.

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CONCLUSIONS: This survey suggests that the vascular lab is an area consistently that is not being focused upon in vascular training programs. These data suggest areas to direct the future areas focus for vascular training. AUTHOR DISCLOSURES: E. Ascher: Nothing to disclose; A. Hingorani: Nothing to disclose; N. Marks: Nothing to disclose; S. Rizvi: Nothing to disclose. PS96. Differences in Case Logs Reports Between  Early Specialization and Traditional Vascular Surgery Training Programs

Rose C. Pedersen, Wesley K. Lew, Kaushal Patel.

Kaiser Permanente - Los Angeles Medical Center, Los Angeles, Calif.

4:35 p.m.

OBJECTIVES: To determine if the operative case experience for graduates of early specialization programs in vascular surgery varies from those in traditional training paradigms. METHODS: Review of the Accreditation Council for Graduate Medical Education (ACGME) national case log reports for graduates of Integrated Vascular Surgery Residencies (IVSR), traditional Vascular Surgery Fellowships (VF), and General Surgery Residencies (GSR) from 2012-2013 was performed. RESULTS: Graduates of IVSR were found to have higher volumes of major vascular cases (495 vs. 399), minor vascular cases (386 vs. 240), and overall vascular cases (851 vs. 784) when compared to traditional fellowship graduates (VF). When comparing IVSR to VF, graduates of early specialization residencies had more exposure in the majority of vascular surgery categories. However, after adding the average vascular experience that a traditional graduate (VF) would have from their general surgery residency, traditional graduates entered independent practice with more overall cases (900 vs. 851) and having more exposure in the following areas: aneurysm repair, carotid disease, peripheral bypasses, upper extremity procedures, and dialysis access surgery. Only peripheral endovascular procedures (322% more) and varicose vein interventions (63% more) remained significantly higher for graduates of early specialization programs. CONCLUSIONS: Residents of early specialization vascular surgery programs (IVSR) enter independent practice with less overall vascular operative exposure and complex open vascular surgery experience than the traditional fellowship trained graduates, but significantly more peripheral endovascular and varicose vein experience. AUTHOR DISCLOSURES: W.K. Lew: Nothing to disclose; K. Patel: Nothing to disclose; R.C. Pedersen: Nothing to disclose. C8e: D  ialysis Access • Cerebrovascular  Including Great Vessels 

3:30 – 5:00 p.m. uAuditorium, Level 2 (enter through Exhibit Hall C)

Moderator: Ravi K. Veeraswamy, MD, Emory University School of Medicine, Atlanta, Ga.

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PS98. Utilization of a Proactive Duplex Ultrasound Protocol  for Hemodialysis Access

3:40 p.m.

Brant W. Ullery, Chelsea Dorsey, George Lee, Oliver Aalami, Fritz Bech, Wei Zhou.

Stanford University Medical Center, Stanford, Calif.

OBJECTIVES: Arteriovenous fistula (AVF) creation is accepted as the initial approach for hemodialysis access, but maturation rates of AVF are merely 30% based on physical examination alone. With the support of SVS Clinical Seed grant program, we established a proactive early duplex ultrasonography (DUS) surveillance protocol for evaluating AVF prior to attempted access. This study is aimed to determine the effectiveness of this protocol in AVF maturation. METHODS: From 2008 to 2013, 192 newly created upper extremity AVF were subjected to our early surveillance protocol. DUS identified 71 dysfunctional AVF (36.9%) in 45 patients. A peak systolic velocity of 375 cm/s or >50% stenosis on gray scale imaging was used to identify hemodynamically significant (î&#x192;Ą50%) stenosis. Digital subtraction angiography (DSA) was used as the reference point for determination of stenosis. RESULTS: Of the 71 dysfunctional AVFs, there were 33 radiocephalic, 16 brachiocephalic, and 22 basilic vein transpositions. The sensitivity, specificity, and accuracy of DUS for the detection of hemodynamically significant stenosis were 73.3%, 55%, and 70%, respectively. DSA detected 60 vascular segments with significant stenosis, including, 4 anastomotic, 21 distal vein, 18 mid vein, 10 proximal vein, and 7 central vein stenoses. Thirty-two of the dysfunctional AVFs (45.1%) were detected on the initial DUS as part of the early surveillance protocol, with 23 of these AVFs ultimately requiring intervention. A maturation rate of 65.6% was achieved among this group of early identified dysfunctional AVFs. CONCLUSIONS: Early DUS surveillance of AVF performed prior to initial access is reasonably sensitive to identify problematic AVFs that may not be apparent on physical examination. Although velocity criteria for significant stenosis has yet to be universally defined, proactive postoperative DUS assists in the early detection of dysfunctional AVFs and optimization of fistula maturation. AUTHOR DISCLOSURES: O. Aalami: Nothing to disclose; F. Bech: Nothing to disclose; C. Dorsey: Nothing to disclose; G. Lee: Nothing to disclose; B.W. Ullery: Nothing to disclose; W. Zhou: Nothing to disclose. PS100. Elevated PSV and VR from Duplex Ultrasound  Are Associated with Hemodynamically Significant Lesions in AV Access

3:45 p.m.

Steven A. Plato, Elizabeth Kudlaty, Matthew Allemang, Daniel Kendrick, Virginia L. Wong, John C. Wang, Vikram S. Kashyap.  University Hospitals Case Medical Center Division of Vascular Surgery and Endovascular Therapy, Cleveland, Ohio. OBJECTIVES: Duplex US is reliably used to detect lesions in the carotid and peripheral vascular beds. Although applied for AV fistulae and grafts the optimal definition of hemodynamically significant lesions in AV access remains poorly characterized. METHODS: A retrospective review of patients with duplex and fistulogram within 30 days from 6/2010 to 11/2012 (50 AV accesses, 42 patients, 42% AV fistulae) was

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performed. Fistulogram data was degree of stenosis, duplex data was peak systolic velocity (PSV) and velocity ratio by segment (VR) in proximal, mid, and distal segments of every AV access (n=136). RESULTS: Median PSV for segments >50% stenosis was 540 cm/sec and 218 cm/sec for segments <50% stenosis (P<0.001). Median VR for segments >50% stenosis was 3.22 and 1.47 for segments <50% stenosis (P<0.001). Sensitivity was 0.60, specificity 0.86, PPV 0.72 and NPV 0.78 for PSV >500 cm/sec. Sensitivity was 0.52, specificity 0.91, PPV 0.77 and NPV 0.75 for VR >3.0. ROC curve discrimination was 0.85 for PSV and 0.84 for VR suggesting good ability to classify lesions as hemodynamically significant. CONCLUSIONS: Duplex peak systolic velocity and velocity ratio provide good sensitivity and specificity to distinguish hemodynamically significant lesions in arteriovenous fistulas and grafts. PSV >500 cm/sec and VR >3.0 can be used as criteria to interrogate AV access for stenoses via angiography with high specificity for hemodynamically significant lesions. AUTHOR DISCLOSURES: M. Allemang: Nothing to disclose; V.S. Kashyap: Nothing to disclose; D. Kendrick: Nothing to disclose; E. Kudlaty: Nothing to disclose; S.A. Plato: Nothing to disclose; J.C. Wang: Nothing to disclose; V.L. Wong: Nothing to disclose.

Figure 1. Receiver operating characteristic for duplex ultrasound derived peak systolic velocity and velocity ratio.

PS102. Dilation of Ipsilateral Extremity Veins — a Beneficial Effect of Dialysis Access Procedures

Sai Divakaruni, Garima Dosi, Peggy Kidwell, Brajesh K. Lal.

University of Maryland School of Medicine, Baltimore, Md.

3:50 p.m.

OBJECTIVES: Several patients are unsuitable for autogenous dialysis access and are consigned to perpetual prosthetic graft placement. We hypothesized that dialysis procedures result in dilation of residual upper extremity (UE) veins not in direct communication with the fistula. Dilation of these veins would have clinical relevance, since some may later became suitable for autogenous accesses. Our aim was to measure the frequency, magnitude, and clinical relevance of this process.

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METHODS: Patients undergoing their first access had duplex ultrasound diameter measurements of cephalic and basilic veins at 8 sites (wrist, distal/mid/proximal forearm, cubital fossa, and distal/mid/proximal arm). An optimal vein segment was 2.5 mm diameter over a 10 cm length. A fistula was constructed using the best available vein segment (forearm non-transposed n=9, forearm transposed n=8, arm transposed n=18). Diameters of the ipsilateral basilic and cephalic vein segments that were not used for the fistula were re-measured on follow-up. RESULTS: 108 patients were screened, 71 met inclusion criteria, and 34 completed the study with a follow-up period of 4-12 months. The mean diameter of vein segments not utilized for fistula creation increased by 52%, from 2.3±0.5 to 3.5±0.5 mm (p=0.01). Two fistulae thrombosed, but new fistulae could be constructed in alternate vein segments that had originally been sub-optimal (<2 mm) in diameter. At least one vein segment dilated to 2.5 mm in 54% of our patients and at least one vein segment dilated to 3 mm in 37% of our patients. CONCLUSIONS: Dialysis access using one UE vein segment results in progressive dilation of the residual venous segments. In about 1/3 of patients undergoing surgery for the first time, vein segments initially deemed suboptimal had dilated to 3 mm. This is especially relevant in patients receiving prosthetic grafts for suboptimal venous anatomy. Our results may impact the DOQI guidelines for selection of dialysis access procedures. AUTHOR DISCLOSURES: S. Divakaruni: Nothing to disclose; G. Dosi: Nothing to disclose; P. Kidwell: Nothing to disclose; B.K. Lal: National Institutes of Health, research grants; VA Research & Development Dept, research grants. PS104. A Pilot Study to Prevent Juxta-Anastomotic  3:55 p.m. AVF Stenosis with Placement of a Viabahn Endograft at the Time of Fistula Creation: The JuxtaBahn Procedure

Oliver Aalami.

Stanford University, Stanford, Calif.

OBJECTIVES: ESRD and the need for dialysis is a growing problem. Over 60% of arterio-venous fistulas are unsuitable for dialysis 5 months post-surgery. This early failure rate is due to severe narrowing of the juxta-anastomotic vein segment in 41%-64% of cases. Trauma to the juxta-anastomotic vein segment during mobilization and turbulent hemodynamic forces are theorized to contribute to the scarring process observed. To prevent juxta-anastomotic stenosis and to promote improved maturation rates, we initiated a pilot study placing a covered endograft into the juxta-anastomotic vein segment at the time of AV fistula creation — the JuxtaBahn procedure. METHODS: Patients referred for long term dialysis access placement underwent radio-cephalic or brachio-cephalic fistula creation. During the standard procedure, a 2 cm or 5 cm Viabahn endograft (6 mm diam) was placed into the juxta-anastomotic segment of the outflow cephalic vein. The anchoring suture in the heel of the anastomosis went through cephalic vein, endograft and artery. The remaining hood of the anastomosis was native vein and the anastomosis was completed in a standard end-to-side fashion. Surveillance ultrasounds were obtained at 1, 3, 6 and 12 months. RESULTS: The JuxtaBahn AV fistula technique was successfully completed in 11 patients (7 radio-cephalic and 4 brachio-cephalic fistulas). Follow up ranged from 3-12 months. No early juxta-anastomotic stenoses were identified. Eighty-two percent of fistulas matured. There were no AV fistula infections. One (9%) AV fistula occluded at 2 weeks (2mm cephalic vein). One AV fistula (1/11) required ligation.

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CONCLUSIONS: The JuxtaBahn procedure is a viable procedure with no major adverse outcomes. No early juxta-anastomotic stenoses were identified in our pilot study. There is a trend toward higher maturation, and lower occlusion rates. A larger prospective, randomized series is required to better evaluate the JuxtaBahn procedure. AUTHOR DISCLOSURES: O. Aalami: Nothing to disclose. PS106. Aneurysm Plication Extends Life of Autologous  Dialysis Fistula Without Compromising Patency

Hue Thai, Yevgeniy Rits, Donna Bednarski, Jeffrey Rubin.

Vascular Surgery, Detroit Medical Center, Detroit, Mich.

4:00 p.m.

OBJECTIVES: The use of native arteriovenous fistula (AVF) for dialysis is associated with fewer overall complications and preserving long-term patency is a priority. The purpose of this study is to compare the patency and number of secondary interventions required of AVF when aneurysms are repaired with interposition prosthetic grafting (IG) versus aneurysm plication (PC). METHODS: Fourteen patients with symptomatic aneurysms (15) of upper extremity autologous AVFs were treated with PC (8) and IG (7) between July 2007 and November 2013 at a single institution. The indications for operation were cutaneous thinning, ulceration, bleeding, and difficulty in cannulation. Patient characteristics, type of repair, patencies and number of secondary interventions were recorded and analyzed. RESULTS: Fourteen consecutive patients (9 men) with mean age of 48, underwent 15 aneurysm repairs. Five (33%) patients had radiocephalic, 9 (60%) brachiocephalic, and 1 (7%) brachiobasilic AVF with mean follow of 9 months. Eight aneurysms (53%) underwent plication vs. 7 (47%) interposition grafts. The average diameter of aneurysm was 2.6 cm (IG) and 2.8 cm (PC)(NS). At 6 months follow up the patency for PC was 62.5% vs. 57.1% for the IG group (p > 0.4). One IG was excised due to infection and another was lost due to an unrelated death. Two patients in the PC group were converted to IG due to aneurysm extension. Overall, IG patients required 8 times more procedures (5 dialysis catheters and 3 endovascular interventions) versus 1 intervention for the PC group, p < 0.01. CONCLUSIONS: Preliminary results show that aneurysm plication extends the life of the native fistula and requires fewer interventions to maintain patency. When possible, this method should be considered as the repair procedure of choice for AVF aneurysms. AUTHOR DISCLOSURES: D. Bednarski: Nothing to disclose; Y. Rits: Nothing to disclose; J. Rubin: Nothing to disclose; H. Thai: Nothing to disclose. PS108. Outcomes Analysis of the Pluripotential  Antecubital Vein Dialysis Fistula

4:05 p.m.

Kyle Markel,3 Marc Webb,1 Ankur Aggarwal,2 Graham Long.2

1  St. Mary Mercy Hospital, Livonia, Mich.; 2William Beaumont Hospital, Royal Oak, Mich.; 3Wayne State University School of Medicine, Detroit, Mich.

OBJECTIVES: To study the single surgeon outcomes of pluripotential antecubital vein fistulas (PAF) for patients with borderline basilic and cephalic vein diameters. METHODS: This is a retrospective analysis of a single surgeon experience with 115 PAFs created from April 2004 to November 2011, using a prospectively maintained patient database. Primary outcome was time to fistula release (TR) for dialysis access. Secondary Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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outcomes were one-year primary and primary assisted patency. Patient comorbidities were recorded. Borderline veins were defined as diameters 3-4 mm. PAF was defined as an arteriovenous fistula in the antecubital fossa with outflow through the upper arm cephalic and basilic veins via the connecting median cubital vein. RESULTS: Of 115 PAFs, 18 (15.7%) were released for dialysis access after the first-stage procedure; a second stage procedure was required in 82 (71.3%). Forty-nine (59.8%) were converted to basilic vein transposition and 33 (40.2%) were converted to selective cephalic vein outflow. A total of 84.3% (97/115) fistulas were released for use after a mean of 89±70 days after the definitive procedure. Eleven (9.6%) underwent a second index procedure due to thrombosis (5), failure to mature (3), body habitus (1), diseased outflow vein (1), and ligation secondary to persistent seroma with arm swelling (1). There was one death (0.9%), one who refused second stage procedure (0.9%), and five lost to follow up (4.3%) from PAF creation. One year follow up was documented in 68% of patients (66/97). Primary one-year patency was 36.4% (24/66); assisted one year patency was 100%. CONCLUSIONS: PAF is a reasonable strategy which yields an acceptable percentage with a functional dialysis fistula. A substantial fraction will require secondary conversion to single-vein outflow and endovascular intervention to maintain patency in the first year. Further study is indicated with larger cohorts and longer follow-up to corroborate these findings. AUTHOR DISCLOSURES: A. Aggarwal: Nothing to disclose; G. Long: Nothing to disclose; K. Markel: Nothing to disclose; M. Webb: Nothing to disclose. PS110. Early Intervention to Salvage Aneurysmal  Dialysis Access Arteriovenous Fistula

Payam Salehi, Wande Pratt, Luis A. Sanchez.

Section of Vascular Surgery, Washington University, St Louis, Mo.

4:10 p.m.

OBJECTIVES: Aneurysmal degeneration of arteriovenous fistulas (AVFs) occurs in about one third of patients on hemodialysis (HD) and can lead to failure of the access. We retrospectively assessed the effectiveness of early surgical intervention to allow continued use of the AVF without the need for a temporary HD catheter. METHODS: Over a 3.5-year period, 68 procedures were performed on 50 patients with AVF aneurysms (>2 times size of the native mature vein) by a single vascular surgeon. Clinical characteristics, symptoms, type of procedure and patency were evaluated. RESULTS: Indications for surgery included skin breakdown in 53%, infection in 4.5% and thin/weakened skin over the aneurysm wall in the rest. 65% of the AVFs were brachiocephalic, 20% radiocephalic and 15% brachiobasilic. The average aneurysm size was 2.6±0.2 cm with flow rates of 2231±250 ml/min. The repair occurred 4.8±0.3 years after the original AVF creation. Resection and primary anastomosis was performed in 64% and partial resection in 36% of cases. 16 patients (32%) had staged procedures for repair of 2 aneurysms. The primary patency rate was 96% at 1 year. Only 3 patients (4.5%) required a temporary HD catheter (all presented with an infected aneurysm). Two patients developed a hematoma after first HD. CONCLUSIONS: Early, and staged if needed, surgical repair by complete or partial resection of AVF aneurysms is a simple and effective strategy to prevent aneurysmassociated complications while avoiding temporary HD catheters. This approach maintains a functioning access, avoids catheters and their complications, and preserves future access sites.

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AUTHOR DISCLOSURES: W. Pratt: Nothing to disclose; P. Salehi: Nothing to disclose; L.A. Sanchez: Nothing to disclose. PS112. Predicting Cognitive Decline After Carotid  Endarterectomy (CEA) or Carotid Artery Stenting (CAS) Using Structural Connectivity Graph Analysis

4:15 p.m.

Salil Soman,1 Gautam Prasad,2 Elizabeth Hitchner,3 Michael Moseley,3 Allyson Rosen,2 Wei Zhou.3 1  Stanford University School of Medicine/War Related Illness and Injury Study Center, Stanford/Palo Alto, Calif.; 2Stanford University Department of Psychology, Stanford, Calif.; 3Stanford University School of Medicine, Stanford, Calif.

OBJECTIVES: Many CEA and CAS patients experience postoperative neurocognitive decline. We sought to apply structural connectivity metrics to identify patients at increased risk for postoperative decline based solely on preoperative imaging. METHODS: Under an IRB approved protocol 28 patients underwent presurgical T1 structural and 30 direction diffusion tensor imaging (DTI) MRI and neuropsychological tests before and 1 month after surgery. Patients with decline showed decreased performance on the Rey-AVLT on 1 month follow up. The T1 images were processed using FreeSurfer 5.3, with resulting segmentations reviewed and edited as needed under neuroradiologist supervision. Whole brain tractography was performed using Diffusion Toolkit and visually inspected. Connectivity matrices were then generated, and graph metrics were computed using the Brain Connectivity Toolbox. RESULTS: Controlling for age, classifiers using the graph analysis metrics “weighted optimal community structure” and “binary component sizes” were able to identify patients with postoperative cognitive decline with 81% sensitivity 83% and specificity (p<.05, false discovery rate .05). These two measures were computed at 10 proportion edge thresholds from .1 to 1 at intervals of .1 in weighted and binary networks respectively. CONCLUSIONS: Applying preoperative structural connectivity analysis in CEA and CAS patients may identify patients at increased risk for postoperative cognitive decline, and in so doing may help better risk stratify patients and guide them to preventive interventions. AUTHOR DISCLOSURES: E. Hitchner: Nothing to disclose; M. Moseley: Nothing to disclose; G. Prasad: Nothing to disclose; A. Rosen: Nothing to disclose; S. Soman: Nothing to disclose; W. Zhou: Nothing to disclose. PS114. Contemporary Results of Carotid Endarterectomy:  Is It a Beneficial Procedure for Women?

4:20 p.m.

Mila H. Ju,1 Mark K. Eskandari,1 William Pearce,1 Karl Y. Bilimoria,1 Clifford Y. Ko,2 Bruce L. Hall,3 Louis L. Nguyen.4

1 Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill.; 2University of California, Los Angeles (UCLA), Los Angeles, Calif.; 3 Washington University in Saint Louis, St. Louis, Mo.; 4Brigham and Women’s Hospital, Boston, Mass.

OBJECTIVES: Previous randomized trials have suggested that carotid endarterectomy (CEA) may not be efficacious for women primarily due to higher postoperative event rates. Our objective was to compare contemporary CEA outcomes among women and men in a “real world” setting. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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METHODS: CEA procedure related data were obtained from the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Symptomatic patients were those with ipsilateral stroke, transient ischemic attack, or amaurosis fugax. Patient characteristics and 30-day postoperative outcomes were examined for sex and symptomatology. RESULTS: Of the 5,423 patients with specific data on CEA, 2,242 (41.3%) were symptomatic and 3,181 (58.7%) were asymptomatic. There were a higher proportion of women in the asymptomatic than symptomatic group (40.3% vs. 37.3%; P=0.025). For the entire cohort, women were more often obese (34.1% vs. 30.9%; P<0.001) and a smoker (29.5% vs. 24.1%; P<0.001), but less often taking statins (75.9% vs. 80.5%; P<0.001) than men. Patch use was equivalent between women and men (76.1% vs. 76.8%; P=0.4997). After adjusting for patient characteristics, there were no statistically significant differences between women and men for postoperative death, stroke, or myocardial infarction for both symptomatic and asymptomatic groups (Table). CONCLUSIONS: Based on this reliable third-party collected and validated data, postoperative outcomes were shown to be similar among women and men regardless of symptom status. However, there remains ample room for improvements in optimal medical therapy for both women and men. AUTHOR DISCLOSURES: K.Y. Bilimoria: Nothing to disclose; M.K. Eskandari: Nothing to disclose; B.L. Hall: Nothing to disclose; M.H. Ju: Nothing to disclose; C.Y. Ko: Nothing to disclose; L.L. Nguyen: Nothing to disclose; W. Pearce: Nothing to disclose.

PS116. Are NASCET and ACAS Guidelines Applicable  to Modern Imaging Measurements: Digital Subtraction Angiography vs. TeraRecon CTA

4:25 p.m.

Ashley Aaron, Adithya Suresh, Steven Santilli, Rumi Faizer, Steven Levin.

University of Minnesota, St. Paul, Minn.

OBJECTIVES: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Artery Surgery Trial, helped establish guidelines for carotid intervention based on conventional angiography measurements of stenosis. However, with improvement in noninvasive imaging techniques the use of computed tomography angiography (CTA) has become widespread. The goal of this retrospective evaluation was to compare the degree of carotid stenosis based on TeraRecon compared to angiography and how these potential differences may impact decisions for intervention. METHODS: Percent carotid stenosis was obtained via DSA and TeraRecon. Study population included 58 patients who underwent carotid artery stenting for symptomatic and asymptomatic carotid stenosis between 2006 and 2013. The TeraRecon CTA and

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angiography stenosis measurements analyzed by student’s t-test to determine if traditional NASCET angiography determinations for intervention are applicable to CTA. RESULTS: TeraRecon CTA measurements of percent carotid artery stenosis were, on average, 6.5% higher than those based on angiography. Analysis with student’s t-test showed a statistically significant difference between the two measurements with a p-value of 0.0033. CONCLUSIONS: Overall we found that measurements of percent carotid artery stenosis in asymptomatic and symptomatic patients undergoing carotid stent placement were higher when using TeraRecon CTA compared to measures with angiography. This begs the question: have we been over-intervening upon patients by using NASCET and ACAS guidelines on patients imaged with CTA? AUTHOR DISCLOSURES: A. Aaron: Nothing to disclose; R. Faizer: Nothing to disclose; S. Levin: Nothing to disclose; S. Santilli: Nothing to disclose; A. Suresh: Nothing to disclose. PS118. Regional Differences in Patient Selection and  Treatment of Carotid Artery Disease in the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI)

4:30 p.m.

John C. McCallum,1 Thomas Curran,1 Dominique B. Buck,1 Jeremy D. Darling,1 Joe Schneider,3 Brian W. Nolan,2 Philip P. Goodney,2 Marc L. Schermerhorn.1 1  Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.; 2 Dartmouth-Hitchcock Medical Center, Hanover, N.H.; 3Northwestern University Feinberg School of Medicine, Chicago, Ill.

OBJECTIVES: There are limited data on the regional variation of carotid endarterectomy (CEA) and carotid stenting (CAS). We use the SVS-VQI to evaluate regional differences in CEA and CAS across the United States. METHODS: We used the SVS-VQI to identify patients undergoing CEA and CAS between 2009 and 2012. Each of 14 regions was evaluated. Regions performing fewer than 50 CAS were excluded, leaving 9 regions. RESULTS: 14,871 cases were performed, and a minority of cases used CAS (vs. CEA) to treat both symptomatic and asymptomatic disease. Substantial regional variation in patient characteristics (e.g., symptom status, stenosis >70%), technical approach (e.g., CEA vs. stent, patch use, shunt use, neurological monitoring, cerebral protection device use and type), and evidence-based process measures (e.g., anti-platelet and statin use, patch use) are demonstrated in the Table. CONCLUSIONS: This first investigation of a national clinical database demonstrates significant regional variation in carotid disease management. Future studies on the association of regional variation with risk-adjusted outcomes offer the opportunity for quality improvement through prospective identification of best practices. AUTHOR DISCLOSURES: D.B. Buck: Nothing to disclose; T. Curran: Nothing to disclose; J.D. Darling: Nothing to disclose; P.P. Goodney: Nothing to disclose; J.C. McCallum: Nothing to disclose; B.W. Nolan: Nothing to disclose; M.L. Schermerhorn: Endologix Inc, consulting fees or other remuneration (payment); Medtronic, Inc, consulting fees or other remuneration (payment); J. Schneider: Nothing to disclose.

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Min

Max

7%

32%

% Asymptomatic Patients Who Had CAS (vs. CEA)

7%

23%

% CEA with Symptoms

20%

42%

% CAS with Symptoms

10%

53%

% CEA with Patch

73%

95%

% CEA with Shunt Use

33%

76%

% CEA Where EEG Used by Surgeons Who Routinely Shunt

0%

68%

% CAS on Both Anti-Platelet & Statin

60%

82%

% Symptomatic Patients Who Had CAS (vs. CEA)

% CAS Discharged on Both Antiplatelet & Statin

75%

91%

% Asymptomatic CAS with Stenosis >70%

67%

97%

% CAS Pre-Dilated

27%

68%

% CAS Post-Dilated

60%

96%

All p<0.01

PS120. Outcomes After Early and Delayed Carotid  Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis

4:35 p.m.

Ying Huang, Peter Gloviczki, Audra A. Duncan, Manju Kalra, Gustavo S. Oderich, Mark D. Fleming, Randall R. De Martino, Thomas C. Bower.  Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. OBJECTIVES: To define outcomes after carotid endarterectomy (CEA) in symptomatic patients when operated within 14 days after onset of symptoms or later. METHODS: Clinical data of consecutive patients who underwent CEA (2003-2012) for symptomatic carotid artery stenosis (CAS) were reviewed. Group 1: symptoms (minor stroke, transient ischemic attack, TIA) occurred ≤14 days; Group 2: > 14 days before CEA. Primary endpoints were combined stroke and death; secondary endpoints were stroke, death and myocardial infarction (MI). RESULTS: 231 CEAs were performed in 226 symptomatic patients (female: 32%; mean age: 72±8.7 years, 58 (25%) in Group 1, 173 (75%) in Group 2. 60 (26%) presented with stroke (Group 1: 19%, Group 2: 28%, P=.16). 30-day stroke and death rate was 2.6%, not significantly different between groups (Table). 3 of 4 early strokes in Group 1 occurred in patients with repeated TIAs within 2 days before CEA. Mean follow-up was 3.9 years (30 days-10.8 years). Table presents 5-year outcomes. In multi-variable analysis, symptoms ≤14 days tended to have increased rate of stroke. CONCLUSIONS: CEA can be performed in symptomatic patients with a 30-day stroke and death rate of 2.6%, but there is a trend to increased rate of stroke if the operation was performed within 14 days after onset of symptoms. Patients with repeated TIAs, operated within 2 days had the highest risk of stroke. For this select group of symptomatic patients outcomes quoted based on prospective randomized trials may not apply. AUTHOR DISCLOSURES: T.C. Bower: Nothing to disclose; R.R. De Martino: Nothing to disclose; A.A. Duncan: Nothing to disclose; M.D. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; Y. Huang: Nothing to disclose; M. Kalra: Nothing to disclose; G.S. Oderich: Cook, consulting fees or other remuneration (payment); Gore, consulting fees or other remuneration (payment).

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Outcomes after CEA 30-Day

5-Year

Overall N=231 N (%)

Group 1 N=58 N (%)

Group 2 N=173 N (%)

Stroke+Death

6(2.6)

4(6.9)

2(1.2)

.29

 

Overall P (%) value

Group 1 (%)

24

37

Group P 2 (%) value 20

.07

Death

1(0.4)

0(0)

1(0.6)

.81

20

29

18

.57

Stroke

5(2.2)

4(6.9)

1(0.6)

.07

7.0

11

5.5

.03

MI

4(1.7)

0(0)

4(2.3)

.24

1.8

0

2.4

.24

C8f: V  ascular Medicine • Practice  Management • Other 

3:30 – 5:00 p.m. uAuditorium, Level 2 (enter through Exhibit Hall C)

Moderator: John A. Curci, MD, Washington University School of Medicine, St Louis, Mo.

PS122. Risk factors for Sub-Optimal Medical Therapy  3:40 p.m. in Patients Undergoing Revascularization for Symptomatic Peripheral Arterial Disease: A Vascular Study Group of Greater New York Initiative Andrew J. Meltzer, Art Sedrakyan, Abby Isaacs, Ellen C. Meltzer, Peter H. Connolly, Darren B. Schneider.  Vascular Surgery, Weill Cornell Medical College, New York City, N.Y. OBJECTIVES: The objective of this study is to identify risk factors for sub-optimal medical therapy among patients undergoing surgical bypass and percutaneous interventions for symptomatic peripheral arterial disease (PAD). METHODS: The Vascular Study Group of Greater New York (VSGGNY) database was used to identify all patients undergoing percutaneous therapy or surgical bypass for PAD (2011-2013). Bivariate analyses were performed to identify factors associated with preoperative statin utilization and antiplatelet therapy. Multivariate relative risk regression models were developed to identify patients at risk for sub-optimal medical therapy. RESULTS: 1030 patients underwent endovascular therapy (n=822; 80%) or surgical bypass (n=208; 20%) for symptomatic peripheral arterial disease (57.2% claudication; 15% rest pain, 27.8% tissue loss). Preoperative statin use was observed in 59%. Antiplatelet therapy was observed in 79% of patients. Bivariate analysis revealed reduced statin use among patients without other cardiovascular risk factors such as hypertension (63% vs. 39.3%; P<0.0001) and coronary artery disease (CAD) with prior cardiac revascularization (CABG/PCI) (75.2% vs. 47.4%; P<0.0001). Multivariate relative risk regression confirmed increased statin use among patients with other cardiovascular risk factors including hypertension [1.14 (1.02-1.27); P=0.02], and CAD with prior CABG/PCI [1.22 (1.13-1.31); P<0.0001]. There was a clear trend towards reduced statin use in patients age>80 [0.92(0.84-0.1.0);P=0.059]. By multivariate regression, antiplatelet therapy use was associated with CAD and prior CABG/PCI [1.11 (1.04-1.17);P=0.0015] and prior peripheral revascularization [1.07(1.01-1.13);P=0.03].

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CONCLUSIONS: Patients with symptomatic PAD, but without an antecedent cardiovascular history, are less likely to be optimally managed with statins and antiplatelet therapy preoperatively, and should be actively targeted for medical optimization by vascular specialists. AUTHOR DISCLOSURES: P.H. Connolly: Nothing to disclose; A. Isaacs: Nothing to disclose; A.J. Meltzer: Nothing to disclose; E.C. Meltzer: Nothing to disclose; D.B. Schneider: Nothing to disclose; A. Sedrakyan: Nothing to disclose. PS124. Smoking Cessation Does Not Impact Limb  Amputation Rates in Buerger’s Disease

3:45 p.m.

Sapan S. Desai,1 Anahita Dua.2 1  Department of Surgery, Duke University, Durham, N.C.; 2 Medical College of Wisconsin, Milwaukee, Wis.

OBJECTIVES: The aim of this study was to evaluate the impact of smoking cessation on the progression of thrombangiitis obliterans (Buerger’s disease). The impact of various comorbidities on limb amputation was also evaluated. METHODS: A retrospective analysis of the cross-sectional National Inpatient Sample (2000-2011) was used to identify patients with a diagnosis of Buerger’s disease (ICD-9 44.31). Patients who underwent extremity amputation were characterized according to smoking status and comorbidities including renal failure, diabetes, coagulopathy, hypertension, heart disease, and chronic obstructive pulmonary disease and compared to those who did not undergo amputation. Odds ratios were calculated for all statistically significant (P<0.05) differences identified using the Fisher exact test and Student’s T-test. RESULTS: 4,489 patients with Buerger’s disease were identified in the United States between 2000 and 2011, of which 193 (4.3%) underwent limb amputation. 1,908 (42.5%) patients were smokers. Smoking was slightly more common among patients who underwent amputation (46.1% vs. 42.3%, P=0.30, 95% CI -0.11 - 0.03). Of the comorbidities evaluated, renal failure was found to be two times more common among patients who underwent amputation (6.2% vs. 3.2%, OR 2, P=0.02, 95% CI -0.06 -0.004). Patients who were former smokers were just as likely to require limb amputation (9.3% vs. 11.5%, P=0.35). CONCLUSIONS: While the association between smoking and Buerger’s disease is well understood, whether smoking leads to the limb amputation from this disease is unclear. This study demonstrates that the primary factor associated with limb amputation from Buerger’s disease is end stage renal disease, not smoking. Further, smoking cessation does not appear to prevent progression to limb amputation in Buerger’s disease. AUTHOR DISCLOSURES: S.S. Desai: Nothing to disclose; A. Dua: Nothing to disclose. PS126. Vascular Surgeons Can Improve the Cardiovascular  Health of Patients with Clinical Atherosclerotic Cardiovascular Disease by Implementing an Intensive Lipid Lowering Regimen and Providing Smoke Cessation Counseling

3:50 p.m.

Naren Gupta,1 Carla Moreira,2 Sarah White,1 Summer Mattera,1 Joseph D. Raffetto,1 Deepak L. Bhatt,3 John M. Gaziano,1 James T. McPhee.1

182

1 VA Boston Health System, Boston, Mass.; 2Boston Medical Center, Boston, Mass.; 3Brigham and Women’s Hospital, Boston, Mass.


OBJECTIVES: To assess the impact of a vascular surgery led program to improve the cardiovascular risk of patients with clinical atherosclerotic cardiovascular disease (ASCVD) by implementing an intensive lipid lowering regimen and providing smoking cessation counseling. METHODS: The records of all patients seen in a single center vascular surgery clinic over a one month period in November 2013 were retrospectively reviewed till October 1, 2011, when the vascular surgery service implemented a cardiovascular risk reduction program in patients with clinical ASCVD. RESULTS: One hundred and forty four consecutive patients were included with a median follow-up of 315 days (range 0-740). Pre-intervention, the baseline median LDL was 86 mg/dl (range 39-197) and 96 patients (71.1%) had an LDL>70 mg/dl. 52 patients (37%) were current smokers, 41 (71%) smoked heavily (>1ppd). 55% of patients had documentation that this intervention was administered at the initial vascular surgery encounter after this program was started. The mean lag time to the first vascular surgery encounter with intervention documentation was 117 days (median 0 days, range 0-721). At latest follow-up, 92 (72%) of the encounters by a vascular surgeon documented that the intervention was administered, final median LDL was 79 mg/dl (range 31-198), 80 patients (62%) had an LDL >70 mg/dl, and 60 patients (47.2%) had a decrease in their LDL. Patients that had no observed decrease in their LDL had a significantly lower mean level at baseline (82.3 mg/dl, stddev 28.7, range 39-197) compared to those with an observed decrease in LDL (mean 98.8, stddev 32.8, range 42-187), P=.003. At latest follow-up, 41 patients (31.5%) were currently smoking, 21 of which (43.7%) smoked heavily (>1ppd). CONCLUSIONS: Vascular surgeons can improve the cardiovascular health of their patients by implementing a program of intensive lipid control and smoking cessation in patients with clinical ASCVD. Further studies are needed to determine the impact on cardiovascular event rates. AUTHOR DISCLOSURES: D.L. Bhatt: Nothing to disclose; J.M. Gaziano: Nothing to disclose; N. Gupta: Nothing to disclose; S. Mattera: Nothing to disclose; J.T. McPhee: Nothing to disclose; C. Moreira: Nothing to disclose; J.D. Raffetto: Nothing to disclose; S. White: Nothing to disclose. PS128. Defining and Reporting Academic Activity:  The Academic RVU Can Justify the Mission

3:55 p.m

Houssam K. Younes, Abindra Sigdel, Uwe Fischer, Marie Unruh, Jean Bismuth, Hosam F. El-sayed, Eric K. Peden, Alan B. Lumsden, Mark G. Davies. Cardiovascular Surgery, DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas. OBJECTIVES: The academic mission is under strain. While clinical activity is easily quantified by the Relative Value Units (RVU), there are multiple ad hoc measures of academic activity. This study reports the use of academic RVU derived for all non-clinical activities to justify non-clinical protected time of individual faculty, prioritize divisional activities and drive the academic. METHODS: All non-clinical activity for divisional faculty were correlated and subjected to a defined scoring system. The system was set up in 5 modules (publications, presentation, clinical trial, grants educational, administration and community). Each module was assigned a set of academic effort values and a series of modulators to describe the strength and weakness of an activity. Only ongoing productive activities were measured and no allowances were made for tenure or previous achievements.

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RESULTS: All activities had effort apportioned to them. Publications were modulated by type, author position and journal impact factor. Presentations were modulated by level of participation, meeting type and CME credit. Grants were weighted by funding source, annual income and investigator classification while clinical trials were assessed by status of recruitment and financial re-imbursement. Teaching was based on defined activities, contributions to the curriculum and learner scores. When faculty members were assessed and their budgeted time allocations compared, all the faculty exceeded their effort requirements. Examples of the system applications to a clinician, clinician administrator, clinician educator and clinician researcher will be shown. CONCLUSIONS: Adoption of a universal system of measuring academic performance is necessary to facilitate faculty focus and development and allow for a rational budgeting of academic time and effort. Production and validation of the aRVU will allow for constructive and appropriate recognition of activity and contributions to the academic mission. AUTHOR DISCLOSURES: J. Bismuth: Nothing to disclose; M.G. Davies: Nothing to disclose; H.F. El-sayed: Nothing to disclose; U. Fischer: Nothing to disclose; A.B. Lumsden: Nothing to disclose; E.K. Peden: Nothing to disclose; A. Sigdel: Nothing to disclose; M. Unruh: Nothing to disclose; H.K. Younes: Nothing to disclose. PS130. Clinical Feasibility and Financial Impact of  Same Day Discharge in Patients Undergoing Endovascular Aortic Repair (EVAR) for Elective Infra-Abdominal Aortic Aneurysm (AAA)

4:00 p.m.

Vincent Moscato, Monica Oâ&#x20AC;&#x2122;Brien-Irr, Maciej Dryjski, Linda Harris.

Department of Surgery, Buffalo General Medical Center, Buffalo, N.Y.

OBJECTIVES: To evaluate potential feasibility/financial impact of same day discharge following elective EVAR for AAA. METHODS: All elective EVAR 1/12- 6/13, were identified. Demographics, comorbidities, complications, nursing care, financial data and length of stay (LOS) were analyzed (SPSS 21). RESULTS: Table I presents care received in 67 elective EVAR (70% PEVAR/61% of AAA). Intra/post-op complications were type I endoleak 1.5%, thrombosis 3%, blood loss requiring transfusion 4.5%, urinary retention 4.5%, MI 3%, and hemodynamic/rhythm alterations 37% (evident in 88%(24) < 6 hours; 13% required therapy). Monitoring only was needed in 28 (42%), ICU in 13.4%. POD1 discharge occurred in 73%; 9% <30 day readmission. Total hospital costs: $29,479: O.R. 80.3%, Anesthesia 2.2%, Pre-Admission 1%, Post Anesthesia Unit 3.1%, ICU 1.9%, Floor 4.7%, Lab/diagnostic tests 1.2%, Pharmacy 1.4%, Other 4.2%. Total cost was similar for those discharged < 24 or >25 hours post-op (P= 0.88), and for monitoring only vs. others ($28,146 vs. $30,545; P= 0.12). Pharmacy ($351 vs. $509: P= 0.05), lab ($86 vs. $354: P=0.01) and diagnostic testing ($3.96 vs. $254: P= 0.02) were lower for uncomplicated cases. CONCLUSIONS: Same day discharge is clinically feasible in >40% of elective EVAR, but requires coordination for adequate postoperative monitoring. Significant savings is unlikely as most cost is O.R./device related and further reduction of costs in uncomplicated cases is unlikely. AUTHOR DISCLOSURES: M. Dryjski: Nothing to disclose; L. Harris: Nothing to disclose; V. Moscato: Nothing to disclose; M. Oâ&#x20AC;&#x2122;Brien-Irr: Nothing to disclose.

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Indicator

(%)

Oxygen

98.5

Mean Hours Postop 19

Telemetry

100

12

Arterial Line

27.3

6

Continuous IV

86.4

12.5 3.5 (initiated)

IV Fluid Bolus

16.7

IV Medication

52.4

Indwelling Urinary Catheter

67.2

19

Straight Catheterization

4.5

14 (initiated)

<3 Labs

76.2

Diabetic Management

37.3

PS132. Mitigating Mortality in Abdominal Aortic  Aneurysmal Disease Through the Use of a Risk Register: Indications for EVAR vs. Open Repair

4:05 p.m.

Sapan S. Desai,2 Anahita Dua,1 SreyRam Kuy,1 Gilbert R. Upchurch Jr.3

1  Medical College of Wisconsin, Milwaukee, Wis.; 2Department of Surgery, Duke University, Durham, N.C.; 3University of Virginia, Charlottesville, Va.

OBJECTIVES: This study aimed to determine risk factors associated with peri-operative mortality in patients undergoing AAA repair nationally and utilize these risk factors to create a scoring system and risk register to determine mortality rate based on risk scores. METHODS: A retrospective analysis was completed using the National Inpatient Sample (NIS) from 2000 to 2010. A discriminant analysis was used to predict in-hospital mortality once predictor variables were identified using a multivariate analysis. A risk register was created using established rates of rupture for various AAA sizes and estimating the average mortality for those patients. This risk was then compared to the in-hospital mortality risk using our discriminant analysis to make recommendations on minimizing overall mortality as a function of aneurysm size and predictors of mortality. RESULTS: In the past decade in the United States, 101,978 patients underwent an AAA repair, of which 95,098 survived and 6,780 (7%) died. The following variables were positive predictors for mortality and assigned point values based on impact on survival: rupture (10 points), anticoagulation usage (4 points), renal failure (1 point), and female gender (1 point). Patients with the lowest risk of mortality were those with a score ranging from -4 to 1 (1.4% risk of mortality), followed by those with a range of 2-6 (13.3% mortality risk), 7-12 (33% mortality risk), and finally 13-16 (45.5%) risk of death. A risk register was created with this data. CONCLUSIONS: This study demonstrates that not all patients with AAA between 5-5.5 cm are candidates for surgery. Higher risk patients may benefit from EVAR, and those patients with smaller aneurysm sizes and few risk factors may benefit from observation. Women, patients with renal failure, and anticoagulated patients all have a greater risk of in-hospital mortality. Patients who undergo EVAR have significantly lower in-hospital mortality, especially those patients who have a ruptured AAA. AUTHOR DISCLOSURES: S.S. Desai: Nothing to disclose; A. Dua: Nothing to disclose; S. Kuy: Nothing to disclose; G.R. Upchurch Jr.: Nothing to disclose.

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PS134. Does Increased Cost in the Treatment of  Superficial Femoral Artery Disease Lead to Better Outcomes?

4:10 p.m.

Karen L. Walker, Jesse A. Columbo, Eva M. Rzucidlo, Samuel T. Simone, Philip P. Goodney, Richard J. Powell.

Vascular Surgery, Dartmouth-Hitchcock, Lebanon, N.H.

OBJECTIVES: Patients considered for endovascular treatment of SFA disease present with a wide array of lesion complexity and treatment options. This study aims to examine the cost drivers of SFA stent treatment and their impact on outcome. METHODS: We retrospectively collected clinical and financial data on patients undergoing SFA stenting to evaluate the relationship between direct procedural cost and 1-year patency. Adjuncts to SFA stenting were defined as: stent-grafts, atherectomy, re-entry, and embolic protection devices. RESULTS: We studied 95 patients who underwent SFA stenting from 1/2010 to 2/2012. Patients had a mean age of 71 years, 62% were male, 41% were diabetic, 46% had CLI, and 24% had a TASC C or D lesion. Primary patency at 1 year was better in patients with claudication than those with CLI (91% v. 74%, p=0.06). While the rate of adjunct use was similar in patients with claudication and CLI (12%), more adjuncts were used in patients with TASC C&D lesions (22% C&D, 8% A&B, p=0.09). Mean direct costs for SFA stenting without adjunct use was $2,838 (95% CI: $2,586-$3,089), while adjunct use increased mean costs to 7,318 (95% CI: $4,817-$9,820) (p<0.01). Multivariate regression showed that TASC C/D classification and adjunct use were associated with the highest tertile of costs, OR 13.5 and 36.8 respectively, p<0.01. There was no association between cost and primary patency (Figure). CONCLUSIONS: Adjunct devices are often necessary to achieve technical success for treatment of TASC C&D SFA lesions. Their use is associated with increased cost, yet has limited impact on mid-term patency. AUTHOR DISCLOSURES: J.A. Columbo: Nothing to disclose; P.P. Goodney: Nothing to disclose; R.J. Powell: Nothing to disclose; E.M. Rzucidlo: Nothing to disclose; S.T. Simone: Nothing to disclose; K.L. Walker: Nothing to disclose.

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PS136. Results of the Retro-Carotid Dissection Technique  in the Treatment of Carotid Body Tumors

4:15 p.m.

Carlos A. Hinojosa,1 Laura J. Ortiz-López,1 Vicente Orozco-Sevilla,2 Ana E. Nuñez-Salgado.1

1 Section of Vascular Surgery and Endovascular Therapy, National Institute of Medical Sciences and Nutrition “Salvador Zubirán”, Mexico City, Mexico; 2 Mount Sinai School of Medicine, Department of Cardiothoracic Surgery, New York City, N.Y.

OBJECTIVES: To determine if the retro-carotid dissection technique has advantages over the standard caudal-cranial approach in regards of bleeding, surgical time, vascular or nervous injury, and hospital stay in patients with carotid body tumors (CBT). METHODS: A prospective cohort of patients who underwent surgical treatment with retro-carotid dissection technique (RC) at our Institution between July 2007 and January 2013 was reviewed. This cohort was compared with a historical group of patients treated with standard approach (SA, caudal-cranial dissection) between 1995 and 2007. Intraoperative parameters and operative outcomes were compared using Fisher’s exact test for categorical variables, and U of Mann and Whitney for continuous variables. A P <0.05 was considered as statistically significant. RESULTS: A total of 68 resections (41 standard approach, 27 retro-carotid) in 68 patients were performed (62 female/8 male, mean age 54.3 years). Comparative analysis identified mean blood loss 476 mL (SD 378) in the RC group, and 694.39 mL (SD 682) for the SA cohort (P <. 31). The mean surgical time was 172 min (SD 60) for the RC group and 260 min (SD 97.7) for the standard approach (P <. 001). The hospital stay was significantly shorter for the RC group with an average of 4.6 ± 2.2 days compared to 8.8 ± 5.9 days for the SA cohort (P < 0.0001). Significant differences in intraoperative vascular lesions were not identified. Cranial nerve damage was observed in 17 patients: 6 transient nerve palsies in the RC cohort, and 11 in the SA group. There were 3 patients with postoperative transient ischemic attacks in the standard approach cohort with no observed TIA’s in the RC group. This translates into a rate of 21% of postoperative complications for the RC cohort and 34% in the SA group (P <. 08). CONCLUSIONS: The retro-carotid dissection technique is a safe, viable option for the treatment of CBT. It is associated with a significant decrease in surgical time and hospital stay. AUTHOR DISCLOSURES: C.A. Hinojosa: Nothing to disclose; A.E. Nuñez-Salgado: Nothing to disclose; V. Orozco-Sevilla: Nothing to disclose; L.J. Ortiz-López: Nothing to disclose. PS138. The Excess Cost of Unplanned Thirty Day  Readmission Following Vascular Surgery

4:20 p.m.

Adam S. Gracon,1 Thomas Easterday,2 Daniel J. Weber,1 James Slaven,3 Gary Lemmon,4 Raghu Motaganahalli.4

1 Indiana University Department of Surgery, Indianapolis, Ind.; 2Indiana University School of Medicine, Indianapolis, Ind.; 3Indiana University Department of Biostatistics, Indianapolis, Ind.; 4Indiana University Department of Surgery-Division of Vascular Surgery, Indianapolis, Ind.

OBJECTIVES: Patients undergoing vascular surgery have a high rate of unplanned 30 day readmission. The costs associated with readmission have not been described.

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The objective of this study is to determine the excess cost due to 30 day unplanned readmission for patients undergoing vascular surgery. METHODS: The ACS-NSQIP database was used to identify patients undergoing vascular surgery at a single institution from January 2011 through June 2012. Cost for each patientâ&#x20AC;&#x2122;s index hospitalization, as well as all unplanned 30 day readmissions were obtained using SAP BusinessObjects. Logistic regression analyses were performed to determine associations between patient characteristics and readmission. T-tests were performed for cost comparison. RESULTS: 689 endovascular and 648 open procedures were performed during the study period. The mean cost of care for patients who required readmission following endo procedures was $48,131 compared to $18,803 for those not requiring readmission (p<0.0001). The mean cost of care for patients who required readmission following open surgery was $49,605 compared to $27,820 for those not requiring readmission (p<0.0001). Refer to Table 1 for results of logistic regression. CONCLUSIONS: Here we have shown that 30 day unplanned readmission after vascular surgery is associated with a significant increase in cost. The mean cost of care for endovascular patients requiring readmission is more than 2.5 times greater than those who do not. Similarly, the mean cost of care for patients readmitted following open procedures is more than 1.75 times greater than those who are not. AUTHOR DISCLOSURES: T. Easterday: Nothing to disclose; A.S. Gracon: Nothing to disclose; G. Lemmon: Nothing to disclose; R. Motaganahalli: Nothing to disclose; J. Slaven: Nothing to disclose; D.J. Weber: Nothing to disclose.

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PS140. Trends in EVAR Length of Stay over a Decade  at a Tertiary Academic Institution

4:25 p.m.

Yana Etkin, Benjamin M. Jackson, Edward Woo, Paul Foley, Jeffrey Rohrbach, Ronald M. Fairman, Grace Wang.

Hospital of University of Pennsylvania, Philadelphia, Pa.

OBJECTIVES: We analyzed trends in EVAR LOS at a tertiary academic institution over the last decade. METHODS: Infrarenal EVARs from 2001-2013 were divided into 3 groups: 2001-04: performed as part of clinical trials, 2005-08: multiple devices were FDA approved, 2009-13: complex EVARs referred to academic institutions. Trends in LOS and correlation with severity of illness (SOI) based on APR-DRG, and admission/disposition status were analyzed. LOS index was compared to University Health Consortium (UHC) Hospitals over the past 3 years. RESULTS: 1265 EVARs were performed: 325-Group 1, 547-Group 2 and 393-Group 3. Average LOS was 5.5 vs. 4.9 vs. 6 days, p<0.01. While moderate SOI was constant over time (p=0.66), prevalence of major/extreme SOI was greater in Group 1, reduced in Group 2, and again increased in Group 3, p<0.01 (graph 1). The complication rate paralleled this pattern (15.2% vs. 8.6% vs. 10.4%, p=0.02). The percentage of patients discharged to nursing home was 5.7% vs. 8.2% vs. 11.5% (p=0.03). Cases performed emergently increased over time: 11.6% vs. 14.9% vs. 21.6% (p=0.01). The risk-adjusted LOS index at our institution was significantly greater (1.25) compared to UHC hospitals (0.75) except in the 1st quarter of FY14, where an EVAR quality initiative project was introduced, resulting in equalization of the LOS index (0.70). The greater increase in expected LOS at our institution (26%) compared to UHC hospitals (7%) partially accounted for the increased LOS index. CONCLUSIONS: Our study suggests a relationship between time of EVAR, SOI, complications and LOS. Attention to these trends can be used to decrease LOS in an increasingly complex patient population. AUTHOR DISCLOSURES: Y. Etkin: Nothing to disclose; R.M. Fairman: Nothing to disclose; P. Foley: Nothing to disclose; B.M. Jackson: Nothing to disclose; J. Rohrbach: Nothing to disclose; G. Wang: Nothing to disclose; E. Woo: Nothing to disclose.

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PS142. Isolated Iliac Artery Aneurysms: The Impact of  Endovascular Repair

4:30 p.m.

Dominique B. Buck,1 Thomas Curran,1 John C. McCallum,1 Jeremy D. Darling,1 Joost A. van Herwaarden,2 Frans L. Moll,2 Marc L. Schermerhorn.1

BIDMC, Boston, Mass.; 2UMCU, Utrecht, Netherlands.

1

OBJECTIVES: Isolated Iliac artery aneurysms (iIAA) are rare, but potentially fatal. The impact of recent trends in the utilization of advances in imaging and endovascular therapies (EVIR) on iIAA-associated mortality is unknown. METHODS: We identified all patients with a primary diagnosis of IAA in the NIS from 1988 to 2011. We examined trends in management (open vs. EVIR) and overall iIAA related deaths (with or without repair). We compared in-hospital mortality and complications for elective open and EVIR from 2000-2011. RESULTS: We identified 17,102 patients undergoing iIAA repair from 1988-2011; 9,016 EVIR and 4,933 open repairs electively from 2000-2011. Endovascular surpassed open repair in 2003. Total repairs increased after introduction of EVIR (p=<.001). Total deaths, including non-operative, decreased after the introduction of EVIR (0.54 to 0.24 per 1M US population, p=<.001). For elective repairs after 2000, EVIR patients were older (72.4 vs. 69.4 years, p=.002) with more prior MI (14.0% vs. 11.3%, <.001) and CRF (7.2% vs. 3.6%, <0.001). Open repair had significantly higher in-hospital mortality (1.8% vs. 0.5%, <0.001), more complications (17.9% vs. 6.7%, <0.001) and a longer length of stay (6.7 vs. 2.3 days, <0.001). CONCLUSIONS: Treatment of iIAA has increased with the introduction of EVIR with lower perioperative mortality, despite a higher burden of comorbid illness. Decreasing iIAA-attributable deaths are likely related to lower elective mortality and rupture prevention. AUTHOR DISCLOSURES: D.B. Buck: Nothing to disclose; T. Curran: Nothing to disclose; J.D. Darling: Nothing to disclose; J.C. McCallum: Nothing to disclose; F.L. Moll: Medtronic, consulting fees or other remuneration (payment); M.L. Schermerhorn: Endologix, consulting fees or other remuneration (payment); Medtronic, consulting fees or other remuneration (payment); J.A. van Herwaarden:

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Medtronic, consulting fees or other remuneration (payment); Philips, consulting fees or other remuneration (payment).

PS144. A Comparison of Estimated Outcomes Using  the ACS NSQIP Universal Risk Calculator Tool to Observed Vascular Procedure Outcomes in a Community Teaching Hospital

4:35 p.m.

Madian Yahya, Stuart Blackwood, Foula Kontonicolas, Andrew McGregor, Alan M. Dietzek.

Surgery, Danbury Hospital, Danbury, Conn.

OBJECTIVES: The NSQIP universal risk calculator tool was designed using 1.4 million cases and over 2,800 different CPT codes to estimate perioperative risk across multiple surgical subspecialties to guide informed consent. We aimed to test whether perioperative risk was accurately estimated for a vascular surgery cohort in a community teaching hospital setting. METHODS: We performed an IRB approved retrospective chart review of all consecutive vascular surgery cases between July 1, 2012 and June 30, 2013. We excluded CPT codes which were not available in the risk calculator and reoperations within 30 days of the index procedure. We reviewed all 23 pre-operative risk factors present in the NSQIP tool for each procedure. An estimated case specific risk for each of ten predicted post-operative complications was then calculated using this tool. We then compared the cumulative estimated risk to our actual observed outcomes. RESULTS: There were 914 consecutive vascular procedures performed in a hospital setting of which only 359 procedures met inclusion criteria. The risk calculator closely approximated the observed mortality rate and slightly underestimated the observed outcomes in eight of the other ten outcome categories. Alternatively, the tool significantly underestimated the observed risk for serious complications.

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CONCLUSIONS: In our study the NSQIP tool would have proved useful for purposes of predicting complications, including death, and informed patient consent. Underestimation of serious complications may reflect our institution specific outcomes rather than a deficiency in the NSQIP calculator. Studies with large vascular patient cohorts are necessary to more accurately evaluate this tool and/or create a more comprehensive one specific to vascular patients. AUTHOR DISCLOSURES: S. Blackwood: Nothing to disclose; A.M. Dietzek: Nothing to disclose; F. Kontonicolas: Nothing to disclose; A. McGregor: Nothing to disclose; M. Yahya: Nothing to disclose. NSQIP Estimated Risk vs. Observed Outcomes Death

Any Cardiac Pneumonia Complication Complication

Surgical Site Infection

Urinary Tract Infection

VTE

Renal Return Failure to OR

Serious Complication

3.06%

15.91%

1.84%

2.07%

2.24%

1.41%

0.99% 1.13% 7.92%

12.35%

2.79%

21.73%

2.79%

4.46%

4.46%

2.51%

0.84% 1.95% 9.75%

20.89%

Top Row: Estimated risk. Bottom Row: Observed outcomes.

C8g: Periphe ral Arterial Disease   

3:30 â&#x20AC;&#x201C; 5:00 p.m. uAuditorium, Level 2 (enter through Exhibit Hall C)

Moderator: Ellen D. Dillavou, MD, University of Pittsburgh Medical Center, Pittsburgh, Pa.

PS146. T  he Effects of Peripheral Arterial Disease on  Mortality in Patients with End Stage Renal Failure

James Cassuto,1 Sateesh Babu,2 Igor Laskowski.2

1

3:40 p.m.

New York Medical College, Valhalla, N.Y.; Westchester Medical Center, Valhalla, N.Y.

2

OBJECTIVES: Peripheral arterial disease (PAD) has been shown to be an independent determinant of all cause mortality in patients with chronic renal failure (CRF). However, a paucity of data exists quantifying the severity of the interaction between PAD and CRF. Our study was designed to investigate the presence and significance of PAD on mortality in the setting of CRF. METHODS: We examined 25,664 adult patients listed for an isolated primary kidney transplant within the UNOS database in a retrospective manner. Multivariate Cox regression was used to model the RR of 5-year mortality with respect to PAD and pre- and dialyzed patients. Multivariate Logistic regression was used to model waitlist survival at 30 and 90 days, and at 1, 3, and 5 years to assess the interaction between PAD and dialysis. Covariates included age, gender, ethnicity, primary cause of CRF, coronary artery disease (CAD), dialysis, and PAD.

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RESULTS: Relative to patients without PAD and not on dialysis (PAD-Dial-, n=4,860), a 31% increase in the risk of death was observed in PAD+Dial- patients (n=308), a 95% increase in the risk of death for PAD-Dial+ patients (n=19,002), and a 190% increase in the risk of death for PAD+Dial+ patients (n=1,494). As an independent covariate, PAD was associated with a 47% increase in the risk of death, while CAD was associated with a 24% increase. Additionally, the combined effects of PAD and dialysis on the risk of mortality increased with time. CONCLUSIONS: To our knowledge, this is the first study to demonstrate that in the setting of CRF, PAD is an independent risk factor for mortality and increases the risk of death synergistically with concomitant dialysis therapy. Additionally, we show that PAD is associated with a greater RR of mortality than moderate CAD. Early diagnosis and modification of PAD or CRF risk factors in patients with CRF or PAD, respectively, should be considered in the management of patients at risk for both. AUTHOR DISCLOSURES: S. Babu: Nothing to disclose; J. Cassuto: Nothing to disclose; I. Laskowski: Nothing to disclose. PS148. The Impact of Vein Harvesting Technique on  Wound Complications and Graft Patency After Infra-Inguinal Arterial Bypass

Pedro G. Teixeira, Karen Woo, Fred Weaver, Vincent Rowe.

University of Southern California, Los Angeles, Calif.

3:45 p.m.

OBJECTIVES: Investigate the impact of vein harvesting technique (VHT) on wound complications and graft patency after infra-inguinal arterial bypass. METHODS: The Vascular Quality Initiative® (VQI) database was utilized to review vein harvest technique of all patients undergoing single segment greater saphenous vein (GSV) graft infra-inguinal arterial bypass from 2003 to 2013. Patients were assigned to 3 groups according to the VHT used (continuous incision, skip incision and endoscopic). Multinomial logistic regression was performed to estimate group assignment propensity scores. Propensity score adjustment was included in multivariate analysis of surgical site infection (SSI) and graft primary patency. RESULTS: 5,066 patients underwent single segment GSV graft infra-inguinal bypass. The VHT was continuous incision in 48.6%, skip incision in 39.7% and endoscopic in 12.7%. SSI rates did not differ significantly among the groups (continuous 4.7%, skip 4.0%, endoscopic 3.4%, p=0.278). On multivariate analysis, there was no difference in discharge primary patency between the three groups. One-year primary patency rates were 66.2% for continuous, 68.6% for skip and 53.9% for endoscopic, p<0.001. After multivariate analysis, endoscopic vein harvest independently increased the risk of one-year primary patency loss compared to continuous (HR 1.38 [95% CI 1.07-1.77], p=0.010). There was no significant difference in one-year primary patency loss between skip and continuous. Endoscopic vein harvest also increased the risk of one-year primary patency loss compared to skip (HR 1.44 [95% CI 1.11-1.87], p=0.006). CONCLUSIONS: The choice of vein harvest technique had no impact on surgical site infection rates in patients undergoing infra-inguinal arterial bypass in the VQI population. Continuous and skip incisions resulted in equivalent one-year primary patency, but endoscopic vein harvest technique significantly reduced one-year primary patency. AUTHOR DISCLOSURES: V. Rowe: Nothing to disclose; P.G. Teixeira: Nothing to disclose; F. Weaver: Nothing to disclose; K. Woo: Nothing to disclose.

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PS150. Determinants of Endothelial Dysfunction in  Peripheral Artery Disease: Importance of Kidney Disease

3:50 p.m.

Karen C. Chong, Christopher D. Owens, Hugh F. Alley, Michael S. Conte, Warren J. Gasper, Marlene Grenon.  Vascular Surgery, University of California, San Francisco, San Francisco, Calif. OBJECTIVES: Peripheral artery disease (PAD) and chronic kidney disease (CKD) are both associated with endothelial dysfunction. CKD may contribute to the progression of endothelial dysfunction in PAD patients. We hypothesized that worsening renal function (RF) is associated with impaired endothelial function (EF) in patients with PAD. METHODS: This was a cross-sectional study of PAD patients presenting to a vascular surgery clinic. Brachial artery flow-mediated vasodilation (FMD) was done to assess EF. RF was determined by calculating eGFR. Linear regression was performed to assess the relationship between EF and RF in claudicants. RESULTS: 115 claudicants with eGFR  30 ml/min participated in this study. Mean age was 69 ± 8 years, 97% were male, and 77% were Caucasian. Comorbidities included hypertension (90%), dyslipidemia (83%), coronary artery disease (41%) and diabetes mellitus (36%). Mean ABI was 0.71 ± 0.15 and mean FMD was 7.0% ± 3.8, indicating impaired EF. As RF declined (p=0.001), EF decreased. After multivariable regression adjusting for age, race, log TNF-a, hypertension, dyslipidemia, and diabetes, only eGFR remained associated with EF (p=0.030). CONCLUSIONS: In patients with PAD, worsening renal function has a stronger association with endothelial dysfunction than traditional cardiovascular (CV) risk factors do. Further longitudinal studies are needed to explore whether stabilization of renal function may decrease the risk of PAD progression associated with endothelial dysfunction, as well as the risk of major adverse CV events and mortality. AUTHOR DISCLOSURES: H.F. Alley: Nothing to disclose; K.C. Chong: Nothing to disclose; M.S. Conte: Nothing to disclose; W.J. Gasper: Nothing to disclose; M. Grenon: Nothing to disclose; C.D. Owens: Nothing to disclose.

Association between CKD stage and FMD.

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PS152. Predicting Outcomes Following Lower Limb  Surgical Revascularization: The United Kingdom Bypass Outcome Model

3:55 p.m.

Graeme K. Ambler,1 Patrick Coughlin,1 Manjit S. Gohel,1 David C. Mitchell,2 Jonathan R. Boyle.1

1 Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; 2Southmead Hospital, Bristol, United Kingdom.

OBJECTIVES: Despite increasing use of endovascular techniques, lower limb surgical revascularization (LLSR) is commonly performed with associated mortality risks. Few studies have reported on robust outcome models that accurately identify high-risk patients. This study aimed to develop robust outcome models using data from the United Kingdom National Vascular Database (NVD). METHODS: Consecutive entries of LLSR into the NVD (January 2008 - October 2012) were analyzed for demographics, co-morbidity, symptoms and type of intervention. The primary outcome measure was in-hospital mortality. Other outcome scores were calculated for comparison (FinnVasc, Prevent III, POSSUM). Multiple imputation methodology was employed to mitigate for missing data. The dataset was divided non-chronologically into model development (2/3) and validation (1/3) subsets. Minimization of the Schwartz-Bayes criterion was used to select pre-operative variables and generate an optimal logistic regression model to predict in-hospital mortality. Model performance was assessed with receiver operating characteristic (ROC) curve analysis. Hosmer-Lemeshow analysis was used to assess calibration. RESULTS: 17980 operations were analyzed. Overall in-hospital mortality was 2.9%. The model generated, which utilized age, ASA grade, statin use, creatinine, white cell count, albumin and heart rate, provided excellent discrimination, with area under the ROC curve (AUC) of 0.83 (95% CI:0.80-0.86). It performed significantly better than the other models assessed (FinnVasc (AUC:0.72), Prevent III (AUC:0.69) and POSSUM (AUC:0.78); P<0.01). There was no evidence of mis-calibration on Hosmer-Lemeshow analysis (p=0.74). CONCLUSIONS: Using rigorous techniques for handling missing data, analysis of the NVD has facilitated development of an optimal new model predicting in-hospital mortality following LLSR, which may be useful both for guiding pre-operative optimization and comparative audit. Prospective validation of the model is now required. AUTHOR DISCLOSURES: G.K. Ambler: Nothing to disclose; J.R. Boyle: Nothing to disclose; P. Coughlin: Nothing to disclose; M.S. Gohel: Nothing to disclose; D.C. Mitchell: Nothing to disclose. PS154. Debulking of the Antero-Lateral Quadrant  4:00 p.m. of the Medial Gastrocnemius for Functional Popliteal Entrapment Syndrome in High Performance Athletes Mohamed Zayed,1 Michael Fredericson,2 Dominik Fleischmann,3 Jason T. Lee.1

1 Stanford University Medical Center, Division of Vascular Surgery, Stanford, Calif.; 2Stanford University Medical Center, Sports Medicine Center, Stanford, Calif.; 3Stanford University Medical Center, Division of Diagnostic Radiology, Stanford, Calif.

OBJECTIVES: Functional popliteal entrapment (FPE) is a rare, but disabling condition in young patients that limits performance. We developed a highly specialized algorithm for the workup, diagnosis, and operative technique that involves provocative CT-A and debulking of a specific portion of the medial head of the gastrocnemius muscle. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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METHODS: 21 (62% female) high performance athletes (11 runners, 2 triathletes, 2 soccer players, 2 lacrosse players, 1 basketball player, 1 gymnast, 1 diver, and 1 high jumper) unable to compete due to claudication were evaluated with a unique CT-A protocol with provocative maneuvers. All patients underwent posterior approach operative mobilization of the popliteal artery, and debulking of the antero-lateral quadrant of the medial gastrocnemius muscle to alleviate compression of the artery onto the lateral femoral condyle. RESULTS: Of the 21 patients treated, 9 had bilateral symptoms (43%), and all 30 popliteal arteries demonstrated obliteration on CT-A with provocative maneuvers. All resting ABIs were normal, but only 42% had abnormal exercise ABIs. Popliteal artery mobilization and debulking of the medial gastrocnemius (mean 7.6 cm3 muscle removal) was performed in all patients. One patient had a postoperative seroma (3%), and all resting ABIs remained normal. During a mean followup of 9 months, 100% of patients had resolution of short distance claudication. 20% of the patients developed some degree of recurrent symptoms, and 53% returned to prior competitive levels. CONCLUSIONS: In patients with FPE, CT-A with provocative maneuvers can guide surgical intervention, which involves debulking of the hypertrophied antero-lateral quadrant of the medial gastrocnemius muscle. Functional outcomes in high performance athletes are adequate, and in the majority of patients provide improved pain-free walking capacity and ability to return to full competitive sport. AUTHOR DISCLOSURES: D. Fleischmann: Nothing to disclose; M. Fredericson: Nothing to disclose; J.T. Lee: Nothing to disclose; M. Zayed: Nothing to disclose. PS156. A 30-Year Experience with Surgical  Management of Popliteal Artery Aneurysms

4:05 p.m.

Raffaele Pulli,1 Walter Dorigo,1 Laura Paperetti,1 Giovanni Pratesi,2 Alessandro Alessi Innocenti,1 Leonidas Azas,1 Carlo Pratesi.1

Vascular Surgery, University of Florence, Florence, Italy; 2 University of Rome Tor Vergata, Rome, Italy. 1

OBJECTIVES: To retrospectively analyze our experience with surgical management of popliteal artery aneurysms (PAAs) in last 30 years, with particular attention paid to early and long term results. METHODS: From January 1981 to December 2012, 223 open surgical interventions for PAA in 189 patients were performed. Data concerning these interventions were prospectively collected in a dedicated database. Early results were analyzed in terms of mortality, thrombosis, reintervention and amputation rates. Follow-up program consisted of clinical and duplex ultrasound (DUS) examinations at 1 month and yearly thereafter. Patients who did not accomplish follow-up examinations had phone interview; additional data regarding long term events were obtained from the Regional Health Care database. Follow-up results were analyzed in terms of survival, primary and secondary patency and amputations rates. RESULTS: PAA was asymptomatic in 92 cases; intermittent claudication was present in 66 cases, while in 60 cases limb-threatening ischemia was present; five patients had a ruptured PAA. There were two perioperative deaths, with a cumulative mortality rate of 0.9%. Perioperative thrombosis occurred in 13 cases (5.5%) and immediate reintervention was performed in all these patients; in nine of them major amputation was unavoidable (amputation rate 4%). Six other adjunctive reinterventions in the perioperative period were performed, with a rate of reinterventions of 8.5%.

196


Mean duration of follow-up was 64.3 months (range 1-312 months). Estimated 13-year survival rate was 50.5% (SE 0.07); at the same time interval primary patency, secondary patency and limb preservation rates were 54% (SE 0.05), 68.5% (SE 0.05) and 85% (SE 0.04). CONCLUSIONS: Open surgical repair of PAAs provided in our experience good results, with low rates of perioperative complications and an excellent durability in the very long term setting, representing the benchmark for alternative techniques, such as endovascular repair. AUTHOR DISCLOSURES: A. Alessi Innocenti: Nothing to disclose; L. Azas: Nothing to disclose; W. Dorigo: Nothing to disclose; L. Paperetti: Nothing to disclose; C. Pratesi: Nothing to disclose; G. Pratesi: Nothing to disclose; R. Pulli: Nothing to disclose. PS158. Nasal Methacillin-Resistant Staphylococcus  Aureus Colonization Is Associated with a Higher Post-Operative Infection Rate After Major Lower Extremity Amputation

4:10 p.m.

Amir F. Azarbal,1 Sheena Harris,2 Erica Mitchell,2 Timothy K. Liem,2 Gregory J. Landry,2 James Edwards,1 Robert McLafferty,1 Gregory L. Moneta.2

Portland Veterans Affairs Medical Center, Portland, Ore.; 2 Vascular Surgery, Oregon Health and Sciences University, Portland, Ore. 1

OBJECTIVES: Post-operative infection and wound occurrence is a cause of significant morbidity after major lower extremity amputation (MLEA). We sought to determine the association between preoperative nasal Methacillin-Resistant Staphylococcus Aureus (MRSA) colonization with post-operative wound infection and wound occurrence after MLEA. METHODS: The medical records of all patients undergoing MLEA from 8/1/11 to 11/1/13 at our institution were reviewed. Demographic data, hemoglobin A1c concentration, albumin concentration, dialysis dependence, and the presence of nasal MRSA colonization and diabetes mellitus (DM) were recorded. The occurrence of open wound infections, non-infected wound occurrence, and overall non-primary healing rates were determined. RESULTS: 83 patients underwent 96 MLEA over a 27 month period. The rates of non-primary healing, open infected wounds, and repeat operations were 40%, 22%, and 24% respectively. Nasal MRSA colonization was present in 26% of patients; and MRSA was the most common cause of post-operative wound infection, occurring in 75% of post-operative wound infections. On univariate analysis, MRSA colonization, HGA1c > 8 mmol/mol, DM, and dialysis dependence are associated with higher rates of non-primary healing (p<0.05), but only nasal MRSA colonization is associated with higher rates of post-operative wound infection (15% v 45%, P<0.01). On multivariate analysis, only MRSA colonization is associated with higher post-operative wound infection rates (p<0.01), while HgA1c > 8 mmol/mol and dialysis dependence are associated with higher rates of non-primary healing (p<0.02). CONCLUSIONS: Nasal MRSA colonization is associated with a higher rate of post-operative wound infection after MLEA. Further studies addressing the effect of eradicating MRSA colonization or extending peri-operative antibiotic coverage on post-operative infection rates are warranted.

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AUTHOR DISCLOSURES: A.F. Azarbal: Nothing to disclose; J. Edwards: Nothing to disclose; S. Harris: Nothing to disclose; G.J. Landry: Nothing to disclose; T.K. Liem: Nothing to disclose; R. McLafferty: Nothing to disclose; E. Mitchell: Nothing to disclose; G.L. Moneta: Nothing to disclose. PS160. Applicability of the Society for Vascular  Surgeryâ&#x20AC;&#x2122;s Objective Performance Goals for Critical Limb Ischemia to Current Practice of Lower Extremity Bypass

4:15 p.m.

Julia Saraidaridis, Virendra I. Patel, Robert T. Lancaster, Shankha Mukhopadhyay, Richard Cambria, Mark F. Conrad.  Massachusetts General Hospital, Boston, Mass. OBJECTIVES: In 2009, the SVS established objective performance goals (OPG) for critical limb ischemia (CLI) based on data from randomized controlled trials of lower extremity bypass (LEB). These OPG sought to establish a benchmark from which to compare future endovascular therapy against established LEB outcomes. However, the cohort used to develop the OPG excluded all patients requiring prosthetic conduit and those with end stage renal disease (ESRD), limiting the generalizability of these recommendations. The goal of this study was to determine if the SVS OPG are applicable to the current population of patients undergoing LEB. METHODS: All patients who underwent infrainguinal LEB for CLI from 2010 to 2012 were identified. Patients were stratified into OPG eligible and ineligible (NOPG) groups based on their demographic and operative characteristics. OPG eligible patients were further stratified into high and average risk. Outcomes included 30 day major adverse limb events (MALE), major adverse cardiac events (MACE), and 1-year amputation free survival (AFS). RESULTS: 80 individual patients were identified. Demographics included: age 68 years, diabetes 53%, dialysis 10%, tissue loss 55 (69%), previous infrainguinal procedure 53 (66%), tibial distal target 40 (50%), and prosthetic conduit 38 (48%). Only 39 (49%) patients met OPG inclusion criteria and 31 (79%) of these stratified to high risk (18% >80yrs, 67% tissue loss, 56% tibial target, and 13% poor conduit). The 30-day MALE was 10% (2.5% OPG vs. 17% NOPG, p=0.03). The MACE was 12.5% with no difference between the cohorts (12% NOPG vs. 13% OPG, p=0.93). The AFS for the entire cohort was 64%+/-5% and was significantly lower in the NOPG group (49% NOPG vs. 80% OPG, p=0.005). CONCLUSIONS: The SVS OPG for LEB are likely not generalizable to current practice as only 50% could be included in the OPG cohort and, of those, 80% were considered high risk. Despite this, the 30-day MALE and 1-year AFS rates were favorable in patients who met inclusion criteria for the OPG cohort. AUTHOR DISCLOSURES: R. Cambria: Nothing to disclose; M.F. Conrad: Nothing to disclose; R.T. Lancaster: Nothing to disclose; S. Mukhopadhyay: Nothing to disclose; V.I. Patel: Nothing to disclose; J. Saraidaridis: Nothing to disclose. PS162. Outcomes and Costs Associated with Secondary  4:20 p.m. Amputation (SA) Following Endovascular Intervention (EVI) Without Healing and Primary Amputation (PA) in the Treatment of Patients with Critical Limb Ischemia (CLI) and Tissue Loss (TL)

198


Maciej Dryjski,1 Monica O’Brien-Irr,1 Hasan H. Dosluoglu,2 Gregory Cherr,1 Sonya Noor,1 G.R. Curl,1 Linda Harris.1

Dept of Surgery, Buffalo General Medical Center, Buffalo, N.Y.; 2 VA WNY Healthcare, Buffalo, N.Y. 1

OBJECTIVES: EVI is increasingly performed in patients with TL and complex anatomy who would otherwise require PA. Guidelines for intervention/outcome analysis have been limited. We compared outcomes and costs associated with SA for nonhealing TL after EVI with PA in patients with CLI and TL. METHODS: All patients who presented to our health care system for surgical management of TL due to CLI from 2008-2010 were identified. Demographics, co-morbidities, post-op complications, insurer costs, follow-up hospitalizations, ambulatory/ living status were analyzed (SPSS 21). RESULTS: There were 304 admissions: 263 (87%) EVI and 41 (13%) PA. Mean follow-up was 27 months (0-101). SA was required in 80 (30%); mean time 6 months (0-46). Independent predictors (likelihood ratio) for SA were: contralateral amp (4.1), gangrene (3.6), dialysis (3.1), TL not confined to the toes or heel alone (4.3), preoperative angiogram: < two vessel runoff (3.1). Comorbidities were comparable for SA and PA, including location of TL and presence of gangrene. Infection was more common in PA: 87.8% vs. 57.5%: P= 0.001. Post-op mortality was higher for PA (4.9% vs. 0%: P=0.05) and 24 month survival was poorer (74% + 8% vs. 87% + 4%: P=0.03). Hospitalizations (including amputation related readmission), total hospital days and insurer costs were higher for SA than PA (table 1). Thirty-nine (48%) SA underwent re-intervention. There were no significant differences between SA and PA in maintenance of independent living (71% vs. 72%: P= 0.95) or ambulation (42% vs. 58%; P=0.33). CONCLUSIONS: While ambulation and maintenance of independent living are comparable between SA and PA, EVI may be justified because of higher mortality in the PA Group. However, multiple re-interventions will increase costs and incapacitation without improving outcomes. AUTHOR DISCLOSURES: G. Cherr: Nothing to disclose; G.R. Curl: Nothing to disclose; H.H. Dosluoglu: Nothing to disclose; M. Dryjski: Nothing to disclose; L. Harris: Nothing to disclose; S. Noor: Nothing to disclose; M. O’Brien-Irr: Nothing to disclose. PA

SA

P Score

Insurer Costs

$30,234

$68,012

<0.001

Hospitalizations >

0%

31%

<0.001

Total Hospital Days

20

35

0.015

PS164. Regional Differences in Patient Selection and  Treatment of Lower Extremity Arterial Disease in the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI)

4:25 p.m.

Thomas Curran,1 John C. McCallum,1 Dominique B. Buck,1 Jeremy D. Darling,1 Shelley Berthiaume,3 Brian Nolan,2 Philip P. Goodney,2 Marc L. Schermerhorn.1

1Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.; 2 Section of Vascular Surgery Dartmouth-Hitchcock, Hanover, N.H.; 3 Sharp HealthCare, San Diego, Calif.

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OBJECTIVES: Studies have shown regional differences in surgical practice though management of lower extremity arterial disease (PAD) has not been investigated. We used the SVS VQI to evaluate regional variation in PAD management. METHODS: SVS VQI was used to identify all infra-inguinal bypass or endovascular intervention (PVI) from 2009 to 2012. Each of 14 quality groups was considered a region. Groups were de-identified. Indications and surgical approach were compared between groups. Groups with fewer than 100 cases were excluded on a per analysis basis. RESULTS: We identified 29,131 patients [20,987 PVI (48% claudicants), 8,144 Bypass (27% claudicants)] from 14 regions. Median case number per region was 1090 (range: 115-10,251). Substantial regional differences in patient comorbidities (e.g., CHF, dialysis), indication for procedures (e.g., infrapopliteal PVI for TASC D lesions), technical approach (e.g., usage of prosthetic graft for infrapopliteal BPG) and utilization of evidence-based process measures (e.g., chlorhexidine skin prep for bypass) are demonstrated in Table (p<.001 for all listed parameters). CONCLUSIONS: This first investigation of a national clinical database demonstrates significant regional variation in PAD management. Future studies on the association of regional variation with risk-adjusted outcomes offer the opportunity for quality improvement through prospective identification of best practices. AUTHOR DISCLOSURES: S. Berthiaume: Nothing to disclose; D.B. Buck: Nothing to disclose; T. Curran: Nothing to disclose; J.D. Darling: Nothing to disclose; P.P. Goodney: Nothing to disclose; J.C. McCallum: Nothing to disclose; B. Nolan: Nothing to disclose; M.L. Schermerhorn: Endologix, consulting fees or other remuneration (payment).

% All Patients with Claudication (vs. all other indications)

Min

Max

24%

64%

% Claudicants Receiving Bypass (vs. PVI)

6%

45%

% Infrapopliteal PVI for Claudication (vs. all other indications)

11%

27%

% Prosthetic Graft for Infrapopliteal Bypass (vs. Vein)

18%

45%

% Bypass Patients with Chlorhexadine Prep (Post 2011)

50%

92%

% Infrapopliteal PVI for TASC D

16%

74%

% Infrapopliteal PVI with Stent (vs. PTA only)

21%

58%

% All Patients Discharged on Anti-Platelet & Statin

52%

77%

% All Patients with CHF

10%

21%

% All Patients with Dialysis Dependence

4%

16%

 

PS166. Risk Stratification of the Overall Survival of  Patient with Critical Limb Ischemia Due to Below the Knee Lesions

4:30 p.m.

Takahiro Ohmine, Kazuomi Iwasa, Terutoshi Yamaoka.

Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Ehime, Japan.

OBJECTIVES: To assess the efficacy and durability of EVT as a first approach, we evaluated the short- and long-term outcomes of the first revascularizations achieved using EVT-first compared with BSX-first. Next, we explored factors influencing overall survival (OS) using multivariate analyses.

200


METHODS: A total of 228 consecutive BTK revascularization procedures (189 patients) for CLI between November 2006 and September 2013 were retrospectively analyzed. Patients undergoing revascularization were divided into two groups. No statistically significant differences were noted between the two groups with respect to preoperative background. RESULTS: The average age was 74.7 years (123 men and 66 women) in both groups. The ratio of lost to follow-up of all subjects was only 1.1 percent. Mean follow-up periods were 22.6 (3-86) months. No significant differences were noted in the short-term results in EVT-first revascularizations compared in BSX-first. The long-term OS rates were slightly better in BSX-first than in EVT-first. Multivariate analysis of all subjects revealed that the OS rates were not affected by EVT-first but by five severe risk factors as follows: 1) age greater than 80 years, 2) hemodialysis, 3) CHF, 4) serum albumin<3g/dL, and 5) a non-ambulatory limb. CONCLUSIONS: OS in patients with CLI due to BTK lesions is worse with three or more of the severe risk factors, and in such patients the EVT-first procedure is effective. AUTHOR DISCLOSURES: K. Iwasa: Nothing to disclose; T. Ohmine: Nothing to disclose; T. Yamaoka: Nothing to disclose. Multivariate Analysis for Overall Survival Using Significant Parameters According to Univariate Analysis. Variables (N=189)

HR

p

Age over 80 Yrs.

2.6

<0.01

EVT First

1.3

0.44

HD

1.7

0.03

CHF

3.0

<0.01

Non-Ambulatory Leg

1.7

0.04

Albumin<3.0

2.2

0.02

BMI<18.5

1.3

0.23

CRP>3.0

1.2

0.43

PS168. Dissecting the Results of Lower Extremity  Revascularization in Dialysis Dependent Patients

4:35 p.m.

John M. Fallon,1 Philip P. Goodney,1 David H. Stone,1 Virendra I. Patel,2 Brian W. Nolan,1 Jeffrey A. Kalish,3 Yuanyuan Zhao,1 Allen D. Hamdan.4 1  Dartmouth-Hitchcock Medical Center, Lebanon, N.H.; 2Massachusetts General Hospital, Boston, Mass.; 3Boston Medical Center, Boston, Mass.; 4Beth Israel Deaconess Medical Center, Boston, Mass.

OBJECTIVES: Optimal patient selection for revascularization remains a clinical challenge among the hemodialysis (HD) dependent, despite advances in surgical care and endovascular techniques. The purpose of this study was to examine contemporary real world outcomes of HD patients to facilitate patient selection for revascularization. METHODS: A regional multi-center registry was queried between 2003 and 2013 for HD dependent patients (N=689) undergoing open surgical bypass (N=295) or endovascular intervention (N=394) for lower extremity revascularization. Patient demographics and co-morbidities were recorded. The primary outcome was overall survival. Secondary outcomes included amputation free survival (AFS), graft patency, and freedom from major adverse limb event (MALE). Short and long term outcomes were examined. Multivariate analysis was performed to identify independent risk factors for MALE and death. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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RESULTS: Among the 689 HD patients undergoing lower extremity revascularization, 66% were male and 83% white. Tissue loss was the most common indication for intervention. One, two, and five-year overall survival remained low at 59%, 43%, and 21% respectively. Observed one and two-year AFS was at 40% and 17%. Mortality was the primary mode of failure for AFS, (70% bypass, 80% endovascular p=0.08). Survival and AFS did not differ significantly between revascularization techniques. Multivariate analysis identified age >80 (HR 1.5, p-value 0.014), pre admission nursing home status (HR 2.19, p-value 0.001), COPD (HR 1.46, p 0.038) and pre-operative wheelchair/bedridden status (HR 1.94, p <0.001) as independent predictors of MALE or death. CONCLUSIONS: Overall survival and AFS among HD dependent patients remains poor, irrespective of revascularization strategy. Mortality remains the primary driver for these findings. Focus for improved results should emphasize predictors of survival to optimize patient selection for revascularization. AUTHOR DISCLOSURES: J.M. Fallon: Nothing to disclose; P.P. Goodney: Nothing to disclose; A.D. Hamdan: Nothing to disclose; J.A. Kalish: Nothing to disclose; B.W. Nolan: Nothing to disclose; V.I. Patel: Nothing to disclose; D.H. Stone: Nothing to disclose; Y. Zhao: Nothing to disclose. C8h: Vascular Trauma â&#x20AC;˘ Venous Disease  3:30 â&#x20AC;&#x201C; 5:00 p.m.  uAuditorium, Level 2  (enter through Exhibit Hall C) Moderator: Mahmoud B. Malas, MD, MHS, Johns Hopkins Hospital, Baltimore, Md.

PS170. Prognostic Factors for Amputation Following  Surgical Repair of Lower Extremity Vascular Trauma: A Systematic Review and Meta-Analysis of Observational Studies

3:40 p.m.

Zane B. Perkins,1 Barbaros Yet,4 Simon Glasgow,1 William Marsh,4 Karim Brohi,1 Todd E. Rasmussen,3 Nigel R. Tai.2

1 Centre for Trauma Sciences, Queen Mary, University of London, London, United Kingdom; 2Royal Centre for Defence Medicine, Birmingham, United Kingdom; 3US Army Institute of Surgical Research, San Antonio, Texas; 4 Queen Mary, University of London, London, United Kingdom.

OBJECTIVES: Lower extremity vascular trauma (LEVT) is a major cause of limb loss. An understanding of prognostic factors for amputation following LEVT repair is essential to inform surgical decision-making, patient counselling and risk stratification. However, evidence for many factors is weak and often conflicting. The objective of this systematic review was to develop a contemporary and accurate understanding of prognostic factors for amputation following surgical repair of LEVT. METHODS: We performed a systematic review according to PRISMA guidelines. MEDLINE, EMBASE and CINAHL databases were searched between January 2000 and July 2012 for observational studies describing LEVT surgical repair outcomes. The primary outcome was amputation. Patient, injury and treatment factors associated with amputation were identified. Unadjusted proportions, odds ratios and risk differences, for all identified prognostic factors, were pooled using Bayesian random-effects meta-analysis models.

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RESULTS: Forty-five articles, totalling 3168 discrete LEVT repairs were included. The overall amputation incidence was 11.6%. Significant prognostic factors for secondary amputation include: gender (male 7% vs. female 12%; OR 0.41), Mechanism of Injury (Blast 19%, Blunt 16%, Penetrating 5%), anatomical site of injury (Iliac 18%, Popliteal 14%, Tibial 9%, Femoral 4%), associated fracture (14% vs. 2%; OR 4.3), major soft tissue injury (28% vs. 9%; OR 6.5), ischaemic time > 6 hours (24% vs. 5%; OR 4.4) and development of compartment syndrome (31% vs. 6%; OR 6.4). Age, associated nerve or venous injuries and shock were not significant prognostic factors for secondary amputation. CONCLUSIONS: A small but important proportion of patients who undergo emergency repair of LEVT will require secondary amputation. The prognostic factors described and the underlying evidence base will facilitate considered surgical judgement, improved risk assessment and informed patient counselling during the post-operative period. AUTHOR DISCLOSURES: K. Brohi: Nothing to disclose; S. Glasgow: Nothing to disclose; W. Marsh: Nothing to disclose; Z.B. Perkins: Nothing to disclose; T.E. Rasmussen: Nothing to disclose; N.R. Tai: Nothing to disclose; B. Yet: Nothing to disclose. PS172. Management and Outcome of Pediatric  Vascular Injuries

3:45 p.m.

Carl Wahlgren,1 Björn Kragsterman.2

1  Department of Vascular Surgery, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden; 2Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.

OBJECTIVES: Vascular injuries in children are relatively uncommon. The objective of this population-based study was to investigate the epidemiology, management and early outcomes of pediatric vascular injuries. METHODS: A nationwide survey of prospectively collected data on pediatric vascular injuries in children ≤ 15 years between 1987 and 2012 was conducted. Data were retrieved from the National Vascular Surgery registry (Swedvasc) and cross-matched with the National Population Register for mortality data. Demographics, operative techniques, and outcomes were analyzed. RESULTS: One hundred sixty-two children (boys n=110; girls n=52); median age was 9 years (range 1-15 years; <6 y 17%, 6-10 y 40%, >10 y 43%). Blunt trauma (106; 65%) was dominating followed by penetrating (43; 27%) and iatrogenic trauma (13; 8%). Anatomical locations of vascular injuries included upper extremities (100; 62%), lower extremities (47; 29%), abdomen (11; 7%), chest (2; 1%), and neck (2; 1%). Repair techniques were interposition graft (41; 25%), patch (32; 20%), by pass (17; 10%), lateral suture (14; 9%), direct anastomosis (4; 2.5%), thrombectomy (3; 1.8%), endovascular techniques (3; 1.8%), ligation (2; 1.2%), and exploration/miscellaneous (46; 28%). Reversed vein/venous patch (n=83) was the dominating graft material and synthetic grafts were only used in two open cases. The most common postoperative complication was arterial occlusion/thrombosis (n=11). At 30-day follow-up, there was one above-knee and two below-knee amputations but no mortality. CONCLUSIONS: This nationwide population based study shows that traumatic vascular injuries in children are associated with high limb salvage rates and low mortality. Blunt trauma is most common and injuries are predominantly located to the upper- and lower extremities. The preferred repair techniques are venous patch and interposition graft, and the frequency of endovascular repair in the pediatric population is low.

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AUTHOR DISCLOSURES: B. Kragsterman: Nothing to disclose; C. Wahlgren: Nothing to disclose. PS174. Use of “Fall-back” Techniques for IVC Filter  Retrieval Leads to 100% Technical Success

3:50 p.m.

Yana Etkin, Julia Glaser, David A. Nation, Paul Foley, Grace Wang, Edward Woo, Ronald Fairman, Benjamin M. Jackson.

University of Pennsylvania, Philadelphia, Pa.

OBJECTIVES: Retrievable inferior vena cava filters (IVCF) left in place for a prolonged period of time can lead to complications including filter migration, fracture and caval thrombosis. “Fall-back” techniques for IVCF retrieval that can be used when standard snaring is unsuccessful have been recently described. The purpose of this study is to analyze how incorporation of these new techniques impacted the outcomes of IVCF retrievals at our institution over the past 5 years. METHODS: Data from all patients undergoing IVCF removal by vascular surgeons at a tertiary academic medical center between 2009 and 2013 were collected, including demographics, procedural and filter characteristics. A standard technique of snaring the retrieval hook was attempted first in all cases; if unsuccessful, a number of “fall-back” techniques were employed, including the use of endoscopic graspers, 18 French sheaths, and snaring a second wire below the collar of the filter to collapse it into the sheath. RESULTS: 274 patients underwent attempted IVCF retrieval; 3 were excluded intraoperatively due to thrombus in the filter. Most filters were Gunther Tulips (99%), 71% had been placed prophylactically prior to bariatric surgery. A total of 267 (98.5%) filters were retrieved successfully, 212 (79%) using standard snaring and 55 (21%) with “fall-back” techniques. In patients undergoing “fall-back” techniques, technical success was achieved 100% of the time. The median time since insertion was significantly longer in the “fall-back” group (173 days vs. 70 days, p<0.0001). Three intraoperative complications occurred: fractured wires embolized to the right atrium or pulmonary artery and were successfully removed endovascularly. The majority of the procedures (80%) were safely performed under sedation in both groups. CONCLUSIONS: Incorporation of “fall-back” techniques may allow 100% technically successful and safe removal of retrievable IVC filters, and is especially useful in removing filters with prolonged dwell time. AUTHOR DISCLOSURES: Y. Etkin: Nothing to disclose; R. Fairman: Nothing to disclose; P. Foley: Nothing to disclose; J. Glaser: Nothing to disclose; B.M. Jackson: Nothing to disclose; D.A. Nation: Nothing to disclose; G. Wang: Nothing to disclose; E. Woo: Nothing to disclose. PS176. Temporary IVC Filters that Are Not Retrieved:  Clinical Predictors in 1,000 Consecutive Cases

3:55 p.m.

Ashley Vavra, Aaron Eifler, Dustin Yoon, Laura Boitano, Katherine Teter, Irene B. Helenowski, Mark K. Eskandari, Melina Kibbe, William Pearce, Mark Morasch, Deborah Epstein, Robert Lewandowski, Ramona Gupta, Jennifer Karp, Riad Salem, Robert Ryu, Heron Rodriguez.

204

Northwestern University, Chicago, Ill.


OBJECTIVES: Compared to permanent filters, higher complication rates occur with long-term use of temporary filters. Our hypothesis is that clinical factors at the time of placement can predict the need for a permanent instead of a temporary filter. METHODS: An IRB-approved retrospective review was performed of both vascular surgery and interventional radiology prospective databases between 2008 and 2013. Protocols to maximize removal were in place. Patients were placed in Group A if retrieval was attempted or Group B if no retrieval attempt was made. Clinical factors for both groups were analyzed and compared (Table 1). RESULTS: Of 1,021 filters, removal was attempted in 60% (Group A) and no attempt at removal in 40% (Group B). Retrieval rate in Group A was 95%. The most common reason removal wasn’t attempted was lost follow-up. In the univariate model (Table 1), factors associated with permanence included male sex, old age, history or indication of VTE with inability to anticoagulate, malignancy and neurologic condition. Factors most predictive of permanence in the multivariate model were malignancy (OR 3.0, p<0.001) or neurologic disorder (OR 2.69, p=0.0005). CONCLUSIONS: Despite protocols, 40% of temporary filters were not removed. These patients are more likely to be older, male, have a malignancy or history of neurologic condition or VTE. These factors can be used prospectively to aid in deciding whether a permanent and not a temporary filter should be used. AUTHOR DISCLOSURES: L. Boitano: Nothing to disclose; A. Eifler: Nothing to disclose; D. Epstein: Nothing to disclose; M.K. Eskandari: Nothing to disclose; R. Gupta: Nothing to disclose; I.B. Helenowski: Nothing to disclose; J. Karp: Nothing to disclose; M. Kibbe: Nothing to disclose; R. Lewandowski: Cook Medical, consulting fees or other remuneration (payment); M. Morasch: Nothing to disclose; W. Pearce: Nothing to disclose; H. Rodriguez: Nothing to disclose; R. Ryu: Nothing to disclose; R. Salem: Nothing to disclose; K. Teter: Nothing to disclose; A. Vavra: Nothing to disclose; D. Yoon: Nothing to disclose.

Factor

Group A (n= 619) (%)

Group B (n=405) (%)

Odds Ratio (95% CI)

p-value

Male Sex

270 (44)

225 (62)

1.61 (1.25-2.07)

0.00002

History of VTE

351 (57)

273 (67)

1.59 (1.22-2.07)

0.0005

Malignancy

153 (25)

200 (49)

2.97 (2.27-3.88)

<0.0001

Neurologic Condition (CVA, paralysis, dementia)

24 (4)

35 (8)

2.35 (1.38-4.02)

0.002

Indication: VTE + AC Contraindication

290 (47)

283 (70)

2.65 (2.07-3.46)

<0.0001

Indication: VTE + AC Complication

25 (4)

49 (12)

3.28 (1.99-5.40)

<0.0001

Indication: VTE + AC Failure

9 (1)

13 (3)

2.25 (0.95-5.32)

0.06

Indication: High Risk VTE

63 (10)

20 (5)

0.46 (0.27-0.77)

0.003

Indication: Prophylaxis

232 (37)

39 (10)

0.17 (0.12-0.25)

<0.0001

VTE=venous thromboembolism. AC=anticoagulation. CVA=stroke.

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PS178. Leave â&#x20AC;&#x2DC;Em or Retrieve â&#x20AC;&#x2DC;Em? Management of  Inferior Vena Cava Filters

4:00 p.m.

Courtney J. Warner,1 Anna E. Condino,2 Elizabeth A. Richey,2 Dyane E. Tower,2 Stephanie J. Tapp,2 Anna N. Tosteson,2 Daniel B. Walsh.1

1Dartmouth-Hitchcock Medical Center, Lebanon, N.H.; 2 The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, N.H.

OBJECTIVES: Inferior vena cava (IVC) filter placement is performed to mitigate the risk of pulmonary embolism (PE) when anticoagulation is contraindicated or ineffective. Technical advances now allow catheter-based filter retrieval. Many believe the benefits of retrieval are self-evident, yet retrieval carries an inherent complication risk and cost. The purpose of this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. METHODS: A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed over the lifetime of the individual and outcomes were expressed in quality-adjusted life years (QALYs). The base case is a 60-year-old male with a filter placed within three months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and/or filter complications. For the base case and sensitivity analyses, we used utilities and probabilities derived from the literature. RESULTS: In the base case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 versus 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval may be preferable if the utility of living with a filter is less than 0.98. For all probabilities of retrieval and PE mortality, leaving the filter in place is preferred. CONCLUSIONS: Leaving a previously placed IVC filter provides a 0.4 QALY benefit over retrieving the filter for the average patient. This decision is sensitive to the utility of living with the IVC filter and underlying PE risk. AUTHOR DISCLOSURES: A.E. Condino: Nothing to disclose; E.A. Richey: Nothing to disclose; S.J. Tapp: Nothing to disclose; A.N. Tosteson: Nothing to disclose; D.E. Tower: Nothing to disclose; D.B. Walsh: Nothing to disclose; C.J. Warner: Nothing to disclose. PS180. Open Surgical Reconstruction for Benign  Superior Vena Cava Syndrome

4:05 p.m.

Sameh Said, Peter Gloviczki, Manju Kalra, Audra A. Duncan, Gustavo S. Oderich, Mark D. Fleming, Randall R. DeMartino, Ying Huang, Thomas C. Bower.

Mayo Clinic, Rochester, Minn.

OBJECTIVES: To review long term outcome of open surgical reconstructions for benign superior vena cava (SVC) syndrome. METHODS: The clinical data of all patients who underwent open reconstruction for benign SVC syndrome between 1989 and 2012 were retrospectively reviewed. Follow up information was obtained from charts, questionnaires or phone calls. RESULTS: Forty-five patients, 29 females, 16 males (mean age, 41 yr; range 4-69 yr) with symptomatic SVC syndrome were included. Etiologies were: central lines (n=20), fibrosing mediastinitis (n=18), pacemaker leads (n=2), others (n=5). Percutaneous recanalization was 206


attempted in 14 patients, 10 underwent previous stenting. Full sternotomy was done in 44 patients, partial in 1. The most common bypasses were left innominate vein to right atrial bypass in 30 patients (67%), left innominate vein to SVC in 8 (18%). Spiral vein graft was used in 21 patients (47%), ePTFE in 13 (29%), femoral vein in 10 (22%), iliac vein homograft in one (2%). There was no early mortality. Two patients (4%) required early re-operation due to graft obstruction, one required early endovascular intervention. The mean follow-up was 6.2±5.8 yr (range: 1 month to 21 yr). Late mortality occurred in 6 patients (13%), all unrelated to the SVC reconstruction. Two patients required late reoperation for graft obstruction. Late angioplasty with or without stenting was required in 14 patients. One and 5 year primary assisted patency rates were 96% and 86%, secondary patency rates were 98% and 98%, respectively. CONCLUSIONS: Benign SVC syndrome that is not suitable or failed endovascular treatment can be safely and effectively treated by open surgical procedures, using either PTFE, femoral vein or spiral vein grafts. Close surveillance and secondary endovascular procedures help assure excellent long term durability. AUTHOR DISCLOSURES: T.C. Bower: Nothing to disclose; R.R. DeMartino: Nothing to disclose; A.A. Duncan: Nothing to disclose; M.D. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; Y. Huang: Nothing to disclose; M. Kalra: Nothing to disclose; G.S. Oderich: Nothing to disclose; S. Said: Nothing to disclose. PS182. Cost Analysis of Negative Pressure Wound  Therapy with Instillation for Wound Bed Preparation Preceding Split-Thickness Skin Grafts for Massive (>100 cm2) Chronic Venous Leg Ulcers

4:10 p.m.

Sean Alcantara, Selena Goss, Jamie Schwartz, Cynthia Gendics, John Lantis.

Vascular Surgery, St. Luke’s Roosevelt Hospital, New York City, N.Y.

OBJECTIVES: The economic burden of venous leg ulceration (VLU) is well documented. Massive VLUs (>100cm2) in particular demonstrate very low closure rates with standard compression therapy. Split thickness skin grafts (STSG) can be used in conjunction with negative pressure wound therapy (NPWT) as an alternative to standard of care. We performed a cost analysis of these two treatments. METHODS: We looked at cost effectiveness of twice weekly multilayer compression wraps compared to the following protocol: 1) surgical debridement, 2) 7 days of inpatient NPWT using a topical antiseptic (quarter strength Dakin’s) instillation (NPWTi), and 3) STSG with 4 days of inpatient NPWT bolster over the graft. Cost was obtained through an independent, not-for-profit medical cost estimator, which estimated cost of a given CPT code adjusted for region. RESULTS: We estimated the cost of 6 months of twice weekly dressing changes to be $23,952, which included costs of office visits and dressing supplies. Cost of the proposed treatment protocol was estimated to be $26,624, which included 11-day hospital stay and monthly follow-up visits. CONCLUSIONS: The protocol of debridement, NPWTi using a topical antiseptic solution, and STSG with NPWT bolster, has the potential to be economically advantageous and a more effective alternative to standard compression therapy for massive, chronic VLUs. As data demonstrates improved wound closure rates in these large ulcers with STSGs, the price difference becomes negligible and may favor using an STSG. AUTHOR DISCLOSURES: S. Alcantara: Nothing to disclose; C. Gendics: KCI, consulting fees or other remuneration (payment); S. Goss: Nothing to disclose; J. Lantis: KCI, consulting fees or other remuneration (payment); J. Schwartz: Nothing to disclose. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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PS184. Compression Therapy Is Not Necessary After  Endovenous Ablation Therapy for the Treatment of Varicose Veins

Angela Kokkosis, Harry Schanzer.

Surgery, Mount Sinai Medical Center, New York City, N.Y.

4:15 p.m.

OBJECTIVES: Compression therapy is routinely used after endovenous saphenous ablation therapy (EVLT) for the treatment of varicose veins. The rationale for compression therapy is enhancement of vein closure and prevention of superficial thrombophlebitis (STP). A common patient complaint postoperatively is the discomfort elicited by the compression. The present work aims to determine whether compression therapy is necessary as an adjunct to EVLT. METHODS: A total of 77 consecutive lower extremities in 62 patients were treated with EVLT. Forty-two of the treated extremities had postoperative compression, 35 did not. All patients had duplex evaluation at one week following EVLT and then were clinically evaluated at one and three months. Primary end points were status of the treated vein, presence or absence of STP, and degree of varicose vein resolution. RESULTS: There was no difference between compression and no-compression groups in sex (63% vs. 63% female), age (59 vs. 55), CEAP class (C2-C3, 81% vs. 91%; C3-C4, 19% vs. 9%), extent of varicose veins (<6 mm, 60% vs. 66%; >6 mm, 40% vs. 34%), type of vein treated ( GSV 80% vs. 66% , SSV 9% vs. 20%, accessory 11% vs. 14%) and operative variables. There was a 95% follow-up rate at 1 week, and all lower extremities demonstrated saphenous vein closure. Three patients in the compression group and 0 patients in the no-compression group had STP. No patients had deep venous thrombosis. At one month both groups had the same rate of varicose vein regression and need for secondary procedures. CONCLUSIONS: Compression therapy does not add any further benefit to EVLT and therefore consideration should be given to eliminating it, thus simplifying and improving the postoperative recovery. AUTHOR DISCLOSURES: A. Kokkosis: Nothing to disclose; H. Schanzer: Vascular Solutions, consulting fees or other remuneration (payment). PS186. Inferior Vena Cava Placement Utilization  Among over 250,000 Patients: National Trends, Complications, and Relative Contraindications

4:20 p.m.

Sapan S. Desai,1 Anahita Dua.2

1  Department of Surgery, Duke University, Durham, N.C.; 2 Medical College of Wisconsin, Milwaukee, Wis.

OBJECTIVES: The aim of this study was to evaluate trends, complications, and risk factors that contribute to morbidity associated with inferior vena cava (IVC) filter placement. METHODS: A retrospective analysis of the National Inpatient Sample (NIS), a 20% cross-section of all US inpatient admissions, was completed from 2000-2011 by identifying all patients who underwent IVC filter placement (ICD-9 38.7). Complications including IVC thrombosis (ICD-9 45.32) and death were determined. Variables that were identified for each patient include Agency for Healthcare Research and Quality (AHRQ) standard comorbidities, clinical covariates including age, gender, race, and insurance status. Propensity matching was done to evaluate the effect of IVC filter placement on reducing morbidity and mortality.

208


RESULTS: 251,295 patients were identified using the NIS, of which 2,262 (0.9%) developed thrombosis of the IVC and 17,566 (7%) died. The average age of admission was 66 years, 14% were elective admissions, and 52% were female. The rate of IVC thrombosis has decreased by 38% since 2000, paralleling the 50% decrease in mortality over the same time period. Patients with comorbidities including diabetes, hypertension, obesity, paralysis, chronic obstructive pulmonary disease, renal failure, and heart disease were up to 2.3 times less likely to develop IVC thrombosis or die after receiving an IVC filter. Healthy males under the age of 66 were 2.2 times more likely to develop IVC thrombosis after IVC filter placement. Overall, IVC filter placement decreased morbidity from refractory deep vein thrombosis and trauma by 30%. CONCLUSIONS: IVC filter placement is effective in reducing morbidity and mortality from deep vein thrombosis and trauma, particularly among patients over the age of 65 who have significant comorbidities. However, IVC filter placement among young, healthy males is disproportionately associated with complications and its use should be re-evaluated among this population. AUTHOR DISCLOSURES: S.S. Desai: Nothing to disclose; A. Dua: Nothing to disclose. PS188. Open Surgical vs. Endovenous Ablation Treatment  of Patients with Klippel-Trenaunay Syndrome

4:25 p.m.

Jennifer Fahrni, Peter Gloviczki, Manju Kalra, Mark D. Fleming, Audra A. Duncan, Gustavo S. Oderich, Haraldur Bjarnason, David Driscoll.

Mayo Clinic, Rochester, Minn.

OBJECTIVES: To assess safety and efficacy of open surgical treatment (OST) vs. endovenous radiofrequency ablation (RFA) in patients with Klippel-Trenaunay syndrome (KTS). METHODS: Clinical data of all patients with complex mixed venous malformation treated for chronic venous insufficiency from 2008 to 2013 were reviewed. Perioperative complications and outcome after OST and RFA were compared. RESULTS: Twenty-seven limbs of 26 patients (14 females, mean age 33 years, range 15-74) were treated. All had varicose veins, 59% had limb overgrowth, 63% had capillary malformations. Three had previous DVT or PE. Inferior vena cava (IVC) filter was placed in 8. In Group 1, 17 limbs were treated with OST (ligation and stripping/excision of saphenous or lateral embryonic veins), in Group 2 10 limbs were treated with RFA. Phlebectomies were performed in both groups, with thigh tourniquet in 21 limbs. Technical success of saphenous/lateral vein ablation was 100% in Group 1, 90% in Group 2. There was no DVT or PE; none had thrombus extension into deep veins after RFA. Perioperative complications occurred in 19% (3/16) in Group 1 (bleeding, wound dehiscence, paresthesia) and 20% (2/10, p=NS) in Group 2 (bleeding, thrombophlebitis). Follow-up averaged 15 months (range 1-57 months). No patients reported worsening of symptoms, none required repeat interventions. Marked improvement in symptoms was reported in 55% in Group 1, 25% in Group 2 (p=NS). All patients continued to wear elastic garments. CONCLUSIONS: Surgical and endovenous treatment in select patients with KTS is safe and can be performed with low rate of complications. More data are needed to justify IVC filter placement. Although symptomatic varicose veins can be removed, residual symptoms due to persistent venous insufficiency are frequent. Lifelong elastic support is warranted.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

209


AUTHOR DISCLOSURES: H. Bjarnason: Nothing to disclose; D. Driscoll: Nothing to disclose; A.A. Duncan: Nothing to disclose; J. Fahrni: Nothing to disclose; M.D. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; M. Kalra: Nothing to disclose; G.S. Oderich: Cook, consulting fees or other remuneration (payment); WL Gore, consulting fees or other remuneration (payment). PS190. Operative Explantation of Inferior  Vena Cava Filters

4:30 p.m.

Mark E. Oâ&#x20AC;&#x2122;Donnell,1 Richard J. Fowl,1 William M. Stone,1 Thomas C. Bower,2 Peter Gloviczki,2 Samuel R. Money.1

Vascular and Endovascular, Mayo Clinic, Phoenix, Ariz.; 2 Mayo Clinic, Rochester, Minn. 1

OBJECTIVES: Inferior vena cava (IVC) filter placement is not without risk. It has been associated with puncture site bleeding, venous thrombosis as well as filter migration and perforation. The objective of this study was to assess our experience with open operative explantation of IVC filters. METHODS: After IRB approval, patients were identified from case logs that had transabdominal IVC filter removal between 1994 and 2013. Patient demographics, thromboembolic risk profile, clinical history, operative indication and outcomes were recorded for each case. RESULTS: Eighteen patients (male=9, mean age=49.6 years) were identified. IVC filters (permanent=4, retrievable=8, unknown=6) were deployed for a combination of significant thromboembolic events (n=16), post-trauma (n=3) or after failure of anticoagulation therapy (n=2). Ten patients had retrievable filters that were not removed percutaneously due to filter strut perforation into surrounding pericaval tissue. Seven patients subsequently presented with abdominal/back pain, hematuria or sepsis. Midline laparotomy was utilized for explantation in eleven patients during oncological resections. A subcostal incision (n=5) was used for planned explantation alone. One patient had robotic-assisted laparoscopic removal and another had an open transjugular removal. Caval venotomy was primarily closed (n=15) or patched with bovine pericardium (n=2). No complications attributed to filter removal were identified in the post-operative period. One patient died from advanced malignancy and the other seventeen patients remain well (mean follow-up 618 days). CONCLUSIONS: Filter strut caval perforation remains the most significant indication for transabdominal removal. Filter removal is often considered incidentally during oncological resection. Although operative explantation still remains infrequent, our series suggests that it may be performed safely without significant post-operative complications. AUTHOR DISCLOSURES: T.C. Bower: Nothing to disclose; R.J. Fowl: Nothing to disclose; P. Gloviczki: Nothing to disclose; S.R. Money: Nothing to disclose; M.E. Oâ&#x20AC;&#x2122;Donnell: Nothing to disclose; W.M. Stone: Nothing to disclose. PS192. Endovascular Venous Ablation in the Setting of  Warfarin Anticoagulation: Experience at a Single-Center Institution

Victoria Lee,1 Jonathan Ekstroem,2 Glenn R. Jacobowitz.1

1

210

Surgery, NYU Medical Center, New York City, N.Y.; 2 Rutgers University, Newark, N.J.

4:35 p.m.


OBJECTIVES: To determine the difference in durability of venous ablation in patients on Warfarin anticoagulation as compared to those without alteration in their coagulation pathway. METHODS: Data was collected from a single-center institution: NYU Medical Center using ICD-9 codes for patients who had undergone radiofrequency or laser venous ablation between 4/2011- 5/2013. Covidian CF7-7-60 2nd generation VNUS catheters were used for radiofrequency ablation and EVLT NeverTouch kits by Angiodynamics for laser ablation. Patients being concomitantly treated with Warfarin were selected for study. Follow-up with venous duplex ultrasound was performed at 1 week, six months, then yearly to check for thrombus extension from the superficial to deep venous system and document occlusion status of the treated veins. RESULTS: There was a total of 72 patients: 40 male (55.5%) and 32 female (44.5%), with 94 limbs and 97 procedures performed. Average follow-up time was 142.5 days (range 7-636). 54 of the procedures (55.7%) were radiofrequency ablations, and 43 (44.3%) laser ablations. A total of 4 veins (4.1%) recanalized within the follow-up time period: one was a radiofrequency ablation (1.9%), and 3 were laser (7.0%). Two of these occurred within a week, the other two between 6-12 months after the procedure. 9 patients in our study (12.5%) were on Aspirin and one (1.3%) on Plavix, all of whom had successful venous ablations without recanalization within the follow-up time period. None of the patients in our study experienced complications. CONCLUSIONS: Based on our experiences the frequency of recanalization following endovenous ablation while on Warfarin is not worse as compared to that described in the literature. Population size of this subset was small, but it appears antiplatelet agents also had no significant impact on incidence of recanalization. Thus we believe it is safe to perform endovenous ablation on systemically anticoagulated patients with no appreciable negative impact on short-term durability or effectiveness. AUTHOR DISCLOSURES: J. Ekstroem: Nothing to disclose; G.R. Jacobowitz: Nothing to disclose; V. Lee: Nothing to disclose. C8i: Research (1)  3:30 – 5:00 p.m.  uAuditorium, Level 2  (enter through Exhibit Hall C) Moderator: Peter K. Henke, MD, University of Michigan, Ann Arbor, Mich.

PS194. Silencing of Int6 Promotes Recovery of  Blood Perfusion After Limb Ischemia by Stabilizing Hypoxia-Inducible Factor 2

3:40 p.m.

Takuya Hashimoto,1 Li Chen,2 Hideo Kimura,1 Alexander Endler,2 Hiroyuki Koyama,1 Tetsuro Miyata,1 Futoshi Shibasaki,2 Toshiaki Watanabe.1

Division of Vascular Surgery, University of Tokyo, Tokyo, Japan; 2 Department of Molecular Medical Research, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan. 1

OBJECTIVES: Hypoxia-inducible factors (HIFs) are transcription factors that transcribe a spectrum of genes during hypoxia and other stress conditions. In particular, the HIF-2 subtype is more stable than HIF-1 in mild hypoxia and plays an essential role in vascular remodeling by transcribing angiogenic factors. We previously observed that silencing of

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Int6, a hypoxia-independent regulator of HIF-2 protein, led to neoangiogenesis by facilitating HIF-2 activity in normoxia. The aim of current study was to test the hypothesis that silencing of Int6 in muscle may enhance the recovery of blood flow in ischemic limbs. METHODS: Using a small interfering RNA (siRNA) plasmid designed to inhibit Int6 gene, the influence of Int6 silencing on the gene and protein expression of mouse myoblasts was assessed by qRT-PCR and western blotting. In vivo, BALB/c mice were randomized to treatment and control groups. After unilateral femoral artery ligation, the Int6 siRNA plasmid was injected into the muscle near the ligation site. Tissue damage and loss of limb function were scored for 28 days. Serial measurements of limb perfusion were also obtained by laser Doppler perfusion imaging. A random siRNA plasmid was given to the control group. RESULTS: Silencing of Int6 in cultured myoblasts led to stabilization of HIF-2 protein, accompanied by up-regulation of angiogenic genes, including bFGF and PDGF-B compared with the control (P < .05). In a mouse model of hindlimb ischemia, intramuscular injection of the Int6 siRNA plasmid significantly enhanced perfusion (P < .05 at days 7, 14) and functional recovery (P< .05 at days 7, 14, 21) of damaged limbs. CONCLUSIONS: Silencing of Int6 in muscle led to enhanced perfusion and functional recovery in ischemic limbs. Int6 may serve as a therapeutic target to control angiogenesis in ischemic diseases. AUTHOR DISCLOSURES: L. Chen: Nothing to disclose; A. Endler: Nothing to disclose; T. Hashimoto: Nothing to disclose; H. Kimura: Nothing to disclose; H. Koyama: Nothing to disclose; T. Miyata: Nothing to disclose; F. Shibasaki: Nothing to disclose; T. Watanabe: Nothing to disclose. PS196. Increased Adipose Derived Mesenchymal  Stem Cells Counts and Pro-B-Type Natriuretic Peptide in Patients with Critical Limb Ischemia

3:45 p.m.

John Dortch, Houssam Farres, Caroline Sutton, Abba Zubair, Warner A. Oldenburg, Albert Hakaim.

Vascular, Mayo Clinic, Jacksonville, Fla.

OBJECTIVES: Mesenchymal stem cells (MSCs) have been shown to improve regeneration of injured tissues in vivo. Several in vitro studies and animal models have demonstrated improvement in MSCs paracrine effects under hypoxic conditions. Moreover, several studies suggested that the pro B-type natriuretic peptide (pro-BNP) could be involved in the stimulation of postischemic vascular regeneration. The purpose of this study was to investigate the effect of critical limb ischemia, in a human model, on in-situ adipose derived mesenchymal stem cells (ADMSCs) and to determine whether serum levels of N-terminal pro-BNP correlate with ADMSCs counts and associated paracrine effects. METHODS: Lipoaspirate samples of  10 mL were collected from ischemic limbs (ischemic group) and compared to control (without ischemia). MSCs were characterized by frequency, viability, differentiation potential, cytokines expression, and cell surface markers. Serum NT pro-BNP was measured as well. RESULTS: MSCs counts were 9-to-10-fold higher in patients with ischemic limbs (mean 7952 MSC/mL ± 542) than controls (mean 790 MSC/mL ± 65). Pro-BNP levels (1878-4757 pg/mL) were approximately 8-to-26-fold higher than in age- and sex-matched controls. Furthermore, there were positive correlations between pro-BNP levels and MSCs counts in the ischemic group.

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CONCLUSIONS: In conclusion, patients with critical limb ischemia (CLI) have higher levels of pro-BNP and MSCs counts than controls. Increased levels of pro-BNP and MSCs counts can be considered humoral and cellular surrogates of ischemia and hypoxia in patients with CLI. This supports recent studies that suggest that the increase production of peripheral BNP may be a stem cells-mediated response to stimulate angiogenesis in the ischemic skeletal muscles. AUTHOR DISCLOSURES: J. Dortch: Nothing to disclose; H. Farres: Nothing to disclose; A. Hakaim: Nothing to disclose; W.A. Oldenburg: Nothing to disclose; C. Sutton: Nothing to disclose; A. Zubair: Nothing to disclose. PS198. Hydrogen Sulfide (H2S) as a Pharmacological  Mitigator of Hindlimb Ischemia-Reperfusion-Injury in a Swine Model

3:50 p.m.

J. Devin B. Watson,1 Daniel J. Scott,1 Robert Houston,1 Richard O. Reinsvold,2 Kyle Sokol,1 Jonathan J. Morrison,3 Brandon W. Propper,1 Zachary M. Arthurs.1

1San Antonio Military Medical Center, Department of Surgery, Fort Sam Houston, Texas; 2San Antonio Military Medical Center, Department of Neurology, Fort Sam Houston, Texas; 3The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom.

OBJECTIVES: Hydrogen Sulfide (H2S) has been described as a pharmacological adjunct to minimize ischemia reperfusion injury (IRI). We sought to evaluate the impact of H2S in a validated hindlimb ischemia model. METHODS: 40 swine (weight [kg] ±SD: 69 ±7.2) were randomized to iliac artery occlusion for 0hr, 3hrs, or 6hrs of ischemia, followed by vessel repair, and systemic infusion of H2S (10 mg/kg/hr) or normal saline for 2 hours post reperfusion. Animals were survived for 14 days with serial evaluation of systemic injury markers, gait analysis, motor and sensory nerve action potentials, and histopathology. RESULTS: Baseline physiologic characteristics were similar between groups. At 0hr of ischemia, H2S increased Aspartate Transaminase (AST) [125.68 IU/L ± 58.36 vs. 303.78 IU/L ± 129.58, P<0.001], Creatinine Phosphokinase (CK) [12014.17 μg/L ± 8181.9 vs. 28667.89 μg/L ±18883.18, P<0.001], and Lactate Dehydrogenase (LDH) [1107.67 U/L ± 754.13 vs. 1954.33 U/L ± 910.25, P=0.004] on post operative day (POD)1. Animals receiving H2S at 3hr of ischemia had lower AST on POD 1 [627.43 IU/L ± 486.6 vs. 1162.43 IU/L ± 580.58, P<0.05] and lower CK on POD 2 [27313.17 μg/L ± 18151.19 vs. 64230.71μg/L ± 40503.18,P<0.05]. LDH levels were significantly lower in 3hr and 6hr ischemia H2S groups on POD 1 (P<0.05). No significant differences were observed between groups with respect to nerve action potentials. CONCLUSIONS: In a hindlimb ischemia model, intravenous H2S administration during reperfusion mitigates the systemic markers of IRI. The moderate ischemia group experienced the greatest benefit with no benefit seen in minimal or severe ischemia groups. AUTHOR DISCLOSURES: Z.M. Arthurs: Nothing to disclose; R. Houston: Nothing to disclose; J.J. Morrison: Nothing to disclose; B.W. Propper: Nothing to disclose; R.O. Reinsvold: Nothing to disclose; D.J. Scott: Nothing to disclose; K. Sokol: Nothing to disclose; J.B. Watson: Nothing to disclose.

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PS200. The Effect of VEGF Activating Transcription Factor  in Therapeutic Angiogenesis and Skeletal Muscle Fiber in the Mouse with Hindlimb Ischemia

3:55 p.m.

Yongjun Li1, Houzao Chen2, Lishan Lian.1

1  Peking Union Medical College Hospital, Beijing, China; 2 Basic Research Peking Union Medical College, Beijing, China.

OBJECTIVES: To test whether VEGF-ATF stimulating endogenous VEGF expression produces more mature neovessels and influences skeletal muscle fiber type remodeling. METHODS: The ischemic limbs received VEGF-ATF treatment or VEGF165 or placebo treatment after unilateral femoral artery ligation and excision. Mice were sacrificed at 7, 14, 21 days post-injection. Limb blood flow was monitored serially by laser Doppler perfusion imaging. VEGF protein expression was examined by Western Blot. Capillary density, endothelial proliferation, and apoptosis were examined using immunohistochemical technique. Besides that, according to rat mesenteric artery immuofluorescence, we observed neovessels maturity with NG-2 for pericyte coverage. Finally, the skeletal muscle fiber type has been derived from myofibrillar adenosine triphosphatase (mATPase) staining. Moreover, the Myosin Heavy Chain RNA isoform was tested with real-time PCR. RESULTS: 1) Constructed the purposed gene into the PVAX1 and the PcDNA3.0 plasmid successfully. 2) VEGF-ATF stimulated VEGF protein expression at 7 days post-injection compared with the VEGF165, control group. 3) VEGF-ATF increased better perfusion recovery and, moreover, produced a higher capillary density. 4) Rat mesenteric artery immuofluorescence indicated that in VEGF-ATF group, the neovessels had more maturity because of whole pericyte coverage. 5) ATPase staining and MHC real-time PCR results showed VEGF-AFP and VEGF165 both performed the remodeling of the muscle fiber type in the gastrocnemius and soleus. CONCLUSIONS: Intra-muscular injection of VEGF-ATF can perform therapeutic angiogenesis in hind-limb ischemic mice model and, moreover, stimulate more mature neovessles from the integrity. In addition, the muscle fiber type shift might supply a potential method for intermittent distance development for patients with peripheral artery disease. AUTHOR DISCLOSURES: H. Chen: Nothing to disclose; Y. Li: Nothing to disclose; L. Lian: Nothing to disclose. PS202. Propagermanium, a CCR2 Signaling Inhibitor,  Suppresses Monocyte Mobilization and Migration in Experimental Aneurysms

4:00 p.m.

Naoki Fujimura,1 Baohui Xu,1 Haojun Xuan,1 Jackson Dalman,1 Yuko Furusho,1 Hiroki Tanaka,1 Keith Glover,1 Martin Rouer,1 Kohji Aoyama,2 Sara A. Michie,3 Ronald L. Dalman.1 1  Department of Surgery, Stanford University School of Medicine, Stanford, Calif.; 2Department of Environmental Medicine, Kagoshima University School of Medicine, Kagoshima, Japan; 3Department of Pathology, Stanford University School of Medicine, Stanford, Calif.

OBJECTIVES: Abdominal aortic aneurysm (AAA) is a life-threatening chronic vascular disease. Previous work showed that AAAs are attenuated in mice deficient for chemokine receptor CCR2, a critical regulator of monocyte mobilization and migration. We evaluated the therapeutic effect of propagermanium (PG), a CCR2 inhibitor, on formation and progression of experimental AAAs.

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METHODS: AAAs were created in 10-week-old male C57BL/6J mice via intra-aortic porcine pancreatic elastase (PPE) infusion. PG treatment (50 mg/kg/day) was initiated prior to or following AAA creation. Influences on AAAs were evaluated using ultrasonography, histology and FACS analyses. RESULTS: PG pretreatment almost completely abolished AAA formation. PG treatment also attenuated further progression in existing AAAs. Histologically, both PG treatment regimens preserved medial elastin and smooth muscle cells, with reduced aortic macrophage accumulation and angiogenesis. In FACS analyses, PG pretreatment significantly diminished circulating and splenic inflammatory monocytes and increased them in bone marrow. In in vivo monocyte migration assays, PG treatment reduced circulating monocyte migration into aneurysmal aortae by nearly 50%. CONCLUSIONS: Treatment with the CCR2 signaling inhibitor PG inhibits monocyte mobilization from bone marrow and subsequent migration into the aorta, leading to AAA suppression. CCR2 signaling inhibition may represent a viable strategy for clinical AAA managements. AUTHOR DISCLOSURES: K. Aoyama: Nothing to disclose; J. Dalman: Nothing to disclose; R.L. Dalman: Nothing to disclose; N. Fujimura: Nothing to disclose; Y. Furusho: Nothing to disclose; K. Glover: Nothing to disclose; S.A. Michie: Nothing to disclose; M. Rouer: Nothing to disclose; H. Tanaka: Nothing to disclose; B. Xu: Nothing to disclose; H. Xuan: Nothing to disclose.

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PS204. Regional Heterogeneity of IL-6 in Thoracic  and Abdominal Aortic Aneurysm

4:05 p.m.

Nicolas H. Pope, Morgan Salmon, William F. Johnston, Guanyi Lu, Gilbert R. Upchurch Jr., Gorav Ailawadi.

Surgery, University of Virginia, Charlottesville, Va.

OBJECTIVES: Thoracic (TAA) and abdominal aortic aneurysms (AAA) represent related but distinct disease processes. We hypothesized that thoracic and abdominal aortas display differential inflammatory profiles in response to injury, and that interleukin-6 (IL-6) is critical in TAA. METHODS: Murine TAAs (n=14) and AAAs (n=14) were created in C57/B6 mice by treating thoracic or abdominal aorta externally with elastase. Aortas were harvested at 14 days.

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Separately, aortas were harvested 7 days post-operatively and aneurysms were analyzed with antibody cytokine array. Finally, to determine the role of IL-6, murine thoracic (n=14) or abdominal (n=14) aortas were treated with elastase in IL-6 knockout (KO) mice. RESULTS: Elastase treatment of thoracic and abdominal aortas yielded dilation of 86.8 ±9.6% and 85.6% ±16.2 respectively. Murine IL-6 and MMP-9 were significantly elevated in TAA compared to AAA for equally sized aneurysms (p=0.004, 0.001, respectively (Figure 1A). Human TAA showed greater levels of IL-6 (p<0.0001) compared to AAA and normal thoracic and abdominal aorta. Importantly, IL-6 KO mice demonstrated significantly smaller TAA size relative to wild-type mice (WT: 100.13%, n=7 versus IL-6 KO: 76.546%, n=7 p=0.04), while IL-6 KO did not show any protection from aneurysm formation in AAA at day 14 (p=0.732). CONCLUSIONS: IL-6 expression is greater in both murine and human TAA compared to AAA suggesting fundamental differences in the two disease processes. IL-6 is critical in experimental TAA and may be a target for thoracic aneurysmal disease. AUTHOR DISCLOSURES: G. Ailawadi: Nothing to disclose; W.F. Johnston: Nothing to disclose; G. Lu: Nothing to disclose; N.H. Pope: Nothing to disclose; M. Salmon: Nothing to disclose; G.R. Upchurch Jr.: Nothing to disclose.

PS206. Use of Computational Fluid Dynamics Studies  in Predicting Aneurysmal Degeneration of Acute Type B Aortic Dissections

4:10 p.m.

Eric K. Shang,1 Derek P. Nathan,2 Ronald M. Fairman,1 Joseph E. Bavaria,1 Robert C. Gorman,1 Joseph H. Gorman,1 Benjamin M. Jackson.1

Department of Surgery, University of Pennsylvania, Philadelphia, Pa.; University of Washington, Seattle, Wash.

1 2

OBJECTIVES: While uncomplicated acute type B aortic dissections are often medically managed with good outcomes, a subset develops subacute or chronic aneurysmal dilatation. We hypothesize that computational fluid dynamics (CFD) simulations may be useful in identifying patients at risk for this complication.

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METHODS: Patients with acute type B dissection complicated by rapidly expanding aortic aneurysms (N=7) were compared to patients with stable aortic diameters (N=7). Three dimensional patient-specific dissection geometries were generated from CTA and used in CFD simulations of pulsatile blood flow. Hemodynamic parameters including false lumen flow and wall shear stress were compared. RESULTS: Patients with rapid aneurysmal degeneration had a growth rate of 5.3 ± 2.7 mm/month compared to those with stable aortic diameters who had rates of 0.2 ± 0.02 mm/month. Groups did not differ in initial aortic diameter (36.1±2.9 vs. 34.4±3.6 mm, P=0.122) or false lumen size (22.6±2.9 vs. 20.2±4.5 mm, P=0.224). In patients with rapidly expanding aneurysms, a greater percentage of total flow passed through the false lumen (78.3±9.3 vs. 56.3±11.8%, P=0.016). The time averaged wall shear stress on the aortic wall was also significantly higher (12.6±3.7 vs. 7.4±2.8 Pa, P=0.028, see Figure). CONCLUSIONS: Hemodynamic parameters derived from CFD simulations of acute type B aortic dissections were significantly different in dissections complicated by aneurysm formation. Thus, CFD may assist in predicting which patients may benefit from early stent grafting. AUTHOR DISCLOSURES: J.E. Bavaria: Nothing to disclose; R.M. Fairman: Nothing to disclose; J.H. Gorman: Nothing to disclose; R.C. Gorman: Nothing to disclose; B.M. Jackson: Nothing to disclose; D.P. Nathan: Nothing to disclose; E.K. Shang: Nothing to disclose.

PS208. Increased Pressure Gradients Within an Aortic Arch  Endograft Are Associated with Rapid Development of In-Stent Stenosis in a Porcine Model

4:15 p.m.

Daniel Silverberg,1 Marcel Goodman,2 Edward Woo,3 Elisha Martinez,4 Udi Willenz,5 Moshe Halak,1 David Planer.6

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Vascular Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel; 2 University of Western Australia, Perth, Western Australia, Australia; 3 Medstar Washington Hospital Center and Medstar Georgetown University 1


Hospital, Philadelphia, Pa.; 4EndoSpan Ltd, Herzelia, Israel; 5The Institute of Animal Research, Kibbutz Lahav, Israel; 6Hebrew University Medical Center, Jerusalem, Israel. OBJECTIVES: To describe the association between pressure gradients within fenestrated aortic arch endografts and the rapid development of in-stent branch stenosis in a porcine model. METHODS: Ten pigs underwent implantation of a modular fenestrated stent-graft in the aortic arch, comprising a main, tapered module with branches to the ascending aorta (AA) and left subclavian artery (LSA). In group 1 (n=6), the leading tapered end of the main module was deployed in the innominate artery (IA) and the distal, large caliber end in the descending thoracic aorta (DTA), orientated so that the fenestrations faced the AA and LSA. Group 2 (n=4) animals underwent a preliminary LSA to carotid artery bypass, followed by implantation of a modified endograft with a larger cross-sectional area of the fenestration for the ascending aorta branch module. Pressure gradients between the AA module and the endograft at different levels in the arch and DTA, the IA and LSA were measured intra-procedurally and at angiography at 1, 3 and 6 months. Pigs were sacrificed after 6 months. RESULTS: Pressure gradients in the main module, IA, LSA and DTA were significantly higher in group 1 compared to group 2. Angiograms performed during the follow up revealed severe in-stent stenosis within the IA and LSA stents in group 1 animals. No in-stent stenosis was seen in group 2 branch modules. This correlated with findings at gross pathological and histological examination of dense fibrous tissue layer lining the stent graft in the IA and LSA of group 1 consistent with intimal hyperplasia. CONCLUSIONS: Elevated pressure gradients observed in aortic arch endografts appear to be associated with rapid development of in-stent stenosis in the porcine model, presumably due to significant hemodynamic disturbance. This potential complication should be taken into consideration when planning experimental arch stent grafts. Care should be taken to eliminate pressure gradients in order to avoid development of in-stent stenosis in this animal model. AUTHOR DISCLOSURES: M. Goodman: Endospan Ltd., consulting fees or other remuneration (payment); M. Halak: Nothing to disclose; E. Martinez: Endospan, Ltd., employment (full or part-time); D. Planer: Endospan Ltd., consulting fees or other remuneration (payment); D. Silverberg: Endospan Ltd., consulting fees or other remuneration (payment); U. Willenz: Nothing to disclose; E. Woo: Endospan Ltd., consulting fees or other remuneration (payment). PS210. Inhibition of VEGFR2 Reduces Angiogenic  Microvessel Leakiness in Murine Vein Graft Atherosclerotic Lesions and Increases Plaque Stability

4:20 p.m.

Margreet de Vries,1 Rob C. de Jong,1 Erna H. Peters,1 Jaap F. Hamming,1 Marie José Goumans,2 Hajo J. van Bockel,1 Paul H. Quax.1

1Vascular Surgery, LUMC, Leiden, Netherlands; 2 Molecular Cell Biology, LUMC, Leiden, Netherlands.

OBJECTIVES: Immature plaque neovessels contribute to atherosclerotic plaque instability and intraplaque hemorrhage by leaking erythrocytes and leukocytes in the plaque. VEGF Receptor 2 (VEGFR2), together with the angiopoietin (Ang)-Tie2 system, regulates the maturation of growing neovessels. We have previously shown that murine vein graft lesions exhibit massive plaque neovascularization and that leaky vessels and

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intraplaque hemorrhage contribute to lesion growth. We hypothesized that inhibition of VEGFR2 results in more mature plaque microvessels and less intraplaque hemorrhage. METHODS: Donor caval veins were engrafted in carotid arteries of recipient hypercholesterolemic ApoE3*Leiden mice (n=14/group). Mice were treated at day 14, 17, 21 and 25 with VEGFR2 blocking antibodies (DC101) or control IgG antibodies (10 mg/kg). At day 28 mice were sacrificed for histological analysis of the vein grafts. RESULTS: Morphometric analysis revealed a striking 50% decrease in vein graft segments that contain leaky vessels in the DC101 treated group. This was accompanied by a significant 25-fold decrease in extravasated erythrocytes. Furthermore, lesions that exhibit intraplaque hemorrhage showed a strong increase in both Ang-1 and Ang-2, indicative for immature neovessels. VEGFR2 blockade however, did not affect the neovessel density in the lesions (control 52±19 neovessels/section; DC101 63±25 neovessels/section). Interestingly, the vein graft lesion area in the DC101 group was significantly reduced with 32% compared to the control group. Moreover, plaque stability was clearly increased in DC101 treated mice, determined by a 50% increase in collagen content and a 120% increase in SMC content. CONCLUSIONS: Blockade of VEGFR2 leads to reduced intraplaque hemorrhage, decreased vein graft lesion area and increased plaque stability. This identifies plaque neovascularization as an attractive target for the treatment of unstable atherosclerotic diseases. AUTHOR DISCLOSURES: R.C. de Jong: Nothing to disclose; M. de Vries: Nothing to disclose; M. Goumans: Nothing to disclose; J.F. Hamming: Nothing to disclose; E.H. Peters: Nothing to disclose; P.H. Quax: Nothing to disclose; H.J. van Bockel: Nothing to disclose. PS212. Increased CircularRNA-16 in Acutely Symptomatic  Carotid Plaques: A Novel Mediator of Carotid Plaque Rupture

4:25 p.m.

Hernan A. Bazan,1 Daniel Lightell,2 W. Charles Sternbergh,1 T. Cooper Woods.2 1  Surgery, Section of Vascular/Endovascular Surgery, Ochsner Clinic, New Orleans, La.; 2Tulane Heart & Vascular Institute, New Orleans, La.

OBJECTIVES: Circular RNAs (circRNAs) are dynamically expressed during development and possess binding sites for microRNAs (miRs), small RNAs that negatively regulate gene expression. We recently demonstrated that miR-221, which is associated with VSMC proliferation and inhibition of apoptosis, is decreased in acutely symptomatic carotid plaques. As circRNA-16 possesses binding sites for miR-221 thru seed sequences found within, we hypothesized that circRNA-16 is increased in acutely symptomatic carotid plaques. METHODS: Relative changes in gene expression levels of circRNA-16 were compared using a real-time PCR assay and the Ct method. All samples were run in duplicate; mean/ standard errors were calculated. One-way ANOVA with Tukey’s test was used to determine significance between groups. RESULTS: Expression of circRNA-16 was confirmed in human VSMC using PCR and resistance to RNAse H. To investigate its role in carotid plaque rupture, levels of circRNA-16 were quantified in patients undergoing urgent CEA for acute neurologic symptoms (n=27), compared to asymptomatic carotid plaques (n=19). In contrast to miR-221, circRNA-16 is increased in the urgent group compared to the asymptomatic carotid plaque group (Figure; 1.51±.26 vs. 1.00±.10, p=.03).

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CONCLUSIONS: We demonstrate circRNA-16 levels are increased and miR-221 levels decreased in acutely ruptured carotid plaques. Furthermore, our data suggest that a circRNA-16/miR-221 axis may be important in fibrous cap degradation and rupture during the transition from a stable to an unstable carotid atherosclerotic plaque. AUTHOR DISCLOSURES: H.A. Bazan: Nothing to disclose; D. Lightell: Nothing to disclose; W. Sternbergh: Nothing to disclose; T. Woods: Nothing to disclose.

PS214. Agreement of Repeatability Coefficients for  Within-Subject Carotid Artery Velocities with Snoring Application

4:30 p.m.

Susan McCormick, Joanna Piwowarczyk, Laurie Lozanski, Besnike Ramadani, Edyta Ilczyk, Christopher L. Skelly.

Section of Vascular Surgery and Endovascular Therapy, University of Chicago, Chicago, Ill.

OBJECTIVES: To determine 1) within-subject variance in carotid artery velocities as measured by ultrasound (US) and 2) if snoring significantly alters carotid velocities. METHODS: 32 bilateral carotid artery US exams were performed on 8 subjects by 2 RVTs (4 exams/subject, 4 subjects/RVT). Steps were taken to ensure measurements were made at identical sites under similar parameters for subsequent exams. PSV and EDV were measured at 8 locations. For each location, limits of agreement were used to calculate PSV and EDV repeatability coefficients, which are the limits within which 95% of the differences will lie for two measurements made on the same subject. Repeatability coefficients were then used to determine significance for observed velocity changes in carotid arteries with and without stenosis during mock snoring. They were also used to access velocity variability in patients scheduled for CEAs. All US exams were performed in an IAC vascular testing accredited laboratory by RVTs.

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RESULTS: Repeatability coefficients for RVT A ranged from 34 to 44 cm/s for PSV and 10 to 22 cm/s for EDV. For RVT B they ranged from 30 to 65 and 8 to 19 cm/s for PSV and EDV, respectively. Maximum values occurred at the ostia of the ICA and in the proximal ICA for RVTs A and B, respectively. In non-stenosed arteries, snoring most frequently caused a significant change in the PSV of the proximal ICA and in the EDV of the mid ICA where it occurred 15% of the time (3/20 arteries). However, the effect of snoring was greatest in stenosed arteries. In 38% (3/8) snoring caused a significant increase in the PSV and EDV of the proximal ICA and in the PSV of the mid ICA. CONCLUSIONS: Repeatability coefficients can be used to determine significant changes in carotid artery velocities within stenosis categories as measured by US. There is a possible connection between snoring, carotid velocities and stenosis which warrants further investigation to determine if it is part of the mechanism by which snoring may increase stroke risk. AUTHOR DISCLOSURES: E. Ilczyk: Nothing to disclose; L. Lozanski: Nothing to disclose; S. McCormick: Nothing to disclose; J. Piwowarczyk: Nothing to disclose; B. Ramadani: Nothing to disclose; C.L. Skelly: Nothing to disclose. PS216. Zizimin1 Overexpression Impairs  Vascular Morphogenesis

4:35 p.m.

Siavash Saadat, Yanmei Qi, Jie Liu, Alan Graham, Shaohua Li.

Rutgers-Robert Wood Johnson Medical School, New Brunswick, N.J.

OBJECTIVES: The Rho subfamily of small GTPases, including RhoA, Rac1, and Cdc42, regulates diverse cellular functions, including polarity, migration, and actin-based cytoskeleton dynamics. Our prior studies established an essential role for Cdc42 in vascular network assembly, demonstrating that the genetic inactivation of Cdc42 yields defective vascular morphogenesis due to impaired migration of endothelial precursor cells. We have further shown that protein kinase Ciota and glycogen synthase kinase-3beta are downstream effectors of Cdc42 and are involved in mediating vascular network assembly. However, the guanine nucleotide exchange factors (GEFs) that activate Cdc42 remain unknown. METHODS: We performed affinity pulldown assays using a nucleotide-free Cdc42 G15A mutant that specifically binds to Cdc42 GEFs. Mass spectrometric analysis identified Zizimin1, an upstream regulatory protein, as a candidate Cdc42 GEF. RESULTS: During vasculogenesis in embryoid bodies (EBs) differentiated from embryonic stem cells, Zizimin1 is highly expressed in aggregated endothelial cell precursors prior to vascular network formation. Surprisingly, stable overexpression of Zizimin1 in EBs resulted in the inhibition of blood vessel formation compared to control, evidenced by immunohistochemistry demonstrating loss of vascular network development. Affinity pulldown assay helped to elucidate that overexpression of Zizimin1 increases Cdc42 activity; however, the activation of Rac1 and RhoA is significantly inhibited. CONCLUSIONS: Since Rac1 and RhoA signaling has been reported to play an essential role in embryonic blood vessel formation, our results suggest that the interplay between Rho GTPases guides vascular network assembly during development. Furthermore, these findings provide novel insights into the mechanisms of embryonic vasculogenesis and also important new information for the design of potential pro- and/or antiangiogenic therapies. AUTHOR DISCLOSURES: A. Graham: Nothing to disclose; S. Li: Nothing to disclose; J. Liu: Nothing to disclose; Y. Qi: Nothing to disclose; S. Saadat: Nothing to disclose.

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C8j: Research (2)  3:30 – 5:00 p.m.  uAuditorium, Level 2  (enter through Exhibit Hall C) Moderator: Benjamin M. Jackson, MD, MS, University of Pennsylvania, Philadelphia, Pa.

PS218. Plasma and Patterning: The New Focus for  the Development of Nanocomposite Vascular Grafts

3:40 p.m.

Debra S. Chong,1 Matthew Dalby,2 Nikolaj Gadegaard,2 Ben Lindsey,1 Alexander Seifalian,1 George Hamilton.1

1Division of Surgery and Interventional Science, University College London, London, United Kingdom; 2University of Glasgow, Glasgow, United Kingdom.

OBJECTIVES: The concept of surface modulation holds much promise for the future development of vascular grafts. Our aim is to enhance a nanocomposite material using surface modification techniques such as plasma technology and surface patterning to augment both surface chemistry and topography with a view towards endothelialisation. METHODS: Polyhedral oligomeric silsesquioxane (POSS) was combined with polycarbonate urea urethane (PCU) to produce a nanocomposite polymer. Microgrooves with pitch size of 25µm was created using photolithography. Fidelity was verified with scanning electron microscopy (SEM) and atomic force microscopy (AFM). The polymer was then exposed to pure O2 plasma and contact angles were measured. Human umbilical vein endothelial cells (HUVECs) were then seeded onto POSS-PCU. The metabolic activity of the cells was assessed and immunostaining was used and subsequently visualised with confocal microscopy. RESULTS: Contact angle results (mean: 85°) show the increased hydrophilicity of the polymer surface. Both AFM and SEM confirm the high replication fidelity of the microgrooves within the surface of the polymer using photolithography. Metabolic activity of HUVECs on the surface modified polymer was significantly increased compared with control (p <0.05). Further immunostaining confirms the adhesive nature of the cells as well as the migratory potential. CONCLUSIONS: Using a combination of plasma technology and surface patterning to augment both surface chemistry and topography on a nanocomposite polymer promotes increased endothelial cell adhesion, migration and proliferation. The ordered microgrooves were seen to enhance cellular adhesion and spreading. Plasma technology and microgrooving is a promising methodology to optimise luminal endothelisation and the prospect for ‘self-endothelisation.’ AUTHOR DISCLOSURES: D.S. Chong: Nothing to disclose; M. Dalby: Nothing to disclose; N. Gadegaard: Nothing to disclose; G. Hamilton: Nothing to disclose; B. Lindsey: Nothing to disclose; A. Seifalian: Nothing to disclose. PS220. Quantitative In Vitro Model for the Study of  Bacterial Attachment on Vascular Conduits

3:45 p.m.

Thomas A. Heafner,1 Clayton Lewis,1 Jonathan Abercrombie, 2 Brandon W. Propper,1 Yiming Ching,1 Zachary M. Arthurs.1

1San Antonio Military Medical Center, Fort Sam Houston, Texas; 2 US Army Institute of Surgical Research, Fort Sam Houston, Texas.

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OBJECTIVES: Despite prophylactic antibiotics and aseptic technique, prosthetic graft infections continue to cause significant morbidity and mortality. In contemporary reports, in vivo models have tested a conduitâ&#x20AC;&#x2122;s infectability using concentrations from 104 to 109 colony-forming units (CFU) per mL. Using an in vitro model, we evaluated the impact of inoculation concentrations on prosthetic graft attachment. METHODS: The 2 and 24hr attachment of Staphylococcus aureus TCH1516 and Pseudomonas aeruginosa PA01-UW were determined on polytetrafluoroethylene, dacron, nitinol, cobalt chromium and Viabahn endoprotheses. Individually and in combination, concentrations at 104, 105, 106, 107, and 108 were tested on 2 mm sections of each graft. Following each time interval, the prosthetics were rinsed to remove non-attached bacteria, sonicated to release the attached bacteria, spiral plated and then analyzed for the attached concentration. RESULTS: After 2 hours, there was a significant difference in the median attachment rates on dacron (14%) compared to nitinol (2.1%), cobalt (1.4%) and Viabahn (0.73%) across all bacterial combinations (p < 0.05). Pseudomonas aeruginosa achieved the greatest attachment at most concentrations regardless of the material. At the 24-hour mark, the median attachment for each concentration was greater than the highest initial concentration (108) with nitinol and cobalt having a statistically significant lower attachment (p < 0.05). CONCLUSIONS: Initial attachment is consistently poor regardless of inoculation concentration, but greater on the synthetic grafts compared to metal stents. However, after 24 hours in a nutrient poor environment, Staphylococcus aureus and Pseudomonas aeruginosa are still able to achieve full attachment throughout. AUTHOR DISCLOSURES: J. Abercrombie: Nothing to disclose; Z.M. Arthurs: Nothing to disclose; Y. Ching: Nothing to disclose; T.A. Heafner: Nothing to disclose; C. Lewis: Nothing to disclose; B.W. Propper: Nothing to disclose. PS222. Characterizing the Evolution of the Extracellular  Matrix During Adaptation of the Venous Limb of the Maturing Arteriovenous Fistula

3:50 p.m.

Michael R. Hall,1 Kota Yamamoto,1 Clinton D. Protack,1 Masayuki Tsuneki,2 Go Kuwahara,1 Roland Assi,1 Kirstyn Brownson,1 Joseph A. Madri,2 Alan Dardik.1

Yale School of Medicine - Department of Surgery, New Haven, Conn.; 2 Yale School of Medicine - Department of Pathology, New Haven, Conn. 1

OBJECTIVES: Using a novel murine AVF model, we sought to study the changes in extracellular matrix (ECM) during normal adaptation of the venous limb of the maturing AVF. METHODS: AVF were created in C57BL/6 mice and the venous limb was extracted at post-operative days (POD) 1, 3, 7, 21, and 42. Specimens were analyzed by RT-PCR, histology, and IHC. Proteases, protease-inhibitors, collagens, glycoproteins and other non-collagenous proteins were characterized. RESULTS: qPCR demonstrated a significant 5-fold increase in MMP-9 and 200-fold increase in MMP-3 mRNA expression at POD 1; MMP-2 and MMP-12 by 15-fold and 100-fold, respectively, at POD 7. All TIMPs mRNA expression were significantly increased at POD 21; TIMP1 was significantly increased by at least 10-fold at POD 1-21. Collagens I, III, and IV mRNA expression were increased significantly at POD 7 with Collagen III increasing earlier at POD 3 by 10-fold. Fibronectin, Perlecan, Syndecan-2, Versican, and Vitronectin mRNA expression were all significantly increased at POD 21. Fibrillin-1 & Elastin were increased at POD 3 and 7. Thrombospondin-2 was significantly increased at POD7;

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Osteopontin was increased nearly 200-fold at POD1. IHC demonstrated this increased expression of MMPs, TIMPs, Collagen I and III, Osteopontin & Fibronectin at respective significant time points; EVG staining characterized elastin deposition at POD7. CONCLUSIONS: Early ECM breakdown is initiated by MMP-3, MMP-9, and TIMP1 in the first few days after creation of AVF; MMP-2 and MMP-12 continue the early ECM remodeling. At 1 week, the foundation for remodeling is established with deposition of Collagens I and III and Fibrillin-1 & Elastin. A transition phase begins with anti-angiogenic Thrombospondin-2 upregulation and all TIMPs increased at POD21. A late-phase remodeling with larger ECM proteins and glycoproteins is underway by POD 21. The remodeling of the venous limb of the AVF is characterized by early ECM breakdown & occurs in phases during the first 3-6 weeks after surgery. AUTHOR DISCLOSURES: R. Assi: Nothing to disclose; K. Brownson: Nothing to disclose; A. Dardik: Nothing to disclose; M.R. Hall: Nothing to disclose; G. Kuwahara: Nothing to disclose; J.A. Madri: Nothing to disclose; C.D. Protack: Nothing to disclose; M. Tsuneki: Nothing to disclose; K. Yamamoto: Nothing to disclose. PS224. Mouse Arteriovenous Fistula Recapitulates the  Course of Human Fistula Maturation

3:55 p.m.

Kota Yamamoto,1 Clinton D. Protack,1 Masayuki Tsuneki,2 Michael R. Hall,1 Go Kuwahara,1 Roland Assi,1 Kirstyn Brownson,1 Hualong Bai,1 Joseph A. Madri,2 Alan Dardik.1 1  Yale University, School of Medicine - Department of Surgery, New Haven, Conn.; 2Yale University, School of Medicine - Department of Pathology, New Haven, Conn.

OBJECTIVES: The arteriovenous fistula (AVF) is the gold standard for hemodialysis access but continually exhibits poor patency compared to other vascular constructs, reflecting our imperfect understanding of fistula maturation and adaptation to the arterial circulation. We hypothesized that the mouse AVF model reflects human AVF maturation and that the shear stress flowing through the AVF determines the maturation and patency of the fistula. METHODS: The aortocaval AVF was created in C57Bl/6 mice using a 25g needle. AVF patency and functional status were determined using ultrasound, histology, blood gas measurement and molecular biological methods. Shear stress was altered using 22g and 28g needles to increase and decrease the shear stress, respectively. RESULTS: The mouse aortocaval fistula showed three distinct phases after a technically successful procedure. In the immediate phase (days 0-1), 23.5% showed occlusion due to thrombosis. The maturation phase (days 2-21) was characterized by a slight increase of AVF patency from 76.5% (day 1) to 80.1% (day 21) and increased IVC diameter by 49%. The failure phase (days 21-42) showed neointimal hyperplasia and occlusion in 33% of the mature AVF. Shear stress in aortae proximal to AVF created with the 22g needle was increased by 109% without a change in diameter at day 1; however, shear stress was normalized by day 7. Patency was 100% and survival was diminished by 50% in these large AVF. Shear stress in AVF created with the 28g needle was decreased by 39% but AVF patency was reduced 50%. Survival was 100%. CONCLUSIONS: This murine aortocaval model faithfully recapitulates the maturation and failure phases of the human AVF; this is the first animal model to show these distinct phases. Shear stress varies according to the diameter of the fistula and AVF patency depends on the AVF shear stress.

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AUTHOR DISCLOSURES: R. Assi: Nothing to disclose; H. Bai: Nothing to disclose; K. Brownson: Nothing to disclose; A. Dardik: Nothing to disclose; M.R. Hall: Nothing to disclose; G. Kuwahara: Nothing to disclose; J.A. Madri: Nothing to disclose; C.D. Protack: Nothing to disclose; M. Tsuneki: Nothing to disclose; K. Yamamoto: Nothing to disclose. PS226. Significant Increase of Urine Fibrinogen in  Mouse Model of Contrast Induced Nephropathy

4:00 p.m.

Luyu Yao,1 Honglin Dong,2 Cynthia Zhao,3 Shu Yang,1 Wayne W. Zhang.1

1 Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, La.; 2Departments of Vascular Surgery, Second Hospital, Shanxi Medical University, Taiyuan, China; 3Department of Pathology, Louisiana State University Health Sciences Center, Shreveport, La.

OBJECTIVES: Contrast induced nephropathy (CIN) is the third leading cause of hospital acquired renal failure. Early diagnosis and treatment of CIN may prevent significant sequelae. It has been reported that urinary fibrinogen (Fg) can be used as a biomarker of ischemia/reperfusion injury in kidney. The objective of this study was to investigate whether urinary Fg can serve as a biomarker for the diagnosis of CIN. METHODS: C57B1/6J mice received a prostaglandin synthesis inhibitor (indomethacin, 10 mg/kg) and a nitric oxide synthase inhibitor (N-Nitro-L-arginine methyl ester, 10 mg/ kg) intraperitoneally (ip) before giving Iodixanol in low-dose (6.24 g iodine/ml ip) and high-dose (12.48 g iodine/kg ip) groups. Mice in control group received normal saline instead of Iodixanol. Urine samples were collected for Fg and creatinine (Cr) analysis using ELISA kit. Kidneys were harvested 24 hours later. RNA was extracted from half of a kidney specimen. qRT-PCR were used to quantify Fg RNA expression, with GAPDH as endogenous control. The other half of the kidney specimen was fixed with formalin, embedded in paraffin and then stained with Hematoxylin and Eosin (H&E) for histopathology evaluation. RESULTS: H&E stain demonstrated mild renal injury in the low-dose group scoring from 0-1, and moderate renal injury in high-dose group scoring from 1-2, based on a pathological grading scale of 0 to 3. Urinary Fg increased significantly from 0.37 ± 0.13 µg/mg Cr in Control group to 3.46 ± 2.89 µg/mg Cr in low-dose group (P < 0.05) and 6.15 ± 2.51 µg/mg Cr in high-dose group (P < 0.01). Fg RNA level increased 40% in high-dose group compared to control (P < 0.05), although no significant changes were detected in low-dose group. CONCLUSIONS: Urinary Fg level increases are consistent with the pathological severity of CIN in animal models. These results suggest that urinary Fg may be a potential biomarker for early diagnosis of CIN. Further investigation in clinical patients is needed. AUTHOR DISCLOSURES: H. Dong: Nothing to disclose; S. Yang: Nothing to disclose; L. Yao: Nothing to disclose; W.W. Zhang: Nothing to disclose; C. Zhao: Nothing to disclose. PS228. Can Edaravone Protect Kidney Damage Caused  by Myonephropathic Metabolic Syndrome in Rats?

4:05 p.m.

Mitsuhiro Yamamaura, Yuji Miyamoto, Masataka Mitsuno, Hiroe Tanaka, Masaaki Ryomoto, Shinya Fukui.  Dept. of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan. 226


OBJECTIVES: Free radicals have been implicated in myonephropathic metabolic syndrome (MNMS), which damages not only muscles but also kidneys. At VAM 2012, we previously reported free radical scavenger, edaravone (Radicut ®, Mitsubishi Tanabe Pharma Co., Japan) suppresses muscle injury by MNMS. In this study, we evaluated whether edaravone can suppress kidney damage by MNMS. METHODS: Lewis male rats (508 ±31 g, n = 10) were intraperitoneally injected with either 3.0 mg/kg of edaravone (edaravone group; n =4), or saline (MNMS group; n = 6). The MNMS models were induced, by clamping the bilateral common femoral arteries for 5 hours and then de-clamping. Five hours after de-clamping, both kidneys were stained with H&E. Normal kidneys were harvested as control (n = 3). Kidney damage was evaluated by the number of cells in glomerulus (glomerulus infiltration) and the number of residual tubular cells (enlargement of tubular cells). RESULTS: The number of cells in glomerulus was significantly increased in MNMS group than in the control (77.2 ±10.3 vs. 49.6 ±2.8 cells/glomerulus, p <0.01). The number of cells in glomerulus was alleviated in edaravone group (62.2 ±10.3 cells/glomerulus, p <0.01). The number of residual tubular cells was significantly decreased in MNMS group than in the control (555 ±24 vs. 957 ±44 cells/mm2, p <0.001). The number of residual tubular cells was maintained in edaravone group (654 ±38 cells/mm2, p =0.06). CONCLUSIONS: MNMS was associated with significant glomerular infiltration and the enlargement of tubular cells. Edaravone may alleviate kidney damages caused by MNMS. AUTHOR DISCLOSURES: S. Fukui: Nothing to disclose; M. Mitsuno: Nothing to disclose; Y. Miyamoto: Nothing to disclose; M. Ryomoto: Nothing to disclose; H. Tanaka: Nothing to disclose; M. Yamamaura: Grant-in-Aid for Researchers, Hyogo College of Medicine 2013, research grants.

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PS230. The Role of Toll-Like Receptor 2 in Platelet Activation 

Maylene Xie, Ryan McEnaney, Xiangdong Cui, Ulka Sachdev.

Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

4:10 p.m.

OBJECTIVES: Recent literature suggests that platelet function supports vessel integrity. Toll-like receptor 2 has been shown to be present and functionally active on platelets. We have previously demonstrated that TLR2KO mice hemorrhage into ischemic hindlimbs. We hypothesize that TLR2 function is required to maintain angiogenic vessel integrity, possibly by promoting normal platelet function. METHODS: Blood from C57BL/6 (control) and TLR2-knockout mice was obtained by cardiac puncture. In some experiments, control C57BL/6 mice were treated with anti-TLR2 antibody and control IgG. Platelets were separated and washed, and treated with 1 U/mL thrombin, 50 ng/mL phorbol-myristate acetate (PMA), 100 ÂľM calcium ionophore A23187, and 30 ÂľM thrombin receptor activating peptide (TRAP6). Fixed platelets were stained with fluorescent antibodies to beta-3 of the GPIIb/IIIa complex, and P-selectin, a plateletactivation marker. Activation was assessed using flow cytometry. RESULTS: Platelets from TLR2KO mice had less P-selectin expression in response to thrombin than controls (p=0.036, Figure). However, compared to controls, activation with TRAP6 and calcium ionophore resulted in higher P-selectin expression in both TLR2KO mice and TLR2 antibody treated mice, respectively (p = 0.056 and 0.0009, respectively). CONCLUSIONS: This data indicates that innate immune receptors on platelets modulate activation in a context specific manner. Further research is necessary to delineate the role of platelet-mediated innate immune responses in angiogenesis after ischemia. AUTHOR DISCLOSURES: X. Cui: Nothing to disclose; R. McEnaney: Nothing to disclose; U. Sachdev: Nothing to disclose; M. Xie: Nothing to disclose.

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PS232. Complications Associated with IVC Filters:  A Large, Single Institution Review

4:15 p.m.

Seth T. Purcell, Marvin D. Atkins, William T. Bohannon, Clifford J. Buckley, Jack L. Eidson.

Baylor Scott & White Hospital and Clinic, Texas A&M Health Science Center, Temple, Texas.

OBJECTIVES: To quantify and evaluate the complications arising from indwelling IVC filters through the examination of incidentally performed CT scans. METHODS: A retrospective review of all patients who had an IVC filter placed at our institution from January 1, 2000 to December 31, 2011. All patients who had incidental CT studies in which the IVC filter was visible and which were performed at least 6 months after placement were included. Two observers independently evaluated the CT scans. Filter model as well as IVC penetration, erosion, migration, filter fracture, and other complications were recorded. Penetration of the IVC was defined by at least one strut of the device being >4 mm outside of the IVC wall. RESULTS: A total of 1470 filters of 8 different models were inserted in the specified time period. Of these, 66% were retrievable, 6.9% were removed and 0.8% failed removal. The number of these patients who had had incidental CT studies performed in which the IVC filters were visible was 335 (22.7%, n 1-60, 1 month - 10 years). Filter penetration of the IVC was observed in 129 (38.5%) of the filters seen on subsequent CT scans, which further calculates to a known overall perforation rate of 9% for the entire series. IVC penetration was observed in 42 of 163 Optease filters (26%), 41 of 107 Trapease filters (38%), 25 of 29 G2/G2X filters (86%), 9 of 14 Greenfield filters (64%), 1 of 9 Vena-Tech filters (11%), 6 of 8 Celect filters (75%), 3 of 3 Eclipse filters, (100%), and 2 of 2 Tulip filters (100%). CONCLUSIONS: IVC filters were found to have a high rate of IVC penetration when observed through incidental CT scans. Further prospective studies and programs are needed to increase IVC filter retrieval rate. AUTHOR DISCLOSURES: M.D. Atkins: Nothing to disclose; W.T. Bohannon: Nothing to disclose; C.J. Buckley: Nothing to disclose; J.L. Eidson: Nothing to disclose; S.T. Purcell: Nothing to disclose. PS234. A Novel Secure Vessel Occluder for Minimally  Invasive and Percutaneous Treatments

Arnold Miller, Nir Lilach, Raanan A. Miller.

Amsel Medical, Cambridge, Mass.

4:20 p.m.

OBJECTIVES: Secure vessel occlusion is critical to the success of all surgical and interventional procedures. This study tested both in vitro and in vivo, the Amsel™ Vessel Occluder (AVO) a novel occlusion clip device for secure blood vessel closure. The AVO, delivered through a fine (18G) hypodermic needle, transfixes the targeted vessel, delivers expandable proximal and distal elements on either side of the vessel wall which lock together for secure vessel occlusion. METHODS: In vitro device testing was conducted on 5 mm silicon tubing. Standard corrosion analysis, material biocompatibility and cytotoxicity were performed on the implantable elements. In vivo studies on 3 swine compared safety and efficacy of the AVO with the medium/large Ligaclip® (J & J) for 1 week. The targeted vessels (carotid/femoral arteries; jugular/femoral veins) were divided between 2 AVO or 2 Ligaclips® devices.

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RESULTS: In vitro testing (N=11) confirmed a holding pressure of 450 mmHg (11/11), excellent clip closure repeatability (11/11), and release mechanism function (11/11). Once applied the AVO was secure and could not be dislodged (0/11). The Ligaclip® was easily dislodged (11/11). No corrosion was observed, material biocompatibility and cytoxicity N=12) were within accepted ranges. In vivo studies (6 arteries; 6 veins) confirmed easy AVO application and superiority in security. The AVO showed no post-operative bleeding (AVO= 0/6), while one Ligaclip® dislodged resulting in a fatal hemorrhage 16 hours post surgery (Ligaclip® =1/6). CONCLUSIONS: The AVO is simple to deploy and securely maintains occlusion by transfixing the targeted vessel, unlike the widely used, non-tranfixing Ligaclip® that has a tendency to dislodge. As such, the Amsel™ secure vessel occluder opens up numerous treatment opportunities in both the venous and arterial systems to minimize open, laparoscopic, robotic surgical and interventional procedures, and reduce patient morbidity. AUTHOR DISCLOSURES: N. Lilach: Amsel Medical Corporation, employment (full or part-time); A. Miller: Amsel Medical Corporation, ownership or partnership; R.A. Miller: Amsel Medical Corporation, employment (full or part-time). PS236. Clinical and Pathological Assessment of Different  Suture Techniques for Vascular Anastomosis in Rat Femoral Artery

4:25 p.m.

Rania Bakry,1 Mohamed Elshazly,2 Khaled Raddad.3

1  Clinical Pathology, Assiut University, Assiut, Egypt; 2 Assiut University Plastic Surgery Center, Assiut, Egypt; 3 Assiut University Veterinary Medicine, Assiut, Egypt.

OBJECTIVES: The study design aimed to examine the differences in the clinical and pathological features after vascular anastomoses of a rat femoral artery using four different suture techniques. METHODS: Sixty Sprage-Dawely rats were divided randomly into 4 groups. Fifteen bisected arteries (one from each animal) in Group I, II, III and IV were sutured with the simple interrupted suture, continuous suture, sleeve suture and cuff suture, respectively. RESULTS: The anastomosis times in Group I, II, III and IV were 28.67, 14.67, 15.47 and 15.93 min, respectively. Immediate bleeding that stopped without intervention (grade I) was observed in 67%, 73% and 60% of the anastomosed vessels in Groups II, III and IV, respectively, while 60% of the vessels in Group I showed light bleeding that was inhibited by gentile pressure (grade II). All vessels examined appeared to be patent at 5 and 15 minutes after the anastomosis. On the seventh day postoperatively, the vessels of Group I showed the highest patency rate (93%) compared with Groups II (67%), III (73%) and IV (87%). Moreover, there were more pronounced pathological changes in Group I than in the other groups. These changes included endothelial loss, endothelial proliferation, degeneration and necrosis of the tunica media. Suture materials surrounded by an inflammatory reaction were also observed. CONCLUSIONS: The simple interrupted suture is preferable for vascular anastomosis due to its highest patency rate. The other techniques investigated can be good alternatives because of their short anastomotic time and moderate pathological changes. AUTHOR DISCLOSURES: R. Bakry: Nothing to disclose; M. Elshazly: Nothing to disclose; K. Raddad: Nothing to disclose.

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PS238. Endo-Microvascular Surgery in Skin Retraction  Optical Cavity Model of the Rat Groin

Mohamed Elshazly.

Assiut University, Assiut, Egypt.

4:30 p.m.

OBJECTIVES: Although the operating microscope is still a must for microsurgical performance, microvascular surgery could be performed, depending on the experiences and facilities, by using other visual-assisting equipment. From this point, the author tried to find less costly and more widespread equipment suitable for performing microsurgery that can, furthermore, be applied in special situations and indications, such as operating in an optical cavity. METHODS: In this experimental project, the author performed vascular microsurgical anastomoses of the rats’ femoral vessels through the endoscopic screen monitor in a created optical cavity of a prefabricated skin retraction model in the groin area of 10 Sprague-Dawley male rats using three skin portals: a central one for the endoscope and two lateral ones for the microsurgical instruments. RESULTS: The microsurgical anastomoses of the femoral vessels and nerves were performed easily in a reasonable time, without recorded difficulties, and with maximum physical and visual comfort for the surgeon. The author spent a mean time of 28.1, 27.3, and 19.2 minutes for the arterial, venous, and neural anastomoses, respectively. In this group of animals, 90 percent vascular patency and 100 percent accurate neural anastomoses were recorded. CONCLUSIONS: This is a new technique of operating in the field of microvascular surgery. With its feasibilities and difficulties, it would be a point of research and application for young generations of microsurgeons. It could be tried when minimal incisions are absolutely indicated, cardiothoracic and general vascular procedures such as aortic artery grafting or aneurysm, which necessitate long abdominal incisions. Additionally, it could be performed if a major vessel is injured during any of the common laparoscopic procedures before transforming the technique to an open one. AUTHOR DISCLOSURES: M. Elshazly: Nothing to disclose. PS240. Factors Affecting the Response of the Vascular  Endothelium to the Micro-Suturing Trauma

Rania Bakry.

Clinical Pathology, Assiut University, Assiut, Egypt.

4:35 p.m.

OBJECTIVES: Many researchers have investigated microvascular anastomoses by scanning electron microscope (SEM); however, there are neither reports on classifying these anastomotic types according to the SEM results nor about studying the factors that affect these results. METHODS: Sixty rat femoral arteries were anastomosed using four different techniques: simple interrupted, continuous, sleeve, and autogenous arterial cuff. The anastomotic sites of each group and other two intact femoral arteries were examined by SEM. RESULTS: Intimal disruption and rebuilding of the blood vessel endothelium after microvascular anastomoses depend upon anastomotic time; suture placement, either intra-luminal or extra-luminal; and mechanical factors. Accordingly, the simple interrupted suture technique has the highest degree of intimal disruption and the lowest degree of

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regeneration, and the continuous and cuff anastomoses have better rebuilding with partial neoendothelial coverage of the cut ends, whereas the sleeve anastomosis has the best regeneration with complete coverage of the cut ends by the new endothelial cells. CONCLUSIONS: This study shows that intimal disruption and rebuilding of blood vessel endothelium after microvascular anastomoses depend upon three factors: anastomotic time, suture placement, and mechanical factors. AUTHOR DISCLOSURES: R. Bakry: Nothing to disclose.

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SCHEDULE IN DETAIL

SATURDAY, JUNE 7

All events held at Hynes Convention Center unless otherwise noted. REGISTRATION 

6:00 a.m. – 5:00 p.m. uHall C, Foyer, Level 2

 BREAKFAST SESSIONS

6:30 – 8:00 a.m.

B7: The Vascular Surgeon in Elective  Multispecialty Operations 

6:30 – 8:00 a.m. uRoom 302

At the end of this session, participants should be able to: 1. Coordinate and plan vascular procedures in elective multispecialty operations. 2. Formulate a treatment approach to retroperitoneal tumors with vessel involvement. 3. Review the key points of spine exposure. 4. Integrate neck anatomy as it relates to cancer surgery and how to choose carotid interventions. 5. Describe common vascular exposures and reconstructions needed with orthopedic surgery. Moderators: Jean M. Panneton, MD, Eastern Virginia Medical School, Norfolk, Va. Thomas C. Bower, MD, Mayo Clinic Rochester, Rochester, Minn. Vascular Surgery for Retroperitoneal Tumors  6:30 a.m. William J. Quinones-Baldrich, MD, University of California, Los Angeles, Calif. Exposure for Complex Spine Surgery  Margaret Clarke Tracci, MD, University of Virginia School of Medicine, Charlottesville, Va.

6:45 a.m.

Vascular Interventions for Head and Neck Cancer  Jean M. Panneton, MD, Eastern Virginia Medical School, Norfolk, Va.

7:00 a.m.

Combined Vascular and Orthopedic Reconstructions  Audra A. Duncan, MD, Mayo Clinic Rochester, Rochester, Minn.

7:15 a.m.

PANEL DISCUSSION

7:30 a.m.

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B8: Opportunities to Improve the Outcomes of Patients  6:30 – 8:00 a.m. with Acute Aortic Syndromes  uBallroom C, Level 3 At the end of this session, participants should be able to: 1. Analyze the opportunities present in their own institution to improve the processes of care for patients with acute aortic syndromes. 2. Assemble the requisite health provider team facilities, and instrumentation to have a successful acute aortic program. 3. Determine the suitability of patients with ruptured abdominal aortic aneurysms for endovascular repair and plan the conduct of that repair. 4. Evaluate patients with traumatic thoracic aortic injuries to determine their suitability for endovascular repair. 5. Formulate a corrective action plan for continued malperfusion despite endograft deployment over a Type B dissection entry tear. Moderators: Alan B. Lumsden, MD, The Methodist DeBakey Heart and Vascular Center, Houston, Texas Benjamin W. Starnes, MD, University of Washington, Seattle, Wash. Kim J. Hodgson, MD, Southern Illinois University, Springfield, Ill. The Rationale and Process for Development of an  Acute Aortic Center Manish Mehta, MD, Institute for Vascular Health and Disease, Albany Medical College, Albany, N.Y.

6:30 a.m.

Endovascular Repair of Ruptured Abdominal Aortic  Aneurysms — When and How to Do It Kim J. Hodgson, MD, Southern Illinois University, Springfield, Ill.

6:45 a.m.

TEVAR for Type B Dissections — What Next When Endograft  Deployment Doesn’t Correct Malperfusion Benjamin W. Starnes, MD, University of Washington, Seattle, Wash.

7:00 a.m.

TEVAR for Thoracic Aortic Trauma or Rupture —  7:15 a.m. Is Open Repair Obsolete? Alan B. Lumsden, MD, The Methodist DeBakey Heart and Vascular Center, Houston, Texas PANEL DISCUSSION 

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7:30 a.m.


B9: Closure and Arterial Access Conundrums 

6:30 – 8:00 a.m. uRoom 304/06

At the end of this session, participants should be able to: 1. Describe the current utility of percutaneous techniques during large vessel access, especially during EVAR/TEVAR. 2. Discuss the approach to radial artery access and the potential utilization for peripheral intervention. 3. Identify when the transapical or antegrade approach to TEVAR may be preferred. 4. Explain how to approach and when to consider the pedal arteries for primary interventional access. 5. Evaluate alternative access sites for intervention and how to manage closure. Moderators: Jean E. Starr, MD, The Ohio State University Wexner Medical Center, Columbus, Ohio Brian G. DeRubertis, MD, UCLA Medical Center, Los Angeles, Calif. Current Status of Large Vessel Closure  Peter R. Nelson, MD, University of South Florida Morsani College of Medicine, Tampa, Fla.

6:30 a.m.

Is the Transradial Approach Feasible for  6:45 a.m. Peripheral Intervention? Jean E. Starr, MD, The Ohio State University Wexner Medical Center, Columbus, Ohio Pearls for Transapical/Antegrade Approach for TEVAR  Shaun MacDonald, MD, University of British Columbia, Vancouver, British Columbia, Canada

7:00 a.m.

Pedal Access — Should We Use It More Often?  7:15 a.m. Dai Yamanouchi, MD, PhD, University of Wisconsin Hospital and Clinics, Madison, Wis. Closure Considerations for Unusual Approaches  7:30 a.m. Rumi Faizer, MD, University of Minnesota Medical Center, Minneapolis, Minn. PANEL DISCUSSION 

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7:45 a.m.

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SVS Leadership Roundtable: Breaking Through  Ethnic and Gender Biases to Become a More  Effective Leader Sponsored by the Diversity and Inclusion Committee 

6:30 – 8:00 a.m. uRoom 210

At the end of this session, participants should be able to: 1· R  eview the differences in ethnicities and genders that may affect our interactions with our colleagues, trainees, support staff and patients. 2. Identify challenging situations that may arise from differences in ethnicities and genders. 3. Analyze different leadership styles to deal with the above-mentioned challenging situations. 4. Develop techniques for a more collaborative and productive work environment. Moderators: Robyn A. Macsata, MD, Veteran Affairs Medical Center, Georgetown University, Washington, D.C. *NOTE: this program is not eligible for CME credit. Successfully Hiring International Medical Graduates (IMGs)  6:30 a.m. for Vascular Surgery Residency and Fellowship Training Programs: What Works, What Doesn’t Work? Guillermo A. Escobar, MD, University of Arkansas for Medical Sciences, Little Rock, Ark. Mark R. Nehler, MD, University of Colorado School of Medicine, Aurora, Colo. Apostolos K. Tassiopoulos, MD, Stony Brook Medicine, Stony Brook, N.Y. How to Successfully Change Xenophobia into 7:00 a.m. Cultural Diversity and Understanding? Fernando L. Joglar, MD, University of Puerto Rico School of Medicine, San Juan, Puerto Rico Ageliki G. Vouyouka, MD, Mount Sinai Hospital, New York City, N.Y. Jonathan Woodson, MD, JD, Assistant Secretary of Defense for Health Care Affairs, Washington, D.C. Luis A. Sanchez, MD, Washington University School of Medicine, St. Louis, Mo. Anil Hingorani, MD, Lutheran Medical Center, Brooklyn, N.Y. Is Gender Still an Issue?  7:30 a.m. Palma Shaw, MD, SUNY Upstate Medical University, Syracuse, N.Y. Vivian Gahtan, MD, SUNY Upstate Medical University, Syracuse, N.Y. Ruth L. Bush, MD, JD, MPH, Texas A&M Health Science Center, College of Medicine, Bryan, Texas  F3: B  eyond the Journal of Vascular Surgery:  ”Top Ten” Papers Relevant to Vascular Surgery

8:00 – 9:30 a.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Describe the types of clinical trials relevant to vascular disease. 2. Examine the bias that can affect the interpretation of trial data. 3. Review publications that may influence clinical practice. Moderators: Gregory L. Moneta, MD, Oregon Health and Sciences University, Portland, Ore. Vikram S. Kashyap, MD, University Hospitals Case Medical Center, Cleveland, Ohio 236


Introduction  8:00 a.m. Gregory L. Moneta, MD, Oregon Health and Sciences University, Portland, Ore 1. T  obacco control and the reduction in smoking-related  premature deaths in the United States, 1964-2012 — JAMA 2014;311(2):164–171 Presentation and discussion led by: Ankur Chandra, MD, University of Rochester, Rochester, N.Y.

8:05 a.m.

2. C  omparison of global estimates of prevalence and  8:10 a.m. risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis — Lancet 2013;382:1329–1340 Presentation and discussion led by: Virginia L. Wong, MD, University Hospitals Case Medical Center, Cleveland, Ohio 3. M  eta-analysis of secure randomized controlled trials  8:15 a.m. of b-blockade to prevent perioperative death in non-cardiac surgery — Heart BMJ 2013;0:1–9 Presentation and discussion led by: Andres Schanzer, MD, MPH, University of Massachusetts Medical Center, Worcester, Mass. 4. D  oxycycline for stabilization of abdominal aortic  8:20 a.m. aneurysms — Annals of Internal Medicine 2013;159(12):815–823 Presentation and discussion led by: B. Timothy Baxter, MD, University of Nebraska Medical Center, Omaha, Neb. 5. S  urveillance intervals for small abdominal aortic  8:25 a.m. aneurysms — JAMA 2013;309(8):806–813 Presentation and discussion led by: Elliot L. Chaikof, MD, Beth Israel Deaconess Medical Center, Boston, Mass. Discussion

8:30 a.m.

Non-selected Papers  Vikram S. Kashyap, MD, University Hospitals Case Medical Center, Cleveland, Ohio

8:40 a.m.

6. S  tenting and medical therapy for atherosclerotic  8:43 a.m. renal-artery stenosis — New England Journal of Medicine 2014; 370:13–22 Presentation and discussion led by: Vikram S. Kashyap, MD, University Hospitals Case Medical Center, Cleveland, Ohio 7. E  ndovascular repair of type B aortic dissection long-term  results of the randomized investigation of stent grafts in aortic dissection trial — Circulation 2013;6:407-416 Presentation and discussion led by: Zachary M. Arthurs, MD, Brooke Medical Center, San Antonio, Texas

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

8:48 a.m.

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8. E  ndovascular repair versus open repair of ruptured  8:53 a.m. abdominal aortic aneurysms — Ann Surg 2013;258:248–256 Presentation and discussion led by: Matthew J. Eagleton, MD, The Cleveland Clinic Foundation, Cleveland, Ohio 9. E  ndovascular or open repair strategy for ruptured  8:58 a.m. abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial — BMJ 2014;348:f7661 Presentation and discussion led by: Matthew J. Eagleton, MD, The Cleveland Clinic Foundation, Cleveland, Ohio 10. Oral apixaban for the treatment of acute venous  thromboembolism — New England Journal of Medicine 2013;369:799–808 Presentation and discussion led by: Karen Woo, MD, Keck Medical Center, University of Southern California, Los Angeles, Calif.

9:03 a.m.

DISCUSSION

9:08 a.m.

EXHIBIT HALL OPEN 

9:00 a.m. – 1:00 p.m. uExhibit Halls C & D, Level 2

COFFEE BREAK AND VASCULAR LIVE PRESENTATIONS

9:30 – 10:00 a.m. uExhibit Halls C & D, Level 2

S6: SVS Plenary Session VI 

10:00 – 11:00 a.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: Bruce A. Perler, MD, Johns Hopkins Hospital, Baltimore, Md. Mark H. Meissner, MD, University of Washington, Seattle, Wash.

SS25. Participation in the Vascular Quality Initiative (VQI)  Is Associated with Improved Perioperative Medication Use and Longer Patient Survival

10:00 a.m.

Randall R. DeMartino,1 Jens Eldrup-Jorgensen,2 Andrew W. Hoel,3 Adam W. Beck,4 John W. Hallett,5 Gilbert R. Upchurch Jr.,6 Jack L. Cronenwett,7 Philip P. Goodney.7

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1Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.; 2 Maine Medical Center, Portland, Maine; 3Northwestern University Feinberg


School of Medicine, Chicago, Ill.; 4University of Florida College of Medicine, Gainesville, Fla.; 5Roper St. Francis Heart & Vascular Center, Charleston, S.C.; 6 University of Virginia, Charlottesville, Va.; 7Dartmouth-Hitchcock Medical Center, Lebanon, N.H. OBJECTIVES: Medical management (MM) with antiplatelet and statin therapy is recommended for most patients undergoing vascular surgery. We tested the association of VQI participation and perioperative MM use over time and the effect of optimal MM on patient survival. METHODS: We studied VQI patients treated with MM pre-operatively and at discharge from 2005-2013, including all elective CEA/CAS (n=19,428), supra/infrainguinal bypass (n=8,462), peripheral vascular interventions (n=15,525), and open/endo AAA repairs (n=9,530). We examined trends of MM use over time, as well as the effect of duration of VQI participation on MM use. Multivariable analyses were performed to identify factors associated with MM use and 2-year survival. RESULTS: MM across VQI centers improved from 56% in 2005 to 69% in 2009, and declined when many new centers joined VQI in 2010 (Figure, Panel A). Longer center participation in VQI was associated with improved MM across all procedure types (Panel B). After multivariable adjustment, centers in VQI >2 years were 40% more likely to have patients on MM (OR 1.4, 95% CI 1.4-1.5 p<0.01). Use of MM was associated with improved 2-year survival (92% vs. 86%, HR for death 0.6, 95% CI 0.5-0.7 p<0.01), as was treatment at centers in VQI >2 years (HR 0.86, 95% CI 0.8-0.9 p<0.01). CONCLUSIONS: These data demonstrate that optimal MM is associated with improved survival after a number of vascular procedures. Importantly, VQI participation improves the use of MM, demonstrating that involvement in an organized quality effort can greatly impact patient outcomes. AUTHOR DISCLOSURES: A.W. Beck: Nothing to disclose; J.L. Cronenwett: Nothing to disclose; R.R. DeMartino: Nothing to disclose; J. Eldrup-Jorgensen: Nothing to disclose; P.P. Goodney: Nothing to disclose; J.W. Hallett: Nothing to disclose; A.W. Hoel: Nothing to disclose; G.R. Upchurch Jr.: Nothing to disclose.

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VS6. Transvenous Embolization of High-Flow Arteriovenous 10:14 a.m. Malformations with a Dominant Outflow Vein

Allan M. Conway, Jennifer Drury, Robert Rosen.

Lenox Hill Hospital, New York City, N.Y.

BACKGROUND: To assess outcomes of retrograde embolization of arteriovenous malformations (AVM) with a dominant outflow vein (DOV), we retrospectively reviewed patients with high-flow AVMs who were noted to have a DOV and subsequently underwent transvenous embolization. Three cases have been selected for video demonstration. From Nov. 2010 to Sept. 2013 eleven patients (three or 27%, male) underwent transvenous embolization of high-flow AVMs with a DOV. Mean age was 42.2 years (16.4-65.8). The AVM was located on an extremity in 6 (55%) and in the pelvis in 5 (45%) patients. The indication for the procedure was pain in 10 (91%) and swelling in 2 (18%) patients. Transvenous embolization was performed with coils in 8 (73%), and with both coils and the Amplatzer Vascular Plug (St. Jude Medical, St. Paul, MN) in 3 (27%) patients. Concurrent use of direct stick embolization of the AVM nidus was utilized in 4 (36%), and transcatheter arterial embolization in 7 (63%) patients. Angiographic success was seen in all patients. Five (45%) patients required further procedures for residual symptoms. Conclusion: AVMs with a DOV can be successfully treated by a transvenous approach. The use of direct stick embolization of the nidus and transcatheter arterial embolization may assist in reducing flow. TECHNICAL DESCRIPTION: Case 1: We demonstrate the use of retrograde transvenous embolization of an upper extremity AVM, fed by branches from the proximal ulnar, radial and common interosseous arteries. Coil embolization of the vein was performed, followed by direct stick embolization of the AVM nidus using nBCA adhesive. Case 2: An AVM involving shunting from the profunda artery to a dysplastic draining vein was treated with coil embolization of the vein, and transcatheter embolization of the profunda branches using nBCA adhesive. Case 3: A pelvic AVM was treated using an Amplatzer Vascular Plug, coil embolization of the outflow vein, and transcatheter arterial embolization of the arterial branches. AUTHOR DISCLOSURES: A.M. Conway: Nothing to disclose; J. Drury: Nothing to disclose; R. Rosen: Nothing to disclose. SS26. Civilian/Military Collaboration in the Management  of Military Vascular Trauma: A 10-Year Report of the SVS Volunteer Program

10:24 a.m.

David L. Gillespie,1 Kenneth J. Cherry,2 Thomas Evans,4 Raul Corpus,3 Todd Rasmussen.5

Cardiovascular Care Center, Southcoast Health System, Fall River, Mass.; 2 University of Virginia, Charlottesville, Va.; 3U.S. Army Institute of Surgical Research, San Antonio, Texas; 4Wilford Hall Medical Center, San Antonio, Texas; 5Uniformed Services University, Bethesda, Md. 1

OBJECTIVES: A longstanding spirit of camaraderie has existed between civilian and military surgeons in the U.S. Volunteers from the SVS assisted active duty military surgeons in filling a critical need for vascular surgery support in the evacuation of injured U.S. soldiers. The objective of this study is to provide an assessment of this program including characterization of workload and perspectives of participating surgeons.

240


METHODS: An online survey instrument (SurveyMonkey ®) consisting of 34 questions was developed and administered to participants (2003-2012) in the program. The survey was comprised of multiple choice and open-ended questions. RESULTS: The response rate was 59% (68 of 115) with 84% indicating they had no prior military experience. The majority of respondents (76%) served one tour while 24% served multiple. The majority (65%) indicated satisfaction in their operative workload, performing 2-5 operations per week while 17% performed 6-10. Seventeen participated in clinical research during the rotation; 70% said that research endeavor resulted in scientific presentation and/or publication. Over half participated in drafting new Clinical Practice Guidelines for care of patients with vascular injuries. Of respondents, 90% (n=61) were either satisfied or very satisfied with the experience and indicated interest in continuing a civilian-military collaboration. Most volunteers found great value in participating first hand with cutting-edge telemedicine and integration of combat casualty care over a broad evacuation system involving 3 continents. CONCLUSIONS: Over a 10-year period civilian vascular surgeons have provided critical open and endovascular care to injured U.S. soldiers. SVS volunteers were clinically and academically active and found value in collaborating with their military colleagues to provide an extremely high level of combat casualty care. This unique collaboration carries on historical traditions of our surgical heritage and is an extremely valuable care model for future use. AUTHOR DISCLOSURES: K.J. Cherry: Nothing to disclose; R. Corpus: Nothing to disclose; T. Evans: Nothing to disclose; D.L. Gillespie: Nothing to disclose; T. Rasmussen: Nothing to disclose. SS27. Outcomes of 102 Patients Treated with Segmental  Inferior Vena Cava Resection and Graft Replacement for Malignant Disease

10:38 a.m.

Thomas C. Bower,1 Bernardo C. Mendes,1 Barbara J. Toomey,1 Peter Gloviczki,1 Stephen S. Cha,1 Audra A. Duncan,1 Manju Kalra,1 Gustavo S. Oderich,1 Mark D. Fleming,1 Randall R. De Martino,1 Kenneth J. Cherry,2 David M. Nagorney.3 1  Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.; 2 University of Virginia, Charlottesville, Va.; 3 Division of Subspecialty General Surgery, Mayo Clinic, Rochester, Minn.

OBJECTIVES: To report early and late outcomes of segmental resection and graft replacement of the inferior vena cava (IVC) for malignant disease. METHODS: All patients who had IVC resection with graft reconstruction from 1990-2013 were reviewed. Patients with tangential excision and primary or patch venorrhaphy were excluded. End-points were early (<30 days) mortality, major adverse events (MAE), graftrelated complications, primary patency and recurrence-free and overall survival. RESULTS: One-hundred-two patients (50% male, age 56±15 years) had IVC resection and graft replacement (prosthetic in 100) among 2305 patients treated for retroperitoneal malignancy. Primary leiomyosarcoma occurred in 33 patients (32%) and other malignancies in 69 (68%; P<.0001). Pre-operative performance status (ECOG) was good or excellent in 92 patients (90%). Resection of multiple IVC segments was required in 59 patients (58%), 24 who needed renal vein reconstruction (24%) and two who had hepatic vein reimplantation.

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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One patient died from intraoperative hemorrhage. Four others died within four months; one death was procedure-related, from duodenal leak and multisystem organ failure. Fifteen patients had MAE (15%), two graft-related. Over a mean follow-up of 56 months, seven patients had graft occlusion (6.9%). At 5 years, overall survival was 51% (range 1-214 months), local recurrence-free survival was 66% and disease-free survival was 35%. Four patients underwent graft-related re-interventions (4%). Kaplan-Meier estimates of IVC graft primary patency were 95%, 92% and 92% at 1, 3 and 5 years, respectively. CONCLUSIONS: IVC Resection and graft replacement for malignant disease is safe, durable and provides excellent local control of the tumor in select patients. AUTHOR DISCLOSURES: T.C. Bower: Nothing to disclose; S.S. Cha: Nothing to disclose; K.J. Cherry: Nothing to disclose; R.R. De Martino: Nothing to disclose; A.A. Duncan: Nothing to disclose; M.D. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; M. Kalra: Nothing to disclose; B.C. Mendes: Nothing to disclose; D.M. Nagorney: Nothing to disclose; G.S. Oderich: Nothing to disclose; B.J. Toomey: Nothing to disclose. F4: Poster Runoff: Championship Round 

11:00 a.m. – Noon uBallroom A/B, Level 3

Moderators: Peter F. Lawrence, MD, UCLA Medical Center, Los Angeles, Calif. Melina R. Kibbe, MD, Northwestern University, Chicago, Ill. Discussants: Julie Ann Freischlag, MD, UC Davis School of Medicine, Sacramento, Calif. Bruce A. Perler, MD, Johns Hopkins Hospital, Baltimore, Md.

LUNCH IN EXHIBIT HALL  VASCULAR SURGERY TRAINEE LUNCHEON See Fellow/Resident/Student Programs Tab.

R1: Rapid Paced Paper Session I 

Noon – 1:00 p.m. uExhibit Halls C & D, Level 2 Noon – 1:00 p.m. uRoom 309

1:00 – 2:10 p.m. uBallroom A/B, Level 3

At the end of this session, participants should be able to: 1. Discuss the methodology, results and conclusions of the research presented in vascular health. 2. Identify new technology for diagnosis and treatment of vascular disease. Moderators: Benjamin W. Starnes, MD, University of Washington, Seattle, Wash. Jason T. Lee, MD, Stanford University Medical Center, Stanford, Calif.

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RR1. A Propensity-Adjusted Analysis of Open and  Endovascular Thoracic Aortic Repair for Chronic Type B Dissection: A 20-Year Evaluation

1:00 p.m.

Guido H. van Bogerijen, Himanshu J. Patel, David M. Williams, Bo Yang, Narasimham L. Dasika, Jonathan L. Eliason, G.M. Deeb.  University of Michigan Samuel and Jean Frankel Cardiovascular Center, Ann Arbor, Mich. OBJECTIVES: Optimal treatment of chronic type B aortic dissection (CBAD), whether open (DTAR) or endovascular (TEVAR), is controversial, suggesting a comparative analysis is warranted. METHODS: 122 of 1049 patients (1993-2013) undergoing descending aortic repair required intervention for CBAD 29.2±34.9 months after the initial acute event and formed the study cohort (mean age 59.7y). Those with a degenerated residual type A dissection were excluded. 88 had extent IIIB CBAD; 11 had intramural hematoma. Indication for surgery included aneurysmal degeneration (105), rupture (8), acute on chronic dissection (8) and extension (1). Open strategy included descending (71) and thoracoabdominal repair (19), with hypothermic arrest used in 66. TEVAR was performed with (2) or without (30) visceral debranching. A treatment strategy propensity score incorporating time since initial acute event, CBAD extent, year of intervention, age, and selected comorbidities was constructed for multivariable analysis. RESULTS: Early outcome included: 30d mortality 4% (n=5), permanent paraplegia 3% (n=4), stroke 2% (n=2), dialysis 7% (n=8) and tracheostomy 3% (n=4). Visceral aorta intervention (OR 3.5, p=0.03) and mean aortic diameter (OR 1.1, p=0.001), but not treatment type (p=0.6) independently predicted an early composite outcome comprised of these variables. 10y survival was 56.2%. Baseline creatinine (HR 1.7, p<0.001) and peripheral vascular disease (HR 2.4, p=0.03), but not treatment type (p=0.2) predicted late mortality. 10y freedom from aortic rupture/need for reintervention was 76.7%. Treatment efficacy was improved after DTAR (3y freedom 96.2% vs. TEVAR 71.8%, p=0.004), and this was confirmed after Cox regression (TEVAR HR 3.2, p=0.04). CONCLUSIONS: Intervention for chronic type B aortic dissection can be performed with excellent results, either by an open or endovascular approach. The higher rate of treatment failure after TEVAR warrants modification of the current device design or endovascular approach before broad application of this treatment strategy. AUTHOR DISCLOSURES: N.L. Dasika: Nothing to disclose; G.M. Deeb: Nothing to disclose; J.L. Eliason: Nothing to disclose; H.J. Patel: WL Gore, consulting fees or other remuneration (payment); G.H. van Bogerijen: Nothing to disclose; D.M. Williams: WL Gore, consulting fees or other remuneration (payment); B. Yang: Nothing to disclose. RR2. Benefit of EndoAnchors in Endovascular Aneurysm  Repair: Analysis by Indication for Use

1:05 p.m.

Jean-Paul de Vries,1 Manish Mehta,2 Kenneth Ouriel,3 William Jordan.4 1  St Antonius Hospital, Nieuwegein, Netherlands; 2Institute for Vascular Health and Disease, Albany, N.Y.; 3Syntactx, New York City, N.Y.; 4University of Alabama-Birmingham, Birmingham, Ala.

OBJECTIVES: EndoAnchors (EA) have been used as an adjunct to EVAR in patients with challenging aortic neck anatomy. The aim of this study was to assess outcome by indication for EA use. Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

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METHODS: 319 patients were enrolled at 43 sites in ANCHOR, a prospective, multinational, real-world study of EA implantation for first-time EVAR (Primary Arm, n=242) or for endoleak/migration developing remote from an initial endovascular repair (Revision Arm, n=77). The Primary Arm was subdivided into a) prophylactic EA use for hostile neck anatomy, b) use for acute type Ia endoleak after endograft deployment, and c) use after unsatisfactory distal endograft deployment. The Revision Arm was subdivided into those undergoing treatment for a) type Ia endoleak alone, b) migration alone, and c) migration with endoleak. Procedural Success was defined as successful EA implantation without type Ia endoleak on completion angiography and Clinical Success was defined as Procedural Success without type Ia endoleak, migration, >5 mm sac enlargement, or secondary procedures over follow-up. RESULTS: Outcome after EA use was satisfactory over early follow-up averaging 9Âą3 months with absence of type Ia endoleaks in 290 patients (90.9%), Procedural success in 279 patients (87.5%), and clinical success in 265 patients (83.1%). CONCLUSIONS: EA appear to offer a useful adjunct to EVAR for prophylaxis against aortic neck complications when hostile anatomy is encountered, and therapeutically when aortic neck complications develop. Definitive conclusions await the availability of longer-term follow-up data. AUTHOR DISCLOSURES: J. de Vries: Aptus Endosystems, research grants, honorarium; W. Jordan: Aptus Endosystems, research grants and consulting fees or other remuneration (payment); M. Mehta: Aptus Endosystems, research grants; K. Ouriel: Syntactx, employment (full or part-time) and ownership or partnership; Aptus Endosystems, consulting fees or other remuneration (payment). Indications for EndoAnchor Use

N

Type Ia Endoleak at Completion

Primary Arm

242

19 (7.9%)

Procedural Success Clinical Success 217 (89.7%)

208 (86.0%)

Prophylactic

186

9 (4.8%)

172 (92.5%)

165 (88.7%)

Acute Endoleak

52

9 (17.3%)

43 (82.7%)

41 (78.8%)

Distal Deployment

4

1 (25.0%)

2 (50.0%)

2 (50.0%)

77

10 (13.0%)

62 (87.5%)

57 (74.0%)

Existing Endoleak

Revision Arm

45

9 (20.0%)

35 (77.8%)

32 (71.1%)

Existing Migration

11

0

8 (72.2%)

8 (72.7%)

Endoleak and Migration

21

1 (4.8%)

19 (90.5%)

17 (81.0%)

RR3. Disease Progression in Patients with Moderate  Asymptomatic Carotid Artery Stenosis: Development of a Risk Prediction Model

1:10 p.m.

Caitlin W. Hicks,1 Joseph K. Canner,1 Isibor Arhuidese,2 Eric Schneider,1 Umair Qazi,2 Katherine Talbott,2 Christopher J. Abularrage,1 Julie Ann Freischlag,1 Bruce A. Perler,1 Mahmoud B. Malas.1 1  Johns Hopkins Hospital, Baltimore, Md.; 2 Johns Hopkins Bayview Medical Center, Baltimore, Md.

OBJECTIVES: Previously, we described risk factors for disease progression in moderate asymptomatic carotid artery stenosis (ASCS). The aim of the current study was to develop a risk prediction model for disease progression in this group. 244


METHODS: All patients presenting with moderate (50-69%) ASCS as determined by carotid artery duplex (01/2005-05/2012) were included. Cox proportional hazard regression models accounting for measured duplex velocities (peak systolic velocity, PSV; end diastolic velocity, EDV; ICA/CCA ratio) and previously identified risk factors for progression (age, smoking, dual antiplatelet therapy) were used to develop receiver operating characteristic (ROC) curves for predicting disease progression. RESULTS: 268 patients were analyzed (71±9 yrs, 52% male, 2.6±1.7 yrs follow-up, 25% disease progression). Initial PSV, EDV, and ICA/CCA ratio were all significant predictors of progression (Table). ROC curve analyses suggested that a prediction model including PSV, ICA/CCA ratio, age, smoking, and dual antiplatelet therapy had optimal prediction efficacy (C-statistic 0.76; Table). CONCLUSIONS: We propose a 5-variable risk prediction model that can be used to predict disease progression in patients with moderate ASCS with good sensitivity and specificity that may be useful for identifying high-risk patients requiring closer follow-up. AUTHOR DISCLOSURES: C.J. Abularrage: Nothing to disclose; I. Arhuidese: Nothing to disclose; J.K. Canner: Nothing to disclose; J.A. Freischlag: Nothing to disclose; C.W. Hicks: Nothing to disclose; M.B. Malas: Nothing to disclose; B.A. Perler: Nothing to disclose; U. Qazi: Nothing to disclose; E. Schneider: Nothing to disclose; K. Talbott: Nothing to disclose. Table: ROC Analyses of Risk Prediction Models for Disease Progression in Moderate Table: ROC Analyses of Risk Prediction Models for Disease Progression in Moderate Asymptomatic Asymptomatic Carotid Artery Stenosis Carotid Artery Stenosis

Risk of Disease Progression

C-Statistic

Unadjusted HR (95% CI)

Adjusted HR* (95% CI)

Unadjusted AUC (95% CI)

Adjusted AUC* (95% CI)

PSV

1.01 (1.01, 1.02)

1.01 (1.01, 1.02)

0.68 (0.61, 0.76)

0.71 (0.63, 0.79)

EDV

1.02 (1.01, 1.03)

1.03 (1.01, 1.04)

0.64 (0.56, 0.72)

0.68 (0.60, 0.76)

ICA/CCA Ratio

3.90 (2.19, 5.25)

3.42 (2.16, 5.41)

0.74 (0.68, 0.81)

0.75 (0.68, 0.76)

PSV + ICA/CCA

2.60 (1.59, 4.25)

2.63 (1.54, 4.47)

0.75 (0.68, 0.82)

0.76 (0.69, 0.83)

HR: hazard ratio. AUC: area under the curve. *Adjusted for age, smoking, and dual antiplatelet therapy **Model equation: Y= exp(-4.84 + 0.005PSV - 0.97ratio - 0.007Age + 0.56Smoking + 0.40Antiplatelet). RR4. Five-Year Survival Among Medicare Beneficiaries  over Age 80 Undergoing Asymptomatic Carotid Endarterectomy

1:15 p.m.

Marcus E. Semel,1 Thomas T. Tsai,1 Edward A. McGillicuddy,1 C. Keith Ozaki,1 Ashish K. Jha,2 Michael Belkin.1 1  Brigham and Women’s Hospital, Boston, Mass.; 2 Harvard School of Public Health, Boston, Mass.

OBJECTIVES: Benefit from asymptomatic carotid endarterectomy (AsCEA) depends on long-term survival. We undertook this study to examine 5-year survival (5-ys) in octogenarians after AsCEA.

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METHODS: National Medicare data from 2006-2011 was used to examine 5-ys in patients 80 who underwent elective AsCEA in 2006 without evidence of TIA or stroke 180 days prior to surgery. We calculated overall mortality and used Kaplan-Meier curves to examine 5-ys. We built Cox proportional hazards (CPH) models to examine the independent predictors of survival after AsCEA. RESULTS: In 2006 16,616 patients 80 underwent AsCEA; 1.3% died within 30 days of surgery. Overall, the probability of 5-ys was 0.56 (95%CI: 0.55-0.57). A multivariate CPH model identified the following comorbidities (COM) as having a significant effect on 5-ys (Hazard Ratio, 95%CI): COPD (1.45, 1.37-1.53), CHF (1.90, 1.78-2.03), diabetes (1.10, 1.04-1.16), renal failure (1.74, 1.62-1.86), and valve disease (1.23, 1.15-1.32). Both age and COM affected 5-ys with the probability of survival ranging from 0.71 (95%CI: 0.690.74) for an 80-year-old (yo) with 0 COM to 0.18 (95%CI: 0.04-0.38) for a 85-yo with 3 COM, p<0.01. Conversely, a 85-yo with 0 COM had survival superior to an 80-yo with 3 COM (0.53, 95%CI: 0.51-0.55 vs. 0.34, 95%CI: 0.23-0.45; p<0.01). CONCLUSIONS: While AsCEA may be appropriate for some older Americans, this study demonstrates that many octogenarians do not live long enough to derive benefit. Careful selection is essential. AUTHOR DISCLOSURES: M. Belkin: Nothing to disclose; A.K. Jha: Nothing to disclose; E.A. McGillicuddy: Nothing to disclose; C.K. Ozaki: Nothing to disclose; M.E. Semel: Nothing to disclose; T.T. Tsai: Nothing to disclose. Probability of 5-ys After AsCEA by Age and # of Comorbidities # of Comorbidities Age

0

1

2

3

Overall

0.64

0.53

0.40

0.29

80

0.71

0.63

0.47

0.34

81

0.71

0.59

0.49

0.42

82

0.69

0.53

0.40

0.31

83

0.67

0.54

0.39

0.33

84

0.65

0.52

0.45

0.25

≥85

0.63

0.43

0.32

0.18

All SEs <0.07.

RR5. Thirty-Day Neurologic Improvement Is Associated  with Early vs. Delayed Carotid Endarterectomy in Symptomatic Patients

1:20 p.m.

Emiliano Chisci,1 Clara Pigozzi,1 Nicola Troisi,1 Leonardo Ercolini,1 Enrico Barbanti,1 Franco Passuello,1 Pierfrancesco Frosini,1 Eugenio Romano,1 Abele Lenzi,1 Molisso Antonio,1 Luciana Tramacere,2 Massimo Cincotta,2 Alessandra Borgheresi,2 Gaetano Zaccara,2 Mario Cecchi,1 Stefano Michelagnoli.1

1 Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, ASF 10., Florence, Italy; 2Neurology Unit, San Giovanni di Dio Hospital, ASF 10., Florence, Italy.

OBJECTIVES: To determine 30-day neurologic improvement (NI) with respect to the timing of carotid endarterectomy (CEA) in symptomatic stable patients. METHODS: Patients included underwent consecutive CEAs (2009-2013) for symptomatic carotid stenosis 60%. They had a National Institutes of Health Stroke Scale (NIHSS) score 246


<5 on presentation. Patients were divided according to time between the qualifying event and surgery (0-14 days, n=100: early CEA;15-30 days, n=222: delayed CEA). Outcomes were death, stroke, myocardial infarct (MI), 30-day major adverse event rate (composite of stroke, death, and MI; MAE), and NI defined as a NIHSS score decrease (1) rate at 30 days. Independent neurologic assessment was performed. RESULTS: Type of qualifying symptoms (stroke vs. TIA) was similar. Early CEA patients had a higher American Society of Anesthesiologists physical status risk (p=.0001) and were more likely under dual antiplatelet therapy (p=.02). Outcomes are summarized in Table. Thirty-day NI was associated with early CEA (OR=1.9, 95% CI=1-3.7. p=.03). CONCLUSIONS: Our results suggest that reducing the time for intervention in selected (NIHSS<5) and stable symptomatic patients is safe and associated with neurologic status improvement at 30 days. AUTHOR DISCLOSURES: M. Antonio: Nothing to disclose; E. Barbanti: Nothing to disclose; A. Borgheresi: Nothing to disclose; M. Cecchi: Nothing to disclose; E. Chisci: Nothing to disclose; M. Cincotta: Nothing to disclose; L. Ercolini: Nothing to disclose; P. Frosini: Nothing to disclose; A. Lenzi: Nothing to disclose; S. Michelagnoli: Nothing to disclose; F. Passuello: Nothing to disclose; C. Pigozzi: Nothing to disclose; E. Romano: Nothing to disclose; L. Tramacere: Nothing to disclose; N. Troisi: Nothing to disclose; G. Zaccara: Nothing to disclose. 30-Day Results: Early vs. Delayed CEA 30-Day Results

Overall (322) n (%) Early CEA (100) n (%) Delayed CEA (222) n (%) p value

Death

0

0

0

-

MAE

8 (2.5)

3 (3)

5 (2.2)

0.7

Any Stroke

4 (1.2)

3 (3)

1(0.4)

0.1

Minor Stroke

2 (0.6)

2 (2)

0

0.1

Major Stroke

2 (0.6)

1 (1) (Hemorrhagic)

1(0.4) (Ischemic)

0.5

Disabling Stroke

2 (0.6)

1 (1)

1 (0.4)

0.5

MI

4 (1.2)

0

4 (1.8)

0.3

30-Day Neurological Status Improved (Decrease NHISS ≥1)

43 (13.3)

19 (19)

24 (10.8)

0.03

Unchanged

275 (85.4)

78 (78)

197 (88.7)

0.01

Impaired

4 (1.2)

3 (3)

1 (0.4)

0.1

MAE: Major Adverse Event (composite of stroke, death, and myocardial infarct); MI: Myocardial Infarct; NHISS: National Institutes of Health Stroke Scale.

RR6. High-Risk Carotid Endarterectomy (CEA) Beyond the  1:25 p.m. SAPPHIRE Trial and Development of a Risk Index to Define Patients at Risk for Adverse Outcomes After CEA, from the Vascular Study Group of New England (VSGNE) Lindsay Gates,1 Robert Botta,2 Felix Schlosser,1 Brian W. Nolan,3 Philip P. Goodney,3 Margriet Fokkema,4 Marc L. Schermerhorn,4 Jeffrey E. Indes.1

Vascular Surgery, Yale New Haven Hospital, East Haven, Conn.; 2 University of Connecticut School of Medicine, Farmington, Conn.; 3 Dartmouth-Hitchcock Medical Center, Lebanon, N.H.; 4 Beth Israel Deaconess Medical Center, Boston, Mass. 1

Vascular Annual Meeting 2014 • June 5 – 7, 2014 • Boston, Massachusetts

247


OBJECTIVES: Recently we defined several independent high-risk criteria that were inclusive and exclusive of the SAPPHIRE trial. The objective of this study was to create a risk index that may predict patients at high risk for CEA. METHODS: Data on 3,098 CEAs between 2003-2011 at 20 VSGNE centers were used for this study. SAPPHIRE general inclusion criteria and primary outcomes of death, stroke, or MI were used, as were other previously reported high-risk criteria. Factors that were associated with the primary outcome by ANOVA (P<0.10) and not linearly dependent, as determined by a Pearsonâ&#x20AC;&#x2122;s correlation analysis, were further assessed for an independent association by multivariate logistic regression. A risk index model was developed for these significant predictors using an integer score as a reliable formula. RESULTS: Multivariate analysis (P<0.05) found the following independently significant risk factors (95% CI; P value): age in years (1.0-1.1; <0.001), pre-admission nursing home (1.2-6.6; 0.020), CHF (1.4-2.8; <0.001), diabetes (1.1-1.3; <0.001), COPD (1.2-1.5; <0.001), any previous cerebrovascular disease (1.1-1.9; 0.003), and contralateral ICA stenosis (1.0-1.2; 0.001). The predictors are age in years (40-49: 0 points; 50-59: 2 points; 60-69: 4 points; 70-79: 6 points; 80-89: 8 points), living in a nursing home (4 points), any CVD (2 points), CHF (5 points), COPD (3 points), diabetes (2 points), degree of contralateral stenosis (<