Prevalence of chronic opioid use in patients with peripheral arterial disease undergoing revascularization.

OBJECTIVE: Opiate use, dependence, and the associated morbidity and mortality are major current public health problems in the United States. Little is known about patterns of opioid use in patients with peripheral arterial disease (PAD). The purpose of this study was to identify the prevalence of chronic preoperative and postoperative prescription opioid use in patients with PAD. A secondary aim was to determine the demographic, comorbid conditions, and operative characteristics associated with chronic opioid use. METHODS: Using a single-institution database of patients with PAD undergoing open or endovascular lower extremity intervention from 2013 to 2014, data regarding opiate use and associated conditions were abstracted for analysis. Patients were excluded if they did not live in North Carolina or surgery was not for PAD. Preoperative (PreCOU) and postoperative chronic opioid use (PostCOU) were defined as consistent opioid prescription filling in the 3 months before and after the index procedure, respectively. Opioid prescription filling was assessed using the North Carolina Controlled Substance Reporting System. Demographics, comorbid conditions, other adjunct pain medication data, and operative characteristics were abstracted from our institutional electronic medical record. Associations with PreCOU were evaluated using the t test, Wilcoxon test, or two-sample median test (continuous), or the χ2 or Fisher exact tests (categorical). RESULTS: A total of 202 patients undergoing open (108; 53.5%) or endovascular (94; 46.5%) revascularization for claudication or critical limb ischemia were identified for analysis. The mean age was 64.6 years, and 36% were female. Claudication was the indication for revascularization in 26.7% of patients, and critical limb ischemia was the indication in 73.3% of patients. The median preoperative ankle-brachial index (ABI) was 0.50. Sixty-eight patients (34%) met the definition for PreCOU. PreCOU was associated with female gender, history of chronic musculoskeletal pain, benzodiazepine use, and self-reported illicit drug use. Less than 50% of patients reported use of non-opiate adjunct pain medications. No association was observed between PreCOU and pre- or postoperative ABI, or number of prior lower extremity interventions. Following revascularization, the median ABI was 0.88. PreCOU was not associated with significant differences in postoperative complications, length of stay, or mortality. Overall, 71 patients (35%) met the definition for PostCOU, 14 of whom had no history of preoperative chronic opiate use. Ten patients with PreCOU did not demonstrate PostCOU. CONCLUSIONS: Chronic opiate use was common in patients with PAD with a prevalence of approximately 35%, both prior to and following revascularization. Revascularization was associated with a termination of chronic opiate use in less than 15% of patients with PreCOU. Additionally, 10% of patients who did not use opiates chronically before their revascularization did so afterwards. Patients with PAD requiring intervention represent a high-risk group with regards to chronic opiate use. Increased diligence in identifying opioid use among patients with PAD and optimizing the use of non-narcotic adjunct pain medications may result in a lower prevalence of chronic opiate use and its attendant adverse effects.

Extrathoracic subclavian artery aneurysm in a patient with suspected genetic arteriopathy.

This is a case of a 4-cm left extrathoracic subclavian artery aneurysm (SCAA) in a 58-year-old man with an aortic root and abdominal aortic aneurysm. The patient had features suggestive of genetic arteriopathy, including vertebral artery tortuosity, pectus excavatum, tall stature, and scoliosis. The SCAA was successfully repaired with an inline prosthetic graft and anastomotic pledgets via a supraclavicular approach. Genetic testing revealed an FBN1 pathogenic variant consistent with Marfan syndrome. Repair is satisfactory 2 years later. Patients with SCAA should include consideration of genetic arteriopathy. Open repair of the extrathoracic SCAA in Marfan syndrome is recommended.

Evaluation of the Performance of ACS NSQIP Surgical Risk Calculator in Emergency General Surgery Patients.

The ACS NSQIP Surgical Risk Calculator is designed to estimate the chance of an unfavorable outcome after surgery. Our goal was to evaluate the accuracy of the calculator in our emergency general surgery population. Surgical outcomes were compared to predicted risk. The risk was calculated with surgeon adjustment scores (SASs) of 1 (no adjustment), 2 (risk somewhat higher), and 3 (risk significantly higher than estimate). Two hundred and twenty-seven patients met the inclusion criteria. An SAS of 1 or 2 accurately predicted risk of mortality (5.7% and 8.5% predicted versus 7.9% actual), whereas a risk adjustment of 3 indicated significant overestimation of mortality rate (14.8% predicted). There was good overall prediction performance for most variables with no clear preference for SAS 1, 2, or 3. Poor correlation was seen with SSI, urinary tract infection, and length of stay variables. The ACS NSQIP Surgical Risk Calculator yields valid predictions in the emergency general surgery population, and the data support its use to inform conversations about outcome expectations.

Grip strength measurement for frailty assessment in patients with vascular disease and associations with comorbidity, cardiac risk, and sarcopenia.

OBJECTIVE: Frailty is associated with adverse events, length of stay, and nonhome discharge after vascular surgery. Frailty measures based on walking-based tests may be impractical or invalid for patients with walking impairment from symptoms or sequelae of vascular disease. We hypothesized that grip strength is associated with frailty, comorbidity, and cardiac risk among patients with vascular disease. METHODS: Dominant hand grip strength was measured during ambulatory clinic visits among patients with vascular disease (abdominal aortic aneurysm [AAA], carotid stenosis, and peripheral artery disease [PAD]). Frailty prevalence was defined on the basis of the 20th percentile of community-dwelling population estimates adjusted for age, gender, and body mass index. Associations between grip strength, Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI), and sarcopenia (based on total psoas area for patients with cross-sectional abdominal imaging) were evaluated using linear and logistic regression. RESULTS: Grip strength was measured in 311 participants; all had sufficient data for CCI calculation, 217 (69.8%) had sufficient data for RCRI, and 88 (28.3%) had cross-sectional imaging permitting psoas measurement. Eighty-six participants (27.7%) were categorized as frail on the basis of grip strength. Frailty was associated with CCI (odds ratio, 1.86; 95% confidence interval, 1.34-2.57; P = .0002) in the multivariable model. Frail participants also had a higher average number of RCRI components vs nonfrail patients (mean ± standard deviation, 1.8 ± 0.8 for frail vs 1.5 ± 0.7 for nonfrail; P = .018); frailty was also associated with RCRI in the adjusted multivariable model (odds ratio, 1.75; 95% confidence interval, 1.16-2.64; P = .008). Total psoas area was lower among patients categorized as frail vs nonfrail on the basis of grip strength (21.0 ± 6.6 vs 25.4 ± 7.4; P = .010). Each 10 cm2 increase in psoas area was associated with a 5.7 kg increase in grip strength in a multivariable model adjusting for age and gender (P < .0001). Adjusted least squares mean psoas diameter estimates were 25.5 ± 1.1 cm2 for participants with AAA, 26.7 ± 2.0 cm2 for participants with carotid stenosis, and 22.7 ± 0.8 cm2 for participants with PAD (P = .053 for PAD vs AAA; P = .057 for PAD vs carotid stenosis; and P = .564 for AAA vs carotid stenosis). CONCLUSIONS: Grip strength is useful for identifying frailty among patients with vascular disease. Frail status based on grip strength is associated with comorbidity, cardiac risk, and sarcopenia in this population. These findings suggest that grip strength may have utility as a simple and inexpensive risk screening tool that is easily implemented in ambulatory clinics, avoids the need for imaging, and overcomes possible limitations of walking-based measures. Lower mean psoas diameters among patients with PAD vs other diagnoses may warrant consideration of specific approaches to morphomic analysis.

Development of a Burn Escharotomy Assessment Tool: A Pilot Study.

Severe burn injuries can require escharotomies which are urgent, infrequent, and relatively high-risk procedures necessary to preserve limb perfusion and sometimes ventilation. The American Burn Association Advanced Burn Life Support© course educates surgeons and emergency providers about escharotomy incisions but lacks a biomimetic trainer to demonstrate, practice, or provide assessment. The goal was to build an affordable biomimetic trainer with discrete points of failure and pilot a validation study. Fellowship-trained burn and plastic surgeons worked with special effect artists and anatomists to develop a biomimetic trainer with three discrete points of failure: median or ulnar nerve injury, fasciotomy, and failure to check distal pulse. Participants were divided between experienced and inexperienced, survey pre- and post-procedure on a biomimetic model while being timed. The trainer total cost per participant was less than $35. Eighteen participants were involved in the study. The inexperienced (0-1 prior escharotomies performed) had significantly more violations at the discrete points of failure relative to more experienced participants (P = .036). Face validity was assessed with 100% of participants agreement that the model appeared similar to real life and was valuable in their training. Given the advancements in biomimetic models and the need to train surgeons in how to perform infrequent, emergent surgical procedures, an escharotomy trainer is needed today. The authors developed an affordable model with a successful pilot study demonstrating discrimination between experienced and inexperienced surgeons. Additional research is needed to increase the reliability and assessment metrics.