Left Subclavian Artery Coverage is Not Associated with Neurological Deficits in Trauma Patients Undergoing Thoracic Endovascular Repair.

BACKGROUND: Endovascular repair of the thoracic aorta (TEVAR) outcomes have been studied with an interest in complications related to left subclavian artery (LSA) coverage in patients with atherosclerotic pathologies; however, specific data on the management of the LSA in a trauma population are lacking. The objective of this study is to evaluate outcomes following TEVAR for traumatic aortic injury based on LSA coverage. METHODS: The Vascular Quality Initiative thoracic endovascular aortic repair module (2010-2017) was analyzed. Patients were included if they had a traumatic aortic injury requiring TEVAR. Patients were placed in 2 groups based on coverage of the LSA. Patients were propensity score matched and the primary outcomes were cerebrovascular symptoms and spinal cord ischemia. Additional clinical and resource utilization outcomes were analyzed. RESULTS: Four hundred and fifty one patients were included in the analysis. There were 268 patients in the LSA not-covered group and 183 patients in the LSA covered group. The mean aortic injury grade was 2.88 ± 0.056 vs. 2.88 ± 0.049 in the covered versus not-covered group (P = 0.957). Glasgow coma scale and injury severity score were not different between the groups. There was no difference between groups for cerebrovascular symptoms or spinal cord ischemia, 1.4% vs. 2.8%, P = 0.684 and 0% vs. 2.1%, P = 0.247, after propensity score matching. Significant differences in access site complications and resource utilization were identified between groups. CONCLUSIONS: This is the largest series to evaluate complications based on LSA coverage following TEVAR in trauma patients. Our data demonstrate that coverage of the LSA during TEVAR following blunt trauma is associated with no difference in central nervous system outcomes. As such, LSA revascularization strategies, while possible, are not directly supported by these data and should be individualized based on each patient's specific clinical scenario.

Complete sternal-sparing left ventricular assist device implantation is associated with improved postoperative mobility.

Left ventricular assist device (LVAD) implantation via a complete sternal-sparing (CSS) technique is gaining interest due to several potential benefits. We hypothesized that the CSS approach for HeartMate 3 (HM3) LVAD implantation improves postoperative mobility and physical independence compared to full sternotomy (FS). We retrospectively reviewed patients who were implanted with a commercial HM3 at our institution from September 2017 to August 2018. The Activity Measure for Post-Acute Care short forms and Functional Independence Measure scores were used to assess the patient's physical limitations postoperatively. A total of 43 patients were included in the study: 27 (63%) CSS patients and 16 (37%) FS patients. At postoperative day 3, the CSS cohort demonstrated improved mobility based on Activity Measure for Post-Acute Care scores compared to the FS group; 40% of the CSS cohort versus 67% of the FS cohort remained 100% impaired. The CSS cohort also demonstrated greater postoperative independence in the Functional Independence Measure sit-to-stand metric with 78% of the CSS cohort achieving modified or complete independence by postoperative day 15 compared to only 21% of the FS patients. These early data suggest that the CSS approach for HM3 LVAD implantation improves postoperative mobility and functional independence compared to FS.

Evaluation of Opioid Prescription and Consumption Habits Following Endovascular Aortic Aneurysm Repair.

BACKGROUND: There has been a dramatic rise in opioid-related deaths over the past decade. Most of the reduction strategies have focused on outpatient use; however, recent studies have demonstrated an association between inpatient opioid use and consumption following discharge across a variety of surgical procedures. The objective of this study is to evaluate the association of inpatient use of opioids as well as the consumption of opioids after discharge following endovascular aortic aneurysm repair (EVAR). METHODS: A prospectively maintained database was reviewed for cases between 2015 and 2018. Patients were included in the study if they underwent an elective EVAR, had an intensive care unit stay less than 1 day and total length of stay less than 3 days. Patients were contacted to participate in a survey of opioid use if they received a prescription at discharge. The primary outcome was percent of prescribed opioids consumed following discharge. Multivariate analyses were performed to determine predictors of receiving an opioid prescription. RESULTS: One hundred seventy-one patients were included in the analysis; 95% patients were white and 85% male. 59% of patients responded to the survey. Seventy-one (42%) received an opioid prescription at discharge. Patients that received a discharge prescription tended to be younger (71 vs. 75 years, P = 0.005) and more likely to have received opioids while in the hospital (79% vs. 45%, P < 0.001). Additionally, patients who received opioids at discharge received a significantly greater amount of milligram oral morphine equivalents (OME) while in the hospital (27.76 ± 38.91 vs. 10.05 ±29.43, P < 0.001). Multivariate analysis demonstrated age, estimated blood loss (EBL), and OME per day to be significant inpatient predictors of requiring an outpatient opioid prescription. Open femoral access (27%) was not a predictor of opioid prescription at discharge. A total of 1185 pills were prescribed (29.6 ± 2.06 per patient), but only 208 pills consumed (5.2 ± 1.27 per patient). Around 82% of total pills prescribed were not consumed. CONCLUSIONS: This study evaluates inpatient opioid use and postdischarge consumption following EVAR. These data identify key factors associated with receiving an opioid prescription at discharge and demonstrate that patients consume far fewer opioids than prescribed. These findings provide insight as to which patients may not require an outpatient prescription following EVAR, leading to potential practice-changing opioid reduction strategies.

Regional Variation in Usage of Ultrasound-Guided Femoral Access in the Vascular Quality Initiative.

BACKGROUND: Access site complications are among the most common complications following peripheral vascular interventions. Previous studies have demonstrated a reduced rate of complications with ultrasound-guided vascular access (UGVA). The objective of this study is to evaluate the regional use of UGVA within the Vascular Quality Initiative (VQI). METHODS: The VQI peripheral intervention module between 2010 and 2018 was evaluated. Regional ID was used to compare distribution of ultrasound usage. Regions were grouped into terciles based on the rate of ultrasound use. Patients were categorized based on type of access. Primary outcome was use of ultrasound across regions. Secondary outcomes were access site complications. RESULTS: Over 43,000 cases across the 18 VQI regions were evaluated. The average rate of ultrasound usage was 71% across the regions with a wide variation (range 38-97%). There is a significant difference in utilization among the top third (87%), middle third (79%), and bottom third (58%) (P < 0.001). Average sheath size was similar across all 3 groups. A higher use of ultrasound-guided access was associated with significantly fewer access site complications (top third 1.96% vs. bottom third 3.04%, P < 0.001), the most significant of which was a decreased rate of access site hematoma (top third 1.37% vs. bottom third 2.35%, P < 0.001). CONCLUSIONS: This is the first study to evaluate ultrasound-guided access across VQI regions. Our results demonstrate that despite strong evidence supporting the utilization of UGVA, there remains a wide variation in ultrasound usage across VQI regions. This is also the first study to show that the prevalence of ultrasound use in peripheral vascular interventions (PVI) is inversely related to access site complications. Given all of the data supporting the usage of UGVA across numerous specialties, our findings encourage the consideration of an ultrasound-first approach for vascular access in PVI and the implementation of targeted strategies and evidence-based guidelines to enhance UGVA utilization in PVI.

Association Between the Atherosclerotic Disease Risk Score and Carotid Artery Stenosis.

BACKGROUND: Carotid artery stenosis (CAS) is the most frequently detected treatable cause of ischemic stroke. However, there are no recommendations to screen asymptomatic patients. The atherosclerotic cardiovascular disease (ASCVD) risk score estimates individuals' 10-year risk for developing cardiovascular disease. The objective of this study is to identify a relationship between the ASCVD risk score and moderate/severe CAS based on ultrasound findings. MATERIALS AND METHODS: We performed a single-institution retrospective review of patients who underwent a surveillance ultrasound for CAS between 2015 and 2018. We used Strandness velocity criteria to separate patients into two cohorts: none to mild CAS (<50%) and moderate/severe CAS (≥50%). We performed Student's t-test, multivariate analysis, and receiver operator characteristic (ROC) curve analysis to determine a relationship between the ASCVD risk score and degree of CAS. We evaluated a new risk score model based on stepwise logistic regression of significant variables on univariate analysis. RESULTS: Two thousand eight hundred and fifty-six patients with carotid ultrasounds (1623 with none to mild, 1161 with moderate, and 72 with severe disease) were included in the study. The ASCVD risk score significantly predicted moderate/severe CAS in an adjusted multivariate analysis. Each 10% increase in the ASCVD risk score corresponded to an additional 11% likelihood of moderate/severe stenosis (OR: 1.11 [1.04-1.20], P = 0.004). The ROC area under the curve for predicting moderate/severe CAS based on the ASCVD risk score was 0.59 (Youden index (J) = 0.14); the optimized ASCVD cutoff point was 28.4%. Our new atherosclerotic disease model demonstrated increased odds of moderate/severe CAS with scores greater than zero (ROC area under the curve = 0.57). CONCLUSIONS: This is the first study to demonstrate an association between atherosclerotic disease risk factors as measured by the ASCVD risk score and moderate/severe CAS. However, this tool is not sensitive or specific for using the ASCVD risk score as a screening mechanism for moderate/severe CAS.

Postdischarge Opioid Use after Lower Extremity Bypass Surgery.

BACKGROUND: Opioid overprescription for acute postoperative pain is an inadvertent contributor to the opioid epidemic via pill diversion and misuse. In response, the surgical community advocates for evidence-based postoperative opioid prescribing guidelines. The objective of this study is to evaluate patient-reported opioid consumption after lower extremity bypass surgery. METHODS: We conducted a retrospective review of a prospectively maintained database of infrainguinal bypass operations from 2016 to 2019. For patients receiving an opioid prescription at discharge, a telephone survey was administered questioning the percentage of pills used. Exclusion criteria included chronic opioid use and reoperations or amputations within 30 days. The primary outcome was the difference in opioids prescribed versus opioids consumed. RESULTS: Forty-nine patients met inclusion criteria. Forty-one (84%) were prescribed opioids at discharge, and 27 (65.9%) completed the survey. The average age was 65.8 ± 7.7 years; 29.6% were women. Oxycodone immediate-release was most commonly prescribed (78%). On average, patients received 318 ± 156 morphine milligram equivalent. A total of 940 opioid pills were prescribed (36.0 ± 11.3 per patient), but only 37% were consumed. This difference resulted in 568 unused pills. CONCLUSIONS: This is the first study to specifically evaluate opioid use in a strictly lower extremity bypass population. Over 60% of pills were unused, which poses significant societal risk for misuse. Our findings contribute to knowledge of operation-specific opioid use, which may shape practice recommendations and reduce opioid overprescription after vascular surgery.

Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection.

BACKGROUND: Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers. METHODS: We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded. RESULTS: Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average. DISCUSSION: In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation. LEVEL OF EVIDENCE: IV, Case Series.

Association of previous cardiac surgery with outcomes in left ventricular assist device patients.

OBJECTIVES: History of prior cardiac surgery has traditionally been considered a risk factor for subsequent cardiac procedures. The aim of this study was to investigate the outcomes of patients implanted with a left ventricular assist device via redo sternotomy. METHODS: Prospectively collected data were reviewed for all patients implanted with a continuous-flow left ventricular assist device at a single institution from December 2006 through June 2018. Patients were separated into 2 cohorts: those with a history of prior cardiac surgery (redo sternotomy) and those undergoing primary sternotomy at the time of left ventricular assist device implantation. The primary outcome was overall survival. RESULTS: Of the 321 patients included in the study, 77 (24%) were implanted via redo sternotomy and 244 (76%) via primary sternotomy. The redo sternotomy cohort was generally older (59 ± 10 vs 57 ± 12 years, P = 0.050) and had a higher incidence of ischaemic disease (70% vs 49%, P = 0.002). The Kaplan-Meier survival analysis demonstrated that overall survival was not significantly different between the redo sternotomy and primary sternotomy groups (6-month survival: 86% vs 92%; 5-year survival: 53% vs 51%; log-rank P = 0.590 for overall difference during follow-up). The propensity score analysis consistently showed that redo sternotomy was not significantly associated with mortality risk (hazard ratio 1.19, 95% confidence interval 0.73-1.93; P = 0.488). Redo sternotomy patients were more likely to require rehospitalization during their first year postoperatively (P = 0.020) and spent less time out of the hospital during the first year (P = 0.046). CONCLUSIONS: The redo sternotomy cohort represents a more technically challenging patient population, but overall survival similar to that of primary sternotomy patients can be achieved.

Opioid Consumption after Carotid Revascularization.

BACKGROUND: Opioid overdose is now the leading cause of injury-related death in the United States. Overprescription of opioids is one factor contributing to this epidemic. Previous studies demonstrated an overprescription of opioids compared with patient consumption after general surgery procedures. The objective of this study is to evaluate opioid consumption after carotid revascularization. METHODS: This is a retrospective review of the opioid-prescribing habits after discharge of carotid revascularization. Patients who were documented to receive an opioid prescription were included in the study. A phone survey was conducted to determine patient consumption of the prescribed pills. Surgical procedures include carotid endarterectomy (CEA) and transcarotid arterial revascularization (TCAR). The primary outcome is the difference between opioids prescribed and opioids consumed. RESULTS: There were 209 patients available for inclusion. The mean age was 68 years with white (98%) males (58%) making up most patients. CEA and TCAR accounted for 75% and 25% of cases, respectively. About 98 (47%) patients were prescribed opioids after discharge. Eight were excluded from analysis (3 for prior opioid use and 5 declined participation). About 71% of patients participated in the survey. A total of 1,623 pills were prescribed (25.4 ± 5.5 per patient), but only 336 pills were consumed (5.3 ± 1.1 per patient). About 1,287 (79% of total) pills were not consumed. CONCLUSIONS: These data are the first to compare opioid prescription with opioid consumption after carotid revascularization. We demonstrate that patients consume much less opioids than prescribed. These findings indicate that a reduction in opioid prescriptions may be possible after carotid revascularization.

Extracorporeal life support to ventricular assist device: potential benefits of sternal-sparing approach.

BACKGROUND: Advancements in left ventricular assist device (LVAD) technology have improved long-term survival for properly selected patients with advanced heart failure. However, the subset of patients in critical cardiogenic shock remain difficult to treat with persistently high patient morbidity and mortality. The goal of this study is to describe our institutional experience utilizing extracorporeal membrane oxygenation (ECMO) as a bridge to LVAD for patients in cardiogenic shock comparing the less invasive complete sternal-sparing (CSS) surgical technique to median sternotomy. METHODS: Data was collected as a single center retrospective review of patients implanted with a continuous-flow LVAD directly off ECMO from 2012 to 2018. Patients were stratified by LVAD surgical technique. The primary outcome was survival to discharge. Secondary outcomes included postoperative complications, resource utilization and survival at 6-months. RESULTS: Of the 37 patients implanted directly off ECMO, 26 (70%) patients were implanted via median sternotomy and 11 (30%) patients by the CSS approach. Median time on ECMO support was 8 days (range, 2-29 days). Preoperative characteristics were similar between groups. Survival to discharge was 78% overall (73% vs. 91% CSS, P=0.391). The CSS cohort had fewer postoperative complications, including fewer transfusions (P=0.044) and trend towards less right ventricular (RV) failure (62% vs. 27% CSS, P=0.079). Both cohorts required similar median length of stay (LOS) in the intensive care unit (ICU) (11 vs. 12 days, P=0.695) and similar overall hospital LOS (34 vs. 22 days, P=0.242). Overall survival was 74% at six months (68% vs. 89% CSS, P=0.386). CONCLUSIONS: VA ECMO can be used effectively as a bridge-to-LVAD for patients in cardiogenic shock. The less invasive CSS approach demonstrates potential advantages to median sternotomy. Further study is needed to better understand the benefits of less invasive surgical techniques.

Complete Sternal-Sparing HeartMate 3 Implantation: A Case Series of 10 Consecutive Patients.

BACKGROUND: Left ventricular assist device (LVAD) therapy has been the standard of care for selected patients with advance heart failure. Even though considerable strides have been achieved with the introduction of the newest centrifugal pump, therapy is still burdened with significant perioperative complications. Smaller devices, along with improved techniques and instruments, have encouraged the adoption of minimally invasive cardiac surgery (MICS) techniques for LVAD implantation to improve perioperative outcomes. METHODS: We describe a technique for complete sternal-sparing (CSS) HeartMate 3 (Abbott Laboratories, Abbott Park, IL) left ventricular assist device (LVAD) implantation using bilateral thoracotomies and discuss early clinical outcomes of the first ten consecutive patients who underwent CSS implantation of the HeartMate 3 LVAD at our institution. RESULTS: The median length of stay in the intensive care unit was 3.5 days. No patients required reexploration for postoperative bleeding. There was no incidence of right ventricle failure, stroke, renal failure, hepatic failure, or myocardial infarction. The median length of hospitalization after LVAD implantation was 14.5 days (interquartile range, 12 to 17 days). CONCLUSIONS: Our early outcomes suggest that the CSS approach may reduce the incidence of right ventricular failure, bleeding, intubation time, and intensive care unit length of stay. Further studies are needed to fully elucidate the advantages of CSS LVAD implantation compared with median sternotomy.