SAVS Annual Meeting

SCOTTSDALE, ARIZ. – “It’s surprising to me today, when I go proctor or watch a case, how people don’t understand the impact of radiation,” Dr. Mark A. Farber, professor of surgery and radiology at the University of North Carolina, Chapel Hill, said at the Southern Association for Vascular Surgery annual meeting. “Many times, I see people’s hands underneath and on the fluoroscopy machine.”

This flouting of the so-called ALARA principle (as low as reasonably achievable) happens in part because the number of complex procedures performed by vascular surgeons is increasing, despite what presenter Dr. Melissa Kirkwood, a vascular surgeon at the University of Texas Southwestern Medical Center, Dallas, told the audience is a lack of training in radiation dose terminology and basic safety principals.

Yet, practicing excellent radiation safety protocols is “paramount” according to Dr. Farber who, along with Dr. Kirkwood, shared insights on how to minimize dose to both patients and vascular specialists, whether it be from primary, leakage, or scatter radiation.

Table up, top down

Minimizing the air gap by as little as 100 mm – from 700 mm to 600 mm, for example – can reduce the dose of radiation from 17% to 29%, whereas a 10-cm increase in the air gap can result in as much as a 20%-38% increase in the radiation skin dose. This is essentially the application of the inverse square law, according to Dr. Kirkwood.

Although Dr. Farber said that some of the newer, more advanced machines have sensors that automatically detect where the collector should be in relation to the patient, he cautioned that, if your machine doesn’t have these “bells and whistles … remember that the skin dose decreases as the air gap decreases.”

Slow the frame rate

Another advantage to using new imaging systems, according to Dr. Farber, is that they allow the use of pulsed fluoroscopy for as few as 2 or 3 pulses/sec. The selected pulse rate determines the number of fluoroscopic image frames that are generated by the machine per second. This is significant when the dose savings are essential or for when performing simpler procedures, he said. “If you go from 7.5 frames down to 3 frames/sec, you can decrease the exposure for both you and your patient.”

Use between 15 and 30 pulses/sec for critical procedures where precision is crucial, but reducing the rate to 7.5 pulses/sec may result is as much as 70% less of a skin dose.

Add barriers

Don’t just assume that the lead shielding is doing the job. “It’s important that you keep up on this and have it tested regularly,” said Dr. Farber, who recently discovered his thyroid shield was cracked and needed to be replaced.

Additionally, consider the lead shielding of your staff, which, even if it is not used as frequently as the physician’s, can suffer from improper handling. “They fold it or crinkle it up and drop it on the floor. This can lead to problems,” he said. And be sure to remember leaded glasses, lead drapes for the sides of the table, and leaded ceiling-mounted or standing shields.

For extra protection, Dr. Farber recommended the use of disposable protective drapes with cut-outs that allow access to the patient while helping to reduce the amount of scatter radiation exposure to the operator’s limbs. At a tally of anywhere from 1 to 10 mGy/hour, scatter radiation emanating from the patient is a particular risk to the operator’s legs from the knees down, said Dr. Kirkwood, “depending on how tall you are.”

Using the disposable drapes also can result in a 12-fold decrease in the amount of scatter on the eyes, a 25-fold decrease in thyroid exposure to scatter, and a 29-fold decrease in the hands being exposed.

“They can be cumbersome at times, I admit,” Dr. Farber said. “But there can be no substitute for using protective drapes.”

Leaded aprons also can help cut radiation transmission rates, even if they are not foolproof. Wearing two-piece leaded apron systems can help cut down the body strain from the weight of the aprons; however, Dr. Farber said that, at his institution, they now use a suspended body shield system operated by a boom so there is no physical stress on the clinician.

Because the weightless system also provides additional protection for the specialist’s head and limbs, Dr. Farber said that the hefty price tag (approximately $50,000) is justified.

“The way I sold it to the hospital was I told them I could stop doing procedures, or they could get me one of these systems so I could do more procedures,” he said, adding he has had a weightless system installed on each side of the table. “They’ll get their money’s worth by the fact that you’re not over your exposure limit.”

And finally, don’t forget to protect the anesthesiologist! A standing shield that gives broad coverage area should suffice, Dr. Farber said.

Vary the technique

Altering the angle can help ensure that one area of the patient’s body isn’t being overexposed to radiation. Since previously irradiated skin reacts abnormally when re-exposed to radiation because the regeneration and repair of the dermis can take up to several weeks after the initial insult, the timing of the intervals between exposures is critical, said Dr. Kirkwood, adding that the Joint Commission recently recommended that all doses of fluoroscopically guided interventions performed within the past 6-12 months should be considered when assessing potential skin injury risk.

Change the collimation

Making it tighter, for example, can help improve image quality and reduce the radiation dose to both the patient and the operator, as can varying the acquisition rates.

Exit the room during DSA

During digital subtraction angiography, Dr. Farber said to “get away from the table if you can! It’s a huge dose you don’t need to be exposed to if you don’t need to be right next to the machine.” Dr. Kirkwood agreed: “Angiography is 10-100 times more dose than fluoroscopy.”

De-mag

Using a larger monitor allows the operator to see more detail without increasing the magnification, which also increases the dose in the amount of the diameter over the diameter squared. “By not magnifying up [from a field of view of 14 to 28] you will save yourself a factor of at least 4,” Dr. Farber said. “And the actual dose may be even less.”

Optimize imaging

Today’s advanced imaging systems mean that it’s easy to produce many high-quality images – CT scans and ultrasounds – that allow a deeper, more complete picture.

Having the number of images it is now possible to have on screen at once is “practice changing” because it can help clinicians see more possibilities for “how to do the case,” said Dr. Farber. “I’ve never heard anyone say, ’Well, I wish I didn’t have that extra imaging next to me.’ ”

Save images

But once you get it, don’t forget to keep it. “Many times you do an acquisition, you move the machine, and you realize you forget to save the image and now you’ve got to go back and do it all over again,” Dr. Farber lamented. But by once again making technology your friend, with functions that allow auto-return to previous positions, among other auto-commands, you can save the needed information and reduce any unnecessary dose exposure for both yourself and the patient, he said.

Protect your eyes

Cataracts are still all too common in the field, according to Dr. Farber. “It’s important that you have side shields on your glasses to cut down on the amount of radiation that comes in and around the glasses.” Eschew glasses that don’t overtly hug your face, he said.

Know your geometry

Don’t forget that, if you’re standing on the side of the imaging source, the scattering effect will be greater than if you’re on the side of the image receptor. Once again, an understanding of the inverse square law can be protective, according to Dr. Kirkwood: “As x-rays exit the source, there is an exponential decrease in the number of x-rays per unit area as the distance from the source increases.”

“It’s simple stuff,” concluded Dr. Farber. “If you get in the habit of doing these things you will cut down your radiation exposure.”

Neither Dr. Farber nor Dr. Kirkwood had any relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – “It’s surprising to me today, when I go proctor or watch a case, how people don’t understand the impact of radiation,” Dr. Mark A. Farber, professor of surgery and radiology at the University of North Carolina, Chapel Hill, said at the Southern Association for Vascular Surgery annual meeting. “Many times, I see people’s hands underneath and on the fluoroscopy machine.”

This flouting of the so-called ALARA principle (as low as reasonably achievable) happens in part because the number of complex procedures performed by vascular surgeons is increasing, despite what presenter Dr. Melissa Kirkwood, a vascular surgeon at the University of Texas Southwestern Medical Center, Dallas, told the audience is a lack of training in radiation dose terminology and basic safety principals.

Yet, practicing excellent radiation safety protocols is “paramount” according to Dr. Farber who, along with Dr. Kirkwood, shared insights on how to minimize dose to both patients and vascular specialists, whether it be from primary, leakage, or scatter radiation.

Table up, top down

Minimizing the air gap by as little as 100 mm – from 700 mm to 600 mm, for example – can reduce the dose of radiation from 17% to 29%, whereas a 10-cm increase in the air gap can result in as much as a 20%-38% increase in the radiation skin dose. This is essentially the application of the inverse square law, according to Dr. Kirkwood.

Although Dr. Farber said that some of the newer, more advanced machines have sensors that automatically detect where the collector should be in relation to the patient, he cautioned that, if your machine doesn’t have these “bells and whistles … remember that the skin dose decreases as the air gap decreases.”

Slow the frame rate

Another advantage to using new imaging systems, according to Dr. Farber, is that they allow the use of pulsed fluoroscopy for as few as 2 or 3 pulses/sec. The selected pulse rate determines the number of fluoroscopic image frames that are generated by the machine per second. This is significant when the dose savings are essential or for when performing simpler procedures, he said. “If you go from 7.5 frames down to 3 frames/sec, you can decrease the exposure for both you and your patient.”

Use between 15 and 30 pulses/sec for critical procedures where precision is crucial, but reducing the rate to 7.5 pulses/sec may result is as much as 70% less of a skin dose.

Add barriers

Don’t just assume that the lead shielding is doing the job. “It’s important that you keep up on this and have it tested regularly,” said Dr. Farber, who recently discovered his thyroid shield was cracked and needed to be replaced.

Additionally, consider the lead shielding of your staff, which, even if it is not used as frequently as the physician’s, can suffer from improper handling. “They fold it or crinkle it up and drop it on the floor. This can lead to problems,” he said. And be sure to remember leaded glasses, lead drapes for the sides of the table, and leaded ceiling-mounted or standing shields.

For extra protection, Dr. Farber recommended the use of disposable protective drapes with cut-outs that allow access to the patient while helping to reduce the amount of scatter radiation exposure to the operator’s limbs. At a tally of anywhere from 1 to 10 mGy/hour, scatter radiation emanating from the patient is a particular risk to the operator’s legs from the knees down, said Dr. Kirkwood, “depending on how tall you are.”

Using the disposable drapes also can result in a 12-fold decrease in the amount of scatter on the eyes, a 25-fold decrease in thyroid exposure to scatter, and a 29-fold decrease in the hands being exposed.

“They can be cumbersome at times, I admit,” Dr. Farber said. “But there can be no substitute for using protective drapes.”

Leaded aprons also can help cut radiation transmission rates, even if they are not foolproof. Wearing two-piece leaded apron systems can help cut down the body strain from the weight of the aprons; however, Dr. Farber said that, at his institution, they now use a suspended body shield system operated by a boom so there is no physical stress on the clinician.

Because the weightless system also provides additional protection for the specialist’s head and limbs, Dr. Farber said that the hefty price tag (approximately $50,000) is justified.

“The way I sold it to the hospital was I told them I could stop doing procedures, or they could get me one of these systems so I could do more procedures,” he said, adding he has had a weightless system installed on each side of the table. “They’ll get their money’s worth by the fact that you’re not over your exposure limit.”

And finally, don’t forget to protect the anesthesiologist! A standing shield that gives broad coverage area should suffice, Dr. Farber said.

Vary the technique

Altering the angle can help ensure that one area of the patient’s body isn’t being overexposed to radiation. Since previously irradiated skin reacts abnormally when re-exposed to radiation because the regeneration and repair of the dermis can take up to several weeks after the initial insult, the timing of the intervals between exposures is critical, said Dr. Kirkwood, adding that the Joint Commission recently recommended that all doses of fluoroscopically guided interventions performed within the past 6-12 months should be considered when assessing potential skin injury risk.

Change the collimation

Making it tighter, for example, can help improve image quality and reduce the radiation dose to both the patient and the operator, as can varying the acquisition rates.

Exit the room during DSA

During digital subtraction angiography, Dr. Farber said to “get away from the table if you can! It’s a huge dose you don’t need to be exposed to if you don’t need to be right next to the machine.” Dr. Kirkwood agreed: “Angiography is 10-100 times more dose than fluoroscopy.”

De-mag

Using a larger monitor allows the operator to see more detail without increasing the magnification, which also increases the dose in the amount of the diameter over the diameter squared. “By not magnifying up [from a field of view of 14 to 28] you will save yourself a factor of at least 4,” Dr. Farber said. “And the actual dose may be even less.”

Optimize imaging

Today’s advanced imaging systems mean that it’s easy to produce many high-quality images – CT scans and ultrasounds – that allow a deeper, more complete picture.

Having the number of images it is now possible to have on screen at once is “practice changing” because it can help clinicians see more possibilities for “how to do the case,” said Dr. Farber. “I’ve never heard anyone say, ’Well, I wish I didn’t have that extra imaging next to me.’ ”

Save images

But once you get it, don’t forget to keep it. “Many times you do an acquisition, you move the machine, and you realize you forget to save the image and now you’ve got to go back and do it all over again,” Dr. Farber lamented. But by once again making technology your friend, with functions that allow auto-return to previous positions, among other auto-commands, you can save the needed information and reduce any unnecessary dose exposure for both yourself and the patient, he said.

Protect your eyes

Cataracts are still all too common in the field, according to Dr. Farber. “It’s important that you have side shields on your glasses to cut down on the amount of radiation that comes in and around the glasses.” Eschew glasses that don’t overtly hug your face, he said.

Know your geometry

Don’t forget that, if you’re standing on the side of the imaging source, the scattering effect will be greater than if you’re on the side of the image receptor. Once again, an understanding of the inverse square law can be protective, according to Dr. Kirkwood: “As x-rays exit the source, there is an exponential decrease in the number of x-rays per unit area as the distance from the source increases.”

“It’s simple stuff,” concluded Dr. Farber. “If you get in the habit of doing these things you will cut down your radiation exposure.”

Neither Dr. Farber nor Dr. Kirkwood had any relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – “It’s surprising to me today, when I go proctor or watch a case, how people don’t understand the impact of radiation,” Dr. Mark A. Farber, professor of surgery and radiology at the University of North Carolina, Chapel Hill, said at the Southern Association for Vascular Surgery annual meeting. “Many times, I see people’s hands underneath and on the fluoroscopy machine.”

This flouting of the so-called ALARA principle (as low as reasonably achievable) happens in part because the number of complex procedures performed by vascular surgeons is increasing, despite what presenter Dr. Melissa Kirkwood, a vascular surgeon at the University of Texas Southwestern Medical Center, Dallas, told the audience is a lack of training in radiation dose terminology and basic safety principals.

Yet, practicing excellent radiation safety protocols is “paramount” according to Dr. Farber who, along with Dr. Kirkwood, shared insights on how to minimize dose to both patients and vascular specialists, whether it be from primary, leakage, or scatter radiation.

Table up, top down

Minimizing the air gap by as little as 100 mm – from 700 mm to 600 mm, for example – can reduce the dose of radiation from 17% to 29%, whereas a 10-cm increase in the air gap can result in as much as a 20%-38% increase in the radiation skin dose. This is essentially the application of the inverse square law, according to Dr. Kirkwood.

Although Dr. Farber said that some of the newer, more advanced machines have sensors that automatically detect where the collector should be in relation to the patient, he cautioned that, if your machine doesn’t have these “bells and whistles … remember that the skin dose decreases as the air gap decreases.”

Slow the frame rate

Another advantage to using new imaging systems, according to Dr. Farber, is that they allow the use of pulsed fluoroscopy for as few as 2 or 3 pulses/sec. The selected pulse rate determines the number of fluoroscopic image frames that are generated by the machine per second. This is significant when the dose savings are essential or for when performing simpler procedures, he said. “If you go from 7.5 frames down to 3 frames/sec, you can decrease the exposure for both you and your patient.”

Use between 15 and 30 pulses/sec for critical procedures where precision is crucial, but reducing the rate to 7.5 pulses/sec may result is as much as 70% less of a skin dose.

Add barriers

Don’t just assume that the lead shielding is doing the job. “It’s important that you keep up on this and have it tested regularly,” said Dr. Farber, who recently discovered his thyroid shield was cracked and needed to be replaced.

Additionally, consider the lead shielding of your staff, which, even if it is not used as frequently as the physician’s, can suffer from improper handling. “They fold it or crinkle it up and drop it on the floor. This can lead to problems,” he said. And be sure to remember leaded glasses, lead drapes for the sides of the table, and leaded ceiling-mounted or standing shields.

For extra protection, Dr. Farber recommended the use of disposable protective drapes with cut-outs that allow access to the patient while helping to reduce the amount of scatter radiation exposure to the operator’s limbs. At a tally of anywhere from 1 to 10 mGy/hour, scatter radiation emanating from the patient is a particular risk to the operator’s legs from the knees down, said Dr. Kirkwood, “depending on how tall you are.”

Using the disposable drapes also can result in a 12-fold decrease in the amount of scatter on the eyes, a 25-fold decrease in thyroid exposure to scatter, and a 29-fold decrease in the hands being exposed.

“They can be cumbersome at times, I admit,” Dr. Farber said. “But there can be no substitute for using protective drapes.”

Leaded aprons also can help cut radiation transmission rates, even if they are not foolproof. Wearing two-piece leaded apron systems can help cut down the body strain from the weight of the aprons; however, Dr. Farber said that, at his institution, they now use a suspended body shield system operated by a boom so there is no physical stress on the clinician.

Because the weightless system also provides additional protection for the specialist’s head and limbs, Dr. Farber said that the hefty price tag (approximately $50,000) is justified.

“The way I sold it to the hospital was I told them I could stop doing procedures, or they could get me one of these systems so I could do more procedures,” he said, adding he has had a weightless system installed on each side of the table. “They’ll get their money’s worth by the fact that you’re not over your exposure limit.”

And finally, don’t forget to protect the anesthesiologist! A standing shield that gives broad coverage area should suffice, Dr. Farber said.

Vary the technique

Altering the angle can help ensure that one area of the patient’s body isn’t being overexposed to radiation. Since previously irradiated skin reacts abnormally when re-exposed to radiation because the regeneration and repair of the dermis can take up to several weeks after the initial insult, the timing of the intervals between exposures is critical, said Dr. Kirkwood, adding that the Joint Commission recently recommended that all doses of fluoroscopically guided interventions performed within the past 6-12 months should be considered when assessing potential skin injury risk.

Change the collimation

Making it tighter, for example, can help improve image quality and reduce the radiation dose to both the patient and the operator, as can varying the acquisition rates.

Exit the room during DSA

During digital subtraction angiography, Dr. Farber said to “get away from the table if you can! It’s a huge dose you don’t need to be exposed to if you don’t need to be right next to the machine.” Dr. Kirkwood agreed: “Angiography is 10-100 times more dose than fluoroscopy.”

De-mag

Using a larger monitor allows the operator to see more detail without increasing the magnification, which also increases the dose in the amount of the diameter over the diameter squared. “By not magnifying up [from a field of view of 14 to 28] you will save yourself a factor of at least 4,” Dr. Farber said. “And the actual dose may be even less.”

Optimize imaging

Today’s advanced imaging systems mean that it’s easy to produce many high-quality images – CT scans and ultrasounds – that allow a deeper, more complete picture.

Having the number of images it is now possible to have on screen at once is “practice changing” because it can help clinicians see more possibilities for “how to do the case,” said Dr. Farber. “I’ve never heard anyone say, ’Well, I wish I didn’t have that extra imaging next to me.’ ”

Save images

But once you get it, don’t forget to keep it. “Many times you do an acquisition, you move the machine, and you realize you forget to save the image and now you’ve got to go back and do it all over again,” Dr. Farber lamented. But by once again making technology your friend, with functions that allow auto-return to previous positions, among other auto-commands, you can save the needed information and reduce any unnecessary dose exposure for both yourself and the patient, he said.

Protect your eyes

Cataracts are still all too common in the field, according to Dr. Farber. “It’s important that you have side shields on your glasses to cut down on the amount of radiation that comes in and around the glasses.” Eschew glasses that don’t overtly hug your face, he said.

Know your geometry

Don’t forget that, if you’re standing on the side of the imaging source, the scattering effect will be greater than if you’re on the side of the image receptor. Once again, an understanding of the inverse square law can be protective, according to Dr. Kirkwood: “As x-rays exit the source, there is an exponential decrease in the number of x-rays per unit area as the distance from the source increases.”

“It’s simple stuff,” concluded Dr. Farber. “If you get in the habit of doing these things you will cut down your radiation exposure.”

Neither Dr. Farber nor Dr. Kirkwood had any relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

PALM BEACH, FLA. – Bedside vena cava filter placement using intravascular ultrasound was a safe and effective option in critically ill patients, according to a retrospective study at the University of Alabama at Birmingham.

During a 5-year period, 98% of the filter placements were successful. Technical success also improved significantly, and the complication rates dropped, reported Dr. Roan J. Glocker during a presentation at the annual meeting of the Southern Association for Vascular Surgery.

Vena cava filters have been used for nearly 4 decades for the prevention of pulmonary embolism. Dr. Glocker said that the bedside methods of filter placement often eliminate the need to transport patients, who are often critically ill or injured. It also eliminates the need for an operating room or angiography usage and reduces the risk that may result from contrast administration and radiation.

In 2010, researchers at the University of Alabama first reported successful outcomes of an algorithm for bedside intravascular ultrasound (IVUS) guided inferior vena cava (IVC) filter placement. Dr. Glocker said that the team wanted to evaluate their experience over a longer period of time, and to determine whether the safety and efficacy of the procedure was sustainable and evaluate the complication rates.

Researchers conducted a retrospective review of 398 patients undergoing bedside IVUS-guided IVC filter placement from 2008 to 2012. Seventy-percent of the patients were male, with a mean age of 77 years old, ranging from 14 to 91 years old. Close to 80% were multitrauma patients. The most common indication for filter placement was VTE prophylaxis in multisystem injury.

Outcomes were analyzed at 30 days. The study had no control groups.

Results showed that the technical success was 98%. The optional filters – Gunther Tulip or Cook Celect – were used in 94% of the patients, and the Greenfield permanent filter was used in the rest.

In 97% of the cases, a single puncture technique was performed. Periprocedural complications occurred only 3% of the time. Thirty patients died within 30 days of filter placement; however, there were no deaths related to pulmonary embolism or filter-related problems, Dr. Glocker reported.

When researchers compared the first and last 100 procedures, the complication rates dropped from 7% to 2 % (P = .08), and the technical success improved significantly from 96% in the first 100 procedures to 100% in the last 100.

Although there has been little change in the basic design of the filters, there have been remarkable improvements in placement techniques, going from the operating room to the radiology suites, to the patient bedside, said Dr. Lazar J. Greenfield Sr., professor emeritus of surgery at the University of Michigan, Ann Arbor, and the inventor of the filter.

But a 2013 study showed that the use of vena cava filters varies widely among hospitals, and some experts say that there’s still not enough evidence about its effectiveness.

In 2010, the Food and Drug Administration issued safety concerns about leaving the filters in place for a long period of time. Currently, the PRESERVE (Predicting the Safety and Effectiveness of Inferior Vena Cava Filters) study, a 5-year, multispecialty, prospective trial, is examining the use of IVC filters by focusing on safety endpoints.

The procedure has a learning curve. The surgeon has to be familiar with the IVUS modality and should have a thorough understanding of deployment of each filter, Dr. Glocker said. He guesstimated that physicians should perform approximately 20-50 procedures to reach competency and start performing the procedure on their own.

Dr. Glocker and Dr. Greenfield had no disclosures.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller

PALM BEACH, FLA. – Bedside vena cava filter placement using intravascular ultrasound was a safe and effective option in critically ill patients, according to a retrospective study at the University of Alabama at Birmingham.

During a 5-year period, 98% of the filter placements were successful. Technical success also improved significantly, and the complication rates dropped, reported Dr. Roan J. Glocker during a presentation at the annual meeting of the Southern Association for Vascular Surgery.

Vena cava filters have been used for nearly 4 decades for the prevention of pulmonary embolism. Dr. Glocker said that the bedside methods of filter placement often eliminate the need to transport patients, who are often critically ill or injured. It also eliminates the need for an operating room or angiography usage and reduces the risk that may result from contrast administration and radiation.

In 2010, researchers at the University of Alabama first reported successful outcomes of an algorithm for bedside intravascular ultrasound (IVUS) guided inferior vena cava (IVC) filter placement. Dr. Glocker said that the team wanted to evaluate their experience over a longer period of time, and to determine whether the safety and efficacy of the procedure was sustainable and evaluate the complication rates.

Researchers conducted a retrospective review of 398 patients undergoing bedside IVUS-guided IVC filter placement from 2008 to 2012. Seventy-percent of the patients were male, with a mean age of 77 years old, ranging from 14 to 91 years old. Close to 80% were multitrauma patients. The most common indication for filter placement was VTE prophylaxis in multisystem injury.

Outcomes were analyzed at 30 days. The study had no control groups.

Results showed that the technical success was 98%. The optional filters – Gunther Tulip or Cook Celect – were used in 94% of the patients, and the Greenfield permanent filter was used in the rest.

In 97% of the cases, a single puncture technique was performed. Periprocedural complications occurred only 3% of the time. Thirty patients died within 30 days of filter placement; however, there were no deaths related to pulmonary embolism or filter-related problems, Dr. Glocker reported.

When researchers compared the first and last 100 procedures, the complication rates dropped from 7% to 2 % (P = .08), and the technical success improved significantly from 96% in the first 100 procedures to 100% in the last 100.

Although there has been little change in the basic design of the filters, there have been remarkable improvements in placement techniques, going from the operating room to the radiology suites, to the patient bedside, said Dr. Lazar J. Greenfield Sr., professor emeritus of surgery at the University of Michigan, Ann Arbor, and the inventor of the filter.

But a 2013 study showed that the use of vena cava filters varies widely among hospitals, and some experts say that there’s still not enough evidence about its effectiveness.

In 2010, the Food and Drug Administration issued safety concerns about leaving the filters in place for a long period of time. Currently, the PRESERVE (Predicting the Safety and Effectiveness of Inferior Vena Cava Filters) study, a 5-year, multispecialty, prospective trial, is examining the use of IVC filters by focusing on safety endpoints.

The procedure has a learning curve. The surgeon has to be familiar with the IVUS modality and should have a thorough understanding of deployment of each filter, Dr. Glocker said. He guesstimated that physicians should perform approximately 20-50 procedures to reach competency and start performing the procedure on their own.

Dr. Glocker and Dr. Greenfield had no disclosures.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller

PALM BEACH, FLA. – Bedside vena cava filter placement using intravascular ultrasound was a safe and effective option in critically ill patients, according to a retrospective study at the University of Alabama at Birmingham.

During a 5-year period, 98% of the filter placements were successful. Technical success also improved significantly, and the complication rates dropped, reported Dr. Roan J. Glocker during a presentation at the annual meeting of the Southern Association for Vascular Surgery.

Vena cava filters have been used for nearly 4 decades for the prevention of pulmonary embolism. Dr. Glocker said that the bedside methods of filter placement often eliminate the need to transport patients, who are often critically ill or injured. It also eliminates the need for an operating room or angiography usage and reduces the risk that may result from contrast administration and radiation.

In 2010, researchers at the University of Alabama first reported successful outcomes of an algorithm for bedside intravascular ultrasound (IVUS) guided inferior vena cava (IVC) filter placement. Dr. Glocker said that the team wanted to evaluate their experience over a longer period of time, and to determine whether the safety and efficacy of the procedure was sustainable and evaluate the complication rates.

Researchers conducted a retrospective review of 398 patients undergoing bedside IVUS-guided IVC filter placement from 2008 to 2012. Seventy-percent of the patients were male, with a mean age of 77 years old, ranging from 14 to 91 years old. Close to 80% were multitrauma patients. The most common indication for filter placement was VTE prophylaxis in multisystem injury.

Outcomes were analyzed at 30 days. The study had no control groups.

Results showed that the technical success was 98%. The optional filters – Gunther Tulip or Cook Celect – were used in 94% of the patients, and the Greenfield permanent filter was used in the rest.

In 97% of the cases, a single puncture technique was performed. Periprocedural complications occurred only 3% of the time. Thirty patients died within 30 days of filter placement; however, there were no deaths related to pulmonary embolism or filter-related problems, Dr. Glocker reported.

When researchers compared the first and last 100 procedures, the complication rates dropped from 7% to 2 % (P = .08), and the technical success improved significantly from 96% in the first 100 procedures to 100% in the last 100.

Although there has been little change in the basic design of the filters, there have been remarkable improvements in placement techniques, going from the operating room to the radiology suites, to the patient bedside, said Dr. Lazar J. Greenfield Sr., professor emeritus of surgery at the University of Michigan, Ann Arbor, and the inventor of the filter.

But a 2013 study showed that the use of vena cava filters varies widely among hospitals, and some experts say that there’s still not enough evidence about its effectiveness.

In 2010, the Food and Drug Administration issued safety concerns about leaving the filters in place for a long period of time. Currently, the PRESERVE (Predicting the Safety and Effectiveness of Inferior Vena Cava Filters) study, a 5-year, multispecialty, prospective trial, is examining the use of IVC filters by focusing on safety endpoints.

The procedure has a learning curve. The surgeon has to be familiar with the IVUS modality and should have a thorough understanding of deployment of each filter, Dr. Glocker said. He guesstimated that physicians should perform approximately 20-50 procedures to reach competency and start performing the procedure on their own.

Dr. Glocker and Dr. Greenfield had no disclosures.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller

PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville Health System Clinical University, Greenville, South Carolina.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the NYU Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller

PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville Health System Clinical University, Greenville, South Carolina.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the NYU Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller

PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville Health System Clinical University, Greenville, South Carolina.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the NYU Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller