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Western Vascular Society (WVS): Annual Meeting
Skin injury after FEVAR less prevalent than expected
CORONADO, CALIF. – Skin injury following fenestrated endovascular aortic stent grafting is less prevalent than expected, results from a single-center retrospective study showed.
“Radiation-induced skin injury is a serious potential complication of fluoroscopically guided interventions,” Dr. Melissa L. Kirkwood said at the annual meeting of the Western Vascular Society. “These injuries are associated with a threshold radiation dose, above which the severity of injury increases with increasing dose. Instances of these injuries are mostly limited to case reports of coronary interventions, TIPS procedures, and neuroembolizations.”
These radiation-induced skin lesions can be classified as prompt, early, mid-term, or late depending on when they present following the fluoroscopically guided intervention. “The National Cancer Institute has defined four grades of skin injury, with the most frequent being transient erythema, a prompt reaction within the first 24 hours occurring at skin doses as low as 2 Gy,” said Dr. Kirkwood of the division of vascular and endovascular surgery at the University of Texas Southwestern Medical Center, Dallas. “With increasing skin doses, more severe effects present themselves. Atrophy, ulceration, and necrosis are possibilities.”
She went on to note that fenestrated endovascular aneurysm repairs often require high doses of radiation, yet the prevalence of deterministic skin injury following these cases is unknown. In a recent study, Dr. Kirkwood and her associates retrospectively reviewed 61 complex fluoroscopically guided interventions that met substantial radiation dose level criteria (SRDL), which is defined by the National Council on Radiation and Protection Measurements as a reference air kerma (RAK) greater than or equal to 5 Gy (J. Vasc. Surg. 2014; 60[3]:742-8). “Despite mean peak skin doses as high as 6.5 Gy, ranging up to 18.5 Gy, we did not detect any skin injuries in this cohort,” Dr. Kirkwood said. “That study, however, was limited by its retrospective design. There was no postoperative protocol in place to ensure that a thorough skin exam was performed on each patient at every follow-up visit. Therefore, we hypothesized that a more thorough postoperative follow-up of patients would detect some skin injury following these cases.”
For the current study, she and her associates sought to examine the prevalence of deterministic effects after FEVAR as well as well as any patient characteristics that may predispose patients to skin injury.
In June 2013, the researchers implemented a new policy regarding the follow-up of FEVAR patients, which involved a full skin exam at postoperative week 2 and 4, and at 3 and 6 months, as well as questioning patients about any skin-related complaints. For the current study, they retrospectively reviewed all FEVARs over a 7-month period after the change in policy and highlighted all the cases that reached a RAK of 5 Gy or greater. The RAK was the dose metric used in this study. It is a measure of the radiation dose to air at the interventional reference point, which, on standard fluoroscopes, is 15 cm along the beam axis toward the focal spot from isocenter. Dr. Kirkwood characterized RAK as “the best real-time indicator of patient dose, because it roughly estimates the dose at the entry point on the patient’s skin.” Peak skin dose, a dose index, and simulated skin dose maps were calculated using customized software employing input data from fluoroscopic machine logs.
Of 317 cases performed, 22 met or exceeded a RAK of 5 Gy. Of these, 21 were FEVARs and one was an embolization. Most patients (91%) were male and their mean body mass index was 30 kg/m2. Comorbidities and risk factors for skin injury included smoking, diabetes, and the concomitant applications of chemotherapeutic agents.
Dr. Kirkwood reported that the average RAK for all FEVARs was 8 Gy, with a range of 5-11 Gy. Slightly more than half of patients (52%) had multiple fluoroscopically guided interventions within 6 months of their SRDL event. The average RAK for this subset of patients was 10 Gy (range of 5 to 15).
The mean peak skin dose for all FEVARs was 5 Gy (a range of 2 to 10 Gy), and the dose index was 0.69. The average peak skin dose for the subset of patients with multiple procedures was 7 Gy (a range of 3 to 9 Gy).
In terms of the follow-up, all 21 FEVAR patients were examined at the 1- or 2-week mark, 81% were examined at 1 month, 52% were examined at 3 months, and 62% were examined at 6 months. No radiation skin injuries were reported. “Based on the published data, we would expect to see all grades of skin injury, especially in the cohort of the 5-10 Gy,” Dr. Kirkwood said.
In the previous study, conducted prior to the new follow-up policy, the dose index for FEVARs was 0.78, “meaning that the peak skin dose that the patient received could be roughly estimated as 78% of the RAK dose displayed on the monitor,” Dr. Kirkwood explained. “In the current work, the dose index decreased to 60%. This suggests that surgeons in our group have now more appropriately and effectively employed strategies to decrease radiation dose to the patient. However, even when the best operating practice is employed, FEVARs still continue to require high radiation doses in order to complete. “
The present study demonstrated that deterministic skin injuries “are uncommon after FEVAR, even at high RAK levels and regardless of cumulative dose,” she concluded. “Even with more comprehensive patient follow-up, the fact that no skin injuries were reported suggests that skin injuries in this patient cohort are less prevalent than the published guidelines would predict.”
Dr. Kirkwood reported having no financial disclosures.
On Twitter @dougbrunk
The dramatic paradigm shift in vascular surgery in the last decade and a half, resulting in the increased and widespread application of catheter-based fluoroscopic interventions makes the topic of radiation injury timely for all of us. This report is a follow up of a study by the same group published in the Journal of Vascular Surgery in 2013 (58:715-21) in which they demonstrated that the use of a variety of radiation safety measures including increasing table height, utilizing collimation and angulation, decreasing magnification modes, and maintaining minimal patient-to-detector distance resulted in a 60% reduction in skin dose to their patients when measured as an index of peak skin dose to reference air kerma (PSD/RAK). Unfortunately, skin exposure remained high for FEVAR despite these measures, underscoring the fact that for very complex interventions, even with excellent radiation safety practices, the risk of skin injury remains a reality.
The fact that skin doses as high as 11 Gy did not result in any deterministic injuries is both reassuring and a little surprising. According to the Centers for Disease Control and Prevention, radiation doses of greater than 2 Gy but less than 15 Gy will usually result in erythema within 1-2 days, with a second period of erythema and edema at 2-5 weeks, occasionally resulting in desquamation at 6-7 weeks. Late changes can include mild skin atrophy and some hyperpigmentation. Although complete healing can usually be expected at these doses, squamous skin cancer can still occur, often more than a decade after exposure.
So why were no injuries seen? It may be that some were missed since follow-up examinations were not performed in 100% of their patients at any time interval, and it’s not stated whether exams were routinely performed in the first 1-2 days, when I would presume most patients were still hospitalized and the first stage of skin erythema is usually seen. Alternatively, it may be that the surrogate measure of either RAK or the index of PSD/RAK overestimated the true radiation skin dose, which seems highly likely, especially if the time of exposure in any one location was based less on the frequent changes in gantry angle and table position so commonly used in these procedures.
In our hospital, the Massachusetts Department of Public Health regulations require the patient and their physician be notified by letter when the estimated total absorbed radiation dose equals or exceeds 2 Gy. This is based on calculations by our physicist who reviews the details of any case in which the RAK measured equals or exceeds 2 Gy. Like the experiences of the authors, this most commonly occurs with lengthy and complex interventions. In our experience, we have never observed a significant skin injury presumably for the same reason – the exposure in any one location tends to be far less than the total calculated skin dose. Nevertheless, this study should not lull surgeons into a sense of complacency regarding the risk to the patient (and themselves and their staff). As our comfort and expertise with complex interventions increases, it is likely that radiation exposure will continue to increase, placing our patients at increased risk. Understanding the risk of radiation skin injury and how to minimize it is critical for any surgeon performing FEVAR and any other complex intervention utilizing fluoroscopic imaging.
Dr. Frank Pomposelli is an associate professor of surgery at Harvard Medical School; clinical chief, division of vascular surgery at the Beth Israel Deaconess Medical Center; and section chief, division of vascular surgery, New England Baptist Hospital, Boston. He is also an associate medical editor for Vascular Specialist.
The dramatic paradigm shift in vascular surgery in the last decade and a half, resulting in the increased and widespread application of catheter-based fluoroscopic interventions makes the topic of radiation injury timely for all of us. This report is a follow up of a study by the same group published in the Journal of Vascular Surgery in 2013 (58:715-21) in which they demonstrated that the use of a variety of radiation safety measures including increasing table height, utilizing collimation and angulation, decreasing magnification modes, and maintaining minimal patient-to-detector distance resulted in a 60% reduction in skin dose to their patients when measured as an index of peak skin dose to reference air kerma (PSD/RAK). Unfortunately, skin exposure remained high for FEVAR despite these measures, underscoring the fact that for very complex interventions, even with excellent radiation safety practices, the risk of skin injury remains a reality.
The fact that skin doses as high as 11 Gy did not result in any deterministic injuries is both reassuring and a little surprising. According to the Centers for Disease Control and Prevention, radiation doses of greater than 2 Gy but less than 15 Gy will usually result in erythema within 1-2 days, with a second period of erythema and edema at 2-5 weeks, occasionally resulting in desquamation at 6-7 weeks. Late changes can include mild skin atrophy and some hyperpigmentation. Although complete healing can usually be expected at these doses, squamous skin cancer can still occur, often more than a decade after exposure.
So why were no injuries seen? It may be that some were missed since follow-up examinations were not performed in 100% of their patients at any time interval, and it’s not stated whether exams were routinely performed in the first 1-2 days, when I would presume most patients were still hospitalized and the first stage of skin erythema is usually seen. Alternatively, it may be that the surrogate measure of either RAK or the index of PSD/RAK overestimated the true radiation skin dose, which seems highly likely, especially if the time of exposure in any one location was based less on the frequent changes in gantry angle and table position so commonly used in these procedures.
In our hospital, the Massachusetts Department of Public Health regulations require the patient and their physician be notified by letter when the estimated total absorbed radiation dose equals or exceeds 2 Gy. This is based on calculations by our physicist who reviews the details of any case in which the RAK measured equals or exceeds 2 Gy. Like the experiences of the authors, this most commonly occurs with lengthy and complex interventions. In our experience, we have never observed a significant skin injury presumably for the same reason – the exposure in any one location tends to be far less than the total calculated skin dose. Nevertheless, this study should not lull surgeons into a sense of complacency regarding the risk to the patient (and themselves and their staff). As our comfort and expertise with complex interventions increases, it is likely that radiation exposure will continue to increase, placing our patients at increased risk. Understanding the risk of radiation skin injury and how to minimize it is critical for any surgeon performing FEVAR and any other complex intervention utilizing fluoroscopic imaging.
Dr. Frank Pomposelli is an associate professor of surgery at Harvard Medical School; clinical chief, division of vascular surgery at the Beth Israel Deaconess Medical Center; and section chief, division of vascular surgery, New England Baptist Hospital, Boston. He is also an associate medical editor for Vascular Specialist.
The dramatic paradigm shift in vascular surgery in the last decade and a half, resulting in the increased and widespread application of catheter-based fluoroscopic interventions makes the topic of radiation injury timely for all of us. This report is a follow up of a study by the same group published in the Journal of Vascular Surgery in 2013 (58:715-21) in which they demonstrated that the use of a variety of radiation safety measures including increasing table height, utilizing collimation and angulation, decreasing magnification modes, and maintaining minimal patient-to-detector distance resulted in a 60% reduction in skin dose to their patients when measured as an index of peak skin dose to reference air kerma (PSD/RAK). Unfortunately, skin exposure remained high for FEVAR despite these measures, underscoring the fact that for very complex interventions, even with excellent radiation safety practices, the risk of skin injury remains a reality.
The fact that skin doses as high as 11 Gy did not result in any deterministic injuries is both reassuring and a little surprising. According to the Centers for Disease Control and Prevention, radiation doses of greater than 2 Gy but less than 15 Gy will usually result in erythema within 1-2 days, with a second period of erythema and edema at 2-5 weeks, occasionally resulting in desquamation at 6-7 weeks. Late changes can include mild skin atrophy and some hyperpigmentation. Although complete healing can usually be expected at these doses, squamous skin cancer can still occur, often more than a decade after exposure.
So why were no injuries seen? It may be that some were missed since follow-up examinations were not performed in 100% of their patients at any time interval, and it’s not stated whether exams were routinely performed in the first 1-2 days, when I would presume most patients were still hospitalized and the first stage of skin erythema is usually seen. Alternatively, it may be that the surrogate measure of either RAK or the index of PSD/RAK overestimated the true radiation skin dose, which seems highly likely, especially if the time of exposure in any one location was based less on the frequent changes in gantry angle and table position so commonly used in these procedures.
In our hospital, the Massachusetts Department of Public Health regulations require the patient and their physician be notified by letter when the estimated total absorbed radiation dose equals or exceeds 2 Gy. This is based on calculations by our physicist who reviews the details of any case in which the RAK measured equals or exceeds 2 Gy. Like the experiences of the authors, this most commonly occurs with lengthy and complex interventions. In our experience, we have never observed a significant skin injury presumably for the same reason – the exposure in any one location tends to be far less than the total calculated skin dose. Nevertheless, this study should not lull surgeons into a sense of complacency regarding the risk to the patient (and themselves and their staff). As our comfort and expertise with complex interventions increases, it is likely that radiation exposure will continue to increase, placing our patients at increased risk. Understanding the risk of radiation skin injury and how to minimize it is critical for any surgeon performing FEVAR and any other complex intervention utilizing fluoroscopic imaging.
Dr. Frank Pomposelli is an associate professor of surgery at Harvard Medical School; clinical chief, division of vascular surgery at the Beth Israel Deaconess Medical Center; and section chief, division of vascular surgery, New England Baptist Hospital, Boston. He is also an associate medical editor for Vascular Specialist.
CORONADO, CALIF. – Skin injury following fenestrated endovascular aortic stent grafting is less prevalent than expected, results from a single-center retrospective study showed.
“Radiation-induced skin injury is a serious potential complication of fluoroscopically guided interventions,” Dr. Melissa L. Kirkwood said at the annual meeting of the Western Vascular Society. “These injuries are associated with a threshold radiation dose, above which the severity of injury increases with increasing dose. Instances of these injuries are mostly limited to case reports of coronary interventions, TIPS procedures, and neuroembolizations.”
These radiation-induced skin lesions can be classified as prompt, early, mid-term, or late depending on when they present following the fluoroscopically guided intervention. “The National Cancer Institute has defined four grades of skin injury, with the most frequent being transient erythema, a prompt reaction within the first 24 hours occurring at skin doses as low as 2 Gy,” said Dr. Kirkwood of the division of vascular and endovascular surgery at the University of Texas Southwestern Medical Center, Dallas. “With increasing skin doses, more severe effects present themselves. Atrophy, ulceration, and necrosis are possibilities.”
She went on to note that fenestrated endovascular aneurysm repairs often require high doses of radiation, yet the prevalence of deterministic skin injury following these cases is unknown. In a recent study, Dr. Kirkwood and her associates retrospectively reviewed 61 complex fluoroscopically guided interventions that met substantial radiation dose level criteria (SRDL), which is defined by the National Council on Radiation and Protection Measurements as a reference air kerma (RAK) greater than or equal to 5 Gy (J. Vasc. Surg. 2014; 60[3]:742-8). “Despite mean peak skin doses as high as 6.5 Gy, ranging up to 18.5 Gy, we did not detect any skin injuries in this cohort,” Dr. Kirkwood said. “That study, however, was limited by its retrospective design. There was no postoperative protocol in place to ensure that a thorough skin exam was performed on each patient at every follow-up visit. Therefore, we hypothesized that a more thorough postoperative follow-up of patients would detect some skin injury following these cases.”
For the current study, she and her associates sought to examine the prevalence of deterministic effects after FEVAR as well as well as any patient characteristics that may predispose patients to skin injury.
In June 2013, the researchers implemented a new policy regarding the follow-up of FEVAR patients, which involved a full skin exam at postoperative week 2 and 4, and at 3 and 6 months, as well as questioning patients about any skin-related complaints. For the current study, they retrospectively reviewed all FEVARs over a 7-month period after the change in policy and highlighted all the cases that reached a RAK of 5 Gy or greater. The RAK was the dose metric used in this study. It is a measure of the radiation dose to air at the interventional reference point, which, on standard fluoroscopes, is 15 cm along the beam axis toward the focal spot from isocenter. Dr. Kirkwood characterized RAK as “the best real-time indicator of patient dose, because it roughly estimates the dose at the entry point on the patient’s skin.” Peak skin dose, a dose index, and simulated skin dose maps were calculated using customized software employing input data from fluoroscopic machine logs.
Of 317 cases performed, 22 met or exceeded a RAK of 5 Gy. Of these, 21 were FEVARs and one was an embolization. Most patients (91%) were male and their mean body mass index was 30 kg/m2. Comorbidities and risk factors for skin injury included smoking, diabetes, and the concomitant applications of chemotherapeutic agents.
Dr. Kirkwood reported that the average RAK for all FEVARs was 8 Gy, with a range of 5-11 Gy. Slightly more than half of patients (52%) had multiple fluoroscopically guided interventions within 6 months of their SRDL event. The average RAK for this subset of patients was 10 Gy (range of 5 to 15).
The mean peak skin dose for all FEVARs was 5 Gy (a range of 2 to 10 Gy), and the dose index was 0.69. The average peak skin dose for the subset of patients with multiple procedures was 7 Gy (a range of 3 to 9 Gy).
In terms of the follow-up, all 21 FEVAR patients were examined at the 1- or 2-week mark, 81% were examined at 1 month, 52% were examined at 3 months, and 62% were examined at 6 months. No radiation skin injuries were reported. “Based on the published data, we would expect to see all grades of skin injury, especially in the cohort of the 5-10 Gy,” Dr. Kirkwood said.
In the previous study, conducted prior to the new follow-up policy, the dose index for FEVARs was 0.78, “meaning that the peak skin dose that the patient received could be roughly estimated as 78% of the RAK dose displayed on the monitor,” Dr. Kirkwood explained. “In the current work, the dose index decreased to 60%. This suggests that surgeons in our group have now more appropriately and effectively employed strategies to decrease radiation dose to the patient. However, even when the best operating practice is employed, FEVARs still continue to require high radiation doses in order to complete. “
The present study demonstrated that deterministic skin injuries “are uncommon after FEVAR, even at high RAK levels and regardless of cumulative dose,” she concluded. “Even with more comprehensive patient follow-up, the fact that no skin injuries were reported suggests that skin injuries in this patient cohort are less prevalent than the published guidelines would predict.”
Dr. Kirkwood reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Skin injury following fenestrated endovascular aortic stent grafting is less prevalent than expected, results from a single-center retrospective study showed.
“Radiation-induced skin injury is a serious potential complication of fluoroscopically guided interventions,” Dr. Melissa L. Kirkwood said at the annual meeting of the Western Vascular Society. “These injuries are associated with a threshold radiation dose, above which the severity of injury increases with increasing dose. Instances of these injuries are mostly limited to case reports of coronary interventions, TIPS procedures, and neuroembolizations.”
These radiation-induced skin lesions can be classified as prompt, early, mid-term, or late depending on when they present following the fluoroscopically guided intervention. “The National Cancer Institute has defined four grades of skin injury, with the most frequent being transient erythema, a prompt reaction within the first 24 hours occurring at skin doses as low as 2 Gy,” said Dr. Kirkwood of the division of vascular and endovascular surgery at the University of Texas Southwestern Medical Center, Dallas. “With increasing skin doses, more severe effects present themselves. Atrophy, ulceration, and necrosis are possibilities.”
She went on to note that fenestrated endovascular aneurysm repairs often require high doses of radiation, yet the prevalence of deterministic skin injury following these cases is unknown. In a recent study, Dr. Kirkwood and her associates retrospectively reviewed 61 complex fluoroscopically guided interventions that met substantial radiation dose level criteria (SRDL), which is defined by the National Council on Radiation and Protection Measurements as a reference air kerma (RAK) greater than or equal to 5 Gy (J. Vasc. Surg. 2014; 60[3]:742-8). “Despite mean peak skin doses as high as 6.5 Gy, ranging up to 18.5 Gy, we did not detect any skin injuries in this cohort,” Dr. Kirkwood said. “That study, however, was limited by its retrospective design. There was no postoperative protocol in place to ensure that a thorough skin exam was performed on each patient at every follow-up visit. Therefore, we hypothesized that a more thorough postoperative follow-up of patients would detect some skin injury following these cases.”
For the current study, she and her associates sought to examine the prevalence of deterministic effects after FEVAR as well as well as any patient characteristics that may predispose patients to skin injury.
In June 2013, the researchers implemented a new policy regarding the follow-up of FEVAR patients, which involved a full skin exam at postoperative week 2 and 4, and at 3 and 6 months, as well as questioning patients about any skin-related complaints. For the current study, they retrospectively reviewed all FEVARs over a 7-month period after the change in policy and highlighted all the cases that reached a RAK of 5 Gy or greater. The RAK was the dose metric used in this study. It is a measure of the radiation dose to air at the interventional reference point, which, on standard fluoroscopes, is 15 cm along the beam axis toward the focal spot from isocenter. Dr. Kirkwood characterized RAK as “the best real-time indicator of patient dose, because it roughly estimates the dose at the entry point on the patient’s skin.” Peak skin dose, a dose index, and simulated skin dose maps were calculated using customized software employing input data from fluoroscopic machine logs.
Of 317 cases performed, 22 met or exceeded a RAK of 5 Gy. Of these, 21 were FEVARs and one was an embolization. Most patients (91%) were male and their mean body mass index was 30 kg/m2. Comorbidities and risk factors for skin injury included smoking, diabetes, and the concomitant applications of chemotherapeutic agents.
Dr. Kirkwood reported that the average RAK for all FEVARs was 8 Gy, with a range of 5-11 Gy. Slightly more than half of patients (52%) had multiple fluoroscopically guided interventions within 6 months of their SRDL event. The average RAK for this subset of patients was 10 Gy (range of 5 to 15).
The mean peak skin dose for all FEVARs was 5 Gy (a range of 2 to 10 Gy), and the dose index was 0.69. The average peak skin dose for the subset of patients with multiple procedures was 7 Gy (a range of 3 to 9 Gy).
In terms of the follow-up, all 21 FEVAR patients were examined at the 1- or 2-week mark, 81% were examined at 1 month, 52% were examined at 3 months, and 62% were examined at 6 months. No radiation skin injuries were reported. “Based on the published data, we would expect to see all grades of skin injury, especially in the cohort of the 5-10 Gy,” Dr. Kirkwood said.
In the previous study, conducted prior to the new follow-up policy, the dose index for FEVARs was 0.78, “meaning that the peak skin dose that the patient received could be roughly estimated as 78% of the RAK dose displayed on the monitor,” Dr. Kirkwood explained. “In the current work, the dose index decreased to 60%. This suggests that surgeons in our group have now more appropriately and effectively employed strategies to decrease radiation dose to the patient. However, even when the best operating practice is employed, FEVARs still continue to require high radiation doses in order to complete. “
The present study demonstrated that deterministic skin injuries “are uncommon after FEVAR, even at high RAK levels and regardless of cumulative dose,” she concluded. “Even with more comprehensive patient follow-up, the fact that no skin injuries were reported suggests that skin injuries in this patient cohort are less prevalent than the published guidelines would predict.”
Dr. Kirkwood reported having no financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: No skin injuries were found after fenestrated endovascular aortic stent grafts (FEVAR) cases that involved high radiation doses.
Major finding: Even though the average reference air kerma (RAK) for all FEVARs was 8 Gy, with a range of 5-11 Gy, no radiation skin injuries were reported.
Data source: An single-center analysis of 21 FEVARs over a 7-month period that reached a RAK of 5 Gy or greater.
Disclosures: Dr. Kirkwood reported having no financial disclosures.
Successful AVF creation a national challenge
CORONADO, CALIF.– Clinicians have a ways to go before they reach the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative Guidelines for vascular access, a recent analysis of national data suggest.
Part of the challenge is because the incidence of renal disease continues to grow over time, Dr. Mark R. Nehler said at the annual meeting of the Western Vascular Society. “The elderly population is growing, and the need for access is growing,” said Dr. Nehler, chief of the section of vascular surgery and endovascular therapy and podiatry at the University of Colorado Anschutz Medical Campus, Aurora. “There’s also large geographic variation in how patients are being treated, and a large percentage of patients do not see a nephrologist before they’re put on dialysis.”
The 2010 targets set by the Kidney Disease Outcomes Quality Initiative Guidelines recommend that clinicians create an arteriovenous fistula (AVF) in 50% of new-onset and 67% of existing hemodialysis patients, respectively, and to use catheters in fewer than 10% of hemodialysis patients. “Over time, the recommendations have become catheter-last rather than fistula-first,” Dr. Nehler said.
According to 2014 incidence data Dr. Nehler presented from Fistula First, a coalition that focuses on increasing the use of AV fistulas and decreasing the use of tunneled dialysis catheters, clinicians are using AVFs in new-onset hemodialysis patients only 20% of the time, 75% are still using catheters, and 5% are using grafts. “If you look at the incidence data for access, we’re not meeting the guidelines,” Dr. Nehler commented. “A fair amount of them have fistulas maturing, but we’re nowhere close to the 50% of patients starting dialysis using a fistula.”
Prevalence data from Fistula First is more on target, with 64% of patients using an AVF, but 19% of patients are using a catheter for prevalent access, “so there’s still some work to be done, but these numbers continue to get better.” States doing a good job implementing the guidelines include Colorado, New Mexico, New Hampshire, Washington, and Utah. “Some of the worst performers are in the South and in the East,” Dr. Nehler said. “When you look at the types of patients that don’t do well with fistulas, you realize that it probably has as much to do with the types of patients [clinicians are] taking care of as it has to do with any particular skill set of the surgeons involved.”
He characterized the rate of fistula maturation as “fairly sobering, where you can see a failure rate of 40%-45%, based on results from randomized trials,” he said. “Failure rate has been associated with advanced age, vein size, forearm AVFs especially in diabetics and in nonwhite patients.”
Dr. Nehler reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF.– Clinicians have a ways to go before they reach the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative Guidelines for vascular access, a recent analysis of national data suggest.
Part of the challenge is because the incidence of renal disease continues to grow over time, Dr. Mark R. Nehler said at the annual meeting of the Western Vascular Society. “The elderly population is growing, and the need for access is growing,” said Dr. Nehler, chief of the section of vascular surgery and endovascular therapy and podiatry at the University of Colorado Anschutz Medical Campus, Aurora. “There’s also large geographic variation in how patients are being treated, and a large percentage of patients do not see a nephrologist before they’re put on dialysis.”
The 2010 targets set by the Kidney Disease Outcomes Quality Initiative Guidelines recommend that clinicians create an arteriovenous fistula (AVF) in 50% of new-onset and 67% of existing hemodialysis patients, respectively, and to use catheters in fewer than 10% of hemodialysis patients. “Over time, the recommendations have become catheter-last rather than fistula-first,” Dr. Nehler said.
According to 2014 incidence data Dr. Nehler presented from Fistula First, a coalition that focuses on increasing the use of AV fistulas and decreasing the use of tunneled dialysis catheters, clinicians are using AVFs in new-onset hemodialysis patients only 20% of the time, 75% are still using catheters, and 5% are using grafts. “If you look at the incidence data for access, we’re not meeting the guidelines,” Dr. Nehler commented. “A fair amount of them have fistulas maturing, but we’re nowhere close to the 50% of patients starting dialysis using a fistula.”
Prevalence data from Fistula First is more on target, with 64% of patients using an AVF, but 19% of patients are using a catheter for prevalent access, “so there’s still some work to be done, but these numbers continue to get better.” States doing a good job implementing the guidelines include Colorado, New Mexico, New Hampshire, Washington, and Utah. “Some of the worst performers are in the South and in the East,” Dr. Nehler said. “When you look at the types of patients that don’t do well with fistulas, you realize that it probably has as much to do with the types of patients [clinicians are] taking care of as it has to do with any particular skill set of the surgeons involved.”
He characterized the rate of fistula maturation as “fairly sobering, where you can see a failure rate of 40%-45%, based on results from randomized trials,” he said. “Failure rate has been associated with advanced age, vein size, forearm AVFs especially in diabetics and in nonwhite patients.”
Dr. Nehler reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF.– Clinicians have a ways to go before they reach the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative Guidelines for vascular access, a recent analysis of national data suggest.
Part of the challenge is because the incidence of renal disease continues to grow over time, Dr. Mark R. Nehler said at the annual meeting of the Western Vascular Society. “The elderly population is growing, and the need for access is growing,” said Dr. Nehler, chief of the section of vascular surgery and endovascular therapy and podiatry at the University of Colorado Anschutz Medical Campus, Aurora. “There’s also large geographic variation in how patients are being treated, and a large percentage of patients do not see a nephrologist before they’re put on dialysis.”
The 2010 targets set by the Kidney Disease Outcomes Quality Initiative Guidelines recommend that clinicians create an arteriovenous fistula (AVF) in 50% of new-onset and 67% of existing hemodialysis patients, respectively, and to use catheters in fewer than 10% of hemodialysis patients. “Over time, the recommendations have become catheter-last rather than fistula-first,” Dr. Nehler said.
According to 2014 incidence data Dr. Nehler presented from Fistula First, a coalition that focuses on increasing the use of AV fistulas and decreasing the use of tunneled dialysis catheters, clinicians are using AVFs in new-onset hemodialysis patients only 20% of the time, 75% are still using catheters, and 5% are using grafts. “If you look at the incidence data for access, we’re not meeting the guidelines,” Dr. Nehler commented. “A fair amount of them have fistulas maturing, but we’re nowhere close to the 50% of patients starting dialysis using a fistula.”
Prevalence data from Fistula First is more on target, with 64% of patients using an AVF, but 19% of patients are using a catheter for prevalent access, “so there’s still some work to be done, but these numbers continue to get better.” States doing a good job implementing the guidelines include Colorado, New Mexico, New Hampshire, Washington, and Utah. “Some of the worst performers are in the South and in the East,” Dr. Nehler said. “When you look at the types of patients that don’t do well with fistulas, you realize that it probably has as much to do with the types of patients [clinicians are] taking care of as it has to do with any particular skill set of the surgeons involved.”
He characterized the rate of fistula maturation as “fairly sobering, where you can see a failure rate of 40%-45%, based on results from randomized trials,” he said. “Failure rate has been associated with advanced age, vein size, forearm AVFs especially in diabetics and in nonwhite patients.”
Dr. Nehler reported having no financial disclosures.
On Twitter @dougbrunk
EXPERT ANALYSIS AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Incidence of cranial nerve injury after CEA is low
CORONADO, CALIF. – Cranial nerve injury occurred in 4.6% of patients who participated in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), with 34% resolution at 1 month and 80.8% at 1 year, a detailed analysis demonstrated.
While cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy, its reported incidence “is highly variable, ranging from 3% to 30% and depends on the intensity and the methods that are used for evaluation,” Dr. Robert J. Hye said at the annual meeting of the Western Vascular Society. “When using clinical criteria as in CREST, the incidence varies from 5% to 8%, and most injuries resolve in a few weeks. But in rare cases it can result in significant long-term disability.”
Most publications that have evaluated CNI discuss the frequency of nerve injury, not resolution or the time to healing. “Previous publications have identified prolonged operations, urgent operations, and re-exploration as predictors of CNI,” said Dr. Hye of the department of general and vascular surgery at Kaiser Permanente, San Diego. “Advocates of CAS [carotid artery stenting] have equated CNI with minor stroke, mitigating some of the benefit of CEA over CAS.”
He and his associates conducted the present study in an effort to evaluate the incidence, predictive factors, and resolution and also to compare health-related quality of life in patients with and without CNI in CREST, a trial conducted at 117 centers in the United States and Canada in which 2,502 patients were randomized to receive either CAS or CEA. Researchers in that trial observed no difference in outcome in the combined primary endpoint of stroke, MI, and death, but periprocedural stroke was significantly more common in the CAS group and periprocedural MI in the CEA group. Quality of life analyses were performed at 2 weeks, 1 month, and 12 months after the interventions (N. Engl. J. Med. 2010;363:11-23).
For the current analysis, patients with CNI were identified from the CREST database and classified using case report forms, adverse event reports, and clinical follow-up notes. Adjudication of the CNIs was performed by two neurologists and one vascular surgeon. Patients with only cutaneous sensory symptoms were excluded from analysis, and postprocedural outcomes were assessed at 30 days and 12 months. The researchers used the SF-36 and disease-specific Likert scales to measure health-related quality of life.
The mean age of patients at baseline was 68 years. Dr. Hye reported that CNI occurred in 53 of 1,151 (4.6%) randomized to CEA who received their operation within 30 days. CNIs were also noted in five additional patients: three who crossed over from CAS to CEA and two who did not undergo CEA within 30 days of randomization. In contrast to prior studies, CNI was significantly more common when general anesthesia was used, but there were no other demographic or procedural characteristics that were predictive of CNI. About one-third of CNIs (34%) were resolved at 30 days, and 80.8% were resolved at 1 year. CNI had a small effect on quality of life, negatively impacting only swallowing and eating at 2 and 4 weeks but not at 1 year (P less than .001).
Injuries to cranial nerves IX and X were most common, followed by injuries to the marginal mandibular branch of the facial nerve and the hypoglossal nerves. All of the hypoglossal injuries resolved, while injuries involving cranial nerves IX and X were least likely to resolve.
Dr. Hye acknowledged certain limitations of the trial, including the fact that CNI diagnosis was made from a clinical standpoint, and there were no routine otolaryngologic exams. “It’s likely that some of the subtle injuries were missed and that the incidence of cranial nerve injury is underestimated,” he added. “On the other hand, patients did have postoperative exams by experienced neurologists and vascular surgeons, so not many of the injuries should have been missed. Another unique thing about the study is the [quality of life] tools [we used]. They may be insufficiently sensitive to detect the consequences of CNI.”
Dr. Hye went on to note that the persistence of CNI at 1 year in CREST is higher than in most other reports available in the medical literature (19.2% vs. 7%-12%, respectively). “We’re not really sure why this is the case,” he said. “It may be that the postoperative assessment in CREST was more detailed and detected more subtle residual deficits from the CNIs.”
The study was funded by the National Institutes of Health, with supplemental funding from Abbott Vascular Inc. Dr. Hye reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Cranial nerve injury occurred in 4.6% of patients who participated in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), with 34% resolution at 1 month and 80.8% at 1 year, a detailed analysis demonstrated.
While cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy, its reported incidence “is highly variable, ranging from 3% to 30% and depends on the intensity and the methods that are used for evaluation,” Dr. Robert J. Hye said at the annual meeting of the Western Vascular Society. “When using clinical criteria as in CREST, the incidence varies from 5% to 8%, and most injuries resolve in a few weeks. But in rare cases it can result in significant long-term disability.”
Most publications that have evaluated CNI discuss the frequency of nerve injury, not resolution or the time to healing. “Previous publications have identified prolonged operations, urgent operations, and re-exploration as predictors of CNI,” said Dr. Hye of the department of general and vascular surgery at Kaiser Permanente, San Diego. “Advocates of CAS [carotid artery stenting] have equated CNI with minor stroke, mitigating some of the benefit of CEA over CAS.”
He and his associates conducted the present study in an effort to evaluate the incidence, predictive factors, and resolution and also to compare health-related quality of life in patients with and without CNI in CREST, a trial conducted at 117 centers in the United States and Canada in which 2,502 patients were randomized to receive either CAS or CEA. Researchers in that trial observed no difference in outcome in the combined primary endpoint of stroke, MI, and death, but periprocedural stroke was significantly more common in the CAS group and periprocedural MI in the CEA group. Quality of life analyses were performed at 2 weeks, 1 month, and 12 months after the interventions (N. Engl. J. Med. 2010;363:11-23).
For the current analysis, patients with CNI were identified from the CREST database and classified using case report forms, adverse event reports, and clinical follow-up notes. Adjudication of the CNIs was performed by two neurologists and one vascular surgeon. Patients with only cutaneous sensory symptoms were excluded from analysis, and postprocedural outcomes were assessed at 30 days and 12 months. The researchers used the SF-36 and disease-specific Likert scales to measure health-related quality of life.
The mean age of patients at baseline was 68 years. Dr. Hye reported that CNI occurred in 53 of 1,151 (4.6%) randomized to CEA who received their operation within 30 days. CNIs were also noted in five additional patients: three who crossed over from CAS to CEA and two who did not undergo CEA within 30 days of randomization. In contrast to prior studies, CNI was significantly more common when general anesthesia was used, but there were no other demographic or procedural characteristics that were predictive of CNI. About one-third of CNIs (34%) were resolved at 30 days, and 80.8% were resolved at 1 year. CNI had a small effect on quality of life, negatively impacting only swallowing and eating at 2 and 4 weeks but not at 1 year (P less than .001).
Injuries to cranial nerves IX and X were most common, followed by injuries to the marginal mandibular branch of the facial nerve and the hypoglossal nerves. All of the hypoglossal injuries resolved, while injuries involving cranial nerves IX and X were least likely to resolve.
Dr. Hye acknowledged certain limitations of the trial, including the fact that CNI diagnosis was made from a clinical standpoint, and there were no routine otolaryngologic exams. “It’s likely that some of the subtle injuries were missed and that the incidence of cranial nerve injury is underestimated,” he added. “On the other hand, patients did have postoperative exams by experienced neurologists and vascular surgeons, so not many of the injuries should have been missed. Another unique thing about the study is the [quality of life] tools [we used]. They may be insufficiently sensitive to detect the consequences of CNI.”
Dr. Hye went on to note that the persistence of CNI at 1 year in CREST is higher than in most other reports available in the medical literature (19.2% vs. 7%-12%, respectively). “We’re not really sure why this is the case,” he said. “It may be that the postoperative assessment in CREST was more detailed and detected more subtle residual deficits from the CNIs.”
The study was funded by the National Institutes of Health, with supplemental funding from Abbott Vascular Inc. Dr. Hye reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Cranial nerve injury occurred in 4.6% of patients who participated in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), with 34% resolution at 1 month and 80.8% at 1 year, a detailed analysis demonstrated.
While cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy, its reported incidence “is highly variable, ranging from 3% to 30% and depends on the intensity and the methods that are used for evaluation,” Dr. Robert J. Hye said at the annual meeting of the Western Vascular Society. “When using clinical criteria as in CREST, the incidence varies from 5% to 8%, and most injuries resolve in a few weeks. But in rare cases it can result in significant long-term disability.”
Most publications that have evaluated CNI discuss the frequency of nerve injury, not resolution or the time to healing. “Previous publications have identified prolonged operations, urgent operations, and re-exploration as predictors of CNI,” said Dr. Hye of the department of general and vascular surgery at Kaiser Permanente, San Diego. “Advocates of CAS [carotid artery stenting] have equated CNI with minor stroke, mitigating some of the benefit of CEA over CAS.”
He and his associates conducted the present study in an effort to evaluate the incidence, predictive factors, and resolution and also to compare health-related quality of life in patients with and without CNI in CREST, a trial conducted at 117 centers in the United States and Canada in which 2,502 patients were randomized to receive either CAS or CEA. Researchers in that trial observed no difference in outcome in the combined primary endpoint of stroke, MI, and death, but periprocedural stroke was significantly more common in the CAS group and periprocedural MI in the CEA group. Quality of life analyses were performed at 2 weeks, 1 month, and 12 months after the interventions (N. Engl. J. Med. 2010;363:11-23).
For the current analysis, patients with CNI were identified from the CREST database and classified using case report forms, adverse event reports, and clinical follow-up notes. Adjudication of the CNIs was performed by two neurologists and one vascular surgeon. Patients with only cutaneous sensory symptoms were excluded from analysis, and postprocedural outcomes were assessed at 30 days and 12 months. The researchers used the SF-36 and disease-specific Likert scales to measure health-related quality of life.
The mean age of patients at baseline was 68 years. Dr. Hye reported that CNI occurred in 53 of 1,151 (4.6%) randomized to CEA who received their operation within 30 days. CNIs were also noted in five additional patients: three who crossed over from CAS to CEA and two who did not undergo CEA within 30 days of randomization. In contrast to prior studies, CNI was significantly more common when general anesthesia was used, but there were no other demographic or procedural characteristics that were predictive of CNI. About one-third of CNIs (34%) were resolved at 30 days, and 80.8% were resolved at 1 year. CNI had a small effect on quality of life, negatively impacting only swallowing and eating at 2 and 4 weeks but not at 1 year (P less than .001).
Injuries to cranial nerves IX and X were most common, followed by injuries to the marginal mandibular branch of the facial nerve and the hypoglossal nerves. All of the hypoglossal injuries resolved, while injuries involving cranial nerves IX and X were least likely to resolve.
Dr. Hye acknowledged certain limitations of the trial, including the fact that CNI diagnosis was made from a clinical standpoint, and there were no routine otolaryngologic exams. “It’s likely that some of the subtle injuries were missed and that the incidence of cranial nerve injury is underestimated,” he added. “On the other hand, patients did have postoperative exams by experienced neurologists and vascular surgeons, so not many of the injuries should have been missed. Another unique thing about the study is the [quality of life] tools [we used]. They may be insufficiently sensitive to detect the consequences of CNI.”
Dr. Hye went on to note that the persistence of CNI at 1 year in CREST is higher than in most other reports available in the medical literature (19.2% vs. 7%-12%, respectively). “We’re not really sure why this is the case,” he said. “It may be that the postoperative assessment in CREST was more detailed and detected more subtle residual deficits from the CNIs.”
The study was funded by the National Institutes of Health, with supplemental funding from Abbott Vascular Inc. Dr. Hye reported having no financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: Cranial nerve injury occurred in fewer than 5% of patients undergoing carotid endarterectomy.
Major finding: About one-third of CNIs sustained by patients who underwent CEA resolved within 30 days (34%), and 80.8% resolved at 1 year.
Data source: An analysis of 1,151 patients who were randomized to carotid revascularization endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).
Disclosures: The study was funded by the National Institutes of Health, with supplemental funding from Abbott Vascular Inc. Dr. Hye reported having no financial disclosures.
Postcarotid stenting hemodynamic instability doesn’t increase stroke risk
CORONADO, CALIF. – Periprocedural hemodynamic instability, which occurs frequently during carotid artery stenting, may increase the risk of transient ischemic attack, a single-center study showed.
“In carotid artery angioplasty and stenting, manipulation of the carotid sinus baroreceptor can lead to decreased sympathetic vascular tone, increased parasympathetic efferent signals, and a resultant bradycardia and hypotension,” Dr. Tiffany Y. Wu said at the annual meeting of the Western Vascular Society.
According to published reports in the medical literature, the incidence of hemodynamic instability (HI) following carotid artery stenting (CAS) has been observed in 46%-84% of cases. Several studies have also shown that different factors may be associated with the development of HI, according to Dr. Wu of the department of surgery at Huntington Hospital, Pasadena, Calif. “For example, gender, age, tobacco use, and diabetes have all been implicated in being associated with an increased incidence of HI,” she said. “However, the impact of HI on major adverse events is still highly controversial. Thus, it was the purpose of our study to determine the predictors and consequences of hemodynamic instability following CAS.”
She and her associates evaluated consecutive patients who underwent CAS at Huntington Hospital between 2005 and 2013. They examined preoperative risk factors, periprocedural hemodynamic status, and the incidence of major adverse events including stroke, transient ischemic attack, myocardial infarction, and death. The researchers used chi-square analysis to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to suffer major adverse events, compared with those who did not.
In all, 199 CAS procedures were performed in 191 patients. More than half (61%) were men, 87% had hypertension, 49% were smokers, 48% had coronary artery disease, 38% had diabetes, 56% were asymptomatic, 24% had experienced a previous TIA, 20% had experienced a previous stroke, 41% were on beta blockers, and 91% received periprocedural atropine.
Hemodynamic instability was classified as hypertension, hypotension, bradycardia, a systolic BP drop of greater than 30 mm Hg, a heart rate drop of more than 20 beats per minute, HI lasting less than 1 hour (transient), or HI lasting more than 1 hour (prolonged).
Dr. Wu reported that 130 cases of HI occurred (65%). Among these, 10% experienced hypotension, 17% experienced bradycardia, and 2.5% experienced a heart rate drop greater than 20 beats per minute. “We also found a low incidence of ICU admission: Only 5.5% of our patients were admitted to the ICU with hemodynamic instability, less than half of whom required the use of vasopressors,” she said. The incidence of major and minor stroke was 1% and 2.5%, respectively, and the incidence of TIA was 2.5%. No MIs or deaths occurred.
The researchers found that age of at least 80 years and female sex were associated with an increased incidence of HI. Previous neck radiation and contralateral occlusion were “somewhat protective against HI,” she noted. “When looking at HI and major adverse events, we found that only prolonged HI was associated with an increased incidence of TIA. However, there was no statistically significant correlation found between HI and stroke.”
Dr. Wu reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Periprocedural hemodynamic instability, which occurs frequently during carotid artery stenting, may increase the risk of transient ischemic attack, a single-center study showed.
“In carotid artery angioplasty and stenting, manipulation of the carotid sinus baroreceptor can lead to decreased sympathetic vascular tone, increased parasympathetic efferent signals, and a resultant bradycardia and hypotension,” Dr. Tiffany Y. Wu said at the annual meeting of the Western Vascular Society.
According to published reports in the medical literature, the incidence of hemodynamic instability (HI) following carotid artery stenting (CAS) has been observed in 46%-84% of cases. Several studies have also shown that different factors may be associated with the development of HI, according to Dr. Wu of the department of surgery at Huntington Hospital, Pasadena, Calif. “For example, gender, age, tobacco use, and diabetes have all been implicated in being associated with an increased incidence of HI,” she said. “However, the impact of HI on major adverse events is still highly controversial. Thus, it was the purpose of our study to determine the predictors and consequences of hemodynamic instability following CAS.”
She and her associates evaluated consecutive patients who underwent CAS at Huntington Hospital between 2005 and 2013. They examined preoperative risk factors, periprocedural hemodynamic status, and the incidence of major adverse events including stroke, transient ischemic attack, myocardial infarction, and death. The researchers used chi-square analysis to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to suffer major adverse events, compared with those who did not.
In all, 199 CAS procedures were performed in 191 patients. More than half (61%) were men, 87% had hypertension, 49% were smokers, 48% had coronary artery disease, 38% had diabetes, 56% were asymptomatic, 24% had experienced a previous TIA, 20% had experienced a previous stroke, 41% were on beta blockers, and 91% received periprocedural atropine.
Hemodynamic instability was classified as hypertension, hypotension, bradycardia, a systolic BP drop of greater than 30 mm Hg, a heart rate drop of more than 20 beats per minute, HI lasting less than 1 hour (transient), or HI lasting more than 1 hour (prolonged).
Dr. Wu reported that 130 cases of HI occurred (65%). Among these, 10% experienced hypotension, 17% experienced bradycardia, and 2.5% experienced a heart rate drop greater than 20 beats per minute. “We also found a low incidence of ICU admission: Only 5.5% of our patients were admitted to the ICU with hemodynamic instability, less than half of whom required the use of vasopressors,” she said. The incidence of major and minor stroke was 1% and 2.5%, respectively, and the incidence of TIA was 2.5%. No MIs or deaths occurred.
The researchers found that age of at least 80 years and female sex were associated with an increased incidence of HI. Previous neck radiation and contralateral occlusion were “somewhat protective against HI,” she noted. “When looking at HI and major adverse events, we found that only prolonged HI was associated with an increased incidence of TIA. However, there was no statistically significant correlation found between HI and stroke.”
Dr. Wu reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Periprocedural hemodynamic instability, which occurs frequently during carotid artery stenting, may increase the risk of transient ischemic attack, a single-center study showed.
“In carotid artery angioplasty and stenting, manipulation of the carotid sinus baroreceptor can lead to decreased sympathetic vascular tone, increased parasympathetic efferent signals, and a resultant bradycardia and hypotension,” Dr. Tiffany Y. Wu said at the annual meeting of the Western Vascular Society.
According to published reports in the medical literature, the incidence of hemodynamic instability (HI) following carotid artery stenting (CAS) has been observed in 46%-84% of cases. Several studies have also shown that different factors may be associated with the development of HI, according to Dr. Wu of the department of surgery at Huntington Hospital, Pasadena, Calif. “For example, gender, age, tobacco use, and diabetes have all been implicated in being associated with an increased incidence of HI,” she said. “However, the impact of HI on major adverse events is still highly controversial. Thus, it was the purpose of our study to determine the predictors and consequences of hemodynamic instability following CAS.”
She and her associates evaluated consecutive patients who underwent CAS at Huntington Hospital between 2005 and 2013. They examined preoperative risk factors, periprocedural hemodynamic status, and the incidence of major adverse events including stroke, transient ischemic attack, myocardial infarction, and death. The researchers used chi-square analysis to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to suffer major adverse events, compared with those who did not.
In all, 199 CAS procedures were performed in 191 patients. More than half (61%) were men, 87% had hypertension, 49% were smokers, 48% had coronary artery disease, 38% had diabetes, 56% were asymptomatic, 24% had experienced a previous TIA, 20% had experienced a previous stroke, 41% were on beta blockers, and 91% received periprocedural atropine.
Hemodynamic instability was classified as hypertension, hypotension, bradycardia, a systolic BP drop of greater than 30 mm Hg, a heart rate drop of more than 20 beats per minute, HI lasting less than 1 hour (transient), or HI lasting more than 1 hour (prolonged).
Dr. Wu reported that 130 cases of HI occurred (65%). Among these, 10% experienced hypotension, 17% experienced bradycardia, and 2.5% experienced a heart rate drop greater than 20 beats per minute. “We also found a low incidence of ICU admission: Only 5.5% of our patients were admitted to the ICU with hemodynamic instability, less than half of whom required the use of vasopressors,” she said. The incidence of major and minor stroke was 1% and 2.5%, respectively, and the incidence of TIA was 2.5%. No MIs or deaths occurred.
The researchers found that age of at least 80 years and female sex were associated with an increased incidence of HI. Previous neck radiation and contralateral occlusion were “somewhat protective against HI,” she noted. “When looking at HI and major adverse events, we found that only prolonged HI was associated with an increased incidence of TIA. However, there was no statistically significant correlation found between HI and stroke.”
Dr. Wu reported having no financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: Prolonged hemodynamic instability after carotid artery stenting is associated with increased incidence of TIA, but not MI or death.
Major finding: Age of at least 80 years and female sex were associated with an increased incidence of post-CAS HI. The only significant adverse effect was TIA in patients with prolonged HI.
Data source: A review of 199 CAS procedures performed in 191 consecutive patients at Pasadena, Calif.–based Huntington Hospital between 2005 and 2013.
Disclosures: Dr. Wu reporting having no financial disclosures.
Carotid stenting outcomes similar between surgeons, interventionalists
CORONADO, CALIF. – Major outcomes of stroke, myocardial infarction, and 30-day mortality following carotid stenting are nearly equivalent between surgeons and interventionalists, results from a national cohort study suggest.
In addition, the volume of cases performed by a clinician, rather than the clinician’s specialty, appears to be a stronger predictor of adverse outcomes for performing carotid stenting. Those are key findings from an evaluation of more than 20,000 carotid stenting procedures extracted from the Nationwide Inpatient Sample (NIS) between 2004 and 2011, which was presented at the annual meeting of the Western Vascular Society.
“Stroke is the third most common cause of death in the United States, and 20%-25% of strokes are attributable to carotid stenosis,” said lead author Dr. Michael D. Sgroi, of the division of vascular and endovascular surgery at the University of California, Irvine. “The current standard of care has been carotid endarterectomy. However, in 2010, carotid stenting was recognized as an alternative treatment. Since that time, there’s been an exhaustive debate regarding which is the best treatment.
“In addition, there has been a broad spectrum of physicians practicing the use of carotid stenting, including vascular surgeons, interventional radiologists, neurovascular interventionalists, and interventional cardiologists. This begs the question: Does specialty make a difference in outcomes for carotid stenting?”
Dr. Sgroi and his associates evaluated 20,663 carotid stenting procedures extracted from the NIS dataset. They divided the cohort based on the type of provider performing the procedure: surgeon or interventionalist. All elective, urgent, and emergent cases of carotid stenting were included in the analysis, while patients who underwent balloon angioplasty were excluded, as were those who underwent carotid endarterectomy. The primary endpoints were postoperative stroke or myocardial infarction (MI) and in-hospital mortality. The secondary endpoint was estimated associations with a 10-unit volume difference among centers.
Upon first glance at the data, the researchers detected low numbers of interventionalists. Therefore, they created criteria to identify physicians who were considered surgeons. They defined a surgeon as a physician who performed a carotid endarterectomy and either a femoral-popliteal artery bypass or an arteriovenous fistula within the same calendar year of the carotid stenting procedure.
Of the 20,663 cases, 15,305 (74%) were performed by surgeons, while 5,358 (26%) were performed by interventionalists. The mean patient age was 71 years, 61% were male, and 72% were white. The majority of cases (97%) were performed at teaching hospitals or at designated teaching institutions (61%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% vs. 4.41%, respectively), MI (2.10% vs. 2.13%), and mortality (0.84% and 1.03%). When the researchers examined the percentage of stroke in 2008, “we saw an initial increase,” Dr. Sgroi said. “This may have been due to the amount of physicians who were performing carotid stenting.”
The researchers observed a statistically significant difference between the two groups in hospital length of stay as well as total hospital charges, with procedures performed by interventionalists resulting in a stay that was about one-third of a day longer, and about $3,000 more expensive.
Adjusted multivariate analysis demonstrated no statistically significant differences between the two types of clinicians in stroke, MI, or hospital mortality. However, hospital length of stay was significantly lower for procedures performed by surgeons, compared with interventionalists (2.81 vs. 3.08 days, respectively), as were total hospital charges ($48,088 vs. $51,719). “The cause of the difference is unclear and not discernible through the available data,” Dr. Sgroi said.
When he and his associates examined the 10-unit volume difference among centers, they found a statistically significant increase in the rate of stroke among lower-volume centers, but no other significant differences in outcomes were observed. “We believe that the rate of complications secondary to carotid stenting has stayed consistent from 2004 to 2011, despite advances in technology,” Dr. Sgroi concluded.
He acknowledged certain limitations of the study, including its retrospective design and the fact that data from the NIS account for only 20% of the U.S. population.
Dr. Sgroi reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Major outcomes of stroke, myocardial infarction, and 30-day mortality following carotid stenting are nearly equivalent between surgeons and interventionalists, results from a national cohort study suggest.
In addition, the volume of cases performed by a clinician, rather than the clinician’s specialty, appears to be a stronger predictor of adverse outcomes for performing carotid stenting. Those are key findings from an evaluation of more than 20,000 carotid stenting procedures extracted from the Nationwide Inpatient Sample (NIS) between 2004 and 2011, which was presented at the annual meeting of the Western Vascular Society.
“Stroke is the third most common cause of death in the United States, and 20%-25% of strokes are attributable to carotid stenosis,” said lead author Dr. Michael D. Sgroi, of the division of vascular and endovascular surgery at the University of California, Irvine. “The current standard of care has been carotid endarterectomy. However, in 2010, carotid stenting was recognized as an alternative treatment. Since that time, there’s been an exhaustive debate regarding which is the best treatment.
“In addition, there has been a broad spectrum of physicians practicing the use of carotid stenting, including vascular surgeons, interventional radiologists, neurovascular interventionalists, and interventional cardiologists. This begs the question: Does specialty make a difference in outcomes for carotid stenting?”
Dr. Sgroi and his associates evaluated 20,663 carotid stenting procedures extracted from the NIS dataset. They divided the cohort based on the type of provider performing the procedure: surgeon or interventionalist. All elective, urgent, and emergent cases of carotid stenting were included in the analysis, while patients who underwent balloon angioplasty were excluded, as were those who underwent carotid endarterectomy. The primary endpoints were postoperative stroke or myocardial infarction (MI) and in-hospital mortality. The secondary endpoint was estimated associations with a 10-unit volume difference among centers.
Upon first glance at the data, the researchers detected low numbers of interventionalists. Therefore, they created criteria to identify physicians who were considered surgeons. They defined a surgeon as a physician who performed a carotid endarterectomy and either a femoral-popliteal artery bypass or an arteriovenous fistula within the same calendar year of the carotid stenting procedure.
Of the 20,663 cases, 15,305 (74%) were performed by surgeons, while 5,358 (26%) were performed by interventionalists. The mean patient age was 71 years, 61% were male, and 72% were white. The majority of cases (97%) were performed at teaching hospitals or at designated teaching institutions (61%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% vs. 4.41%, respectively), MI (2.10% vs. 2.13%), and mortality (0.84% and 1.03%). When the researchers examined the percentage of stroke in 2008, “we saw an initial increase,” Dr. Sgroi said. “This may have been due to the amount of physicians who were performing carotid stenting.”
The researchers observed a statistically significant difference between the two groups in hospital length of stay as well as total hospital charges, with procedures performed by interventionalists resulting in a stay that was about one-third of a day longer, and about $3,000 more expensive.
Adjusted multivariate analysis demonstrated no statistically significant differences between the two types of clinicians in stroke, MI, or hospital mortality. However, hospital length of stay was significantly lower for procedures performed by surgeons, compared with interventionalists (2.81 vs. 3.08 days, respectively), as were total hospital charges ($48,088 vs. $51,719). “The cause of the difference is unclear and not discernible through the available data,” Dr. Sgroi said.
When he and his associates examined the 10-unit volume difference among centers, they found a statistically significant increase in the rate of stroke among lower-volume centers, but no other significant differences in outcomes were observed. “We believe that the rate of complications secondary to carotid stenting has stayed consistent from 2004 to 2011, despite advances in technology,” Dr. Sgroi concluded.
He acknowledged certain limitations of the study, including its retrospective design and the fact that data from the NIS account for only 20% of the U.S. population.
Dr. Sgroi reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Major outcomes of stroke, myocardial infarction, and 30-day mortality following carotid stenting are nearly equivalent between surgeons and interventionalists, results from a national cohort study suggest.
In addition, the volume of cases performed by a clinician, rather than the clinician’s specialty, appears to be a stronger predictor of adverse outcomes for performing carotid stenting. Those are key findings from an evaluation of more than 20,000 carotid stenting procedures extracted from the Nationwide Inpatient Sample (NIS) between 2004 and 2011, which was presented at the annual meeting of the Western Vascular Society.
“Stroke is the third most common cause of death in the United States, and 20%-25% of strokes are attributable to carotid stenosis,” said lead author Dr. Michael D. Sgroi, of the division of vascular and endovascular surgery at the University of California, Irvine. “The current standard of care has been carotid endarterectomy. However, in 2010, carotid stenting was recognized as an alternative treatment. Since that time, there’s been an exhaustive debate regarding which is the best treatment.
“In addition, there has been a broad spectrum of physicians practicing the use of carotid stenting, including vascular surgeons, interventional radiologists, neurovascular interventionalists, and interventional cardiologists. This begs the question: Does specialty make a difference in outcomes for carotid stenting?”
Dr. Sgroi and his associates evaluated 20,663 carotid stenting procedures extracted from the NIS dataset. They divided the cohort based on the type of provider performing the procedure: surgeon or interventionalist. All elective, urgent, and emergent cases of carotid stenting were included in the analysis, while patients who underwent balloon angioplasty were excluded, as were those who underwent carotid endarterectomy. The primary endpoints were postoperative stroke or myocardial infarction (MI) and in-hospital mortality. The secondary endpoint was estimated associations with a 10-unit volume difference among centers.
Upon first glance at the data, the researchers detected low numbers of interventionalists. Therefore, they created criteria to identify physicians who were considered surgeons. They defined a surgeon as a physician who performed a carotid endarterectomy and either a femoral-popliteal artery bypass or an arteriovenous fistula within the same calendar year of the carotid stenting procedure.
Of the 20,663 cases, 15,305 (74%) were performed by surgeons, while 5,358 (26%) were performed by interventionalists. The mean patient age was 71 years, 61% were male, and 72% were white. The majority of cases (97%) were performed at teaching hospitals or at designated teaching institutions (61%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% vs. 4.41%, respectively), MI (2.10% vs. 2.13%), and mortality (0.84% and 1.03%). When the researchers examined the percentage of stroke in 2008, “we saw an initial increase,” Dr. Sgroi said. “This may have been due to the amount of physicians who were performing carotid stenting.”
The researchers observed a statistically significant difference between the two groups in hospital length of stay as well as total hospital charges, with procedures performed by interventionalists resulting in a stay that was about one-third of a day longer, and about $3,000 more expensive.
Adjusted multivariate analysis demonstrated no statistically significant differences between the two types of clinicians in stroke, MI, or hospital mortality. However, hospital length of stay was significantly lower for procedures performed by surgeons, compared with interventionalists (2.81 vs. 3.08 days, respectively), as were total hospital charges ($48,088 vs. $51,719). “The cause of the difference is unclear and not discernible through the available data,” Dr. Sgroi said.
When he and his associates examined the 10-unit volume difference among centers, they found a statistically significant increase in the rate of stroke among lower-volume centers, but no other significant differences in outcomes were observed. “We believe that the rate of complications secondary to carotid stenting has stayed consistent from 2004 to 2011, despite advances in technology,” Dr. Sgroi concluded.
He acknowledged certain limitations of the study, including its retrospective design and the fact that data from the NIS account for only 20% of the U.S. population.
Dr. Sgroi reported having no financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: Outcomes of carotid stenting were similar whether performed by surgeons or interventionalists.
Major finding: Adjusted multivariate analysis demonstrated no significant differences in the rates of stroke, MI, and mortality among cases of carotid stenting performed by surgeons and interventionalists.
Data source: An analysis of 20,663 cases of carotid stenting extracted from the Nationwide Inpatient Sample database between 2004 and 2011.
Disclosures: Dr. Sgroi reported having no financial disclosures.
Intraoperative evaluation may be best for predicting AVF success
CORONADO, CALIF. – Intraoperative vessel assessment, not preoperative vein mapping, was more accurately associated with maturation and cumulative functional patency rates of arteriovenous fistulas, results from a 5-year, single-center retrospective study showed.
“The prevalence of chronic kidney disease has increased over the last 3 decades, and efforts by the Centers for Medicare & Medicaid Services and the National Kidney Foundation have sought to increase the use of fistulas,” Dr. Khanh P. Nguyen said at the annual meeting of the Western Vascular Society.
“Since 2003, the incidence and prevalence of fistulas have increased. More recently, even higher goals have been set. Arteriovenous fistulas are the preferred procedures due to higher patency rates, reduced rates of reintervention, and lower costs, compared with central venous catheters or grafts.”
Dr. Nguyen, formerly of Loma Linda (Calif.) Medical Center who is now a vascular surgery fellow at Oregon Health and Science University, noted that while many studies as well as the Society for Vascular Surgery have advocated the use of routine preoperative ultrasound in predicting the success of arteriovenous fistulas (AVFs), its use varies among vascular surgeons. “Given the additional costs and time of preoperative ultrasound, this study was undertaken to examine the use of this technique and compare it to intraoperative assessment,” she said.
The researchers examined all autologous AVFs created for patients with end-stage-renal disease at the Veterans Affairs Loma Linda Health System between February 2007 and July 2012. Preoperative ultrasound mapping of upper-extremity veins occurred, and patients were divided into two groups: those with veins less than 3 mm in size and those with veins 3 mm or greater in size. Subjective intraoperative evaluation was conducted by the operative surgeon, who rated the vein as either “good” or “poor” because of factors such as inadequate diameter, sclerosis, and calcification. Kaplan-Meier analysis was used to calculate maturation and patency rates.
Over the 5-year period, 387 fistulas were created in 361 patients. Of these, 198 had preoperative vein mapping; 36% were less than 3 mm in size, and 64% were 3 mm or greater in size.
By intraoperative assessment, 14% of patients were determined to have had poor vessels, and 86% were found to have good vessels. About half of the fistulas (51%) were created at the wrist. The average age of patients was 65 years, their mean body mass index was 28 kg/m2, and their mean time on dialysis was 84 years. The majority (97%) were male.
Among patients with preoperative veins less than 3 mm in size or 3 mm in size or greater, the maturation and overall failure rates were similar at 71% vs. 75% (P = .61) and 68% vs. 58% (P = .15). However, among patients with assessments of poor or good veins at the time of operation, the maturation and overall failure rates were 42% vs. 82% (P < .001) and 86% vs. 54% (P < .001).
Subgroup analysis revealed that patients with good intraoperative evaluation, regardless of preoperative ultrasound findings, had higher maturation rates. “Likewise, patients with good intraoperative assessment, regardless of preoperative ultrasound findings, had higher cumulative functional patency rates. Of note, no patient who had both poor preoperative ultrasound and intraoperative assessments had a functional fistula at the time of last follow-up.”
Dr. Nguyen and her associates concluded that intraoperative vessel assessment, and not preoperative ultrasound, was more accurately associated with maturation and cumulative functional patency rates. “Even in patients with inadequate preoperative ultrasound vein mapping, intraoperative assessment may still be warranted,” she said. “If both preoperative and intraoperative assessments conclude that vessels are inadequate, do not create an AVF at that site.”
Dr. Nguyen reported having no relevant financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Intraoperative vessel assessment, not preoperative vein mapping, was more accurately associated with maturation and cumulative functional patency rates of arteriovenous fistulas, results from a 5-year, single-center retrospective study showed.
“The prevalence of chronic kidney disease has increased over the last 3 decades, and efforts by the Centers for Medicare & Medicaid Services and the National Kidney Foundation have sought to increase the use of fistulas,” Dr. Khanh P. Nguyen said at the annual meeting of the Western Vascular Society.
“Since 2003, the incidence and prevalence of fistulas have increased. More recently, even higher goals have been set. Arteriovenous fistulas are the preferred procedures due to higher patency rates, reduced rates of reintervention, and lower costs, compared with central venous catheters or grafts.”
Dr. Nguyen, formerly of Loma Linda (Calif.) Medical Center who is now a vascular surgery fellow at Oregon Health and Science University, noted that while many studies as well as the Society for Vascular Surgery have advocated the use of routine preoperative ultrasound in predicting the success of arteriovenous fistulas (AVFs), its use varies among vascular surgeons. “Given the additional costs and time of preoperative ultrasound, this study was undertaken to examine the use of this technique and compare it to intraoperative assessment,” she said.
The researchers examined all autologous AVFs created for patients with end-stage-renal disease at the Veterans Affairs Loma Linda Health System between February 2007 and July 2012. Preoperative ultrasound mapping of upper-extremity veins occurred, and patients were divided into two groups: those with veins less than 3 mm in size and those with veins 3 mm or greater in size. Subjective intraoperative evaluation was conducted by the operative surgeon, who rated the vein as either “good” or “poor” because of factors such as inadequate diameter, sclerosis, and calcification. Kaplan-Meier analysis was used to calculate maturation and patency rates.
Over the 5-year period, 387 fistulas were created in 361 patients. Of these, 198 had preoperative vein mapping; 36% were less than 3 mm in size, and 64% were 3 mm or greater in size.
By intraoperative assessment, 14% of patients were determined to have had poor vessels, and 86% were found to have good vessels. About half of the fistulas (51%) were created at the wrist. The average age of patients was 65 years, their mean body mass index was 28 kg/m2, and their mean time on dialysis was 84 years. The majority (97%) were male.
Among patients with preoperative veins less than 3 mm in size or 3 mm in size or greater, the maturation and overall failure rates were similar at 71% vs. 75% (P = .61) and 68% vs. 58% (P = .15). However, among patients with assessments of poor or good veins at the time of operation, the maturation and overall failure rates were 42% vs. 82% (P < .001) and 86% vs. 54% (P < .001).
Subgroup analysis revealed that patients with good intraoperative evaluation, regardless of preoperative ultrasound findings, had higher maturation rates. “Likewise, patients with good intraoperative assessment, regardless of preoperative ultrasound findings, had higher cumulative functional patency rates. Of note, no patient who had both poor preoperative ultrasound and intraoperative assessments had a functional fistula at the time of last follow-up.”
Dr. Nguyen and her associates concluded that intraoperative vessel assessment, and not preoperative ultrasound, was more accurately associated with maturation and cumulative functional patency rates. “Even in patients with inadequate preoperative ultrasound vein mapping, intraoperative assessment may still be warranted,” she said. “If both preoperative and intraoperative assessments conclude that vessels are inadequate, do not create an AVF at that site.”
Dr. Nguyen reported having no relevant financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Intraoperative vessel assessment, not preoperative vein mapping, was more accurately associated with maturation and cumulative functional patency rates of arteriovenous fistulas, results from a 5-year, single-center retrospective study showed.
“The prevalence of chronic kidney disease has increased over the last 3 decades, and efforts by the Centers for Medicare & Medicaid Services and the National Kidney Foundation have sought to increase the use of fistulas,” Dr. Khanh P. Nguyen said at the annual meeting of the Western Vascular Society.
“Since 2003, the incidence and prevalence of fistulas have increased. More recently, even higher goals have been set. Arteriovenous fistulas are the preferred procedures due to higher patency rates, reduced rates of reintervention, and lower costs, compared with central venous catheters or grafts.”
Dr. Nguyen, formerly of Loma Linda (Calif.) Medical Center who is now a vascular surgery fellow at Oregon Health and Science University, noted that while many studies as well as the Society for Vascular Surgery have advocated the use of routine preoperative ultrasound in predicting the success of arteriovenous fistulas (AVFs), its use varies among vascular surgeons. “Given the additional costs and time of preoperative ultrasound, this study was undertaken to examine the use of this technique and compare it to intraoperative assessment,” she said.
The researchers examined all autologous AVFs created for patients with end-stage-renal disease at the Veterans Affairs Loma Linda Health System between February 2007 and July 2012. Preoperative ultrasound mapping of upper-extremity veins occurred, and patients were divided into two groups: those with veins less than 3 mm in size and those with veins 3 mm or greater in size. Subjective intraoperative evaluation was conducted by the operative surgeon, who rated the vein as either “good” or “poor” because of factors such as inadequate diameter, sclerosis, and calcification. Kaplan-Meier analysis was used to calculate maturation and patency rates.
Over the 5-year period, 387 fistulas were created in 361 patients. Of these, 198 had preoperative vein mapping; 36% were less than 3 mm in size, and 64% were 3 mm or greater in size.
By intraoperative assessment, 14% of patients were determined to have had poor vessels, and 86% were found to have good vessels. About half of the fistulas (51%) were created at the wrist. The average age of patients was 65 years, their mean body mass index was 28 kg/m2, and their mean time on dialysis was 84 years. The majority (97%) were male.
Among patients with preoperative veins less than 3 mm in size or 3 mm in size or greater, the maturation and overall failure rates were similar at 71% vs. 75% (P = .61) and 68% vs. 58% (P = .15). However, among patients with assessments of poor or good veins at the time of operation, the maturation and overall failure rates were 42% vs. 82% (P < .001) and 86% vs. 54% (P < .001).
Subgroup analysis revealed that patients with good intraoperative evaluation, regardless of preoperative ultrasound findings, had higher maturation rates. “Likewise, patients with good intraoperative assessment, regardless of preoperative ultrasound findings, had higher cumulative functional patency rates. Of note, no patient who had both poor preoperative ultrasound and intraoperative assessments had a functional fistula at the time of last follow-up.”
Dr. Nguyen and her associates concluded that intraoperative vessel assessment, and not preoperative ultrasound, was more accurately associated with maturation and cumulative functional patency rates. “Even in patients with inadequate preoperative ultrasound vein mapping, intraoperative assessment may still be warranted,” she said. “If both preoperative and intraoperative assessments conclude that vessels are inadequate, do not create an AVF at that site.”
Dr. Nguyen reported having no relevant financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: Routine preoperative ultrasound is not reliable for predicting the success of arteriovenous fistulas.
Major finding: Among patients with assessments of poor or good veins at the time of operation, the maturation and overall failure rates were 42% vs. 82% (P < .001) and 86% vs. 54% (P < .001).
Data source: A retrospective study of 387 AVFs created in 361 patients at the VA Loma Linda Health System between February 2007 and July 2012.
Disclosures:Dr. Nguyen reported having no relevant financial disclosures.
