History Of Peripheral Vascular Disease Research Articles

Crystal-proven gout patients have an increased mortality due to cardiovascular diseases, cancer, and infectious diseases especially when having tophi and/or high serum uric acid levels: a prospective cohort study

To investigate the cause-specific mortality and the possible involved clinical characteristics with increased mortality in a cohort of 700 patients with crystal-proven gout. The cause-specific mortality of gout was compared to the mortality of the general population. Patients with arthritis referred for diagnosis were consecutively included in the Gout Arnhem-Liemers Cohort (GOAL). Joint fluid analysis was performed in all patients and only crystal-proven gout patients were included in this study. At inclusion clinical characteristics and laboratory values were collected. At follow-up patients who died were identified. Standardized mortality ratios (SMRs) were calculated for all-causes, cardiovascular diseases, cancer, and infectious diseases using indirect standardization methods for mortality outcomes and compared with the general population. The clinical characteristics of the patients who died were compared with those of the survivors and were analyzed by a logistic regression analysis to identify any associations with mortality. The study population at inclusion contained 573 (81.9%) men and 127 (18.1%) females with an average age of 62.0 (SD 13.4). During 3500 person-years from inclusion visit till 31 May 2016, in 700 gout patients, 66 deaths (27 cardiovascular deaths, 15 cancer-related deaths, 8 infectious deaths, 16 various other causes) occurred in this cohort. The all-cause standardized mortality ratio in gout patients was 2.21 (95% CI 1.68-2.74). In this cohort, gout patients had a higher SMR for death attributed to cardiovascular diseases (6.75; 95% CI 4.64-8.86), infectious diseases (4.66; 95% CI 1.51-7.82) and cancer (3.58; 95% CI 1.77-5.39). Corrected for confounders high serum uric acid levels (SUA; > 0,56mmol/L), tophaceous gout, a history of peripheral vascular disease, myocardial infarction, and heart failure at the inclusion visit were associated with increased mortality during follow-up. Compared to the general population, gout patients have an increased association with all-cause disease mortality, especially attributed to cardiovascular diseases, cancer, and infectious diseases. This association is strongest in hyperuricemic (uric acid levels > 0,56mmol/l) and tophaceous patients and in those with a history of peripheral vascular disease, myocardial infarction, and heart failure. Preventive measures like treatment of high SUA levels and treatment of cardiovascular risk factors need to be considered and evaluated.

Risk factors of atrial fibrillation occurring after radical surgery of esophageal carcinoma

BackgroundAtrial fibrillation (AF) is a common complication after radical surgery of esophageal cancer. The aim of this study was to explore AF risk factors after radical surgery of esophageal carcinoma.MethodThe data of 335 patients with esophageal cancer who were admitted in our hospital from January 2014 to August 2016 for the first time were retrospectively analyzed. We retrieved the papers in some data banks using the search terms including English and Chinese search terms, and obtained 13 factors which were mentioned in more than 6 papers. The 13 factors including age, gender, history of smoking, history of hypertension, history of peripheral vascular disease, history of cardiac stents or angina pectoris, preoperative pulmonary infection, preoperative brain natriuretic peptide (BNP) level, preoperative left ventricular diastolic dysfunction, operative method, lesion location, intraoperative blood transfusion, adhesion between lymph nodes and pericardium, underwent univariate and multivariate analyses.ResultsOf the 335 patients with esophageal cancer, 48 had AF within one week after operation. Univariate analysis indicated that the age (OR: 4.89; CI: 2.53–9.47, P: 0.000), gender (OR: 2.26; CI: 1.17–4.37, P: 0.013), history of peripheral vascular disease (OR: 2.29; CI: 1.06–4.92, P: 0.030), history of cardiac stents or angina pectoris (OR: 27.30; CI: 12.44–59.91, P: 0.000), preoperative BNP level (OR: 27.13; CI: 10.97–67.06, P: 0.000), preoperative left ventricular diastolic dysfunction (OR: 2.22; CI: 1.19–4.14, P: 0.012), operative method (OR: 2.09; CI: 1.002–4.380, P: 0.046), intraoperative blood transfusion (OR: 20.24; CI: 8.39–48.82, P: 0.000), and adhesion between lymph nodes and pericardium were risk factors (OR: 2.05; CI: 1.08–3.87, P: 0.024). Furthermore, multivariate analysis displayed that advanced age (OR: 5.044; CI: 1.748–14.554, P: 0.003), male (OR: 6.161; CI: 2.143–17.715, P: 0.001), history of cardiac stents or angina pectoris (OR: 48.813; CI: 13.674–174.246, P: 0.000), preoperative BNP > 100 (OR: 41.515; CI: 9.380–183.732, P: 0.000), open surgery (OR: 3.357; CI: 1.026–10.983, P: 0.045), intraoperative blood transfusion (OR: 58.404; CI: 10.777–316.509, P: 0.000), and adhesion between lymph nodes and pericardium (OR: 3.954; CI: 1.364–11.459, P: 0.011) were risk factors which could increase the incidence of postoperative AF.ConclusionWe should pay attention to the above risk factors in order to reduce the incidence of postoperative AF.

Cerebral Small Vessel, But Not Large Vessel Disease, Is Associated With Impaired Cerebral Autoregulation During Cardiopulmonary Bypass: A Retrospective Cohort Study.

Impaired cerebral blood flow (CBF) autoregulation during cardiopulmonary bypass (CPB) is associated with stroke and other adverse outcomes. Large and small arterial stenosis is prevalent in patients undergoing cardiac surgery. We hypothesize that large and/or small vessel cerebral arterial disease is associated with impaired cerebral autoregulation during CPB. A retrospective cohort analysis of data from 346 patients undergoing cardiac surgery with CPB enrolled in an ongoing prospectively randomized clinical trial of autoregulation monitoring were evaluated. The study protocol included preoperative transcranial Doppler (TCD) evaluation of major cerebral artery flow velocity by a trained vascular technician and brain magnetic resonance imaging (MRI) between postoperative days 3 and 5. Brain MRI images were evaluated for chronic white matter hyperintensities (WMHI) by a vascular neurologist blinded to autoregulation data. "Large vessel" cerebral vascular disease was defined by the presence of characteristic TCD changes associated with stenosis of the major cerebral arteries. "Small vessel" cerebral vascular disease was defined based on accepted scoring methods of WMHI. All patients had continuous TCD-based autoregulation monitoring during surgery. Impaired autoregulation occurred in 32.4% (112/346) of patients. Preoperative TCD demonstrated moderate-severe large vessel stenosis in 67 (25.2%) of 266 patients with complete data. In adjusted analysis, female sex (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.25-0.86; P = .014) and higher average temperature during CPB (OR, 1.23; 95% CI, 1.02-1.475; P = .029), but not moderate-severe large cerebral arterial stenosis (P = .406), were associated with impaired autoregulation during CPB. Of the 119 patients with available brain MRI data, 42 (35.3%) demonstrated WMHI. The presence of small vessel cerebral vascular disease was associated with impaired CBF autoregulation (OR, 3.25; 95% CI, 1.21-8.71; P = .019) after adjustment for age, history of peripheral vascular disease, preoperative hemoglobin level, and preoperative treatment with calcium channel blocking drugs. These data confirm that impaired CBF autoregulation is prevalent during CPB predisposing affected patients to brain hypoperfusion or hyperperfusion with low or high blood pressure, respectively. Small vessel, but not large vessel, cerebral vascular disease, male sex, and higher average body temperature during CPB appear to be associated with impaired autoregulation.

A Retrospective, Descriptive Analysis of Hospital-acquired Deep Tissue Injuries

The purpose of the current research was to describe the characteristics of DTIs and patient/care variables that may affect their development and outcomes at the time of hospital discharge. A retrospective, descriptive, single-site cohort study of electronic medical records was conducted between October 1, 2010, and September 30, 2012, to identify common demographic, intrinsic (eg, mobility status, medical comorbidities, and incontinence), extrinsic (ie, surgical and procedural events, medical devices, head-of-bed elevation), and care and treatment factors related to outcomes of hospital-acquired DTIs; additional data points related to DTI development or descriptive of the sample (Braden Scale scores and subscale scores, hospital length of stay [LOS], intensive care unit [ICU] LOS, days from admission to DTI, time in the operating room, serum albumin levels, support surfaces/specialty beds, and DTI locations) also were retrieved. DTI healing outcomes, grouped by resolved, partial-thickness/stable, and full-thickness/unstageable, and 30 main patient/treatment variables were analyzed using Kruskal-Wallis, chi-squared, and Fischer exact tests. One hundred, seventy-nine (179) DTIs occurred in 141 adult patients (132 in men, 47 in women; mean patient age 64 [range 19-94]). Of those patients, 110 had a history of peripheral vascular disease and 122 had hypertension. Sixty-nine (69) DTIs were documented in patients who died within 1 year of occurrence. Most common DTI sites were the coccyx (47 [26%]) and heel (42 [23%]); 41 (22%) were device-related. Median hospital LOS was 23 (range 4-258) days and median ICU LOS was 12 (range 1-173) days; 40 DTIs were identified before surgery and 120 after a diagnostic or therapeutic procedure. Data for DTI outcome groups at hospital discharge included 28 resolved, 131 partial-thickness/stable, and 20 full-thickness/unstageable; factors significantly different between outcome groups included mechanical ventilation (15/42/12; P = .01), use of a feeding tube (15/46/12; P = .02), anemia (14/30/9; P = .005), history of cerebrovascular accident (12/27/7; P = .03), hospital LOS (67/18/37.5; P <.001), ICU LOS (23/10/12; P = .03), time-to-event (13.5/8/9; P = .001), vasopressor use after DTI (13/31/11; P = .003), low-air-loss surface (10/9/3; P = .005), and device-related (14/24/4; P = .002). DTI risk factors mirrored those of other PUs, but progression to full-thickness injury was not inevitable. Early and frequent assessment and timely intervention may help prevent DTI progression.

Comparing Outcomes of Patients with Early Stage Non-Small Cell Lung Cancer Treated with Stereotactic Body Radiation Therapy Based on Frailty Status

Patient frailty is an important topic of interest, and a modified frailty index (mFI) has been applied in the surgical fields to show that frailty is associated with worse outcomes. However, there is limited literature discussing frailty in patients with lung cancer treated with stereotactic body radiation therapy (SBRT). This study aims to assess the relationship between frailty and overall survival (OS), tumor control, and toxicity in patients with early stage non-small cell lung cancer (NSCLC) treated with SBRT. A retrospective review of patients with early stage NSCLC treated with SBRT at a single institution between February 2009 and September 2014 was performed. A mFI consisting of 8 variables (hypertension requiring medication, diabetes, ECOG performance status≥2, history of transient ischemic attack or cerebrovascular accident, history of congestive heart failure, history of peripheral vascular disease, history of chronic obstructive pulmonary disease (COPD), and history of coronary artery disease) was created. One point was assigned to each variable, and patients were categorized as non-frail (mFI≤2) or frail (mFI>2). OS, recurrence free survival (RFS), and local, regional, and distant control (LC, RC, DC) were compared between frail and non-frail patients using Kaplan-Meier analysis and log rank tests. Univariate and multivariate analyses were conducted. Comparison of toxicity levels between frail and non-frail groups was analyzed using test of proportions. One hundred forty cases of early stage NSCLC were included, with 49 (35.0%) frail and 91 (65.0%) non-frail. Most patients had T1aN0 stage (55.0%), and the highest stage was T2bN0. All of the variables in the mFI were found to be significantly greater in frail than in non-frail patients except for COPD. OS was significantly lower in frail than non-frail patients (p=0.007) with 3-year OS of 59% vs. 82%. LC and DC were significantly lower in frail patients than non-frail (LC: p=0.017, 3-year LC of 85% vs 97%; DC: p=0.03, 3-year DC of 81% vs 93%), as was RFS (p=0.014, 3-year RFS of 53% vs. 75%). Frailty remained a significant predictor for shorter overall survival on multivariate analysis (HR=1.98, 95% CI [1.02-3.85], p=0.04). Toxicity did not significantly differ between the two groups. Frailty is associated with reduced OS and worse tumor control in patients with early stage NSCLC treated with SBRT. Characterizing frailty using a mFI prior to treatment could potentially help predict treatment outcomes and guide decision making and patient counseling. Future studies should evaluate associations between frailty, inflammatory markers, and radiation response, and compare outcomes between surgical and SBRT treatment approaches for NSCLC patients stratified by frailty to explore the possibility of an expanded role for SBRT in non-frail patients.

One-year clinical outcomes in older patients with non-ST elevation acute coronary syndrome undergoing coronary angiography: An analysis of the ICON1 study

AimsThe aim of this prospective, observational study was to identify predictors of adverse outcome at one year, following invasive care of older patients with non-ST-elevation acute coronary syndrome (NSTEACS) according to frailty status. MethodsOlder patients (aged ≥ 75 years), presenting with NSTEACS, undergoing invasive coronary angiography with a view to revascularisation, underwent assessment of frailty, cognition, functional status and quality of life. Participants were categorised as robust, pre-frail or frail using the Fried criteria. The primary outcome comprised a composite of all-cause mortality, myocardial infarction, stroke, unplanned revascularisation and major bleeding, at one year. Cox proportional hazards regression was used to derive a multivariate risk score. ResultsOverall, the composite endpoint was observed in 81 participants (29%). There was a significant difference in the occurrence of the primary outcome in the 3 frailty groups (robust 18.0%, pre-frail 27.5% and frail 39%; p = 0.03; hazard ratio (HR) for frail vs. robust: 2.79, 95% Confidence Interval [CI] 1.28–6.08). Fried frailty classification, age (categorised as ≥85 years), raised Killip class, systolic blood pressure on admission, history of peripheral vascular disease (PVD), problems dressing self and implantation of a bare metal stent were identified as predictors of adverse events at one year, with a C-statistic of 0.77 (95% CI 0.71–0.83). A point-based clinical risk score (FRAIL-HEART) was defined, which had a C-statistic of 0.70 (95% CI 0.63–0.77) and significantly outperformed the GRACE 2 score. ConclusionFrailty is associated with adverse clinical outcomes, following invasive management of older patients with NSTEACS. The derived risk models may enable improved risk stratification in practice.

Comparison of outcomes in patients undergoing rotational atherectomy after unsuccessful coronary angioplasty versus elective rotational atherectomy.

IntroductionRevascularization of patients with heavily calcified coronary arteries can be a challenge for interventional cardiologists. The procedural success rate in these patients can be improved by using rotational atherectomy (RA).AimTo compare in-hospital outcomes and those at 12-month follow-up between patients who underwent RA as a bailout procedure secondary to failed conventional angioplasty or as an elective procedure.Material and methodsThis is a retrospective analysis of 156 consecutive patients hospitalized at a high-volume percutaneous coronary intervention (PCI) center who underwent RA. In 43 (27.6%) patients, RA was performed on an elective basis (group 1). In 113 (72.4%) patients RA was carried out after unsuccessful traditional angioplasty (group 2).ResultsPatients in group 1 more often had a history of peripheral vascular disease (32.6% vs. 15.9%; p = 0.03). Group 1 was dominated by patients with multivessel disease (62.8% vs. 33.6%; p < 0.001). The left main coronary artery was more often treated in group 1 (25.6% vs. 2.7%; p < 0.001). Success rates in the two groups were similar: 93.0% for group 1 and 91.2% for group 2 (p = 0.71). The rate of in-hospital complications did not significantly differ between the groups. Twelve-month MI, TLR, and TVR rates were similar in both groups. There was no difference in the 12-month survival rate (86.1% vs. 92.0% in group 2; p = 0.27) or MACE (16.3% vs. 15.0%; p = 0.8).ConclusionsRotational atherectomy is associated with high efficacy and a relatively low risk of complications, with no significant differences in outcomes between patients treated with primary and secondary RA procedures.

Outcomes in Women and Minorities Compared With White Men 1 Year After Everolimus-Eluting Stent Implantation

There exist limited outcomes data for women and minorities after contemporary percutaneous coronary intervention (PCI). To examine 1-year outcomes in women and minorities vs white men after PCI with everolimus-eluting stents. The PLATINUM Diversity study was a single-arm study enrolling women and minorities. Patient-level pooling with the PROMUS Element Plus Post-Approval Study was prespecified. Data on social determinants of health and language were collected in the PLATINUM Diversity cohort, which included 1501 patients at 52 US sites. The PROMUS Element Plus Post-Approval study enrolled 2681 patients at 52 US sites with some site overlap and included an "all-comers" population. All patients were enrolled beginning in October 2014 and were followed for 12 months. Analyses began in August 2016. Patients received 1 or more everolimus-eluting stent implantation. The primary end point was 1-year major adverse cardiac events (MACE), which included death/myocardial infarction (MI)/target vessel revascularization. Secondary ischemic end points were also evaluated. The pooled study consisted of 4182 patients: 1635 white men (39.1%), 1863 women (white and minority) (44.5%), and 1059 minority patients (women and men) (25.3%). Women and minorities had a higher prevalence of diabetes, prior stroke, hypertension, renal disease, and congestive heart failure than white men but lower rates of multivessel disease, prior coronary artery bypass graft surgery, prior MI, and smoking. Unadjusted 1-year MACE rates (white men, 7.6%; women, 8.6%; minorities, 9.6%) were similar between groups with no significant differences after risk adjustment. The adjusted risk of death/MI was higher among women (odds ratio, 1.6; 95% CI, 1.1-2.4) and minorities (odds ratio, 1.9; 95% CI, 1.2-2.8) compared with white men and the adjusted risk of MI was higher in minorities (odds ratio, 2.6; 95% CI, 1.4-4.8). These differences were driven primarily by nonstent-related MIs. Within the PLATINUM Diversity cohort, the independent predictors of MACE were cardiogenic shock, renal disease, history of peripheral vascular disease, multivessel disease, widowhood, and lack of private insurance. After contemporary everolimus-eluting stent implantation, women and minorities experience a similar risk of 1-year MACE but a higher adjusted risk of recurrent ischemic events primarily because of nonstent-related MIs. Both clinical and angiographic factors and social determinants of health, including widowhood and insurance status, contribute to 1-year MACE among women and minorities.

Osseointegrated Transtibial Implants in Patients with Peripheral Vascular Disease: A Multicenter Case Series of 5 Patients with 1-Year Follow-up.

Osseointegration is an alternative treatment for amputees who are unable to wear or have difficulty wearing a socket prosthesis. Although the majority of limb amputations are due to vascular disease, such amputations have been perceived as a contraindication to osseointegration surgery. We report the outcomes of osseointegrated reconstruction in a series of 5 patients with limb amputation due to peripheral vascular disease. Five patients with transtibial amputation and a history of peripheral vascular disease who received an osseointegration implant from 2014 to 2015 were followed for 12 months. Clinical and functional outcomes were assessed, including pain, the amount of time the patient wore the prosthesis, mobility, walking ability, and quality of life. Adverse events, including infection, fracture, implant failure, revision surgery, additional amputation, and death, were monitored and recorded. Five transtibial amputees (56 to 84 years of age) followed for 1 year after osseointegration surgery were included in this case series. The mobility of all patients was improved at the time of follow-up. Three patients were wheelchair-bound prior to the surgery but all 5 were able to walk and perform daily activities at the time of follow-up. Four of the 5 patients were pain-free at 12 months postoperatively, and all 5 were using the osseointegrated prosthesis. Two patients had a single episode of superficial soft-tissue infection. An osseointegrated implant may be considered a feasible alternative to the conventional socket prosthesis for patients with peripheral vascular disease. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Resident Involvement in Microsurgery: An American College of Surgeons National Surgical Quality Improvement Program Analysis

In the current healthcare climate, there is increased focus on medical errors, patient outcomes, and the influence of resident participation on these metrics. Other studies have examined the influence of resident involvement on surgical outcomes, but the arena of microsurgery, with added complexity and learning curve, has yet to be investigated. A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to find patients undergoing procedures with free tissue transfer by screening for Current Procedural Terminology codes. Primary outcomes measured include flap failure, wound, infectious, and major and minor complications. This study was conducted at the Methodist Hospital, an academic hospital located in Houston, Texas. Patients in the National Surgical Quality Improvement Program database between the years 2005 and 2012 undergoing microsurgical procedures were included in this analysis. A total of 1466 patients met inclusion criteria. There was a statistically significant association of major complications with age, peripheral vascular disease, American Society of Anesthesiologists (ASA) classification of 3 or greater, total operative time, and year of operation. Multivariate analysis on minor complications demonstrated significant association with ASA class of 3 or 4. Resident involvement was not a significant factor among any outcome measures including major complications, minor complications, flap failure, wound complications, infectious complications, bleeding requiring transfusion, and unexpected reoperation rates within 30 days. This study provides further evidence in support of the claim that resident involvement in microsurgery is safe and effective, with similar rates of major complications, minor complications, flap failure, and unexpected reoperation. High ASA classification and history of peripheral vascular disease were strong predictors of major complications and should be optimized preoperatively before free tissue transfer. Later years were associated with decreased major complication rates, which may be reflective of enhanced supervision standards.

PC052 Causes and Outcomes of Finger Ischemia in Hospitalized Patients in the Intensive Care Unit

Vascular surgeons are frequently consulted to evaluate hospitalized patients in the intensive care unit (ICU) with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in ICU patients. All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger plethysmography. Patient demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were recorded. We identified 97 patients (54 male, 43 female). Mean age was 57.3 ± 16.8. Of these patients, 42 (43%) were in the surgical ICU and 55 (57%) in the medical ICU, 70 (72%) had abnormal results on finger plethysmographies, 67 (69%) unilateral and 30 (31%) bilateral, 36 (37%) had ischemia associated with an arterial line, 12 (13%) had concomitant toe ischemia, and 76 (78%) were on vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (30%), epinephrine (26%), vasopressin (25%), dopamine (7%), dobutamine (6%).Treatment was with therapeutic anticoagulation in 46 (47%), aspirin in 50 (52%), and clopidogrel in 15 (16%). Other frequent associated conditions included mechanical ventilation at the time of diagnosis (37%), diabetes (33%), history of peripheral vascular disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 2-year survival were 85%, 73%, and 65%. By Cox proportional hazards modelling, cancer (hazard ratio, 6.3; P = .012) and dialysis (hazard ratio, 4.9; P = .026) were independent predictors of mortality. Finger ischemia in ICU patients has a variety of causes but is frequently associated with the presence of arterial lines and the use of vasoactive medications, of which phenylephrine and norepinephrine are the most frequent. Either anticoagulation or antiplatelet therapy is appropriate treatment. While progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in the presence of cancer or dialysis.

Abstract 250: Role of First Degree Atrioventricular Block and Long Term Mortality in U.S. Veterans With Atherothrombotic Risk Factors

Background: First-degree atrioventricular (AV) block [PR interval exceeding 200 milliseconds (ms)] on a 12-lead electrocardiogram is a common finding. Previous studies suggested that first-degree AVB has a benign prognosis, but more recent reports suggest that first-degree AVB may be associated with adverse outcomes. We investigated the relationship between PR interval and long term morality in U.S. Veterans with atherothrombotic risk factors. Methods: We retrospectively collected and analyzed data from a Veterans Affairs (VA) medical center for consecutive patients (October 2001 to January 2005) who presented for coronary angiography. Results: Of 1193 charts, 1082 had a PR interval reading recorded (mean = 172.5±30.5 ms; median = 168 ms [range 59-334]). Mean follow-up period was 103±52 months. Mean age was 63.2±10.8 years with 98% male. Mean body mass index was 30.0±5.9. The prevalence of selected comorbidities was: hypertension (88%), hyperlipidemia (79%), obstructive coronary artery disease (73%), diabetes mellitus (45%), smoker (39%), history of peripheral vascular disease (17%), and history of cerebrovascular accident (8%). Mean left ventricular ejection fraction was 47%±13%. Eighty-two percent were on beta-blockers (BB), and 25% were on calcium channel blockers (CCB) while intraventricular conduction delay was seen in 6%. In a comparison of patients with PR interval ≤200 ms (n=936) vs. &gt;200 ms (n=146), long term mortality was higher with PR interval &gt;200 ms (58.2% vs. 44.4%, p=0.002). Mortality rate was also higher with patients on BB or CCB vs. not on either (49.8% vs 39.7%, p=0.024). While PR interval was a significant univariate predictor of mortality, it was not significant when adjusted for the covariates listed above [not including BB and CCB] (odds ratio = 1.08 [95% Cl = 0.70 to 1.66], p = 0.73). Conclusion: In this study of US Veterans with atherothrombotic risk factors, the long term mortality rate was higher with first-degree AV block. PR interval has prognostic value within this specific cohort.

Abstract 128: Vascular Assessment in Patients With Non-healing Foot Wounds

Background: Chronic lower extremity wounds have become a major challenge to healthcare systems and are a significant source of morbidity and mortality. Assessment of lower extremity perfusion is strongly recommended for non-healing lower extremity wounds. However, there is wide variation in treatment practices and the frequency of vascular assessment in an outpatient setting remains unknown. Methods: Our retrospective cohort included all adult patients seen in Parkland Hospital’s outpatient foot wound clinic over a six month time period (2/2014-6/2014). Charts were reviewed to collect demographic characteristics, wound characteristics, common vascular risk factors, vascular assessment and subsequent interventions. Peripheral arterial disease was defined as an ankle-brachial index (ABI&lt;0.9) or non-compressible (ABI&gt;1.4). Wounds were characterized as non-healing if there was no evidence of improvement after 3 months of follow up. Statistical analysis was then performed on patients with non-healing wounds and no previous history of peripheral vascular disease. Results: Our retrospective cohort included a total of 438 patients that were followed for a median of 2.1 years. The population was 70% male with a median age of 56 and a median BMI of 30. The majority of patients were Hispanic (45%) and there was high prevalence of hypertension (82%), hyperlipidemia (59%), diabetes (87%), tobacco use (51%), peripheral vascular disease (36%) and coronary artery disease (19%). Follow up data was missing in 39 patients. Among all patients seen in the foot wound clinic, an ABI was performed in 185 (42%) patients. At 3 months, 170 patients (38%) had evidence of a non-healing wound. After excluding patients with a known history of PVD, an ABI was performed in 27% patients (27 of 99) with non-healing wounds. Those patients undergoing ABIs were older (56 vs 50, p=0.006), had lower BMI (30 vs 34, p=0.04) and higher prevalence of CKD (40% vs 15%, p=0.007). After adjusting for common risk factors both age and CKD were remained statistically significant (p=0.004 and p=0.001, respectively). Among the ABIs performed, 15% (4 of 27) were found to have PAD, 48% (13 of 27) were normal and 37% (10 of 27) had non-compressible disease. Patients with PAD were also more likely to undergo peripheral angiography with intervention compared to patients with (50% vs 7%, p=0.02) and remained statistically significant after adjusting for traditional risk factors (p=0.001) Discussion: Although the foot wound population has a high rate of vascular risk factors, a vascular assessment was performed in the minority of patients. Patients who underwent vascular assessment and were found to have evidence of ischemia were more likely to undergo subsequent revascularization.

Complications Associated With Femoral Cannulation During Minimally Invasive Cardiac Surgery

Different types of cannulation techniques are available for minimally invasive cardiac surgery. At our institution, we favor a femoral platform for most minimally invasive cardiac procedures. Here, we review our results utilizing this cannulation approach. We retrospectively reviewed all minimally invasive valve surgeries that were performed at our institution between January 2009 and January 2015. Operative times, lengths of stay, postoperative complications, and mortality were analyzed. We identified 2,645 consecutive patients. The mean age was 69.7 ± 12.77 years, and 1,412 patients (53.4%) were male. Three hundred fifty-eight patients (13.5%) had a history of cerebrovascular accident, 422 (16%) had previous heart surgery, and 276 (10.4%) had a history of peripheral vascular disease. The procedures performed were isolated aortic valve replacements (42.1%), isolated mitral valve operations (40.6%), tricuspid valve repairs (0.57%), double valve surgery (15%), triple valve surgery (0.3%), and ascending aortic aneurysm resection with and without circulatory arrest (5%). Femoral cannulation and central cannulation were utilized in 2,400 patients (90.7%) and 244 patients (9.3%), respectively. The median aortic cross-clamp time and cardiopulmonary bypass time were 81 minutes (interquartile range, 65 to 105) and 113 minutes (interquartile range, 92 to 142), respectively. The median postoperative hospital length of stay was 6 days (interquartile range, 5 to 9). There were 31 cerebrovascular accidents (1.17%), no aortic dissections, two compartment syndromes, two femoral arterial pseudoaneurysms, and 174 (6.65%) groin wound seromas. The overall 30-day mortality was 57 patients (2.15%). Minimally invasive cardiac surgical procedures utilizing femoral cannulation techniques have a low risk of complications.

Foot insensitivity is associated with renal function decline in patients with type 2 diabetes: a cohort study.

BackgroundIdentifying patients with diabetes at increased risk of chronic kidney disease (CKD) is essential to prevent/slow the progression to end-stage renal disease (ESRD). CKD and diabetic peripheral neuropathy (DPN) share common mechanisms. Hence, we aimed to examine the relationship between foot insensitivity and CKD in patients with Type 2 diabetes.MethodsA prospective observational cohort study in adults with Type 2 diabetes. Patients with ESRD were excluded. Foot insensitivity was assessed using the 10-g monofilament test. Renal function was assessed using estimated glomerular filtration rate (eGFR) based on the MDRD equation. Albuminuria was defined as the presence of urinary albumin/creatinine ratio (ACR) >3.4 mg/mmol.ResultsTwo hundred and twenty eight patients were recruited and followed-up for 2.5 years. One hundred and ninety patients (83.4%) had eGFR ≥ 60 ml/min/1.73 m2. Seventy six (33.3%) patients had foot insensitivity (i.e. abnormal monofilament test). Patients with foot insensitivity had lower eGFR and higher prevalence of albuminuria compared to patients with normal monofilament test. After adjustment for age, gender, ethnicity, diabetes duration, HbA1c, body mass index, insulin treatment, number of anti-hypertensives, history of peripheral vascular disease, and baseline eGFR (R2 0.87), baseline foot insensitivity was associated with study-end eGFR (B = −3.551, p = 0.036).ConclusionsPatients with Type 2 diabetes and foot insensitivity are at increased risk of eGFR decline. Identifying these patients offers an opportunity to intensify metabolic and blood pressure control to prevent/retard the development of CKD. Future studies of larger sample size and longer follow up from multiple centres are needed to assess the diagnostic performance of our findings in predicting CKD development, and to compare the performance of the monofilament test with albuminuria.

Identifying beliefs about smoking in patients with peripheral vascular disease

Peripheral vascular disease (PVD) is a chronic disabling illness that frequently results in the occlusion of arteries in lower limbs and may cause ischemia, gangrene, or infection. The single most significant factor contributing to both the onset and progression of PVD is smoking, which has addictive properties. Once smoking becomes a habitual behavior, combined with the atherosclerotic process, a disastrous pathway ensues. The aim of this project was to gain an understanding of the beliefs of patients with PVD who smoked. A nonexperimental, descriptive design was used. Data were obtained from a sample of participants with a known history of PVD who have had a previous vascular intervention and who are established patients in a vascular surgeon's private office N=50. The majority of participants were male (n=31; 63%) 65-74years of age (n=18; 36%), were unemployed (n=30; 60%), and have smoked for greater than 51+years (n=13; 26%). A scale that was developed guided by the behavioral beliefs subscale revealed that PVD patients enjoyed smoking, smoking helped them to relax, and they believed that they were addicted to smoking. Results from the normative beliefs subscale indicated that the spouse or significant other, children or those whom they lived with, did not approve of their smoking and also that their healthcare provider had discussed smoking cessation with them. The control beliefs subscale results demonstrated that most patients had attempted to quit smoking and believed that it would be a difficult behavior to stop and they would require the assistance of a patch or medication and feared the withdrawal symptoms. In conclusion, exploring the beliefs and thought process of patients who smoked provided a rich body of knowledge which can afford thehealthcare professional with the ability to better understand the smoking experience as seen through the patients' eyes.

Saved by the Collaterals: A Case of Chronic Mesenteric Ischemia

A 59-year-old male with a history of peripheral vascular disease came to the hospital with worsening, dull but diffuse abdominal pain for one month. The pain was worsened after eating and associated with episodes of loose, non-bloody bowel movements. He had a decreased appetite and steadily lost about 20lbs of weight over the past few months. On initial presentation, he was frail and ill appearing with hypothermia of 36°C, tachypnea of 24bpm and tachycardia around 120bpm. He was otherwise awake with stable blood pressures. His abdomen was diffusely tender on palpation but soft with normal bowel sounds and no guarding, rebound or rigidity. He was found to have leukocytosis of 21x103/uL and a lactate of 15.9mmol/L. He had an elevated anion gap metabolic acidosis with a gap of 44, bicarbonate of 5mmol/L, pCO2 of 15mmHg and pH 7.11. He was immediately started on aggressive fluid resuscitation in an effort to clear his lactic acidosis. A CTA of the abdomen revealed a celiac artery occlusion, proximal SMA occlusion and occlusion of the IMA by his aorto-bifemoral bypass graft. It was diagnostic of mesenteric ischemia. Fortunately, he had collateral circulation supplying his liver and colon, which protected him from complete necrosis of the bowel and ischemic liver disease. The left gastric artery and iliac collaterals to the distal colon provided much of the circulation. He underwent angiography and stenting of his SMA. There was atherosclerotic disease with an acute thrombus overlapping. He improved after the surgery and fluid stabilization with his lactate declining to 1.3mmol/L, acidemia, anion gap and white blood cell count improving back to normal range. He was anticoagulated with heparin to warfarin bridging and then later discharged to a short-term rehab facility. Chronic mesenteric ischemia is episodic or constant hypo-perfusion of the intestines usually caused by stenosis or occlusion. Atherosclerosis of the mesenteric vessels is fairly common in the general population. 18 percent of the population above 65 is eventually found to have significant stenosis. Clinical manifestations are usually rare due to the development of a large collateral circulation network over time. Patients usually present with dull, cramping, post-prandial pain with gradual weight loss. An acute thrombosis can set off acute mesenteric ischemia requiring prompt revascularization usually with angiography and stenting. Close follow-up is needed, as restenosis is common.

CLINICAL EVALUATION OF CUTFAR OINTMENT IN THE DERMATOLOGICAL DISORDERS

An open label non - randomized Phase - III study was conducted to assess the safety and efficacy of Cutfar Ointment in patients of chilblain, cracked heels, rough skin, cuts and wounds . Three hundred fifty patients suffering from chilblain, cracked heels, rough skin, cuts and wounds, scaling, pruritus, wrinkles, were included in the study. Patients with history of peripheral vascular disease, known dermatological di sease, use of any topic al steroids or moisturizers on the feet in previous 2 weeks were excluded in the study. All the patients were instructed to wash the affected part with lukewarm water and gently apply Cutfar ointment twice a day, massaging properly until it gets fully abso rbed. All the patients were checked after 03 and 06 days treatment. A significant recovery was observed after the treatment. The study concluded that, Cutfar an Ayurvedic medicine, is an effective treatment for various skin problems such as chilblain, crac ked heels, rough skin, cuts and wounds, scaling, pruritus, wrinkles, pigmentation, and laxity of skin. Cutfar soothes and softens the skin, has tissue repair property and enhance s healing. Cutfar also possess keratolytic and emollient action.

Predicting 30-day postoperative mortality for emergent anterior abdominal wall hernia repairs using the American College of Surgeons National Surgical Quality Improvement Program database.

Anterior abdominal wall hernias are among the most commonly encountered surgical disease. We sought to identify risk factors that are associated with 30-day postoperative mortality following emergent abdominal wall hernia repair using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. A retrospective analysis of data from the ACS NSQIP from 2005 to 2010 was performed. Patients were selected using Current Procedural Terminology (CPT) and International Classification of Disease 9 Clinical Modification (ICD9) codes for the repair of inguinal, femoral, umbilical, epigastric, ventral, or incisional hernias that were incarcerated, obstructed, strangulated, or gangrenous. Only emergent cases occurring within two days of admission and admitted as inpatients were included. Univariate and multivariable analysis was performed. A risk score was also created. There were 4298 cases of emergent anterior abdominal wall hernia surgery. The most common was inguinal (25.3%), followed by incisional (23.8%), umbilical (23.5%), ventral (12.1%), femoral (8.8%), and epigastric (6.5%) hernias. Multivariable analysis demonstrated six statistically significant predictors of short-term mortality, including history of congestive heart failure (CHF) [odds ratio (OR) 8.24, 95 % confidence interval (CI) 4.05-16.75), age (OR 5.52, 95% CI 3.48-8.77), history of peripheral vascular disease (PVD) (OR 4.98, 95% CI 2.08-11.92), presence of ascites (OR 3.16, 95% CI 1.64-6.08), preoperative blood urea nitrogen (OR 1.35, 95% CI 1.22-1.49), and preoperative white blood cell count (OR 1.22, 95% CI 1.02-1.45). The C-statistic for the risk model was 0.858. We present a large study on short-term mortality following emergent anterior abdominal wall hernia repairs based on the ACS NSQIP with a derived risk model that demonstrates excellent discriminative ability.

Pulmonary hypertension is an independent predictor of cardiovascular events and mortality in haemodialysis patients.

The evidence about prevalence, associated factors of pulmonary hypertension (PH) and its impact on patient's outcomes is limited. We included 211 haemodialysis patients, we estimated the systolic pulmonary artery pressure (SPAP) by 2D Doppler echocardiography defining PH as a SPAP above 35 mmHg, the median follow-up was 39 (19-56) moths, and the primary endpoints were all cause mortality and cardiovascular events. We found PH in 91 patients (43.9%). Independent determinants of PH were age, previous cardiovascular disease, the Nt-pro-BNP level hs-TnT, the systolic dysfunction, diastolic dysfunction and left ventricular hypertrophy. Over the follow-up 94 cardiovascular events occurred, variables associated were: PH, age, history cardiovascular disease, dyslipidaemia, elevated concentration of Nt-pro-BNP and hs-TnT, systolic and diastolic dysfunction, in a multivariate model, the PH maintained its independent association. Mortality data: 88 patients died (41.7%); 35 (29.5%) in the no PH group and 53 (58.5%) in the PH group (P < 0.001). In the Cox survival analysis, we found an association between mortality and age, previous cardiovascular disease, history of peripheral vascular disease, Nt-pro-BNP levels. In a multivariate model the PH remains as independent predictor of mortality. Pulmonary hypertension is a common finding in HD patients and a valuable predictor of mortality and cardiovascular events. Prospective studies are needed to assess the effect of intervention on risk factors in improving patient's outcomes.