Preoperative Revascularization Research Articles

Angiosome-Guided Revascularization in Local Flap Reconstruction of the Foot and Ankle: Comparable Outcomes With Both Direct and Indirect Revascularization.

Among patients with critical limb ischemia and tissue loss, revascularization is an essential component for limb salvage. Local flaps of the foot and ankle remain a versatile tool in reconstructive limb salvage but is dependent on adequate arterial flow. In patients with arterial occlusive disease requiring revascularization, there is a lack of evidence in the current literature investigating on the necessity of direct arterial flow to the respective angiosome for local flaps reconstruction. Our study thereby compares the outcomes of direct (DR) and indirect (IR) revascularization for local flap success. Patients who received endovascular revascularization (ER) prior to local flap reconstruction for chronic wounds in the foot and ankle were retrospectively reviewed. IR was performed in patients where DR could not be performed. DR was defined as an intervention on the same pedicle used for the local flap. IR was defined as an intervention performed on a different angiosome than the pedicle used for the local flap. Patient demographics, Charlson Comorbidity Index (CCI), angiographic details, postoperative complications, and long-term outcomes were collected. A total of 33 patients underwent 43 local flap reconstruction with preoperative ER: 58.1% (n = 25) received DR and 41.2% (n = 18) received IR. Patients had a mean CCI of 6.7 ± 1.8, with a high prevalence of diabetes mellitus (93.9%), peripheral arterial disease (90.9%), and end-stage renal disease (33.3%) with no significant differences between groups. In the immediate postoperative period (postoperative day 0 to 12), there were no significant differences in immediate flap success (DR: 100% vs IR: 88.9%, P = 0.169) or partial flap necrosis between (DR: 0.0% vs IR: 16.7%, P = 0.066). Rates of major complications from infection (DR: 28.2% vs IR: 22.2%, P = 0.736), ischemia (DR: 4.0% vs IR: 11.1%, P = 0.562), or dehiscence (DR: 8.0% vs IR: 16.7%, P = 0.634) requiring reoperation were similar between 2 groups. Overall limb salvage rate was 84.9%, and comparable between groups (DR: 78.6% vs IR: 89.5%, P = 0.628). DR and IR achieve similar rates of limb salvage and flap success after local flap reconstruction. A multidisciplinary vasculo-plastic approach that incorporates preoperative arteriogram and revascularization should be utilized for this highly comorbid patient population to achieve optimal success and limb salvage.

Comparison of open and endovascular left subclavian artery revascularization for zone 2 thoracic endovascular aortic repair

ObjectiveIn patients undergoing elective thoracic endovascular aortic repair (TEVAR) and left subclavian artery (LSA) coverage, routine preoperative LSA revascularization is recommended. However, in the current endovascular era, the optimal surgical approach is debated. We compared baseline characteristics, procedural details, and perioperative outcomes of patients undergoing open or endovascular LSA revascularization in the setting of TEVAR. MethodsAdult patients undergoing TEVAR with zone 2 proximal landing and LSA revascularization between 2013 and 2023 were identified in the Vascular Quality Initiative. We excluded patients with traumatic aortic injury, aortic thrombus, or ruptured presentations, and stratified based on revascularization type (open vs any endovascular). Open LSA revascularization included surgical bypass or transposition. Endovascular LSA revascularization included single-branch, fenestration, or parallel stent grafting. Primary outcomes were stroke, spinal cord ischemia (SCI), and perioperative mortality (Pearson's χ2 test). Multivariable logistic regression was used to evaluate associations between revascularization type and primary outcomes. Secondarily, we studied other in-hospital complications and 5-year mortality (Kaplan-Meier, multivariable Cox regression). Sensitivity analyses were performed in patients undergoing concomitant LSA revascularization to TEVAR. ResultsOf 2489 patients, 1842 (74%) underwent open and 647 (26%) endovascular LSA revascularization. Demographics and comorbidities were similar between open and endovascular cohorts. Compared with open, endovascular revascularization had shorter procedure times (median, 135 minutes vs 174 minutes; P < .001), longer fluoroscopy times (median, 23 minutes vs 16 minutes; P < .001), lower estimated blood loss (median, 100 mL vs 123 mL; P < .001), and less preoperative spinal drain use (40% vs 49%; P < .001). Patients undergoing endovascular revascularization were more likely to present urgently (24% vs 19%) or emergently (7.4% vs 3.4%) (P < .001). Compared with open, endovascular patients experienced lower stroke rates (2.6% vs 4.8%; P = .026; adjusted odds ratio [aOR], 0.50 [95% confidence interval (CI), 0.25-0.90]), but had comparable SCI (2.9% vs 3.5%; P = .60; aOR, 0.64 [95% CI, 0.31-1.22]) and perioperative mortality (3.1% vs 3.3%; P = .94; aOR, 0.71 [95% CI, 0.34-1.37]). Compared with open, endovascular LSA revascularization had lower rates of overall composite in-hospital complications (20% vs 27%; P < .001; aOR, 0.64 [95% CI, 0.49-0.83]) and shorter overall hospital stay (7 vs 8 days; P < .001). After adjustment, 5-year mortality was similar among groups (adjusted hazard ratio, 0.85; 95% CI, 0.64-1.13). Sensitivity analyses supported the primary analysis with similar outcomes. ConclusionsIn patients undergoing TEVAR starting in zone 2, endovascular LSA revascularization had lower rates of postoperative stroke and overall composite in-hospital complications, but similar SCI, perioperative mortality, and 5-year mortality rates compared with open LSA revascularization. Future comparative studies are needed to evaluate the mid- to long-term safety of endovascular LSA revascularization and assess differences between specific endovascular techniques.

Lung transplant survival with past and concomitant cardiac revascularization

Coronary artery disease is common among lung transplant (LTx) candidates and has historically been viewed as a contraindication to the procedure. Survival outcomes of lung transplant recipients with concomitant coronary artery disease who had prior or perioperative revascularization remain a topic of conversation. A retrospective analysis of all single and double lung transplant patients from Feb, 2012 to Aug, 2021 at a single center was performed (n=880). Patients were split into 4 groups: (1) those who received a preoperative percutaneous coronary intervention, (2) those who received preoperative coronary artery bypass grafting, (3) those who received coronary artery bypass grafting during transplantation, and (4) those who had lung transplantation without revascularization. Groups were compared for demographics, surgical procedure, and survival outcomes using STATA Inc. A p value<0.05 was considered significant. Most patients receiving LTx were male and white. Pump type (p = 0.810), total ischemic time (p= 0.994), warm ischemic time (p = 0.479), length of stay (p =0.751), and lung allocation score (p = 0.332) were not significantly different between the four groups. The no revascularization group was younger than the other groups (p<0.01). The diagnosis of Idiopathic Pulmonary Fibrosis was predominant in all groups except the no revascularization group. The pre-coronary artery bypass grafting group had a higher portion of single LTx procedures (p = 0.014). Kaplan-Meier analysis showed no significantly different survival rates after post-LTx between the groups (p = 0.471). Cox Regression analysis showed diagnosis significantly impacted survival rates (p 0.009). Preoperative or intraoperative revascularization did not affect survival outcomes in lung transplant patients. Selected patients with coronary artery disease may benefit when intervened during lung transplant procedures.

Left Subclavian Artery Revascularization May Not Influence the Incidence of Spinal Cord Ischemia in Elective Thoracic Endovascular Aortic Aneurysm Repair

To analyze whether left subclavian artery (LSA) revascularization in patients undergoing elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) is associated with decreased spinal cord ischemia (SCI). The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with acute aortic dissections or aortic ruptures were excluded from the analysis. Only patients undergoing elective TEVAR for TAA and had their LSA covered during the procedure were included. Patients were divided into two groups according to their LSA revascularization (before or during TEVAR). A descriptive analysis was done to evaluate the change in frequency of LSA revascularization over the study interval. Univariate analysis was done to compare preoperative and intraoperative variables, and primary outcomes of SCI and cerebral stroke between the two groups. Among patients who had elective TEVAR for TAA, 669 patients had the LSA covered. The LSA was revascularized in 67% of these patients (n = 446). The incidence of LSA revascularization increased over the study period (Fig 1) (P < .001). Average age was 69 years, and 65% (n = 433) were male. Demographics and past medical history are summarized in Table I. Spinal cord ischemia developed in 20 patients (3%), and cerebral stroke in 29 patients (4%). No significant difference was seen when comparing postoperative SCI, cerebral stroke, 30-day or 1-year mortality between patients who had LSA revascularization and those who did not (Table II). Long-term survival did not differ between the two groups on Kaplan-Meier analysis (Fig 2). In patients with TAA undergoing elective TEVAR with LSA coverage, an increasing percentage of patients underwent preoperative or concomitant LSA revascularization over the course of the study—81% in 2021. In this study, LSA revascularization, however, did not aff5ct the incidence of postoperative SCI, cerebral stroke, or short or long-term mortality. In conclusion, LSA revascularization did not protect against SCI and may carry its own morbidity in elective TAAs requiring LSA coverage. More detailed studies are needed to help define the role of LSA revascularization in this setting.TableComparison of baseline characteristics, comorbidities, intraoperative variables, and postoperative outcomes between patients who had left subclavian artery (LSA) revascularization and those who did notOverall (n = 669)LSA nonrevascularized (n = 223)LSA revascularized (n = 446)P valueBaseline characteristics Age, years, mean (SD)69 (11)70 (11)69 (11).48 Gender, No. (%).69Male433 (65)142 (64)291 (65)Female236 (35)81 (36)155 (35) Race, No. (%).41African American115 (17)39 (18)76 (17)White474 (71)164 (74)310 (70)Others80 (12)20 (9)60 (14) BMI, mean (SD)28.4 (6.7)28.1 (6.8)28.5 (6.7).45 Smoking status, No. (%).94Never171 (26)59 (27)112 (25)Prior343 (51)113 (51)230 (52)Current154 (23)51 (23)103 (23)Medical History CVD, No. (%)81 (12)31 (14)50 (11).31 CAD, No. (%)111 (17)43 (19)68 (15).19 Congestive heart failure, No. (%)93 (14)33 (15)60 (13).63 COPD, No. (%)193 (29)73 (33)120 (27).12 Hypertension, No. (%)608 (91)199 (89)409 (92).22 Diabetes, No. (%)97 (14)38 (17)59 (13).19 Prior aortic surgery, No. (%)279 (42)103 (46)176 (40).10 Prior aneurysm repair, No. (%)226 (34)82 (36)145 (32).50Intraoperative variables Contrast volume, mL, mean (SD)118 (73)115 (72)120 (73).41 EBL, mL, mean (SD)243 (448)228 (399)251.2 (470).01 Fluoro time, minutes, mean (SD)23.2 (20.3)22.6 (23.0)23.5 (18.9).061 Procedure time, minutes, mean (SD)176 (100)158 (111)186 (94)<.01 Spinal drain placement, No. (%).38None343 (51.4%)111 (49.8%)232 (52.3%)Prophylactic311 (46.6%)106 (47.5%)205 (46.2%)Postoperative11 (1.6%)6 (2.7%)5 (1.1%)Outcomes Spinal cord ischemia, No. (%)20 (3)8 (4)12 (3).52 Cerebral stroke, No. (%)29 (4)9 (4)20 (5).79 30-Day mortality, No. (%)26 (4)5 (2)21 (5).12 1-Year mortality, No. (%)65 (10)21 (9)44 (10).85COPD, Chronic obstructive pulmonary disease; CVD, cerebrovascular disease; EBL, estimated blood loss; PCI, percutaneous coronary interventions; SD, standard deviation. Open table in a new tab Fig 2Kaplan-Meier curves comparing long-term survival between patients who underwent left subclavian artery (LSA) revascularization and those who did not.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prior and Perioperative Revascularization Impact on Survival in Lung Transplant Patients

<h3>Purpose</h3> Survival outcomes of lung transplant recipients with concomitant coronary artery disease who had prior or perioperative revascularization remains a topic of conversation. We hypothesized concomitant-CABG can be a safe and viable option during lung transplantation in a select group of patients. <h3>Methods</h3> A retrospective analysis of all single and double lung transplant patients from Feb-2012 to Aug-2021 (n=868) was performed. Patients were split into 4 groups: (1) those who received a preoperative percutaneous coronary intervention (n=58), (2) those who received pre-operative coronary artery bypass grafting (CABG) (n=39), (3) those who received concomitant CABG during transplantation (n=51), and (4) those who had lung transplantation without revascularization (n=720). Groups were compared for demographics, surgical procedure, and survival outcomes using STATA Inc. P-value <0.05 was considered significant. <h3>Results</h3> Throughout all groups, a majority of patients receiving LTx were males (p<0.01) and ethnically white (p<0.01). The no revascularization group was significantly younger than the other groups (p<0.01). The diagnosis of IPF constituted the largest portion of all groups except the no revascularization group (p<0.01). In terms of transplant type, the pre-CABG group had a higher portion of single LTx procedures (p=0.014). The antero-axillary thoracotamy approach was the most utilized approach in all groups except Con-CABG (p=0.014). Kaplan-Meier analysis showed that survival rates post-LTx were not significantly different between the groups (p=0.471). Cox Regression analysis showed diagnosis significantly impacted survival rates (p=0.009). <h3>Conclusion</h3> These results continue to suggest that preoperative or intraoperative revascularization did not affect survival outcomes in lung transplant patients. Select patients with coronary artery disease may benefit when intervened during lung transplant procedure with similar outcomes to patients without intervention.

Carotid Duplex Poorly Predicts Stroke Risk During Transcatheter Aortic Valve Replacement

Patients undergoing surgical aortic valve replacement, in isolation or with concomitant coronary artery bypass grafting, have historically been screened for carotid artery disease prior to surgery. Over the past decade, transcatheter aortic valve replacement (TAVR) has incrementally become the predominant technique for the treatment of severe aortic stenosis. The relationship between internal carotid artery stenosis (ICAS) and risk of periprocedural stroke in the TAVR population is uncertain. We sought to evaluate our institution's outcomes with the TAVR procedure and the association with preoperative carotid duplex scan (CDS) results. A retrospective review of a single institution TAVR registry over a 5-year period was performed. All patients with pre-operative carotid imaging were included. Outcomes included in-hospital, 30-day, and 1-year stroke and all-cause mortality rates. The diagnosis of post-operative stroke was based on neurological exam and confirmed by radiologic imaging. Standard statistical analysis was performed. A total of 436 patients met inclusion criteria. The prevalence of ICAS >50% was 18.3% and 70-99% stenosis was 4.8%. The in-hospital stroke and mortality rates were 2.3% and 1.2%, respectively. The cumulative 30-day and 1- year stroke rates were 3.7% and 6%, respectively. All were ischemic in nature. Bilateral infarcts were identified in 46.2% of stroke patients and 11.5% had an ipsilateral ICAS >50%. A large majority of stroke patients (23, 88.5%) had an ipsilateral ICAS of <50%. Less than 0.5% of patients had ICAS >70% and subsequently had an ipsilateral stroke within 30 days of procedure. The preoperative CDS identified carotid lesions that met criteria for elective repair in only 4.8% of patients. Of these, 9.5% suffered a stroke in the first 30 days after surgery. Over 90% of patients who had a stroke had less than 70% stenosis present in either carotid artery and there was no correlation between degree of ICAS and risk of stroke during the follow-up period. Routine CDS prior to TAVR does not predict in-hospital or 30-day stroke. As TAVR programs evolve, expand, and proliferate across the country, routine preoperative CDS is unlikely to determine the need for pre-operative carotid revascularization or predict stroke risk.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

443-P: Outcomes of Bedside Diabetic Foot Amputation by a Diabetologist

Complying with simple operating rules, a diabetologist might perform Bedside Toe Amputation (BTA) for necrosis complicating diabetic foot ulcer (DFU) in case of inappropriate delay scheduled or disagreement with the amputation level proposed by the surgeon. We conducted a monocentric, retrospective, observational study in our diabetes department. Patients with DFU and isolated toe necrosis indicating a transphalangeal amputation (TPA), a metatarsophalangeal disarticulation (MPD) or a single transmetatarsal amputation (TMA) decided during a multidisciplinary DFU team were included. The primary endpoint was the need for reoperation or reamputation (partial/complete TMA, transtibial (TTA) or transfemoral (TFA)) performed by a surgeon. From May 2016 to September 2020, 147 out of 709 patients admitted for DFU required a surgical treatment (21%). After DFU team agreement and patient’s informed consent obtained, 101/147 patients needed TPA, MPD or TMA (69%) and 43/101 were performed at bedside by the diabetologist (43%). The characteristics of the population were: men=75%, age=65±14 years, type 2 diabetes=95%, duration of diabetes=19±11 years, preoperative arteriography=84%, preoperative revascularization=30%, mean number of permeable arteries at the time of the procedure=2±0.9, permeable dorsal arch=58%, permeable plantar arch=45%. Type of BTA: TPA=28%, MPD=65%, TMA=7%. Median follow-up=12 months. Secondary conventional surgery was needed for 13 patients (30%) (TMA/TTA/debridement respectively in 54, 30 and 16% cases). Poor vascular arterial bed was the significant determinant of failure (≤ 1 leg artery, p=0.006). Annual mortality rates in the groups with or without the need for a surgeon were respectively 15 and 10% (p=0.6). Performed by a diabetologist, BTA might be an option to treat limited toe necrosis complicating DFU in case of ≥ 2 leg arteries permeable at the time of the procedure. A head-to-head comparison with conventional surgery is now required. Disclosure F. Feron: None. J. Riveline: None. J. Gautier: None. J. Kevorkian: None.

Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association.

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.

Lung Transplant Survival Regarding Past and Concomitant Cardiac Revascularization

<h3>Purpose</h3> Coronary artery disease (CAD) is not uncommon among lung transplant (LTx) and has been often carefully evaluated before LTx. Those who undergo these pre- and or post-lung transplantation percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) procedures may be at risk to LTx short-term mortality. The survival outcome of prior or perioperative revascularization has not been adequately established. <h3>Methods</h3> A single-center retrospective analysis of all single and double LTx patients from Feb-2012 to Mar-2020 (n=748) was performed. Patients were split into 4 groups: (1) patients who received a preoperative PCI (Pre-PCI) (n=55), (2) those who received preoperative CABG (Pre-CABG) (n=38), (3) those who received concomitant CABG during LTx (Con-CABG) (n=47), (4) those who had LTx with no need for revascularization (n=607). Groups were compared for demographics, surgical procedure, and survival outcomes using STATA Inc. P-value <0.05 was considered significant. <h3>Results</h3> The no revascularization group was statistically younger than the rest (P<0.0001). The lung allocation score was significantly lower in the no revascularization group (P=0.03). All groups were predominantly diagnosed with idiopathic pulmonary fibrosis. The proportion of patients with chronic obstructive pulmonary disease (COPD) was greatest in the group not requiring revascularization (P<0.0001). Length of stay and transplant type were similar among all groups (LOS P=0.758; Tx-type P=0.212). Of the concomitant-CABG patients, 24 patients needed more than 1 graft (mean, 1.7 ± 0.99 grafts). Posttransplant survival outcomes among all groups were similar (P=0.551), however were significantly affected by diagnosis' "other" than COPD or IPF (P=0.003). <h3>Conclusion</h3> Our results suggest that preoperative or intraoperative revascularization did not affect survival outcomes in lung transplant patients. Selected patients with coronary artery disease may benefit when intervened during lung transplant procedure.

Abstract 14915: Incidence, Predictors and Clinical Impact of Left Ventricular Functional Recovery Following Coronary Artery Bypass Grafting in Patients With Ischemic Cardiomyopathy

Introduction: CABG is considered the standard treatment for patients with ischemic cardiomyopathy (ICM). However, it remains unknown who would achieve postoperative LV function recovery after CABG. Furthermore, the relationship of postoperative LV function recovery with long-term outcomes remains unclear. Hypothesis: In patients with ICM who undergo CABG, postoperative LV function recovery, which would be influenced by degree of LV remodeling at baseline, is associated with improved outcomes. Methods: This multicenter retrospective study comprised 490 cases with LVEF of ≤40% who underwent CABG between 1993 and 2015. Clinical follow-up was completed in 467 cases (95%), with a mean follow-up of 65±46 months (range, 0-266). A total of postoperative echocardiographic assessments were carried with an average number of 3.7±2.4. LV function recovery was defined as LVEF ≥35% at more than one exam. Association of LV function recovery with mortality after adjustments for clinically relevant covariates was estimated using Cox proportional hazard model. Pre- and intraoperative associates of LV function recovery were identified using logistic regression model. Results: During follow-up, there were 203 mortalities (41%) and overall 10-year survival was 45%. LV function recovery was found in 368 cases (75%), while not in 122 (25%). Overall 10-year survival was significantly higher in patients who achieved LV function recovery as compared with those who did not achieve it (52% vs. 23%). Multivariate analysis identified LV function recovery was independently associated with decreased overall mortality (adjusted HR 0.40, p&lt;0.0001). Preoperative LVDs (adjusted OR 0.92, p&lt;0.0001), eGFR (adjusted OR 1.12, p=0.016) and revascularization using bilateral internal thoracic arteries (BITA) (adjusted OR 2.81, p=0.018) are the independent predictors of LV function recovery. Conclusions: Among patients with ICM who underwent CABG, 75% achieved substantial postoperative LV function recovery, in association with better long-term survival, as compared with the remaining 25% of patients who did not achieve it. Preoperative less LV remodeling and preserved renal function as well as revascularization with use of BITA might be associated with LV function recovery.

Mortality and Conversion Rate to Below Knee or Above Knee Amputation Following Transmetatarsal Amputation

Category:Midfoot/Forefoot; Diabetes; OtherIntroduction/Purpose:Non-traumatic lower extremity amputations (LEA), especially those performed in dysvascular and diabetic patients, are known to have poor long-term prognosis. Perioperative mortality has been reported at between 4 and 10%, and the 1 and 5 year mortality rates range between 22-33% and 39-69%, respectively. While poor outcomes in these patients have been described, there is no consensus as to the predictors of mortality. The purpose of the study is to determine the percentage of patients who had a complication following transmetatarsal amputation (TMA) and identify associated risk factors for complications and mortality.Methods:We queried our institution’s administrative database to identify 247 TMA procedures performed in 229 patients between January, 2002 and December, 2016. Electronic health records were reviewed to document complications defined as reoperation, amputation and mortality. Mortality was also verified using the National Death Index. Additionally, we recorded risk factors including diabetes, A1c level, end stage renal disease (ESRD), cardiovascular disease (CVD), peripheral vascular disease (PVD), history of revascularization, contralateral amputation, and neuropathy. The majority of the study patients were males (157, 69%) and the average age was 57 years (range 24-91). The median BMI was 28 (range 16-58) and 29% of the study patients were obese with a BMI ≥ 30. Fishers Exact tests were used to compare categorical variables. Kruskal-Wallis and Independent T-tests were used to compare numeric data. All data were analyzed using SAS/STAT software version 9.4 (Carey, NC) and a 0.05 level of significance was defined apriori.Results:The conversion rate to below (BKA) or above knee amputation (AKA) was 26% (64 of 247). Males (p=.0274), diabetics (p=.0139), patients in ESRD (p=.019), and patients with a history of CVD (p=.0247) or perioperative revascularization (p=.022) were more likely to undergo further amputation following an index TMA. BMI was significantly higher in patients requiring BKA/AKA (p=.0305). There were no significant differences in age (p=.2723) or A1c levels (p=.4219). The overall mortality rate was 35% (84 of 229). Diabetes (p=.0272), ESRD (p=.0031), history of CVD (p<.0001) or PVD (p=.0179) were all significantly associated with mortality. Patients who died were significantly older (p=.0006) and had significantly higher A1c levels (p=.0373). BMI was not significantly associated with mortality. Twenty-two patients who had 23 further amputations subsequently died.Conclusion:In our series of patients undergoing TMA, 26% underwent further amputation and 35% of patients died. Conversion rate to BKA or AKA occurred at a high rate regardless of preoperative revascularization or the use of tendo-achilles or gastrocnemius lengthening procedures. Male sex, diabetes, ESRD, history of CVD or revascularization are significant risk factors for further amputation. ESRD, diabetes, history of CVD or PVD, older age and higher A1c levels are significant risk factors for mortality. These data provide useful insight into risk factors to be emphasized when counseling patients and their families to establish realistic postoperative expectations.

Prior and Perioperative Revascularization Does Not Affect Survival in Lung Transplant Patients

Coronary artery disease is common in lung transplant patients and has historically been viewed as a contraindication to the procedure. Although this mindset is changing, the effect of prior or perioperative revascularization on lung transplant survival outcomes is not adequately established. We performed a single-center retrospective analysis of all single and double lung transplant patients from 2012 to 2018 (n= 468). Patients were split into 4 groups: (1) patients who received a preoperative percutaneous coronary intervention (n= 34), (2) those who received coronary artery bypass grafting (CABG) before transplantation (n= 25), (3) those that received concomitant CABG during transplantation (n= 29), and (4) those who had lung transplantation with no need for revascularization (n= 380). Groups were compared for demographics, surgical procedure, and survival outcomes. The no-revascularization group was statistically younger than the rest (P= .001). The lung allocation score trended toward being higher in the concomitant coronary artery bypass group (P= .03). All groups were predominantly diagnosed with idiopathic pulmonary fibrosis. The proportion of patients with chronic obstructive pulmonary disease was greatest in the group not requiring revascularization (P= .001). Patients with previous CABG were more likely to receive a single lung transplant than a double one (21 versus 4; P= .054). Length of stay, posttransplant survival, and postoperative adverse events were similar among all groups. Results suggest that preoperative or intraoperative revascularization does not negatively affect survival in lung transplant patients; lung recipients with coronary artery disease have comparable survival when adequately revascularized.

Thoracic aortic stentgraft implantations in Hungary from 2012 to 2016

Thoracic aortic endograft implantation has become a widespread procedure in recent years, yet no report is available about Hungarian outcomes. Examination of our results is crucial to define further treatment strategies. Analysis of perioperative data from Hungarian thoracic endograft implantations based on the experience of 5 years is presented. Our retrospective, multicentric study analysed voluntarily reported data from all Hungarian institutions where thoracic endograft implantations are performed. Information was collected from every procedure performed in 5 years. Between 2012 and 2016, 131 thoracic stent graft implantations were performed in Hungary (67.18% male, mean age 62.80 years). 25.19% of the procedures were acute. 13.74% of the patients were diabetic. Indications for the procedure were aneurysm (64.89%), dissection (17.56%), aortic trauma (6.87%) and other conditions (10.69%). 73.91% of the dissection cases were acute. 16.47% of repaired aneurysms were ruptured. Additional preoperative revascularization (debranching) was performed in 26.72% of the cases. Postoperative stroke occured in 4.58%, temporary hemodialysis was needed in 1.53%, bowel ischaemia was present in 2.29% and reoperation within 30 days was needed in 5.34% of all cases. Thirty-day mortality of the procedure was 9.92%, 5-year long-term mortality reached 16.03%. Endovascular repair of the thoracic aorta is an effective procedure and our national data comfirmed its advantages compared to open thoracic surgery. Further use of the procedure in Hungary depends on the centralised care in vascular surgery and financial matters. Multidisciplinary cooperation and proper logistics are needed to provide patients with optimal treatment. Orv Hetil. 2018; 159(2): 53-57.

TCT-722 Association of Pre-Operative Myocardial Perfusion Imaging and Revascularization with Post-Operative Cardiac Events in Patients Undergoing Elective Non-Cardiac Surgery

TCT-722 Association of Pre-Operative Myocardial Perfusion Imaging and Revascularization with Post-Operative Cardiac Events in Patients Undergoing Elective Non-Cardiac Surgery

Use of revascularized artery as a recipient in microvascular reconstruction of the lower leg: An analysis of 62 consecutive free flap transfers

This study aimed to demonstrate the safety and reliability of combined preoperative angioplasty and free flap transfer in patients with peripheral arterial occlusive disease (PAOD) by analyzing the surgical outcomes. Between October 2011 and October 2015, patients who had undergone lower extremity angiography and subsequent free flap transfer were retrospectively reviewed. Data collected included demographics, perioperative data, and postoperative outcomes. The cases were divided into two groups: one group with microanastomosis performed on revascularized artery by balloon angioplasty and the other group performed on native artery. Multiple logistic regression model using propensity score and linear regression was computed to determine the association between preoperative angioplasty and the surgical outcomes. A total of 62 lower limb reconstruction cases (19 angioplastied cases and 43 nonangioplastied cases) were included in the study. Complications occurred in 6 cases in the angioplastied group and in 11 cases in the control group. The overall limb salvage rate was 100% during the average follow-up of 29.5 months in the angioplastied group and 97.7% in the nonangioplastied control group during the average follow-up of 31.1 months. Preoperative angioplasty was not a significant predictor of increased complications and longer postoperative downtime in logistic and linear regression model, both in the weighted and unweighted model. The combined approach of preoperative endovascular revascularization and free flap transfer for limb reconstruction in PAOD patients can be performed safely and effectively with acceptable morbidity.

Abstract 328: Cardiovascular Disease Associated with Ability to Achieve Renal Transplant and Post-Transplant Adverse Events

Introduction: Patients with end stage renal disease suffer from a high burden of cardiovascular disease (CVD). Renal transplant offers mortality and morbidity benefits. Hypothesis: We predict that patients with CVD are less likely to obtain a renal transplant after being listed and that CVD may be associated with post-transplant adverse events. Methods: We conducted a retrospective analysis of all adult patients listed for first time renal transplantation at the University Of Illinois Chicago from 2002 till 2006. We defined Coronary Artery Disease (CAD) as a history of myocardial infarction or coronary revascularization. We defined reduced ejection fraction (rEF) as an EF less than or equal to 40%. CAD equivalents were defined as a history of diabetes, stroke or peripheral vascular disease. We assessed the outcome of achieving transplantation in a multivariate logistic regression model. We assessed post-transplant events of death or graft failure in a Cox proportional hazards regression model. Results: Of the 460 patients studied African-Americans accounted for 52% and men for 58%. CAD was present in 10.9% of patients and rEF was present in 9.6%. Pre-operative revascularization occurred in 8.9% of patients (74% percutaneous coronary intervention, 26% bypass surgery. Patients with CAD or a CAD equivalent were older (54.7 vs. 43.2 years old, p &lt;0.01), had higher systolic blood pressure (147.2 vs. 140.6 mmHg, p&lt;0.01) and lower diastolic blood pressure (79.3 vs. 83.6 mmHg, p&lt;0.01). Beta-blocker (63% vs. 54%, p = 0.06) statin (45% vs. 11%, p&lt;0.01) and aspirin (40% vs 12%, p&lt;0.01) use was more common in those with CAD or equivalent. In a multivariate logistic regression model controlling for sex, medications, pre-operative revascularization, and comorbidities, age (OR 0.975, 95% CI 0.954 to 0.997, p = 0.03) and history of CAD (OR 0.385 95% CI 0.159 to 0.932, p= 0.03) were associated with lower odds of receiving transplant. In a Cox proportional hazards model controlling for age, sex, pre-operative revascularization, type of transplant, and comorbidities, CAD (HR 2.56 95% CI 1.08 - 6.10, p = 0.03) and rEF (HR 2.37 95% CI 1.06 - 5.35, p = 0.03) were associated with an increased hazard of graft failure or death. Of 337 patients that received transplant only 4 peri-operative myocardial infarcts and 1 stroke occurred. Conclusions: CVD is common in patients listed for renal transplant. CAD is independently associated with lower odds of receiving a transplant. CAD and rEF are independently associated with increased hazard of post-transplant death or graft failure. Future efforts should focus measures to optimize outcomes in patients with CVD awaiting transplant.

DOES A SIMILAR PROCEDURE RESULT IN SIMILAR SURVIVAL FOR WOMEN AND MEN UNDERGOING ISOLATED CORONARY ARTERY BYPASS GRAFTING?

Women and men come to coronary artery bypass grafting (CABG) with different comorbidity profiles and clinical presentation. We sought to identify sex-related differences in preoperative risk factors and revascularization strategies, and examine the influence of these strategies on outcomes. From 1/

Further Consideration for Subclavian Revascularization with TEVAR

Management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) continues to be controversial, despite recent guidelines submitted by the Society for Vascular Surgery recommending routine revascularization of the LSA in most circumstances. Up to one third of patients require coverage of the LSA during TEVAR. The LSA provides extensive circulation to the upper extremity, spinal cord, and brain, consequently, sacrifice of this great vessel might not be physiologically tolerated. Studies supporting routine preoperative revascularization of the LSA note increased rates of spinal cord ischemia, strokes, and upper extremity ischemia when the LSA is sacrificed. Other studies supporting a selective revascularization strategy note no difference in neurologic outcomes and recommend expectant management of upper extremity ischemia. In addition, LSA revascularization has associated complications that are avoided by selective revascularization. The purpose of this article is to review and focus the available data in support of routine versus selective LSA revascularization.

Predictors of Healing and Functional Outcome Following Transmetatarsal Amputations

To evaluate factors that predict healing and to assess functional outcome and survival following transmetatarsal amputations (TMAs) for forefoot gangrene. Retrospective case-control study. University hospital. All patients undergoing TMA from January 1, 2004, through December 31, 2010. Transmetatarsal amputations performed in all patients. Transmetatarsal amputation healing, ambulation, living status, and survival. Demographic characteristics, preoperative vascular status, and perioperative variables were analyzed as predictor variables. Univariate and multivariate analyses were performed to determine predictors of healing and survival. Sixty-two TMAs were performed in 57 patients. Healing occurred in 33 TMAs (53%), with 22 TMAs (35%) in patients who proceeded to below-knee amputation and 7 TMAs (11%) in patients who died without healing. No demographic or perioperative variables significantly predicted healing. Independent ambulation was achieved in 24 patients with healed TMAs (73%) but in only 4 patients with nonhealed TMAs (14%) (P < .001). Mean survival was 16.5 months (range, 0-94 months), with no difference between patients with healed and those with nonhealed TMA. Significant predictors of mortality were dialysis-dependent renal failure (odds ratio, 4.85; 95% confidence interval, 1.01-23.30) (P = .047), nonindependent living (17.80; 3.03-104.80) (P = .001), and need for preoperative revascularization (4.80; 1.24-18.50) (P = .02). Transmetatarsal amputations have low healing rates, and patient demographic characteristics and preoperative assessment do not help predict healing. Transmetatarsal amputation healing, however, significantly predicts subsequent ambulatory status and should be pursued in patients with good rehabilitation potential.