World Federation of Vascular Societies (WFVS) Congress 2014

CHICAGO – Remote ischemic preconditioning reduced the risk of myocardial injury following angioplasty in patients with peripheral artery occlusive disease, and appeared to improve clinical outcome in an ongoing prospective study of 64 patients.

The rise in cardiac troponin I blood levels was significantly attenuated 24-hours after angioplasty (with or without stenting) in patients who were randomized to remote ischemic preconditioning applied 1 hour before surgery at the arm via three cycles of 5-minute blood pressure cuff inflation, followed by 5 minutes of deflation, compared with those receiving no preconditioning (log 0.025 mcg/L vs. 0.240 mcg/L; P = .01).

Preprocedure troponin levels among the 64 consecutive patients were similar between arms (log 0.042 mcg/L vs. 0.046 mcg/L; P = .94).

At 1-year follow-up, two patients in the control group experienced an acute MI, compared with none in the preconditioned group, Dr. Jeanne Adele Lubbe said at the annual meeting of the World Federation of Vascular Societies. Acute MI was defined according to American Heart Association guidelines, and took into account cardiac troponin levels, electrocardiographic changes, and clinical symptoms.

"This is clinically significant, and suggests that the magnitude of cardiac troponin I release has prognostic value," she said.

Audience members described the findings as surprising and intriguing, as several studies have reported an effect on troponin levels with remote ischemic preconditioning but were unable to tie this to a clinical effect – much less in a group of patients who were considered at relatively low risk for a cardiac event.

Comparisons were also made between preconditioning and the protective effects observed with perioperative beta blockade in some surgical patients. "If this pans out further down the track ... is this the sort of thing you’d chase?" one attendee asked.

Dr. Lubbe replied, "To think that blowing up a blood pressure cuff would have a lasting effect is a bit strange. But this is not something that we’re going to start applying to patients without having a firming up of this effect."

Preconditioning can be applied to patients with claudication and is ideal in patients who are known to be at high risk of MI, especially if it can be predicted when they are at the highest risk for myocardial ischemia, explained Dr. Lubbe of the University of Stellenbosch in Tygerberg, South Africa.

Among the 32 control and 32 study patients, there were no differences in the number of stents placed during angioplasty (eight vs. nine), stent length (mean, 118 mm vs. 143 mm), balloon inflation pressure (mean, 9.5 atmospheres vs. 10.1 atmospheres), or total fluoroscopic screening time (mean, 25 minutes vs. 20.5 minutes).

At baseline, there were no significant differences between the control and experimental groups in their use of beta blockers (66% vs. 44%), calcium channel blockers (13% vs. 25%), ACE inhibitors (50% vs. 72%), nitrate (13% vs. 3%), or nicorandil/glibenclamide (25% vs. 22%), Dr. Lubbe said.

Heart failure was present in 16% of patients in both arms, and 34% had a history of angina. Controls and patients undergoing preconditioning had similar rates of previous MI (22% vs. 16%) and coronary revascularization (13% vs. 6%). Dr. Lubbe noted that all patients could possibly be protected by the effect of antecedent chronic ischemia, but she said that this was minimized by instructing patients to avoid overexertion prior to the intervention.

The first control patient who was diagnosed with MI had undergone percutaneous transluminal arterial angioplasty (PTA) and stenting of a right-sided iliac artery stenosis prior to diagnosis of the MI, which was treated medically. The second patient experienced acute cardiac arrest 9 hours after undergoing PTA of his superficial femoral artery and posterior tibial vessels. Coronary angiogram revealed critical four-vessel disease, but the patient refused revascularization and subsequently died.

Dr. Lubbe and her colleagues are continuing to evaluate additional patients, and they plan to report 1- and 3-year major adverse cardiovascular and cerebrovascular events at a future meeting.

Dr. Lubbe and her coauthors report no conflicts of interest.

CHICAGO – Remote ischemic preconditioning reduced the risk of myocardial injury following angioplasty in patients with peripheral artery occlusive disease, and appeared to improve clinical outcome in an ongoing prospective study of 64 patients.

The rise in cardiac troponin I blood levels was significantly attenuated 24-hours after angioplasty (with or without stenting) in patients who were randomized to remote ischemic preconditioning applied 1 hour before surgery at the arm via three cycles of 5-minute blood pressure cuff inflation, followed by 5 minutes of deflation, compared with those receiving no preconditioning (log 0.025 mcg/L vs. 0.240 mcg/L; P = .01).

Preprocedure troponin levels among the 64 consecutive patients were similar between arms (log 0.042 mcg/L vs. 0.046 mcg/L; P = .94).

At 1-year follow-up, two patients in the control group experienced an acute MI, compared with none in the preconditioned group, Dr. Jeanne Adele Lubbe said at the annual meeting of the World Federation of Vascular Societies. Acute MI was defined according to American Heart Association guidelines, and took into account cardiac troponin levels, electrocardiographic changes, and clinical symptoms.

"This is clinically significant, and suggests that the magnitude of cardiac troponin I release has prognostic value," she said.

Audience members described the findings as surprising and intriguing, as several studies have reported an effect on troponin levels with remote ischemic preconditioning but were unable to tie this to a clinical effect – much less in a group of patients who were considered at relatively low risk for a cardiac event.

Comparisons were also made between preconditioning and the protective effects observed with perioperative beta blockade in some surgical patients. "If this pans out further down the track ... is this the sort of thing you’d chase?" one attendee asked.

Dr. Lubbe replied, "To think that blowing up a blood pressure cuff would have a lasting effect is a bit strange. But this is not something that we’re going to start applying to patients without having a firming up of this effect."

Preconditioning can be applied to patients with claudication and is ideal in patients who are known to be at high risk of MI, especially if it can be predicted when they are at the highest risk for myocardial ischemia, explained Dr. Lubbe of the University of Stellenbosch in Tygerberg, South Africa.

Among the 32 control and 32 study patients, there were no differences in the number of stents placed during angioplasty (eight vs. nine), stent length (mean, 118 mm vs. 143 mm), balloon inflation pressure (mean, 9.5 atmospheres vs. 10.1 atmospheres), or total fluoroscopic screening time (mean, 25 minutes vs. 20.5 minutes).

At baseline, there were no significant differences between the control and experimental groups in their use of beta blockers (66% vs. 44%), calcium channel blockers (13% vs. 25%), ACE inhibitors (50% vs. 72%), nitrate (13% vs. 3%), or nicorandil/glibenclamide (25% vs. 22%), Dr. Lubbe said.

Heart failure was present in 16% of patients in both arms, and 34% had a history of angina. Controls and patients undergoing preconditioning had similar rates of previous MI (22% vs. 16%) and coronary revascularization (13% vs. 6%). Dr. Lubbe noted that all patients could possibly be protected by the effect of antecedent chronic ischemia, but she said that this was minimized by instructing patients to avoid overexertion prior to the intervention.

The first control patient who was diagnosed with MI had undergone percutaneous transluminal arterial angioplasty (PTA) and stenting of a right-sided iliac artery stenosis prior to diagnosis of the MI, which was treated medically. The second patient experienced acute cardiac arrest 9 hours after undergoing PTA of his superficial femoral artery and posterior tibial vessels. Coronary angiogram revealed critical four-vessel disease, but the patient refused revascularization and subsequently died.

Dr. Lubbe and her colleagues are continuing to evaluate additional patients, and they plan to report 1- and 3-year major adverse cardiovascular and cerebrovascular events at a future meeting.

Dr. Lubbe and her coauthors report no conflicts of interest.

CHICAGO – Remote ischemic preconditioning reduced the risk of myocardial injury following angioplasty in patients with peripheral artery occlusive disease, and appeared to improve clinical outcome in an ongoing prospective study of 64 patients.

The rise in cardiac troponin I blood levels was significantly attenuated 24-hours after angioplasty (with or without stenting) in patients who were randomized to remote ischemic preconditioning applied 1 hour before surgery at the arm via three cycles of 5-minute blood pressure cuff inflation, followed by 5 minutes of deflation, compared with those receiving no preconditioning (log 0.025 mcg/L vs. 0.240 mcg/L; P = .01).

Preprocedure troponin levels among the 64 consecutive patients were similar between arms (log 0.042 mcg/L vs. 0.046 mcg/L; P = .94).

At 1-year follow-up, two patients in the control group experienced an acute MI, compared with none in the preconditioned group, Dr. Jeanne Adele Lubbe said at the annual meeting of the World Federation of Vascular Societies. Acute MI was defined according to American Heart Association guidelines, and took into account cardiac troponin levels, electrocardiographic changes, and clinical symptoms.

"This is clinically significant, and suggests that the magnitude of cardiac troponin I release has prognostic value," she said.

Audience members described the findings as surprising and intriguing, as several studies have reported an effect on troponin levels with remote ischemic preconditioning but were unable to tie this to a clinical effect – much less in a group of patients who were considered at relatively low risk for a cardiac event.

Comparisons were also made between preconditioning and the protective effects observed with perioperative beta blockade in some surgical patients. "If this pans out further down the track ... is this the sort of thing you’d chase?" one attendee asked.

Dr. Lubbe replied, "To think that blowing up a blood pressure cuff would have a lasting effect is a bit strange. But this is not something that we’re going to start applying to patients without having a firming up of this effect."

Preconditioning can be applied to patients with claudication and is ideal in patients who are known to be at high risk of MI, especially if it can be predicted when they are at the highest risk for myocardial ischemia, explained Dr. Lubbe of the University of Stellenbosch in Tygerberg, South Africa.

Among the 32 control and 32 study patients, there were no differences in the number of stents placed during angioplasty (eight vs. nine), stent length (mean, 118 mm vs. 143 mm), balloon inflation pressure (mean, 9.5 atmospheres vs. 10.1 atmospheres), or total fluoroscopic screening time (mean, 25 minutes vs. 20.5 minutes).

At baseline, there were no significant differences between the control and experimental groups in their use of beta blockers (66% vs. 44%), calcium channel blockers (13% vs. 25%), ACE inhibitors (50% vs. 72%), nitrate (13% vs. 3%), or nicorandil/glibenclamide (25% vs. 22%), Dr. Lubbe said.

Heart failure was present in 16% of patients in both arms, and 34% had a history of angina. Controls and patients undergoing preconditioning had similar rates of previous MI (22% vs. 16%) and coronary revascularization (13% vs. 6%). Dr. Lubbe noted that all patients could possibly be protected by the effect of antecedent chronic ischemia, but she said that this was minimized by instructing patients to avoid overexertion prior to the intervention.

The first control patient who was diagnosed with MI had undergone percutaneous transluminal arterial angioplasty (PTA) and stenting of a right-sided iliac artery stenosis prior to diagnosis of the MI, which was treated medically. The second patient experienced acute cardiac arrest 9 hours after undergoing PTA of his superficial femoral artery and posterior tibial vessels. Coronary angiogram revealed critical four-vessel disease, but the patient refused revascularization and subsequently died.

Dr. Lubbe and her colleagues are continuing to evaluate additional patients, and they plan to report 1- and 3-year major adverse cardiovascular and cerebrovascular events at a future meeting.

Dr. Lubbe and her coauthors report no conflicts of interest.

CHICAGO – A dedicated protocol that streamlines the care pathway dramatically improved the timely care of patients with life-threatening ruptured abdominal aortic aneurysms, although overall outcomes held relatively steady.

Among 62 patients, the median overall door-to-treatment time decreased significantly from a preprotocol 183.5 minutes to 157 minutes post protocol (P = .05).

That included a significant drop in median emergency department-to-operating room time (35 minutes vs. 23 minutes; P = .035) and nonsignificant reductions in time spent at the referring hospital (150.5 minutes vs. 110 minutes) and in transit (52 minutes vs. 35 minutes), Dr. Raghu Motaganahalli reported on behalf of his colleagues at Indiana University, Indianapolis.

Data available on three-fourths of the patients suggest that the expedited care improved immediate outcomes. The percentage of patients who had a Glasgow Aneurysm Score greater than 100 and survived increased from 20% to 69% post-implementation, Dr. Motaganahalli said at the annual meeting of the Peripheral Vascular Surgery Society.

"Various therapeutic interventions, including endovascular therapy, have added to patient mortality," he said. "However, there’s still a need to have a dedicated protocol that enables early recognition by increasing awareness, effective communication, and rapid transfer to centers taking care of patients with ruptured aneurysms."

The Protocol at Indiana University Methodist Hospital

The level I vascular emergency program at Indiana University Methodist Hospital instituted a protocol for acute aortic emergencies, as well as limb-threatening ischemia, in August 2009. The transferring emergency department (ED) or attending physician initiates the process by calling a Lifeline Telecom toll-free number.

Lifeline Telecom arranges the transportation of the patient and calls the hospital operator, who sends out a burst page to the on-call vascular surgeon, OR charge nurse and vascular fellow, as well as the emergency medicine and trauma center (EMTC) charge nurse, cardiovascular critical care charge nurse, patient access team leader, level I vascular coordinator, main admission office, transfer center, chaplain, and security.

Meanwhile, the transferring ED faxes the patient’s face sheet to Lifeline, and the referring ED nurse calls in the patient report to the receiving ED charge nurse, Dr. Motaganahalli explained.

Upon receiving the page, the receiving surgeon and OR charge nurse call the same Lifeline number and hold a conference call with the transferring ED physician to determine whether the patient should go to the ED or directly to an OR. The surgeon then directs the OR charge nurse on the type of procedure to prepare, and the nurse sends a burst page to the OR team.

The surgeon is transferred by the operator to the EMTC physician, who reads the CT scans if they’re available. Indiana University Methodist Hospital is developing a central site where referring hospitals can upload images directly to its website, but for now, the hospital relies on transmission via CV Express or discs that arrive with the patient, Dr. Motaganahalli said.

The patients are mostly male, are transported by air, and have CT scans obtained at the referring facility. Of the 90 patients who have been treated since the protocol was adopted through November 2010, eight have died in transit or upon arrival.

Although all 26 preprotocol patients were treated with open repair, 36% of the 36 postprotocol patients have undergone endovascular repair, he said.

In all, 8 (30.7%) preprotocol patients died, compared with 11 (30.5%) postprotocol patients, including 3 who were treated endovascularly. Hospital length of stay and patient disposition were also similar.

Invited discussant Dr. Ravi Veeraswamy, a vascular surgeon from Emory University in Atlanta, asked whether there is a protocol in place for endovascular repair, and why shorter treatment times didn’t translate into a greater improvement in outcomes. Dr. Motaganahalli replied that the university is attracting more sick patients from across the state who previously would have died, and that these patients have worse hemodynamic values when they arrive.

He added that endovascular repair is based on purely anatomical criteria, and that they may use aortic balloon occlusion to temporarily obtain hemodynamic stability, but that these patients go on to open repair.

The authors reported no disclosures.

CHICAGO – A dedicated protocol that streamlines the care pathway dramatically improved the timely care of patients with life-threatening ruptured abdominal aortic aneurysms, although overall outcomes held relatively steady.

Among 62 patients, the median overall door-to-treatment time decreased significantly from a preprotocol 183.5 minutes to 157 minutes post protocol (P = .05).

That included a significant drop in median emergency department-to-operating room time (35 minutes vs. 23 minutes; P = .035) and nonsignificant reductions in time spent at the referring hospital (150.5 minutes vs. 110 minutes) and in transit (52 minutes vs. 35 minutes), Dr. Raghu Motaganahalli reported on behalf of his colleagues at Indiana University, Indianapolis.

Data available on three-fourths of the patients suggest that the expedited care improved immediate outcomes. The percentage of patients who had a Glasgow Aneurysm Score greater than 100 and survived increased from 20% to 69% post-implementation, Dr. Motaganahalli said at the annual meeting of the Peripheral Vascular Surgery Society.

"Various therapeutic interventions, including endovascular therapy, have added to patient mortality," he said. "However, there’s still a need to have a dedicated protocol that enables early recognition by increasing awareness, effective communication, and rapid transfer to centers taking care of patients with ruptured aneurysms."

The Protocol at Indiana University Methodist Hospital

The level I vascular emergency program at Indiana University Methodist Hospital instituted a protocol for acute aortic emergencies, as well as limb-threatening ischemia, in August 2009. The transferring emergency department (ED) or attending physician initiates the process by calling a Lifeline Telecom toll-free number.

Lifeline Telecom arranges the transportation of the patient and calls the hospital operator, who sends out a burst page to the on-call vascular surgeon, OR charge nurse and vascular fellow, as well as the emergency medicine and trauma center (EMTC) charge nurse, cardiovascular critical care charge nurse, patient access team leader, level I vascular coordinator, main admission office, transfer center, chaplain, and security.

Meanwhile, the transferring ED faxes the patient’s face sheet to Lifeline, and the referring ED nurse calls in the patient report to the receiving ED charge nurse, Dr. Motaganahalli explained.

Upon receiving the page, the receiving surgeon and OR charge nurse call the same Lifeline number and hold a conference call with the transferring ED physician to determine whether the patient should go to the ED or directly to an OR. The surgeon then directs the OR charge nurse on the type of procedure to prepare, and the nurse sends a burst page to the OR team.

The surgeon is transferred by the operator to the EMTC physician, who reads the CT scans if they’re available. Indiana University Methodist Hospital is developing a central site where referring hospitals can upload images directly to its website, but for now, the hospital relies on transmission via CV Express or discs that arrive with the patient, Dr. Motaganahalli said.

The patients are mostly male, are transported by air, and have CT scans obtained at the referring facility. Of the 90 patients who have been treated since the protocol was adopted through November 2010, eight have died in transit or upon arrival.

Although all 26 preprotocol patients were treated with open repair, 36% of the 36 postprotocol patients have undergone endovascular repair, he said.

In all, 8 (30.7%) preprotocol patients died, compared with 11 (30.5%) postprotocol patients, including 3 who were treated endovascularly. Hospital length of stay and patient disposition were also similar.

Invited discussant Dr. Ravi Veeraswamy, a vascular surgeon from Emory University in Atlanta, asked whether there is a protocol in place for endovascular repair, and why shorter treatment times didn’t translate into a greater improvement in outcomes. Dr. Motaganahalli replied that the university is attracting more sick patients from across the state who previously would have died, and that these patients have worse hemodynamic values when they arrive.

He added that endovascular repair is based on purely anatomical criteria, and that they may use aortic balloon occlusion to temporarily obtain hemodynamic stability, but that these patients go on to open repair.

The authors reported no disclosures.

CHICAGO – A dedicated protocol that streamlines the care pathway dramatically improved the timely care of patients with life-threatening ruptured abdominal aortic aneurysms, although overall outcomes held relatively steady.

Among 62 patients, the median overall door-to-treatment time decreased significantly from a preprotocol 183.5 minutes to 157 minutes post protocol (P = .05).

That included a significant drop in median emergency department-to-operating room time (35 minutes vs. 23 minutes; P = .035) and nonsignificant reductions in time spent at the referring hospital (150.5 minutes vs. 110 minutes) and in transit (52 minutes vs. 35 minutes), Dr. Raghu Motaganahalli reported on behalf of his colleagues at Indiana University, Indianapolis.

Data available on three-fourths of the patients suggest that the expedited care improved immediate outcomes. The percentage of patients who had a Glasgow Aneurysm Score greater than 100 and survived increased from 20% to 69% post-implementation, Dr. Motaganahalli said at the annual meeting of the Peripheral Vascular Surgery Society.

"Various therapeutic interventions, including endovascular therapy, have added to patient mortality," he said. "However, there’s still a need to have a dedicated protocol that enables early recognition by increasing awareness, effective communication, and rapid transfer to centers taking care of patients with ruptured aneurysms."

The Protocol at Indiana University Methodist Hospital

The level I vascular emergency program at Indiana University Methodist Hospital instituted a protocol for acute aortic emergencies, as well as limb-threatening ischemia, in August 2009. The transferring emergency department (ED) or attending physician initiates the process by calling a Lifeline Telecom toll-free number.

Lifeline Telecom arranges the transportation of the patient and calls the hospital operator, who sends out a burst page to the on-call vascular surgeon, OR charge nurse and vascular fellow, as well as the emergency medicine and trauma center (EMTC) charge nurse, cardiovascular critical care charge nurse, patient access team leader, level I vascular coordinator, main admission office, transfer center, chaplain, and security.

Meanwhile, the transferring ED faxes the patient’s face sheet to Lifeline, and the referring ED nurse calls in the patient report to the receiving ED charge nurse, Dr. Motaganahalli explained.

Upon receiving the page, the receiving surgeon and OR charge nurse call the same Lifeline number and hold a conference call with the transferring ED physician to determine whether the patient should go to the ED or directly to an OR. The surgeon then directs the OR charge nurse on the type of procedure to prepare, and the nurse sends a burst page to the OR team.

The surgeon is transferred by the operator to the EMTC physician, who reads the CT scans if they’re available. Indiana University Methodist Hospital is developing a central site where referring hospitals can upload images directly to its website, but for now, the hospital relies on transmission via CV Express or discs that arrive with the patient, Dr. Motaganahalli said.

The patients are mostly male, are transported by air, and have CT scans obtained at the referring facility. Of the 90 patients who have been treated since the protocol was adopted through November 2010, eight have died in transit or upon arrival.

Although all 26 preprotocol patients were treated with open repair, 36% of the 36 postprotocol patients have undergone endovascular repair, he said.

In all, 8 (30.7%) preprotocol patients died, compared with 11 (30.5%) postprotocol patients, including 3 who were treated endovascularly. Hospital length of stay and patient disposition were also similar.

Invited discussant Dr. Ravi Veeraswamy, a vascular surgeon from Emory University in Atlanta, asked whether there is a protocol in place for endovascular repair, and why shorter treatment times didn’t translate into a greater improvement in outcomes. Dr. Motaganahalli replied that the university is attracting more sick patients from across the state who previously would have died, and that these patients have worse hemodynamic values when they arrive.

He added that endovascular repair is based on purely anatomical criteria, and that they may use aortic balloon occlusion to temporarily obtain hemodynamic stability, but that these patients go on to open repair.

The authors reported no disclosures.