2012 Vascular Annual Meeting

NATIONAL HARBOR, MD. – Covered stents may reduce the recurrence of chronic mesenteric ischemia and the need for reintervention in patients undergoing primary interventions, according to Dr. Gustavo S. Oderich.

Freedom from symptom recurrence among primary intervention patients was 92% for those with covered stents, compared with 47% for those with bare metal stents (BMS), he reported at the Vascular Annual Meeting. This difference was significant.

Similarly, freedom from reintervention was 91% at 5 years for the covered-stent group, compared with 54% for the BMS group, also a significant difference.

The findings come from a review of patients who were treated for chronic mesenteric ischemia (CMI) using BMS or covered stents (2000-2010). End points included freedom from symptom recurrence, reintervention, and primary and secondary patency rates.

"Mesenteric angioplasty and stenting [have been] plagued by high rates of restenosis and reinterventions in the range of 30%-60% in different reports," said Dr. Oderich, professor of vascular and endovascular surgery at the Mayo Clinic in Rochester, Minn. Covered stents have been shown to lower restenosis rates when used for renal alignment in fenestrated endografts and for the treatment of failing arteriovenous grafts.

The researchers compared BMS and iCast covered stents (Atrium USA) to determine if covered stents could also reduce restenosis in patients with CMI.

In all, 352 patients were treated for CMI, of which 247 had endovascular revascularization. The researchers included 191 patients in the primary intervention group; of these, 149 (78%) had BMS, 42 patients had covered stents, and 22 patients had angioplasty alone. (The angioplasty-alone patients were excluded from the study.) The primary intervention population included 191 patients; the reintervention population included 36 patients who had undergone open primary intervention.

The two groups were similar in terms of demographics, cardiovascular risk factors, and clinical presentation, but the BMS patients tended to have greater rates of chronic pulmonary disease. The anatomical and procedural variables – including extent of disease, type of approach, number of vessels treated, and stent length and diameter – were also similar, as were early outcomes.

Technical success (defined as successful stent implantation without local complications or stenosis less than 30%) was 95% and 98% for the BMS and covered-stent groups, respectively. Mortality was 3% and 0% for the BMS and covered stent groups, respectively.

The primary patency rate at 5 years was 92% for those with covered stents, compared with 47% for those with BMS, in the primary intervention group. There was no difference in secondary patency rates between the two groups. The average follow-up for the cohort was 29 months.

Multivariate analysis of the primary intervention group showed that the use of a covered stent was a protective factor for loss of primary patency, symptom recurrence, and reintervention.

Other independent predictors of loss of primary patency included age, female sex, and current smoking history. For symptom recurrence, other independent predictors included female sex and current smoking history. For reintervention, age and female sex were independent predictors.

Covered stents also were associated with less recurrence and fewer reinterventions in patients undergoing reintervention for mesenteric chronic ischemia. The reintervention group included 15 patients who were treated with BMS and 21 patients treated with covered stents. The two groups were similar in terms of demographics, cardiovascular risk factors, and clinical presentation. In all, 16 vessels were treated with BMS and 22 with covered stents. The two groups had similar approaches, number of vessels treated, and stent dimensions – with the exception of a slight trend toward longer stents in the covered-stent group.

Dr. Oderich reported that he is the principal investigator of a clinical trial sponsored by Cook Medical.

NATIONAL HARBOR, MD. – Covered stents may reduce the recurrence of chronic mesenteric ischemia and the need for reintervention in patients undergoing primary interventions, according to Dr. Gustavo S. Oderich.

Freedom from symptom recurrence among primary intervention patients was 92% for those with covered stents, compared with 47% for those with bare metal stents (BMS), he reported at the Vascular Annual Meeting. This difference was significant.

Similarly, freedom from reintervention was 91% at 5 years for the covered-stent group, compared with 54% for the BMS group, also a significant difference.

The findings come from a review of patients who were treated for chronic mesenteric ischemia (CMI) using BMS or covered stents (2000-2010). End points included freedom from symptom recurrence, reintervention, and primary and secondary patency rates.

"Mesenteric angioplasty and stenting [have been] plagued by high rates of restenosis and reinterventions in the range of 30%-60% in different reports," said Dr. Oderich, professor of vascular and endovascular surgery at the Mayo Clinic in Rochester, Minn. Covered stents have been shown to lower restenosis rates when used for renal alignment in fenestrated endografts and for the treatment of failing arteriovenous grafts.

The researchers compared BMS and iCast covered stents (Atrium USA) to determine if covered stents could also reduce restenosis in patients with CMI.

In all, 352 patients were treated for CMI, of which 247 had endovascular revascularization. The researchers included 191 patients in the primary intervention group; of these, 149 (78%) had BMS, 42 patients had covered stents, and 22 patients had angioplasty alone. (The angioplasty-alone patients were excluded from the study.) The primary intervention population included 191 patients; the reintervention population included 36 patients who had undergone open primary intervention.

The two groups were similar in terms of demographics, cardiovascular risk factors, and clinical presentation, but the BMS patients tended to have greater rates of chronic pulmonary disease. The anatomical and procedural variables – including extent of disease, type of approach, number of vessels treated, and stent length and diameter – were also similar, as were early outcomes.

Technical success (defined as successful stent implantation without local complications or stenosis less than 30%) was 95% and 98% for the BMS and covered-stent groups, respectively. Mortality was 3% and 0% for the BMS and covered stent groups, respectively.

The primary patency rate at 5 years was 92% for those with covered stents, compared with 47% for those with BMS, in the primary intervention group. There was no difference in secondary patency rates between the two groups. The average follow-up for the cohort was 29 months.

Multivariate analysis of the primary intervention group showed that the use of a covered stent was a protective factor for loss of primary patency, symptom recurrence, and reintervention.

Other independent predictors of loss of primary patency included age, female sex, and current smoking history. For symptom recurrence, other independent predictors included female sex and current smoking history. For reintervention, age and female sex were independent predictors.

Covered stents also were associated with less recurrence and fewer reinterventions in patients undergoing reintervention for mesenteric chronic ischemia. The reintervention group included 15 patients who were treated with BMS and 21 patients treated with covered stents. The two groups were similar in terms of demographics, cardiovascular risk factors, and clinical presentation. In all, 16 vessels were treated with BMS and 22 with covered stents. The two groups had similar approaches, number of vessels treated, and stent dimensions – with the exception of a slight trend toward longer stents in the covered-stent group.

Dr. Oderich reported that he is the principal investigator of a clinical trial sponsored by Cook Medical.

NATIONAL HARBOR, MD. – Covered stents may reduce the recurrence of chronic mesenteric ischemia and the need for reintervention in patients undergoing primary interventions, according to Dr. Gustavo S. Oderich.

Freedom from symptom recurrence among primary intervention patients was 92% for those with covered stents, compared with 47% for those with bare metal stents (BMS), he reported at the Vascular Annual Meeting. This difference was significant.

Similarly, freedom from reintervention was 91% at 5 years for the covered-stent group, compared with 54% for the BMS group, also a significant difference.

The findings come from a review of patients who were treated for chronic mesenteric ischemia (CMI) using BMS or covered stents (2000-2010). End points included freedom from symptom recurrence, reintervention, and primary and secondary patency rates.

"Mesenteric angioplasty and stenting [have been] plagued by high rates of restenosis and reinterventions in the range of 30%-60% in different reports," said Dr. Oderich, professor of vascular and endovascular surgery at the Mayo Clinic in Rochester, Minn. Covered stents have been shown to lower restenosis rates when used for renal alignment in fenestrated endografts and for the treatment of failing arteriovenous grafts.

The researchers compared BMS and iCast covered stents (Atrium USA) to determine if covered stents could also reduce restenosis in patients with CMI.

In all, 352 patients were treated for CMI, of which 247 had endovascular revascularization. The researchers included 191 patients in the primary intervention group; of these, 149 (78%) had BMS, 42 patients had covered stents, and 22 patients had angioplasty alone. (The angioplasty-alone patients were excluded from the study.) The primary intervention population included 191 patients; the reintervention population included 36 patients who had undergone open primary intervention.

The two groups were similar in terms of demographics, cardiovascular risk factors, and clinical presentation, but the BMS patients tended to have greater rates of chronic pulmonary disease. The anatomical and procedural variables – including extent of disease, type of approach, number of vessels treated, and stent length and diameter – were also similar, as were early outcomes.

Technical success (defined as successful stent implantation without local complications or stenosis less than 30%) was 95% and 98% for the BMS and covered-stent groups, respectively. Mortality was 3% and 0% for the BMS and covered stent groups, respectively.

The primary patency rate at 5 years was 92% for those with covered stents, compared with 47% for those with BMS, in the primary intervention group. There was no difference in secondary patency rates between the two groups. The average follow-up for the cohort was 29 months.

Multivariate analysis of the primary intervention group showed that the use of a covered stent was a protective factor for loss of primary patency, symptom recurrence, and reintervention.

Other independent predictors of loss of primary patency included age, female sex, and current smoking history. For symptom recurrence, other independent predictors included female sex and current smoking history. For reintervention, age and female sex were independent predictors.

Covered stents also were associated with less recurrence and fewer reinterventions in patients undergoing reintervention for mesenteric chronic ischemia. The reintervention group included 15 patients who were treated with BMS and 21 patients treated with covered stents. The two groups were similar in terms of demographics, cardiovascular risk factors, and clinical presentation. In all, 16 vessels were treated with BMS and 22 with covered stents. The two groups had similar approaches, number of vessels treated, and stent dimensions – with the exception of a slight trend toward longer stents in the covered-stent group.

Dr. Oderich reported that he is the principal investigator of a clinical trial sponsored by Cook Medical.

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.