Faculty Bibliography

Background: Unlike for coronary artery disease, the association between neutrophil-lymphocyte ratio (NLR) and peripheral artery disease (PAD) has not been well established. The aim of this study was to determine the association between neutrophil-lymphocyte ratio and the severity of lower extremity peripheral artery disease. Methods: A retrospective chart review analysis identified 928 patients referred for peripheral angiography at a tertiary care center between December 2012 and June 2015. NLR was assessed from routine pre-procedural hemograms with automated differentials and available in 733 (79%) patients. Outcomes of interest included extent of disease on peripheral angiography and target vessel revascularization. Median follow-up was 10.4 months. Odds ratio (OR) [95% confidence intervals] was assessed using a logistic regression model. Results: There was a significant association between elevated NLR and the presence of severe multi-level PAD versus isolated suprapopliteal or isolated infrapopliteal disease (OR 1.42 [1.18-1.70], p=<0.001). This association between NLR and severe multi-level PAD remained significant even after adjustment for age (OR 1.31 [1.09-1.58], p=0.004); age, sex, race, and body mass index (OR 1.27 [1.05-1.5], p=0.015); and age, sex, race, body mass index, hypertension, diabetes, coronary artery disease, and creatinine (OR 1.25 [1.03-1.53], p=0.024). In patients who underwent endovascular intervention (n=523), there was no significant difference in the rate of target vessel revascularization on follow-up across tertiles of NLR (1st tertile 14.8%, 2nd tertile 14.1%, 3rd tertile 20.1%; p= 0.32). Conclusion: In a contemporary cohort of patients undergoing peripheral angiography with possible endovascular intervention, elevated NLR was independently associated with severe multi-level PAD

OBJECTIVES: To assess the relationship between the resting (RG) and hyperemic (HG) translesional peripheral gradients, with the functional and anatomic parameters before and after an infrainguinal endovascular procedure. BACKGROUND: RGs and HGs are objective tools in defining the hemodynamic significance of an arterial stenosis. METHODS: In 25 subjects with infrainguinal arterial stenosis, RG and HG were measured via a pressure wire before and after angioplasty. Before and after the procedure, all subjects had an ankle-brachial index (ABI) and Duplex ultrasound evaluation, recording prelesion and in-lesion peak systolic velocity (PSV-L), and calculating a peak systolic velocity ratio (PSV-R). A Pearson R correlation coefficient was calculated. RESULTS: The mean age was 73 +/- 12 years, 70% were men, median Rutherford class 3. At baseline and after angioplasty, mean ABI was 0.78 +/- 0.2 and 0.99 +/- 0.1, mean PSV-L was 459 +/- 110 cm/s and 126 +/- 35 cm/s, and mean PSV-R was 6.7 +/- 4 and 1.2 +/- 0.5, respectively. RG and HG significantly improved (P<.001) from baseline to after angioplasty (28.7 +/- 20.5 mm Hg to 5 +/- 13 mm Hg and 40.2 +/- 21.4 mm Hg to 10 +/- 13 mm Hg, respectively). RG before and after the procedure correlated well with ABI (r = -0.58; r = -0.41), PSV-L (r = 0.40; r = 0.52), and PSV-R (r = 0.46; r = 0.42). An improvement of 9 mm Hg in RG predicted a change of 0.1 in ABI. CONCLUSIONS: Improvement in RG during endovascular intervention in superficial femoral artery correlates well with the improvement in ABI, PSV-L, and PSV-R. A postprocedural decrease in RG of 9 mm HG predicts an improvement in ABI of 0.1.

BACKGROUND Transfemoral transcatheter aortic valve replacement (TF TAVR) can be performed under general anesthesia (GA) or moderate sedation (MS). Despite observational studies suggesting a shorter length of stay (LOS), shorter procedural time and a similar mortality rate with MS, only 5% of patients undergoing TF TAVR in the United States are done with this type of anesthesia. We reviewed the implementation of a MS for TF TAVR protocol at a single institution with no previous experience with this technique. METHODS Patients with severe obstructive sleep apnea (OSA), likely difficult intubation, inability to tolerate supine position due to musculoskeletal disease, or barriers to communication including altered mental status were performed under GA with intraoperative transesophageal echocardiography. All others received MS with an ilioinguinal nerve block and intraoperative transthoracic echocardiography. The MS for TF TAVR protocol was implemented on October 9th, 2014. The records of patients undergoing TF TAVR 6 months before and after protocol implementation were retrospectively reviewed. RESULTS In the pre protocol group 33 patients underwent TF TAVR under GA and no patients received MS. In the post protocol group, 97 underwent TF TAVR, 81 (83.5%) of which received MS. OSA was the most common reason for GA (N=10, 62.5%). Conversion from MS to GA occurred in 2 cases (2.5%) due to procedural complications, of which 1 resulted in death. All other cases involving MS were tolerated well and there were no anesthesia related complications. Post procedural LOS (3.2 days vs. 5.0 days, p=0.002) and procedure time (144.0 minutes vs. 96.1 minutes, p<0.001) were both significantly shorter in post protocol group. The post protocol group was also significantly less likely to require a skilled nursing facility upon discharge (24.2% vs. 8.2%, p=0.027). In hospital mortality was similar between groups (N=2 6.1% vs. N=3, 3.1%, p=0.601). (Table Presented) CONCLUSIONS The MS for TF TAVR protocol appears safe and can be rapidly implemented at institutions with no previous MS experience. This technique is feasible in the majority of patient undergoing TF TAVR. Post procedural LOS and procedural time are multifactorial, but this data further suggests MS may be beneficial in select patients