Use of angiotensin-converting enzyme inhibitors and freedom from amputation after lower extremity revascularization.

OBJECTIVE: Angiotensin-converting enzyme inhibitors (ACEIs) have not been well evaluated in conjunction with lower extremity revascularization (LER). This study evaluated freedom from amputation in patients who underwent either an open (OPEN) or endovascular (ENDO) revascularization with and without utilization of an ACEI. MATERIALS AND METHODS: Patients who underwent LER were identified from 2007-2008 Medicare Provider Analysis and Review files. Demographics, comorbidities, and disease severity were obtained. Post-procedural use of an ACEI was confirmed using combining them with National Drug Codes and Part D Files. Outcomes were analyzed using chi-square analysis, Kaplan-Meier test, and Cox regression. RESULTS: We identified 22,954 patients who underwent LER: 8,128 (35.4%) patients with claudication, 3,056 (13.3%) with rest pain, and 11,770 (51.3%) with ulceration or gangrene. More patients underwent ENDO (14,353) than OPEN (8,601) revascularization and 38% of the cohort was taking an ACEI. Overall, ACEI utilization compared to patients not taking ACEI was not associated with lower amputation rates at 30 days (13.5% vs. 12.6%), 90 days (17.7% vs. 17.1%), or 1 year (23.9% vs. 22.8%) (P>0.05 for all). After adjustment for comorbidities, ACEI utilization was associated with higher amputation rates for patients with rest pain (hazard ratio: 1.4; 95% confidence interval: 1.1-1.8). CONCLUSION: ACEI utilization was not associated with overall improved rates of amputation-free survival or overall survival in the vascular surgery population. However, an important finding of this study was that patients presenting with a diagnosis of rest pain and taking an ACEI who underwent a LER had statistically higher amputation rates and a lower amputation-free survival at 1 year. Further analysis is needed to delineate best medical management for patients with critical limb ischemia and taking ACEI who undergo vascular revascularization.

Carotid artery dissection and motor vehicle trauma: patient demographics, associated injuries and impact of treatment on cost and length of stay.

BACKGROUND: Blunt carotid arterial injury (BCI) is a rare injury associated with motor vehicle collision (MVC). There are few population based analyses evaluating carotid injury associated with blunt trauma and their associated injuries as well as outcomes. METHODS: The Nationwide Inpatient Sample (NIS) 2003-2010 data was queried to identify patients after MVC who had documented BCI during their hospitalizations utilizing ICD-9-CM codes. Demographics, associated injuries, interventions performed, length of stay, and cost were evaluated. RESULTS: 1,686,867 patients were estimated having sustained MVC; 1,168 BCI were estimated. No patients with BCI had open repair, 4.24 % had a carotid artery stent (CAS), and 95.76 % of patients had no operative intervention. Age groups associated with BCI were: 18-24 (27.8 %), 47-60 (22.3 %), 35-46 (20.6 %), 25-34 (19.1 %), >61 (10.2 %). Associated injuries included long bone fractures (28.5 %), stroke and intracranial hemorrhage (28.5 %), cranial injuries (25.6 %), thoracic injuries (23.6 %), cervical fractures (21.8 %), facial fractures (19.9 %), skull fractures (18.8 %), pelvic fractures (18.5 %), hepatic (13.3 %) and splenic (9.2 %) injuries. Complications included respiratory (44.2 %), bleeding (16.1 %), urinary tract infections (8.9 %), and sepsis (4.9 %). Overall mortality was 14.1 % without differences with regard to intervention (18.5 % vs. 13.9 %; P = 0.36). Stroke and intracranial hemorrhage was associated with a 2.7 times greater risk of mortality. Mean length of stay for patients with BCI undergoing stenting compared to no intervention were similar (13.1 days vs. 15.9 days) but had a greater mean cost ($83,030 vs. $63,200, p = 0.3). CONCLUSION: BCI is a rare injury associated with MVC, most frequently reported in younger patients. Frequently associated injuries were long bone fractures, stroke and intracranial hemorrhage, thoracic injuries, and pelvic fractures which are likely associated with the force/mechanism of injury. The majority of patients were treated without intervention, but when CAS was utilized, it did not impact mortality and trended toward increased costs.