Sherry Boschert

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.

PALM SPRINGS, CALIF. – With chronic pain affecting 65 million patients in the United States, the 6,000 pain specialists need help – and they’re looking at you, primary care physicians.

"The next major advancement in pain medicine will be in the training and expertise of the primary care provider," Dr. Bill H. McCarberg said at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

It won’t be easy, and he expects that primary care physicians will come "kicking and screaming" into pain management. "Primary care doesn’t want to do this, but I think that they didn’t want to do many of the other tasks that they’re doing right now," said Dr. McCarberg, a family physician himself and founder of the Chronic Pain Management Program at Kaiser Permanente, San Diego.

He recalled a time when he sent all of his patients who had hypercholesterolemia to a local cholesterol clinic in order to save himself the time of having to manage their statins, follow cholesterol levels, check liver functions, and so on. The problem is, every other time-pressed primary care physician in the area did the same.

"A funny thing happened to the cholesterol clinic. It shut down because it was inundated," he said. Similar trends are affecting pain specialists and opioid management clinics that are becoming overwhelmed, in part because primary care physicians are reluctant to manage pain they way they do other chronic diseases, he said.

Data suggest that primary care physicians manage 94% of patients with asthma, 92% with hypertension, 91% with stroke, 90% with diabetes, 89% with chronic obstructive pulmonary disease, and 86% with arteriosclerotic cardiovascular disease, he noted.

"If you look at all the other chronic illnesses that are around, we’re the ones that are managing those. There was much concern that we couldn’t do any of these because we didn’t have the expertise, but we’re doing a pretty good job at all of these. If you look at hypertension rates or stroke rates, we’re making big changes in those," Dr. McCarberg said.

Pain specialists will need to help primary care physicians improve their skills and provide consultations on difficult patients in order to build expertise, he said. Instead of feeling lost or intimidated when a patient comes back from a referral to a pain specialist with an unfamiliar diagnosis or a complicated therapy, primary care physicians should be hearing from the pain specialist about what can be done in the primary care office the next time a similar patient comes in, he suggested.

Physicians in the audience said they came to Dr. McCarberg’s session because they’re experiencing the problematic scenarios that he described.

One physician from Vermont said there is a single pain specialist in the state, so primary care must become the foundation of pain management. A Minnesota pain specialist who also is a general physician said there are few pain specialists in his state and many family physicians who don’t want to be involved in patients’ opioid therapy.

An interventional pain specialist from Reno, Nev., said 70 primary care physicians in the area "punt" patients to her so that they don’t have to deal with chronic pain. Often, no one has done a toxicology screen until the patient sees her. She has to dismiss patients who have controlled substances of unknown origin in their urine, and they go back to the primary care physicians without getting help for their pain. She also talks about options with some patients who might better be helped by opioid therapy than by an intervention, but the primary care physicians are reluctant to manage opioids, she said.

Dr. McCarberg encouraged her to pursue one-on-one education of any primary care physician who might seem open to taking a larger role in managing patients’ chronic pain, so that eventually this might lead to a cadre of primary care physicians showing that it can be done.

"The best people to take care of most pain problems are primary care doctors," because they understand the complexity of the patient and the problem, noted Dr. Ilene R. Robeck, a primary care internist in the Bay Pines (Fla.) Veterans Affairs Health Care System. Primary care physicians will step into the lead in pain management not just because no one else will, but "because we’re really the best people to do it, given the time and resources and education."

Dr. McCarberg agreed, but he acknowledged the challenges that he and his associates identified in extensive interviews with 56 primary care physicians in various parts of the United States who had referred a patient to a pain specialist. Time pressures are a key issue, the respondents said.

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.

"I get paid according to the hemoglobin A1_c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.

The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.

These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.

It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.

Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.

"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."

That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.

A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.

Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.

Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.

Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.

PALM SPRINGS, CALIF. – An intensive interdisciplinary outpatient program successfully treated 246 patients at high risk of substance abuse, alongside 230 low-risk patients, for their debilitating chronic pain.

At the start of the 3-week pain rehabilitation program, the two groups did not differ significantly in their duration of pain (nearly 12 years on average) or duration of opioid use (6 years on average). They reported similar levels of pain severity.

The high-risk patients, however, had significantly worse scores on measures of depression, pain interference with life, pain catastrophizing, and perceived control of life and pain. Despite comparable pain severity and duration, they were taking significantly greater morphine-equivalent doses of pain medications, compared with doses taken by low-risk patients (124 vs. 60 mg/day).

By the end of the program, which incorporated substance abuse education and support, both the high-risk and low-risk groups had improved in all these measures, and there was no longer any significant difference in scores between the two groups, Sarah E. Hayes reported in an award-winning poster and plenary session at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

The intensive program at the Mayo Clinic, Rochester, Minn. provides more than can be offered in a typical ambulatory setting, coinvestigator Dr. Michael Hooten said in an interview. The results suggest that high-risk patients can be included in pain rehabilitation programs without affecting treatment outcomes, said Dr. Hooten of the Mayo Clinic.

Patients attend sessions 8 hours per day, 5 days per week, focused on functional restoration, withdrawal from opioids, and reduced polypharmacy rather than on attempted cures or interventional procedures for their chronic pain. Approximately 97% completely taper off of opioids, said Ms. Hayes, who conducted the study while she was a research associate at the Mayo Clinic and is now a student at New York University.

The interdisciplinary staff includes physicians, psychologists, pharmacists, nurses, physical therapists, and occupational therapists. The foundation of treatment is a cognitive-behavioral model that includes biofeedback, relaxation training, and stress management. Patients receive education in "chemical health" and in "wellness" topics such as sleep hygiene and healthy diets. Pain management training covers activity moderation and eliminating behaviors that cause pain. Family education and after-care assistance are provided.

Patients were identified as high risk if they had a history of using mood-altering substances, used pain medications in ways other than those prescribed, showed aberrant drug-related behaviors, had family members or health care providers who expressed concern, had a family history of substance abuse, or had other health risks (such as polypharmacy and high-dose opioid use).

At entry, they were significantly more likely than the low-risk group to have used opioids (75% vs. 46%), benzodiazepines (51% vs. 34%), or a combination of opioids, benzodiazepines, and sedative hypnotics (18% vs. 7%), and they were significantly more likely to be dependent on nicotine (37% vs. 10%), to have a history of heavy alcohol use (27% vs. 6%), and to be currently using cannabis (13% vs. 0.4%).

For the high-risk group, approximately 18 of the 120 hours in the program were devoted to a substance use curriculum that covered the physical and medical aspects of substance abuse, the cycle of pain and how substance use has become a part of that cycle, and how to manage high-risk situations and triggers for substance abuse. Patients explored their personal substance use patterns, family aspects, the effects of substance use on relationships, and their life goals.

"We’re increasingly noticing that chronic pain patients often have comorbid chemical dependency issues," Ms. Hayes said. Both chronic pain and substance abuse need to be addressed at the same time, she suggested.

The investigators plan to conduct longitudinal studies to identify how best to support high-risk patients after they complete the pain rehabilitation program.

The study included consecutive patients treated from February 2010 to May 2011. Patients averaged 45 years in age, ranging from 18 to 90 years. Back pain, fibromyalgia, and headache were the most common types of pain. Patients in the high-risk group were significantly more likely than those in the low-risk group to be living with back pain (27% vs. 21%) and significantly less likely to be living with fibromyalgia (15% vs. 21%).

Significantly fewer high-risk patients completed the 3-week program compared with low-risk patients (87% vs. 94%).

Functional status was assessed at the start and the end of the program using multiple tools including the Multidimensional Pain Inventory, the Center for Epidemiological Studies Depression Scale, the Pain Self-Efficacy Questionnaire, and the Pain Catastrophizing Scale.

A physician in the audience urged the investigators to mass market the tools to help chronic pain patients who are at high risk of substance abuse. "In the private setting, we don’t have the tools to provide the kind of program that you do," he said.

The investigators reported having no relevant financial disclosures.

PALM SPRINGS, CALIF. – An intensive interdisciplinary outpatient program successfully treated 246 patients at high risk of substance abuse, alongside 230 low-risk patients, for their debilitating chronic pain.

At the start of the 3-week pain rehabilitation program, the two groups did not differ significantly in their duration of pain (nearly 12 years on average) or duration of opioid use (6 years on average). They reported similar levels of pain severity.

The high-risk patients, however, had significantly worse scores on measures of depression, pain interference with life, pain catastrophizing, and perceived control of life and pain. Despite comparable pain severity and duration, they were taking significantly greater morphine-equivalent doses of pain medications, compared with doses taken by low-risk patients (124 vs. 60 mg/day).

By the end of the program, which incorporated substance abuse education and support, both the high-risk and low-risk groups had improved in all these measures, and there was no longer any significant difference in scores between the two groups, Sarah E. Hayes reported in an award-winning poster and plenary session at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

The intensive program at the Mayo Clinic, Rochester, Minn. provides more than can be offered in a typical ambulatory setting, coinvestigator Dr. Michael Hooten said in an interview. The results suggest that high-risk patients can be included in pain rehabilitation programs without affecting treatment outcomes, said Dr. Hooten of the Mayo Clinic.

Patients attend sessions 8 hours per day, 5 days per week, focused on functional restoration, withdrawal from opioids, and reduced polypharmacy rather than on attempted cures or interventional procedures for their chronic pain. Approximately 97% completely taper off of opioids, said Ms. Hayes, who conducted the study while she was a research associate at the Mayo Clinic and is now a student at New York University.

The interdisciplinary staff includes physicians, psychologists, pharmacists, nurses, physical therapists, and occupational therapists. The foundation of treatment is a cognitive-behavioral model that includes biofeedback, relaxation training, and stress management. Patients receive education in "chemical health" and in "wellness" topics such as sleep hygiene and healthy diets. Pain management training covers activity moderation and eliminating behaviors that cause pain. Family education and after-care assistance are provided.

Patients were identified as high risk if they had a history of using mood-altering substances, used pain medications in ways other than those prescribed, showed aberrant drug-related behaviors, had family members or health care providers who expressed concern, had a family history of substance abuse, or had other health risks (such as polypharmacy and high-dose opioid use).

At entry, they were significantly more likely than the low-risk group to have used opioids (75% vs. 46%), benzodiazepines (51% vs. 34%), or a combination of opioids, benzodiazepines, and sedative hypnotics (18% vs. 7%), and they were significantly more likely to be dependent on nicotine (37% vs. 10%), to have a history of heavy alcohol use (27% vs. 6%), and to be currently using cannabis (13% vs. 0.4%).

For the high-risk group, approximately 18 of the 120 hours in the program were devoted to a substance use curriculum that covered the physical and medical aspects of substance abuse, the cycle of pain and how substance use has become a part of that cycle, and how to manage high-risk situations and triggers for substance abuse. Patients explored their personal substance use patterns, family aspects, the effects of substance use on relationships, and their life goals.

"We’re increasingly noticing that chronic pain patients often have comorbid chemical dependency issues," Ms. Hayes said. Both chronic pain and substance abuse need to be addressed at the same time, she suggested.

The investigators plan to conduct longitudinal studies to identify how best to support high-risk patients after they complete the pain rehabilitation program.

The study included consecutive patients treated from February 2010 to May 2011. Patients averaged 45 years in age, ranging from 18 to 90 years. Back pain, fibromyalgia, and headache were the most common types of pain. Patients in the high-risk group were significantly more likely than those in the low-risk group to be living with back pain (27% vs. 21%) and significantly less likely to be living with fibromyalgia (15% vs. 21%).

Significantly fewer high-risk patients completed the 3-week program compared with low-risk patients (87% vs. 94%).

Functional status was assessed at the start and the end of the program using multiple tools including the Multidimensional Pain Inventory, the Center for Epidemiological Studies Depression Scale, the Pain Self-Efficacy Questionnaire, and the Pain Catastrophizing Scale.

A physician in the audience urged the investigators to mass market the tools to help chronic pain patients who are at high risk of substance abuse. "In the private setting, we don’t have the tools to provide the kind of program that you do," he said.

The investigators reported having no relevant financial disclosures.

PALM SPRINGS, CALIF. – An intensive interdisciplinary outpatient program successfully treated 246 patients at high risk of substance abuse, alongside 230 low-risk patients, for their debilitating chronic pain.

At the start of the 3-week pain rehabilitation program, the two groups did not differ significantly in their duration of pain (nearly 12 years on average) or duration of opioid use (6 years on average). They reported similar levels of pain severity.

The high-risk patients, however, had significantly worse scores on measures of depression, pain interference with life, pain catastrophizing, and perceived control of life and pain. Despite comparable pain severity and duration, they were taking significantly greater morphine-equivalent doses of pain medications, compared with doses taken by low-risk patients (124 vs. 60 mg/day).

By the end of the program, which incorporated substance abuse education and support, both the high-risk and low-risk groups had improved in all these measures, and there was no longer any significant difference in scores between the two groups, Sarah E. Hayes reported in an award-winning poster and plenary session at the annual meeting of the American Academy of Pain Medicine.

Sherry Boschert/IMNG Medical Media

The intensive program at the Mayo Clinic, Rochester, Minn. provides more than can be offered in a typical ambulatory setting, coinvestigator Dr. Michael Hooten said in an interview. The results suggest that high-risk patients can be included in pain rehabilitation programs without affecting treatment outcomes, said Dr. Hooten of the Mayo Clinic.

Patients attend sessions 8 hours per day, 5 days per week, focused on functional restoration, withdrawal from opioids, and reduced polypharmacy rather than on attempted cures or interventional procedures for their chronic pain. Approximately 97% completely taper off of opioids, said Ms. Hayes, who conducted the study while she was a research associate at the Mayo Clinic and is now a student at New York University.

The interdisciplinary staff includes physicians, psychologists, pharmacists, nurses, physical therapists, and occupational therapists. The foundation of treatment is a cognitive-behavioral model that includes biofeedback, relaxation training, and stress management. Patients receive education in "chemical health" and in "wellness" topics such as sleep hygiene and healthy diets. Pain management training covers activity moderation and eliminating behaviors that cause pain. Family education and after-care assistance are provided.

Patients were identified as high risk if they had a history of using mood-altering substances, used pain medications in ways other than those prescribed, showed aberrant drug-related behaviors, had family members or health care providers who expressed concern, had a family history of substance abuse, or had other health risks (such as polypharmacy and high-dose opioid use).

At entry, they were significantly more likely than the low-risk group to have used opioids (75% vs. 46%), benzodiazepines (51% vs. 34%), or a combination of opioids, benzodiazepines, and sedative hypnotics (18% vs. 7%), and they were significantly more likely to be dependent on nicotine (37% vs. 10%), to have a history of heavy alcohol use (27% vs. 6%), and to be currently using cannabis (13% vs. 0.4%).

For the high-risk group, approximately 18 of the 120 hours in the program were devoted to a substance use curriculum that covered the physical and medical aspects of substance abuse, the cycle of pain and how substance use has become a part of that cycle, and how to manage high-risk situations and triggers for substance abuse. Patients explored their personal substance use patterns, family aspects, the effects of substance use on relationships, and their life goals.

"We’re increasingly noticing that chronic pain patients often have comorbid chemical dependency issues," Ms. Hayes said. Both chronic pain and substance abuse need to be addressed at the same time, she suggested.

The investigators plan to conduct longitudinal studies to identify how best to support high-risk patients after they complete the pain rehabilitation program.

The study included consecutive patients treated from February 2010 to May 2011. Patients averaged 45 years in age, ranging from 18 to 90 years. Back pain, fibromyalgia, and headache were the most common types of pain. Patients in the high-risk group were significantly more likely than those in the low-risk group to be living with back pain (27% vs. 21%) and significantly less likely to be living with fibromyalgia (15% vs. 21%).

Significantly fewer high-risk patients completed the 3-week program compared with low-risk patients (87% vs. 94%).

Functional status was assessed at the start and the end of the program using multiple tools including the Multidimensional Pain Inventory, the Center for Epidemiological Studies Depression Scale, the Pain Self-Efficacy Questionnaire, and the Pain Catastrophizing Scale.

A physician in the audience urged the investigators to mass market the tools to help chronic pain patients who are at high risk of substance abuse. "In the private setting, we don’t have the tools to provide the kind of program that you do," he said.

The investigators reported having no relevant financial disclosures.

SCOTTSDALE, ARIZ. – Endovascular treatment of acute, symptomatic inferior vena cava thrombosis produced "good" short-term clinical results, according to investigators who retrospectively studied 19 patients.

This aggressive approach to treating acute caval thrombosis seemed warranted even in the presence of a thrombosed inferior vena cava filter, Dr. Charles C. Sticco said. The risk of a poor prognosis appeared to be higher in patients with phlegmasia cerulea dolens, he said at the annual meeting of the Southern Association for Vascular Surgery.

Photos courtesy of Dr. Quinhua Pu

Dr. Sticco, of Staten Island (N.Y.) University Hospital, and his associates reviewed the records of all patients treated for acute thrombosis of the inferior vena cava (AT-IVC) between 2004 and 2011. Patients had been symptomatic for an average of 6 days before endovascular treatment. All patients had a history of deep vein thrombosis.

Endovascular treatment of the AT-IVC was successful in all 19 patients. Two of eight patients who presented with phlegmasia cerulea dolens died of multiorgan system failure in the immediate postoperative period. During a mean follow-up of 6 months, three patients were lost to follow-up.

Among the remaining 14 patients, 6 had complete relief of symptoms (43%), and 8 had partial symptom relief (57%), Dr. Sticco said. The American Venous Registry index (also known as Mewissen score) decreased from nearly 14 before treatment to approximately 3 after treatment.

Follow-up ultrasound evaluations showed no evidence of deep vein thrombosis in six patients (43%), chronic deep vein thrombosis in six patients (43%), and recurrent acute deep vein thrombosis in two patients (14%). Valve reflux was seen in three patients (21%). Two patients developed recurrent inferior vena cava thrombosis.

The 6-month follow-up findings were "promising," he said. On the CEAP (Clinical, Etiologic, Anatomic, and Pathophysiologic) classification of venous insufficiency, patients had a mean classification of 2.2 out of 6. On the Villalta scale, a clinical assessment of post-thrombosis syndrome, patients had a mean score of 3.4, suggesting no post-thrombotic syndrome on average.

Eleven of the 14 patients were free of new acute DVT (80%), and 11 were free of post-thrombotic symptoms (80%) at 6 months, Dr. Sticco said.

A "low incidence of complications" in the whole cohort of 19 patients included major bleeding in two patients (11%) and minor bleeding in five patients (26%), he said. Eight patients received a blood transfusion (42%). Six patients developed renal insufficiency (32%), and one patient each had a nonfatal arrhythmia, fasciotomy, above-knee amputation secondary to venous gangrene (in a patient who presented with phlegmasia), or pulmonary embolism.

All patients had presented with both swelling and pain. Eight had phlegmasia cerulea dolens (42%), 14 showed motor dysfunction (74%), and 12 had sensory deficits (63%). Risk factors included a history of pulmonary embolism in 14 patients, a hypercoagulable state in 11, cancer in 6 patients, immobility in 4, and recent surgery in 2.

Fifteen patients had a prior IVC filter placed (79%). "At our institution, we have seen an increase in the insertion of IVC filters, and an increase in occlusion of these filters with associated caval thrombosis," Dr. Sticco said.

The thrombosis extended to the iliac veins in a majority of patients (10, or 53%).

For management of the AT-IVC, all patients were continued on their medical therapy for anticoagulation and were transitioned to warfarin therapy. Five patients who were on warfarin therapy when they developed AT-IVC had a subtherapeutic International Normalized Ratio, he noted. All patients received fluid resuscitation, leg elevation, and an aggressive IV heparin bolus that was maintained at therapeutic levels.

Endovascular treatment under conscious sedation and local anesthesia consisted of catheter-directed thrombolysis (with tissue plasminogen activator) in 3 patients and catheter-directed thrombolysis plus pharmacomechanical thrombectomy in 13. Two patients were treated solely with pharmacomechanical thrombectomy, using the AngioJet Rheolytic Thrombectomy System alone in one patient and the AngioJet plus the Trellis Peripheral Infusion System in one patient.

Adjunctive procedures included angioplasty in 14 patients (74%) and stent placement in 9 (47%). At discharge all patients were given thigh-high compression stockings.

AT-IVC is known to cause post-thrombotic syndrome, limb loss, pulmonary embolism, and death. Endovascular treatment of AT-IVC provided immediate symptom relief, and may reduce the incidence of these complications, he said.

Dr. Sticco reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Endovascular treatment of acute, symptomatic inferior vena cava thrombosis produced "good" short-term clinical results, according to investigators who retrospectively studied 19 patients.

This aggressive approach to treating acute caval thrombosis seemed warranted even in the presence of a thrombosed inferior vena cava filter, Dr. Charles C. Sticco said. The risk of a poor prognosis appeared to be higher in patients with phlegmasia cerulea dolens, he said at the annual meeting of the Southern Association for Vascular Surgery.

Photos courtesy of Dr. Quinhua Pu

Dr. Sticco, of Staten Island (N.Y.) University Hospital, and his associates reviewed the records of all patients treated for acute thrombosis of the inferior vena cava (AT-IVC) between 2004 and 2011. Patients had been symptomatic for an average of 6 days before endovascular treatment. All patients had a history of deep vein thrombosis.

Endovascular treatment of the AT-IVC was successful in all 19 patients. Two of eight patients who presented with phlegmasia cerulea dolens died of multiorgan system failure in the immediate postoperative period. During a mean follow-up of 6 months, three patients were lost to follow-up.

Among the remaining 14 patients, 6 had complete relief of symptoms (43%), and 8 had partial symptom relief (57%), Dr. Sticco said. The American Venous Registry index (also known as Mewissen score) decreased from nearly 14 before treatment to approximately 3 after treatment.

Follow-up ultrasound evaluations showed no evidence of deep vein thrombosis in six patients (43%), chronic deep vein thrombosis in six patients (43%), and recurrent acute deep vein thrombosis in two patients (14%). Valve reflux was seen in three patients (21%). Two patients developed recurrent inferior vena cava thrombosis.

The 6-month follow-up findings were "promising," he said. On the CEAP (Clinical, Etiologic, Anatomic, and Pathophysiologic) classification of venous insufficiency, patients had a mean classification of 2.2 out of 6. On the Villalta scale, a clinical assessment of post-thrombosis syndrome, patients had a mean score of 3.4, suggesting no post-thrombotic syndrome on average.

Eleven of the 14 patients were free of new acute DVT (80%), and 11 were free of post-thrombotic symptoms (80%) at 6 months, Dr. Sticco said.

A "low incidence of complications" in the whole cohort of 19 patients included major bleeding in two patients (11%) and minor bleeding in five patients (26%), he said. Eight patients received a blood transfusion (42%). Six patients developed renal insufficiency (32%), and one patient each had a nonfatal arrhythmia, fasciotomy, above-knee amputation secondary to venous gangrene (in a patient who presented with phlegmasia), or pulmonary embolism.

All patients had presented with both swelling and pain. Eight had phlegmasia cerulea dolens (42%), 14 showed motor dysfunction (74%), and 12 had sensory deficits (63%). Risk factors included a history of pulmonary embolism in 14 patients, a hypercoagulable state in 11, cancer in 6 patients, immobility in 4, and recent surgery in 2.

Fifteen patients had a prior IVC filter placed (79%). "At our institution, we have seen an increase in the insertion of IVC filters, and an increase in occlusion of these filters with associated caval thrombosis," Dr. Sticco said.

The thrombosis extended to the iliac veins in a majority of patients (10, or 53%).

For management of the AT-IVC, all patients were continued on their medical therapy for anticoagulation and were transitioned to warfarin therapy. Five patients who were on warfarin therapy when they developed AT-IVC had a subtherapeutic International Normalized Ratio, he noted. All patients received fluid resuscitation, leg elevation, and an aggressive IV heparin bolus that was maintained at therapeutic levels.

Endovascular treatment under conscious sedation and local anesthesia consisted of catheter-directed thrombolysis (with tissue plasminogen activator) in 3 patients and catheter-directed thrombolysis plus pharmacomechanical thrombectomy in 13. Two patients were treated solely with pharmacomechanical thrombectomy, using the AngioJet Rheolytic Thrombectomy System alone in one patient and the AngioJet plus the Trellis Peripheral Infusion System in one patient.

Adjunctive procedures included angioplasty in 14 patients (74%) and stent placement in 9 (47%). At discharge all patients were given thigh-high compression stockings.

AT-IVC is known to cause post-thrombotic syndrome, limb loss, pulmonary embolism, and death. Endovascular treatment of AT-IVC provided immediate symptom relief, and may reduce the incidence of these complications, he said.

Dr. Sticco reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Endovascular treatment of acute, symptomatic inferior vena cava thrombosis produced "good" short-term clinical results, according to investigators who retrospectively studied 19 patients.

This aggressive approach to treating acute caval thrombosis seemed warranted even in the presence of a thrombosed inferior vena cava filter, Dr. Charles C. Sticco said. The risk of a poor prognosis appeared to be higher in patients with phlegmasia cerulea dolens, he said at the annual meeting of the Southern Association for Vascular Surgery.

Photos courtesy of Dr. Quinhua Pu

Dr. Sticco, of Staten Island (N.Y.) University Hospital, and his associates reviewed the records of all patients treated for acute thrombosis of the inferior vena cava (AT-IVC) between 2004 and 2011. Patients had been symptomatic for an average of 6 days before endovascular treatment. All patients had a history of deep vein thrombosis.

Endovascular treatment of the AT-IVC was successful in all 19 patients. Two of eight patients who presented with phlegmasia cerulea dolens died of multiorgan system failure in the immediate postoperative period. During a mean follow-up of 6 months, three patients were lost to follow-up.

Among the remaining 14 patients, 6 had complete relief of symptoms (43%), and 8 had partial symptom relief (57%), Dr. Sticco said. The American Venous Registry index (also known as Mewissen score) decreased from nearly 14 before treatment to approximately 3 after treatment.

Follow-up ultrasound evaluations showed no evidence of deep vein thrombosis in six patients (43%), chronic deep vein thrombosis in six patients (43%), and recurrent acute deep vein thrombosis in two patients (14%). Valve reflux was seen in three patients (21%). Two patients developed recurrent inferior vena cava thrombosis.

The 6-month follow-up findings were "promising," he said. On the CEAP (Clinical, Etiologic, Anatomic, and Pathophysiologic) classification of venous insufficiency, patients had a mean classification of 2.2 out of 6. On the Villalta scale, a clinical assessment of post-thrombosis syndrome, patients had a mean score of 3.4, suggesting no post-thrombotic syndrome on average.

Eleven of the 14 patients were free of new acute DVT (80%), and 11 were free of post-thrombotic symptoms (80%) at 6 months, Dr. Sticco said.

A "low incidence of complications" in the whole cohort of 19 patients included major bleeding in two patients (11%) and minor bleeding in five patients (26%), he said. Eight patients received a blood transfusion (42%). Six patients developed renal insufficiency (32%), and one patient each had a nonfatal arrhythmia, fasciotomy, above-knee amputation secondary to venous gangrene (in a patient who presented with phlegmasia), or pulmonary embolism.

All patients had presented with both swelling and pain. Eight had phlegmasia cerulea dolens (42%), 14 showed motor dysfunction (74%), and 12 had sensory deficits (63%). Risk factors included a history of pulmonary embolism in 14 patients, a hypercoagulable state in 11, cancer in 6 patients, immobility in 4, and recent surgery in 2.

Fifteen patients had a prior IVC filter placed (79%). "At our institution, we have seen an increase in the insertion of IVC filters, and an increase in occlusion of these filters with associated caval thrombosis," Dr. Sticco said.

The thrombosis extended to the iliac veins in a majority of patients (10, or 53%).

For management of the AT-IVC, all patients were continued on their medical therapy for anticoagulation and were transitioned to warfarin therapy. Five patients who were on warfarin therapy when they developed AT-IVC had a subtherapeutic International Normalized Ratio, he noted. All patients received fluid resuscitation, leg elevation, and an aggressive IV heparin bolus that was maintained at therapeutic levels.

Endovascular treatment under conscious sedation and local anesthesia consisted of catheter-directed thrombolysis (with tissue plasminogen activator) in 3 patients and catheter-directed thrombolysis plus pharmacomechanical thrombectomy in 13. Two patients were treated solely with pharmacomechanical thrombectomy, using the AngioJet Rheolytic Thrombectomy System alone in one patient and the AngioJet plus the Trellis Peripheral Infusion System in one patient.

Adjunctive procedures included angioplasty in 14 patients (74%) and stent placement in 9 (47%). At discharge all patients were given thigh-high compression stockings.

AT-IVC is known to cause post-thrombotic syndrome, limb loss, pulmonary embolism, and death. Endovascular treatment of AT-IVC provided immediate symptom relief, and may reduce the incidence of these complications, he said.

Dr. Sticco reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Six years of having intravascular ultrasound guidance available during thoracic and abdominal endografting procedures for aortic pathologies has convinced one surgeon that it’s a sometimes necessary, sometimes complementary imaging modality – not an expensive, redundant novelty.

Among 449 cases of aortic endografting for aneurysmal, dissection, or traumatic pathologies, Dr. Martin R. Back chose to use intravascular ultrasound (IVUS) guidance in 194 cases (43%), he reported at the meeting. He used IVUS guidance in 76 (66%) of 115 thoracic cases and 118 (35%) of 334 abdominal cases.

IVUS guidance may replace most maneuvers that currently require contrast angiography during endovascular aneurysm repair and thoracic endovascular aortic repair, said Dr. Back, professor of surgery at the University of South Florida, Tampa.

He found IVUS guidance indispensable during treatment of acute aortic dissections, using it in all 25 cases. It also was especially helpful in 8 (57%) of 14 hybrid thoracoabdominal cases, he said at the annual meeting of the Southern Association for Vascular Surgery.

"I found it particularly useful in these cases to turn these into a single-stage procedure" with visceral branching done up front, endografting done primarily with IVUS guidance, and very-low-volume contrast used to assess completion of the repair, he said.

IVUS use reduced the volume of contrast needed during abdominal cases and significantly reduced the risk of worsening renal function after aortic endografting in patients with preexisting renal insufficiency.

Average contrast dye volume during abdominal cases was 47 mL in IVUS-guided cases and 92 mL in cases without IVUS, a significant difference. Procedural contrast dye volume was marginally lower with IVUS use compared with no IVUS in thoracic cases – 91 mL vs. 106 mL, respectively.

Among thoracic cases, 26 of 115 patients (23%) had existing chronic renal insufficiency, and he used IVUS guidance in 22 of these 26 patients (85%). Among abdominal cases, 70 of 334 patients (21%) had chronic renal insufficiency, and he used IVUS guidance in 43 of these 70 cases (62%).

Among 89 patients with preoperative chronic renal insufficiency and complete follow-up data 30 days after the procedure, renal function worsened in 7 of 60 patients (12%) who had IVUS guidance and 9 of 29 patients (31%) with no IVUS, a significant difference. Worsening renal function was defined as greater than a 50% increase in baseline creatinine or dialysis by day 30.

"IVUS use cuts down on dye use and spares kidneys in that higher-risk population," he said.

Among 331 patients without preexisting chronic renal insufficiency who had 30 days of follow-up data, renal function worsened in 9 (8%) of 107 patients who had IVUS guidance and in 12 (5%) of 224 patients without IVUS, which was not significantly different between groups.

"This is not really a diagnostic tool but can be used as an intraprocedural guidance tool with fluoroscopy to supplant the need for angiographic injections throughout the performance of an endovascular aortic intervention," he said. In general, IVUS guidance appeared to be safe and accurate for endografting, he said. In a random sample of 25 cases with IVUS guidance and 51 cases without IVUS in patients with similar-sized aneurysms and fixation lengths, measurements from the lowest renal artery to the endograft device and from the hypogastric arteries to the end of the device were similar in accuracy, Dr. Back said.

Cost is an issue, with IVUS catheters being approximately $500 each. "I’m not advocating for all these patients" to have IVUS-guided endografting, but there are "subgroups here that I think really benefit from its use," he said.

Dr. Back reported being a paid trainer and speaker for Volcano Corp., which markets the IVUS equipment that he used in his case series.

SCOTTSDALE, ARIZ. – Six years of having intravascular ultrasound guidance available during thoracic and abdominal endografting procedures for aortic pathologies has convinced one surgeon that it’s a sometimes necessary, sometimes complementary imaging modality – not an expensive, redundant novelty.

Among 449 cases of aortic endografting for aneurysmal, dissection, or traumatic pathologies, Dr. Martin R. Back chose to use intravascular ultrasound (IVUS) guidance in 194 cases (43%), he reported at the meeting. He used IVUS guidance in 76 (66%) of 115 thoracic cases and 118 (35%) of 334 abdominal cases.

IVUS guidance may replace most maneuvers that currently require contrast angiography during endovascular aneurysm repair and thoracic endovascular aortic repair, said Dr. Back, professor of surgery at the University of South Florida, Tampa.

He found IVUS guidance indispensable during treatment of acute aortic dissections, using it in all 25 cases. It also was especially helpful in 8 (57%) of 14 hybrid thoracoabdominal cases, he said at the annual meeting of the Southern Association for Vascular Surgery.

"I found it particularly useful in these cases to turn these into a single-stage procedure" with visceral branching done up front, endografting done primarily with IVUS guidance, and very-low-volume contrast used to assess completion of the repair, he said.

IVUS use reduced the volume of contrast needed during abdominal cases and significantly reduced the risk of worsening renal function after aortic endografting in patients with preexisting renal insufficiency.

Average contrast dye volume during abdominal cases was 47 mL in IVUS-guided cases and 92 mL in cases without IVUS, a significant difference. Procedural contrast dye volume was marginally lower with IVUS use compared with no IVUS in thoracic cases – 91 mL vs. 106 mL, respectively.

Among thoracic cases, 26 of 115 patients (23%) had existing chronic renal insufficiency, and he used IVUS guidance in 22 of these 26 patients (85%). Among abdominal cases, 70 of 334 patients (21%) had chronic renal insufficiency, and he used IVUS guidance in 43 of these 70 cases (62%).

Among 89 patients with preoperative chronic renal insufficiency and complete follow-up data 30 days after the procedure, renal function worsened in 7 of 60 patients (12%) who had IVUS guidance and 9 of 29 patients (31%) with no IVUS, a significant difference. Worsening renal function was defined as greater than a 50% increase in baseline creatinine or dialysis by day 30.

"IVUS use cuts down on dye use and spares kidneys in that higher-risk population," he said.

Among 331 patients without preexisting chronic renal insufficiency who had 30 days of follow-up data, renal function worsened in 9 (8%) of 107 patients who had IVUS guidance and in 12 (5%) of 224 patients without IVUS, which was not significantly different between groups.

"This is not really a diagnostic tool but can be used as an intraprocedural guidance tool with fluoroscopy to supplant the need for angiographic injections throughout the performance of an endovascular aortic intervention," he said. In general, IVUS guidance appeared to be safe and accurate for endografting, he said. In a random sample of 25 cases with IVUS guidance and 51 cases without IVUS in patients with similar-sized aneurysms and fixation lengths, measurements from the lowest renal artery to the endograft device and from the hypogastric arteries to the end of the device were similar in accuracy, Dr. Back said.

Cost is an issue, with IVUS catheters being approximately $500 each. "I’m not advocating for all these patients" to have IVUS-guided endografting, but there are "subgroups here that I think really benefit from its use," he said.

Dr. Back reported being a paid trainer and speaker for Volcano Corp., which markets the IVUS equipment that he used in his case series.

SCOTTSDALE, ARIZ. – Six years of having intravascular ultrasound guidance available during thoracic and abdominal endografting procedures for aortic pathologies has convinced one surgeon that it’s a sometimes necessary, sometimes complementary imaging modality – not an expensive, redundant novelty.

Among 449 cases of aortic endografting for aneurysmal, dissection, or traumatic pathologies, Dr. Martin R. Back chose to use intravascular ultrasound (IVUS) guidance in 194 cases (43%), he reported at the meeting. He used IVUS guidance in 76 (66%) of 115 thoracic cases and 118 (35%) of 334 abdominal cases.

IVUS guidance may replace most maneuvers that currently require contrast angiography during endovascular aneurysm repair and thoracic endovascular aortic repair, said Dr. Back, professor of surgery at the University of South Florida, Tampa.

He found IVUS guidance indispensable during treatment of acute aortic dissections, using it in all 25 cases. It also was especially helpful in 8 (57%) of 14 hybrid thoracoabdominal cases, he said at the annual meeting of the Southern Association for Vascular Surgery.

"I found it particularly useful in these cases to turn these into a single-stage procedure" with visceral branching done up front, endografting done primarily with IVUS guidance, and very-low-volume contrast used to assess completion of the repair, he said.

IVUS use reduced the volume of contrast needed during abdominal cases and significantly reduced the risk of worsening renal function after aortic endografting in patients with preexisting renal insufficiency.

Average contrast dye volume during abdominal cases was 47 mL in IVUS-guided cases and 92 mL in cases without IVUS, a significant difference. Procedural contrast dye volume was marginally lower with IVUS use compared with no IVUS in thoracic cases – 91 mL vs. 106 mL, respectively.

Among thoracic cases, 26 of 115 patients (23%) had existing chronic renal insufficiency, and he used IVUS guidance in 22 of these 26 patients (85%). Among abdominal cases, 70 of 334 patients (21%) had chronic renal insufficiency, and he used IVUS guidance in 43 of these 70 cases (62%).

Among 89 patients with preoperative chronic renal insufficiency and complete follow-up data 30 days after the procedure, renal function worsened in 7 of 60 patients (12%) who had IVUS guidance and 9 of 29 patients (31%) with no IVUS, a significant difference. Worsening renal function was defined as greater than a 50% increase in baseline creatinine or dialysis by day 30.

"IVUS use cuts down on dye use and spares kidneys in that higher-risk population," he said.

Among 331 patients without preexisting chronic renal insufficiency who had 30 days of follow-up data, renal function worsened in 9 (8%) of 107 patients who had IVUS guidance and in 12 (5%) of 224 patients without IVUS, which was not significantly different between groups.

"This is not really a diagnostic tool but can be used as an intraprocedural guidance tool with fluoroscopy to supplant the need for angiographic injections throughout the performance of an endovascular aortic intervention," he said. In general, IVUS guidance appeared to be safe and accurate for endografting, he said. In a random sample of 25 cases with IVUS guidance and 51 cases without IVUS in patients with similar-sized aneurysms and fixation lengths, measurements from the lowest renal artery to the endograft device and from the hypogastric arteries to the end of the device were similar in accuracy, Dr. Back said.

Cost is an issue, with IVUS catheters being approximately $500 each. "I’m not advocating for all these patients" to have IVUS-guided endografting, but there are "subgroups here that I think really benefit from its use," he said.

Dr. Back reported being a paid trainer and speaker for Volcano Corp., which markets the IVUS equipment that he used in his case series.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

Controversy around payments to physicians from companies that make pharmaceuticals and medical devices has been much in the news lately, especially related to pain medicine.

ProPublica reported on deep ties between two physician leaders in pain treatment and the pharmaceutical industry. A nifty page created by ProPublica lets viewers search for their physician’s name in the database of payments reported by industry.

The Milwaukee-Wisconsin Journal Sentinel reported that the steep increase in use of pain medications in recent years is paralleled – and their headline says “fueled” – by a network of physicians, researchers and organizations pushing for greater access to narcotics while taking money from drug companies. They published a graphic and a case study to help make the case.

Most recently, the New Haven (Conn.) Independent reported that a dozen doctors in the state continued to receive money or gifts from drug companies while being sanctioned by the state for prescription-related offenses.

Sherry Boschert/IMNG Medical Media

At the annual meeting of the American Academy of Pain Medicine, I asked one of the speakers at a session on ethics to comment on all this. Dr. Jerome Schofferman said he is not a trained bioethicist but he follows ethics with a passion. How passionate is he? Dr. Schofferman refused to wear the lanyard that all attendees received in their registration package because it had a company’s name on it. He brought his own.

Part of the problem, he said, is that drug companies develop a lot of “me too” drugs that work like other available drugs, then avoid doing head-to-head comparisons so that no one can say their drug isn’t as good as another, and pour their resources into marketing their drug to boost sales.

“There’s no doubt that these drugs are overmarketed and probably overprescribed, but they work for a lot of people,” so we need to keep the potential benefits in mind in all of this too, he said.

Relationships between industry and physicians or patient advocacy organizations can be a mutually beneficial thing and aren’t inherently bad, but the lack of full and up-front disclosure of the relationships gives the impression that something’s not right and prevents people from making informed judgements, he said.

In the articles on industry and pain medicine, “No one has ever really shown in this context that this is bad. It’s just the perception is that it can’t be good. It can be good if the American Pain Foundation accomplishes a lot of good things,” Dr. Schofferman said. Too many groups and physicians hide their industry connections instead of making them easy to find. “If there had always been disclosure at the top of their Web site or their publications, a lot of this wouldn’t come up. It wouldn’t be a story, and it wouldn’t have that oomph factor,” he added.

In his talk at the meeting, though, Dr. Schofferman was a bit stricter than in our interview, arguing that disclosures alone are not enough.

He cited an article suggesting that 61% of physicians say that conflicts of interest do not influence their decisions, but 84% of physicians admit that conflicts of interest might compromise other physicians (JAMA 2003;290:252-255). Bias and influence are neurobiological social processes that can alter behavior in unconscious ways, he explained. People may want and choose to behave ethically but still be influenced by economic factors because human nature inherently reverts to reciprocity and self-interest, functional MRI studies suggest.

Dr. Schofferman suggested several ways to personally minimize industry influence:

1) Don’t be in a company’s speakers bureau. These are “marketing by proxy,” he said.

 2) Don’t attend industry-sponsored satellite sessions or marketing dinners at meetings. Get your medical education from accredited sources.

3) If you’re an educator, divorce yourself from industry, or at least provide full disclosure including dollar amounts of anything you receive.

4) Don’t be an industry “advisor” or “consultant” unless you truly are a thought leader and innovator with specialized skills, knowledge, or experience that you bring to the relationship. Spell out that relationship in a written contract describing details of the work product to be delivered and a timeline for delivery. Charge only fair market value for your time and expertise.

5) If you are an industry speaker, advisor, or consultant, do not seek leadership positions in professional medical associations.

6) Professional medical organizations and conferences should limit industry participation to ads in journals and to exhibit halls (“But don’t put food in there!”), and stop splashing corporate logos on everything, such as lanyards. “We’re like NASCAR drivers” at these meetings, Dr. Schofferman complained.

Starting in September 2013, industry payments and gifts to physicians will be posted online under the Physician Payment Sunshine Act.

–Sherry Boschert (@sherryboschert on Twitter)

Controversy around payments to physicians from companies that make pharmaceuticals and medical devices has been much in the news lately, especially related to pain medicine.

ProPublica reported on deep ties between two physician leaders in pain treatment and the pharmaceutical industry. A nifty page created by ProPublica lets viewers search for their physician’s name in the database of payments reported by industry.

The Milwaukee-Wisconsin Journal Sentinel reported that the steep increase in use of pain medications in recent years is paralleled – and their headline says “fueled” – by a network of physicians, researchers and organizations pushing for greater access to narcotics while taking money from drug companies. They published a graphic and a case study to help make the case.

Most recently, the New Haven (Conn.) Independent reported that a dozen doctors in the state continued to receive money or gifts from drug companies while being sanctioned by the state for prescription-related offenses.

Sherry Boschert/IMNG Medical Media

At the annual meeting of the American Academy of Pain Medicine, I asked one of the speakers at a session on ethics to comment on all this. Dr. Jerome Schofferman said he is not a trained bioethicist but he follows ethics with a passion. How passionate is he? Dr. Schofferman refused to wear the lanyard that all attendees received in their registration package because it had a company’s name on it. He brought his own.

Part of the problem, he said, is that drug companies develop a lot of “me too” drugs that work like other available drugs, then avoid doing head-to-head comparisons so that no one can say their drug isn’t as good as another, and pour their resources into marketing their drug to boost sales.

“There’s no doubt that these drugs are overmarketed and probably overprescribed, but they work for a lot of people,” so we need to keep the potential benefits in mind in all of this too, he said.

Relationships between industry and physicians or patient advocacy organizations can be a mutually beneficial thing and aren’t inherently bad, but the lack of full and up-front disclosure of the relationships gives the impression that something’s not right and prevents people from making informed judgements, he said.

In the articles on industry and pain medicine, “No one has ever really shown in this context that this is bad. It’s just the perception is that it can’t be good. It can be good if the American Pain Foundation accomplishes a lot of good things,” Dr. Schofferman said. Too many groups and physicians hide their industry connections instead of making them easy to find. “If there had always been disclosure at the top of their Web site or their publications, a lot of this wouldn’t come up. It wouldn’t be a story, and it wouldn’t have that oomph factor,” he added.

In his talk at the meeting, though, Dr. Schofferman was a bit stricter than in our interview, arguing that disclosures alone are not enough.

He cited an article suggesting that 61% of physicians say that conflicts of interest do not influence their decisions, but 84% of physicians admit that conflicts of interest might compromise other physicians (JAMA 2003;290:252-255). Bias and influence are neurobiological social processes that can alter behavior in unconscious ways, he explained. People may want and choose to behave ethically but still be influenced by economic factors because human nature inherently reverts to reciprocity and self-interest, functional MRI studies suggest.

Dr. Schofferman suggested several ways to personally minimize industry influence:

1) Don’t be in a company’s speakers bureau. These are “marketing by proxy,” he said.

 2) Don’t attend industry-sponsored satellite sessions or marketing dinners at meetings. Get your medical education from accredited sources.

3) If you’re an educator, divorce yourself from industry, or at least provide full disclosure including dollar amounts of anything you receive.

4) Don’t be an industry “advisor” or “consultant” unless you truly are a thought leader and innovator with specialized skills, knowledge, or experience that you bring to the relationship. Spell out that relationship in a written contract describing details of the work product to be delivered and a timeline for delivery. Charge only fair market value for your time and expertise.

5) If you are an industry speaker, advisor, or consultant, do not seek leadership positions in professional medical associations.

6) Professional medical organizations and conferences should limit industry participation to ads in journals and to exhibit halls (“But don’t put food in there!”), and stop splashing corporate logos on everything, such as lanyards. “We’re like NASCAR drivers” at these meetings, Dr. Schofferman complained.

Starting in September 2013, industry payments and gifts to physicians will be posted online under the Physician Payment Sunshine Act.

–Sherry Boschert (@sherryboschert on Twitter)

Controversy around payments to physicians from companies that make pharmaceuticals and medical devices has been much in the news lately, especially related to pain medicine.

ProPublica reported on deep ties between two physician leaders in pain treatment and the pharmaceutical industry. A nifty page created by ProPublica lets viewers search for their physician’s name in the database of payments reported by industry.

The Milwaukee-Wisconsin Journal Sentinel reported that the steep increase in use of pain medications in recent years is paralleled – and their headline says “fueled” – by a network of physicians, researchers and organizations pushing for greater access to narcotics while taking money from drug companies. They published a graphic and a case study to help make the case.

Most recently, the New Haven (Conn.) Independent reported that a dozen doctors in the state continued to receive money or gifts from drug companies while being sanctioned by the state for prescription-related offenses.

Sherry Boschert/IMNG Medical Media

At the annual meeting of the American Academy of Pain Medicine, I asked one of the speakers at a session on ethics to comment on all this. Dr. Jerome Schofferman said he is not a trained bioethicist but he follows ethics with a passion. How passionate is he? Dr. Schofferman refused to wear the lanyard that all attendees received in their registration package because it had a company’s name on it. He brought his own.

Part of the problem, he said, is that drug companies develop a lot of “me too” drugs that work like other available drugs, then avoid doing head-to-head comparisons so that no one can say their drug isn’t as good as another, and pour their resources into marketing their drug to boost sales.

“There’s no doubt that these drugs are overmarketed and probably overprescribed, but they work for a lot of people,” so we need to keep the potential benefits in mind in all of this too, he said.

Relationships between industry and physicians or patient advocacy organizations can be a mutually beneficial thing and aren’t inherently bad, but the lack of full and up-front disclosure of the relationships gives the impression that something’s not right and prevents people from making informed judgements, he said.

In the articles on industry and pain medicine, “No one has ever really shown in this context that this is bad. It’s just the perception is that it can’t be good. It can be good if the American Pain Foundation accomplishes a lot of good things,” Dr. Schofferman said. Too many groups and physicians hide their industry connections instead of making them easy to find. “If there had always been disclosure at the top of their Web site or their publications, a lot of this wouldn’t come up. It wouldn’t be a story, and it wouldn’t have that oomph factor,” he added.

In his talk at the meeting, though, Dr. Schofferman was a bit stricter than in our interview, arguing that disclosures alone are not enough.

He cited an article suggesting that 61% of physicians say that conflicts of interest do not influence their decisions, but 84% of physicians admit that conflicts of interest might compromise other physicians (JAMA 2003;290:252-255). Bias and influence are neurobiological social processes that can alter behavior in unconscious ways, he explained. People may want and choose to behave ethically but still be influenced by economic factors because human nature inherently reverts to reciprocity and self-interest, functional MRI studies suggest.

Dr. Schofferman suggested several ways to personally minimize industry influence:

1) Don’t be in a company’s speakers bureau. These are “marketing by proxy,” he said.

 2) Don’t attend industry-sponsored satellite sessions or marketing dinners at meetings. Get your medical education from accredited sources.

3) If you’re an educator, divorce yourself from industry, or at least provide full disclosure including dollar amounts of anything you receive.

4) Don’t be an industry “advisor” or “consultant” unless you truly are a thought leader and innovator with specialized skills, knowledge, or experience that you bring to the relationship. Spell out that relationship in a written contract describing details of the work product to be delivered and a timeline for delivery. Charge only fair market value for your time and expertise.

5) If you are an industry speaker, advisor, or consultant, do not seek leadership positions in professional medical associations.

6) Professional medical organizations and conferences should limit industry participation to ads in journals and to exhibit halls (“But don’t put food in there!”), and stop splashing corporate logos on everything, such as lanyards. “We’re like NASCAR drivers” at these meetings, Dr. Schofferman complained.

Starting in September 2013, industry payments and gifts to physicians will be posted online under the Physician Payment Sunshine Act.

–Sherry Boschert (@sherryboschert on Twitter)

SCOTTSDALE, ARIZ. – The presence of contralateral carotid artery occlusion is no reason to treat carotid artery stenosis with stenting instead of carotid endarterectomy, a review of 713 patients suggested.

Either endarterectomy or carotid artery stenting can be performed on patients with contralateral occlusion with good 30-day and midterm results, Dr. Luke P. Brewster and his associates reported at the annual meeting of the Southern Association for Vascular Surgery.

Sherry Boschert

"We do not support contralateral occlusion as an independent criterion for carotid artery stenting" over carotid endarterectomy in patients with contralateral occlusion, said Dr. Brewster of Emory University, Atlanta.

Among 57 patients who underwent carotid artery therapy who also had contralateral occlusion, 7 of 39 patients died after carotid artery stenting (18%), compared with 1 of 18 patients after carotid endarterectomy (6%), during a mean midterm follow-up of 28 and 29 months, respectively.

In general, stroke risk is increased in patients with internal carotid artery occlusion contralateral to a carotid artery with significant stenosis. Contralateral occlusion has been suggested as an indication for stenting because of theoretical advantages from reduced ischemic procedural time, and because the procedure can be done without a vascular shunt and without general anesthesia. Carotid endarterectomy, on the other hand, has been associated with a lower procedural stroke rate.

The investigators retrospectively reviewed Emory University’s data on 713 consecutive patients who underwent either carotid endarterectomy or carotid artery stenting from February 2007 to July 2011.

Among the 8% of patients who had contralateral occlusion, the treatment approach was based on the preference of each patient’s vascular surgeon, cardiologist, and/or interventional radiologist.

Patients in the carotid artery stenting group were more likely to have had prior neck surgery (18 of 39 patients; 46%), compared with patients in the carotid endarterectomy group (1 of 18 patients; 6%). The groups did not differ significantly in age (67 and 70 years, respectively), sex, proportion of symptomatic patients, degree of stenosis, history of carotid artery stenting on the contralateral side, smoking history, or rates of hypertension, transient ischemic attack, stroke, diabetes, myocardial infarction, or other factors.

In the carotid artery stenosis group, six procedures involved flow reversal. The main indications for stenting were prior neck surgery, contralateral occlusion, or radiation of the neck. In the carotid endarterectomy group, two procedures were performed with the patient awake, and 15 involved a shunt.

All the endarterectomies were completed; one stenting procedure was aborted and the patient underwent an endarterectomy during the same hospitalization.

At 30 days after surgery, two patients (5%) in the stenting group had died following an access-site bleed or respiratory failure in a patient with a seizure disorder. No patients in the endarterectomy group died. Two patients in the stenting group developed transient ischemic attacks. There was no MI or stroke in either group, Dr. Brewster said.

Patients in the endarterectomy group stayed in the hospital significantly longer (average, 3 days vs. 2 days in the stenting group). Five patients (28%) in the endarterectomy group were admitted to the ICU, all for observation due to medical morbidities. Seven patients (18%) in the stenting group were admitted to the ICU, three of them due to bradycardia or hypotension.

Midterm results included a mean of 29 months of follow-up in the endarterectomy group and 28 months in the stenting group. Two patients required reinterventions after carotid artery stenting, compared with none after endarterectomy.

Five more patients in the stenting group died at a mean of 23 months after the procedure (excluding the two perioperative deaths), compared with one death at a mean of 42 months after endarterectomy. All six of these late deaths were in patients with hypertension, five of whom also had chronic obstructive pulmonary disease. Three of the six patients had diabetes, and two had a history of prior stroke.

The findings "fail to demonstrate superiority of carotid artery stenting over carotid endarterectomy in patients with contralateral occlusion," Dr. Brewster said.

Dr. Brewster reported having no financial disclosures.

SCOTTSDALE, ARIZ. – The presence of contralateral carotid artery occlusion is no reason to treat carotid artery stenosis with stenting instead of carotid endarterectomy, a review of 713 patients suggested.

Either endarterectomy or carotid artery stenting can be performed on patients with contralateral occlusion with good 30-day and midterm results, Dr. Luke P. Brewster and his associates reported at the annual meeting of the Southern Association for Vascular Surgery.

Sherry Boschert

"We do not support contralateral occlusion as an independent criterion for carotid artery stenting" over carotid endarterectomy in patients with contralateral occlusion, said Dr. Brewster of Emory University, Atlanta.

Among 57 patients who underwent carotid artery therapy who also had contralateral occlusion, 7 of 39 patients died after carotid artery stenting (18%), compared with 1 of 18 patients after carotid endarterectomy (6%), during a mean midterm follow-up of 28 and 29 months, respectively.

In general, stroke risk is increased in patients with internal carotid artery occlusion contralateral to a carotid artery with significant stenosis. Contralateral occlusion has been suggested as an indication for stenting because of theoretical advantages from reduced ischemic procedural time, and because the procedure can be done without a vascular shunt and without general anesthesia. Carotid endarterectomy, on the other hand, has been associated with a lower procedural stroke rate.

The investigators retrospectively reviewed Emory University’s data on 713 consecutive patients who underwent either carotid endarterectomy or carotid artery stenting from February 2007 to July 2011.

Among the 8% of patients who had contralateral occlusion, the treatment approach was based on the preference of each patient’s vascular surgeon, cardiologist, and/or interventional radiologist.

Patients in the carotid artery stenting group were more likely to have had prior neck surgery (18 of 39 patients; 46%), compared with patients in the carotid endarterectomy group (1 of 18 patients; 6%). The groups did not differ significantly in age (67 and 70 years, respectively), sex, proportion of symptomatic patients, degree of stenosis, history of carotid artery stenting on the contralateral side, smoking history, or rates of hypertension, transient ischemic attack, stroke, diabetes, myocardial infarction, or other factors.

In the carotid artery stenosis group, six procedures involved flow reversal. The main indications for stenting were prior neck surgery, contralateral occlusion, or radiation of the neck. In the carotid endarterectomy group, two procedures were performed with the patient awake, and 15 involved a shunt.

All the endarterectomies were completed; one stenting procedure was aborted and the patient underwent an endarterectomy during the same hospitalization.

At 30 days after surgery, two patients (5%) in the stenting group had died following an access-site bleed or respiratory failure in a patient with a seizure disorder. No patients in the endarterectomy group died. Two patients in the stenting group developed transient ischemic attacks. There was no MI or stroke in either group, Dr. Brewster said.

Patients in the endarterectomy group stayed in the hospital significantly longer (average, 3 days vs. 2 days in the stenting group). Five patients (28%) in the endarterectomy group were admitted to the ICU, all for observation due to medical morbidities. Seven patients (18%) in the stenting group were admitted to the ICU, three of them due to bradycardia or hypotension.

Midterm results included a mean of 29 months of follow-up in the endarterectomy group and 28 months in the stenting group. Two patients required reinterventions after carotid artery stenting, compared with none after endarterectomy.

Five more patients in the stenting group died at a mean of 23 months after the procedure (excluding the two perioperative deaths), compared with one death at a mean of 42 months after endarterectomy. All six of these late deaths were in patients with hypertension, five of whom also had chronic obstructive pulmonary disease. Three of the six patients had diabetes, and two had a history of prior stroke.

The findings "fail to demonstrate superiority of carotid artery stenting over carotid endarterectomy in patients with contralateral occlusion," Dr. Brewster said.

Dr. Brewster reported having no financial disclosures.

SCOTTSDALE, ARIZ. – The presence of contralateral carotid artery occlusion is no reason to treat carotid artery stenosis with stenting instead of carotid endarterectomy, a review of 713 patients suggested.

Either endarterectomy or carotid artery stenting can be performed on patients with contralateral occlusion with good 30-day and midterm results, Dr. Luke P. Brewster and his associates reported at the annual meeting of the Southern Association for Vascular Surgery.

Sherry Boschert

"We do not support contralateral occlusion as an independent criterion for carotid artery stenting" over carotid endarterectomy in patients with contralateral occlusion, said Dr. Brewster of Emory University, Atlanta.

Among 57 patients who underwent carotid artery therapy who also had contralateral occlusion, 7 of 39 patients died after carotid artery stenting (18%), compared with 1 of 18 patients after carotid endarterectomy (6%), during a mean midterm follow-up of 28 and 29 months, respectively.

In general, stroke risk is increased in patients with internal carotid artery occlusion contralateral to a carotid artery with significant stenosis. Contralateral occlusion has been suggested as an indication for stenting because of theoretical advantages from reduced ischemic procedural time, and because the procedure can be done without a vascular shunt and without general anesthesia. Carotid endarterectomy, on the other hand, has been associated with a lower procedural stroke rate.

The investigators retrospectively reviewed Emory University’s data on 713 consecutive patients who underwent either carotid endarterectomy or carotid artery stenting from February 2007 to July 2011.

Among the 8% of patients who had contralateral occlusion, the treatment approach was based on the preference of each patient’s vascular surgeon, cardiologist, and/or interventional radiologist.

Patients in the carotid artery stenting group were more likely to have had prior neck surgery (18 of 39 patients; 46%), compared with patients in the carotid endarterectomy group (1 of 18 patients; 6%). The groups did not differ significantly in age (67 and 70 years, respectively), sex, proportion of symptomatic patients, degree of stenosis, history of carotid artery stenting on the contralateral side, smoking history, or rates of hypertension, transient ischemic attack, stroke, diabetes, myocardial infarction, or other factors.

In the carotid artery stenosis group, six procedures involved flow reversal. The main indications for stenting were prior neck surgery, contralateral occlusion, or radiation of the neck. In the carotid endarterectomy group, two procedures were performed with the patient awake, and 15 involved a shunt.

All the endarterectomies were completed; one stenting procedure was aborted and the patient underwent an endarterectomy during the same hospitalization.

At 30 days after surgery, two patients (5%) in the stenting group had died following an access-site bleed or respiratory failure in a patient with a seizure disorder. No patients in the endarterectomy group died. Two patients in the stenting group developed transient ischemic attacks. There was no MI or stroke in either group, Dr. Brewster said.

Patients in the endarterectomy group stayed in the hospital significantly longer (average, 3 days vs. 2 days in the stenting group). Five patients (28%) in the endarterectomy group were admitted to the ICU, all for observation due to medical morbidities. Seven patients (18%) in the stenting group were admitted to the ICU, three of them due to bradycardia or hypotension.

Midterm results included a mean of 29 months of follow-up in the endarterectomy group and 28 months in the stenting group. Two patients required reinterventions after carotid artery stenting, compared with none after endarterectomy.

Five more patients in the stenting group died at a mean of 23 months after the procedure (excluding the two perioperative deaths), compared with one death at a mean of 42 months after endarterectomy. All six of these late deaths were in patients with hypertension, five of whom also had chronic obstructive pulmonary disease. Three of the six patients had diabetes, and two had a history of prior stroke.

The findings "fail to demonstrate superiority of carotid artery stenting over carotid endarterectomy in patients with contralateral occlusion," Dr. Brewster said.

Dr. Brewster reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Repairing a first abdominal aortic aneurysm by endovascular techniques instead of open surgery improves survival if the patient eventually needs a second aortic repair of either kind, a retrospective study of 149 patients suggests.

Among 2,256 abdominal aneurysm repairs performed at one institution in 1986-2011, 149 patients (7%) required secondary aortic procedures – EVAR (endovascular aneurysm repair) or TEVAR (transthoracic endovascular aneurysm repair) in 77 patients, and an open surgical repair after initial EVAR/TEVAR in 72 patients.

For the 77 patients who first underwent EVAR or TEVAR (referred to jointly as EVAR in the study), 10 of 61 patients died within 1 year of a second EVAR (16%) and 2 of 16 patients died within 1 year of an open repair after the initial EVAR (13%).

Sherry Boschert

Among the 72 patients who first underwent open surgical aneurysm repair, 10 of 36 patients died within 1 year of EVAR after an initial open repair (28%), and 8 of 36 patients died within 1 year of a second open repair (22%), Dr. Dean J. Yamaguchi and his associates reported at the annual meeting of the Southern Association for Vascular Surgery.

"The initial operative approach to abdominal aortic aneurysm influences mortality in patients who require secondary repair," said Dr. Yamaguchi of the University of Alabama at Birmingham. "Survival is greatest for patients who undergo initial EVAR, even if a secondary open repair is required."

Previous studies have suggested that 12%-20% of patients undergoing EVAR eventually require secondary interventions because of stent graft migration, fracture, or aneurysmal disease progression (N. Engl. J. Med. 2005;352:2398-405; Lancet 2005;365:2179-86). Although a second EVAR may be possible in most of these patients, it hasn’t been clear how this might affect mortality, he said.

A review of the University of Alabama at Birmingham’s experience with EVAR and open aortic aneurysm repair found that patients undergoing EVAR had better long-term survival than did patients treated by open repair, but the EVAR group required more secondary procedures related to the aortic graft. Patients in the open-repair group required more nonvascular interventions subsequently (J. Vasc. Surg. 2011;54:1592-8).

The current study of patients undergoing secondary aortic repairs excluded secondary interventions involving the ascending aorta or iliac arteries.

Patients who had an initial open repair were significantly younger than patients who initially underwent EVAR, and the time between the primary and secondary interventions was significantly longer after initial open repairs than after initial EVAR.

The mean age at the time of the first intervention was 69 years for patients who underwent two EVARs, 68 years in the initial EVAR and secondary open-repair group, 60 years in the initial open-repair and secondary EVAR group, and 63 years for patients who underwent two open repairs. The interval between the first and second intervention was 3 years in the EVAR/open group, 2 years in the EVAR/EVAR group, 13 years in the open/EVAR group, and 7 years in the open/open group.

In a multivariate analysis that adjusted for the effects of confounding factors, the risk of dying within 1 year of a secondary intervention was three times higher in the open/EVAR group, compared with the EVAR/EVAR group, a statistically significant difference. The 1-year death rates after secondary intervention were higher in the open/open group and lower in the EVAR/open group, compared with the EVAR/EVAR group, but these differences were not statistically significant, Dr. Yamaguchi reported.

The study controlled for the effects of age at the time of the secondary aortic procedure; sex; race; duration between first and second aortic procedures; coronary artery disease; hypertension; hyperlipidemia; stroke; obesity; and diabetes.

The study is limited by its retrospective nature and by drawing data from a single institution. Also, the study did not include anatomical data, and EVAR may be chosen for intervention based on anatomy, not necessarily by medical condition, he said.

The patient groups did not differ significantly in age at the time of secondary intervention; sex; the percentage of nonwhite patients or smokers; or in the proportions of patients with a history of coronary artery disease, stroke, diabetes, hypertension, or hyperlipidemia.

Dr. Yamaguchi reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Repairing a first abdominal aortic aneurysm by endovascular techniques instead of open surgery improves survival if the patient eventually needs a second aortic repair of either kind, a retrospective study of 149 patients suggests.

Among 2,256 abdominal aneurysm repairs performed at one institution in 1986-2011, 149 patients (7%) required secondary aortic procedures – EVAR (endovascular aneurysm repair) or TEVAR (transthoracic endovascular aneurysm repair) in 77 patients, and an open surgical repair after initial EVAR/TEVAR in 72 patients.

For the 77 patients who first underwent EVAR or TEVAR (referred to jointly as EVAR in the study), 10 of 61 patients died within 1 year of a second EVAR (16%) and 2 of 16 patients died within 1 year of an open repair after the initial EVAR (13%).

Sherry Boschert

Among the 72 patients who first underwent open surgical aneurysm repair, 10 of 36 patients died within 1 year of EVAR after an initial open repair (28%), and 8 of 36 patients died within 1 year of a second open repair (22%), Dr. Dean J. Yamaguchi and his associates reported at the annual meeting of the Southern Association for Vascular Surgery.

"The initial operative approach to abdominal aortic aneurysm influences mortality in patients who require secondary repair," said Dr. Yamaguchi of the University of Alabama at Birmingham. "Survival is greatest for patients who undergo initial EVAR, even if a secondary open repair is required."

Previous studies have suggested that 12%-20% of patients undergoing EVAR eventually require secondary interventions because of stent graft migration, fracture, or aneurysmal disease progression (N. Engl. J. Med. 2005;352:2398-405; Lancet 2005;365:2179-86). Although a second EVAR may be possible in most of these patients, it hasn’t been clear how this might affect mortality, he said.

A review of the University of Alabama at Birmingham’s experience with EVAR and open aortic aneurysm repair found that patients undergoing EVAR had better long-term survival than did patients treated by open repair, but the EVAR group required more secondary procedures related to the aortic graft. Patients in the open-repair group required more nonvascular interventions subsequently (J. Vasc. Surg. 2011;54:1592-8).

The current study of patients undergoing secondary aortic repairs excluded secondary interventions involving the ascending aorta or iliac arteries.

Patients who had an initial open repair were significantly younger than patients who initially underwent EVAR, and the time between the primary and secondary interventions was significantly longer after initial open repairs than after initial EVAR.

The mean age at the time of the first intervention was 69 years for patients who underwent two EVARs, 68 years in the initial EVAR and secondary open-repair group, 60 years in the initial open-repair and secondary EVAR group, and 63 years for patients who underwent two open repairs. The interval between the first and second intervention was 3 years in the EVAR/open group, 2 years in the EVAR/EVAR group, 13 years in the open/EVAR group, and 7 years in the open/open group.

In a multivariate analysis that adjusted for the effects of confounding factors, the risk of dying within 1 year of a secondary intervention was three times higher in the open/EVAR group, compared with the EVAR/EVAR group, a statistically significant difference. The 1-year death rates after secondary intervention were higher in the open/open group and lower in the EVAR/open group, compared with the EVAR/EVAR group, but these differences were not statistically significant, Dr. Yamaguchi reported.

The study controlled for the effects of age at the time of the secondary aortic procedure; sex; race; duration between first and second aortic procedures; coronary artery disease; hypertension; hyperlipidemia; stroke; obesity; and diabetes.

The study is limited by its retrospective nature and by drawing data from a single institution. Also, the study did not include anatomical data, and EVAR may be chosen for intervention based on anatomy, not necessarily by medical condition, he said.

The patient groups did not differ significantly in age at the time of secondary intervention; sex; the percentage of nonwhite patients or smokers; or in the proportions of patients with a history of coronary artery disease, stroke, diabetes, hypertension, or hyperlipidemia.

Dr. Yamaguchi reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Repairing a first abdominal aortic aneurysm by endovascular techniques instead of open surgery improves survival if the patient eventually needs a second aortic repair of either kind, a retrospective study of 149 patients suggests.

Among 2,256 abdominal aneurysm repairs performed at one institution in 1986-2011, 149 patients (7%) required secondary aortic procedures – EVAR (endovascular aneurysm repair) or TEVAR (transthoracic endovascular aneurysm repair) in 77 patients, and an open surgical repair after initial EVAR/TEVAR in 72 patients.

For the 77 patients who first underwent EVAR or TEVAR (referred to jointly as EVAR in the study), 10 of 61 patients died within 1 year of a second EVAR (16%) and 2 of 16 patients died within 1 year of an open repair after the initial EVAR (13%).

Sherry Boschert

Among the 72 patients who first underwent open surgical aneurysm repair, 10 of 36 patients died within 1 year of EVAR after an initial open repair (28%), and 8 of 36 patients died within 1 year of a second open repair (22%), Dr. Dean J. Yamaguchi and his associates reported at the annual meeting of the Southern Association for Vascular Surgery.

"The initial operative approach to abdominal aortic aneurysm influences mortality in patients who require secondary repair," said Dr. Yamaguchi of the University of Alabama at Birmingham. "Survival is greatest for patients who undergo initial EVAR, even if a secondary open repair is required."

Previous studies have suggested that 12%-20% of patients undergoing EVAR eventually require secondary interventions because of stent graft migration, fracture, or aneurysmal disease progression (N. Engl. J. Med. 2005;352:2398-405; Lancet 2005;365:2179-86). Although a second EVAR may be possible in most of these patients, it hasn’t been clear how this might affect mortality, he said.

A review of the University of Alabama at Birmingham’s experience with EVAR and open aortic aneurysm repair found that patients undergoing EVAR had better long-term survival than did patients treated by open repair, but the EVAR group required more secondary procedures related to the aortic graft. Patients in the open-repair group required more nonvascular interventions subsequently (J. Vasc. Surg. 2011;54:1592-8).

The current study of patients undergoing secondary aortic repairs excluded secondary interventions involving the ascending aorta or iliac arteries.

Patients who had an initial open repair were significantly younger than patients who initially underwent EVAR, and the time between the primary and secondary interventions was significantly longer after initial open repairs than after initial EVAR.

The mean age at the time of the first intervention was 69 years for patients who underwent two EVARs, 68 years in the initial EVAR and secondary open-repair group, 60 years in the initial open-repair and secondary EVAR group, and 63 years for patients who underwent two open repairs. The interval between the first and second intervention was 3 years in the EVAR/open group, 2 years in the EVAR/EVAR group, 13 years in the open/EVAR group, and 7 years in the open/open group.

In a multivariate analysis that adjusted for the effects of confounding factors, the risk of dying within 1 year of a secondary intervention was three times higher in the open/EVAR group, compared with the EVAR/EVAR group, a statistically significant difference. The 1-year death rates after secondary intervention were higher in the open/open group and lower in the EVAR/open group, compared with the EVAR/EVAR group, but these differences were not statistically significant, Dr. Yamaguchi reported.

The study controlled for the effects of age at the time of the secondary aortic procedure; sex; race; duration between first and second aortic procedures; coronary artery disease; hypertension; hyperlipidemia; stroke; obesity; and diabetes.

The study is limited by its retrospective nature and by drawing data from a single institution. Also, the study did not include anatomical data, and EVAR may be chosen for intervention based on anatomy, not necessarily by medical condition, he said.

The patient groups did not differ significantly in age at the time of secondary intervention; sex; the percentage of nonwhite patients or smokers; or in the proportions of patients with a history of coronary artery disease, stroke, diabetes, hypertension, or hyperlipidemia.

Dr. Yamaguchi reported having no financial disclosures.

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.

SAN FRANCISCO – Recent surveys of patients and attending surgeons show differing views on disclosures, Dr. Susan Lee Char said at the clinical congress of the American College of Surgeons.

She and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey presented a hypothetical case of a patient’s undergoing elective partial hepatectomy and asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale.

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosure may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients and 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively. A total of 41% of patients and 5% of surgeons said the patient should be told the number of times the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed.

A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential. Patients scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure. And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

Dr. Char had no conflicts of interest.