William P. Shutze Sr. M.D.

Shutze, W., R. Shutze, P. Dhot and G. O. Ogola (2018). “Patient-reported outcomes of endovenous superficial venous ablation for lower extremity swelling.” Phlebology Nov 22. [Epub ahead of print].

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OBJECTIVE: To evaluate the effect of endovenous ablation in patients presenting with leg swelling. METHODS: We identified Clinical, Etiology, Anatomy, Pathophysiology (CEAP) clinical class 3 (C3) patients undergoing endovenous ablation from 21 January 2005 to 19 March 2015 with an 810-nm or 1470-nm laser. Patients were surveyed regarding the degree of edema, use of compression stockings, and satisfaction with the procedure. RESULTS: A total of 1634 limbs were treated by endovenous ablation for incompetent saphenous veins with or without adjunctive segmental varicose vein microphlebectomy. Of these, 528 limbs were treated for CEAP C3. The average time period from the procedure date until the survey date was 1494 days (range, 562-2795 days). Ninety-two respondents accounted for 130 ablations in 128 limbs with an average venous segmental disease score of 2.7. Ninety-seven limbs (75.8%) had reduced or resolved swelling, 29 limbs (22.6%) were unchanged, and 2 limbs (1.6%) had increased swelling. The vast majority (81%) were satisfied with their decision to have the procedure. CONCLUSIONS: Endovenous ablation for edema secondary to superficial venous insufficiency is effective and has high patient satisfaction. Further investigation is needed regarding risk factors for immediate failure and delayed recurrence of edema.

Lytle, M. E., J. West, J. N. Burkes, B. Beteck, T. Fisher, Y. Daoud, D. R. Gable and W. P. Shutze (2018). “Limited Clinical Relevance of Vertebral Artery Injury in Blunt Trauma.” Ann Vasc Surg 53: 53-62.

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BACKGROUND: Blunt cerebrovascular injury (BCVI), although rare, is more common than previously thought and carries a substantial stroke and mortality risk. The purpose of our study was to evaluate the differences between blunt carotid artery (CA) and vertebral artery (VA) injuries, assess the stroke and death rates related to these injuries, and identify the relationship of Injury Severity Score (ISS) with stroke and mortality in BCVI. METHODS: Using a retrospective review of the trauma registry at a level I trauma center, we identified patients with BCVI. The study period began in January 2003 and ended in July 2014. Demographics, injuries reported, investigative studies performed, and outcomes data were obtained and analyzed. Radiographic images of both blunt CA and VA injuries were reviewed and graded by an independent radiologist, according to the current classification of blunt CA injuries. RESULTS: BCVI involving 114 vessels was identified in 103 patients. This population consisted of 65 males and 38 females with an average age of 45 years (15-92, range). The average ISS was 22 (4-75, range). Cervical spine fracture occurred in 80% of VA injuries (64 total patients). Injuries involved the CA in 33, the VA in 59, and both in 11. The CA group had a higher incidence of traumatic brain injury (61% vs. 46%), ISS (27 vs. 18), and stroke (24% vs. 3%), compared to the VA group. Mortality in the CA group was 30% compared to 3% in the VA group. Patients with high ISS (>/=25) had increased stroke rates compared to those with lower (<25) ISS (19% vs. 6.7%). All mortalities occurred with ISS >25. Logistic regression revealed that vessel injured, ISS, and Glasgow Coma Scale (GCS) were significant risk factors for mortality. Multivariate analysis demonstrated carotid injury, and lowest GCS were independently associated with mortality. CONCLUSIONS: In this comparison of CA and VA injuries in BCVI, VA injuries were more common and more frequently found with cervical spine fractures than CA injuries. However, VA injuries had a lower incidence of CVA and mortality. A high ISS was associated with stroke and mortality while carotid injury and lowest GCS were independently associated with increased mortality.

Beteck, B., W. Shutze, B. Richardson, R. Shutze, K. Tran, A. Dao, G. O. Ogola and G. Pearl (2018). “Comparison of athletes and non-athletes undergoing thoracic outlet decompression for neurogenic TOS.” Ann Vasc Surg Aug 3. [Epub ahead of print].

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BACKGROUND: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of TOS and may occur from injury, occupational stress or athletic endeavors. While most patients with NTOS will improve after first rib resection and scalenectomy (FRRS), the prognostic risk factors for success remain unclear. Athletes are a very motivated and disciplined demographic and therefore should be a group more likely to respond to FRRS for NTOS than non-athletes. We hypothesized that athletes would do better after FRRS than non-athletes despite the added physical stress that sporting activity imposes. METHODS: We reviewed our office records for all patients treated for TOS from July 2009 to May 2014, and extracted demographic, historical, procedural, and follow-up data. We contacted these patients to complete a survey to assess patient-centered outcomes of FRRS, and compared athlete versus non-athlete survey responses. RESULTS: 564 patients had FRRS for NTOS, and 184 (33%) responded to the survey. Of the 184 who responded, 97 were athletes (53%) and 87 were non-athletes (47%). Survey results suggested that 87% were improved in pain medication use (athletes 93% vs. non-athletes 80%, p=0.013), 77% would undergo FRRS on the contralateral side if needed (athletes 75% vs non-athletes 79%, p= 0.49), 73% had resolution of TOS symptoms (athletes 80% vs. non-athletes 65%, p=0.02), 86% could perform activities of daily living without limitation (athletes 95% vs. non-athletes 77%, p=0.0004). Although 24% of respondents required another non-TOS procedure (athletes 27% vs. non-athletes 22%, p=0.6), 89% felt that they had made the right decision (athletes 93% vs. non-athletes 80%, p=0.09). Multivariable analysis of age, race, gender, previous surgery, pre-operative physical therapy, preoperative narcotic use, and athletic status confirmed that athletic status was a significant predictor for improvement in pain medication use, complete TOS resolution, and the ability to perform activities of daily living. CONCLUSION: Most patients undergoing FRRS for NTOS are improved and satisfied with the result and indicate they made the correct choice to have FRRS. While being an athlete was an independent variable for better outcomes in activity and pain medication use, their satisfaction following FRRS was similar to that in non-athletes. Further investigation is needed to determine if these findings are due to physical and/or psychosocial factors.

Shutze, W., V. Suominem, W. Jordan, P. Cao, S. Oweida and R. Milner (2018). “The incidence and effect of noncylindrical neck morphology on outcomes after endovascular aortic aneurysm repair in the Global Registry for Endovascular Aortic Treatment.” J Vasc Surg. May 23. [Epub ahead of print].

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BACKGROUND: The Gore Global Registry for Endovascular Aortic Treatment (GREAT) was designed to evaluate real-world outcomes after treatment with Gore aortic endografts used in a real-world, global setting. We retrospectively analyzed the GREAT data to evaluate the incidence and effects of noncylindrical neck anatomy in patients undergoing endovascular aortic aneurysm repair. METHODS: The present analysis included patients with data in the GREAT who had been treated with the EXCLUDER endograft from August 2010 to October 2016. A noncylindrical neck was defined when the proximal aortic landing zone diameter had changed >/=2 mm over the first 15 mm of the proximal landing zone, indicating a tapered, conical, or hourglass morphology. Cox multivariate regression analyses were performed for any reintervention (including reinterventions on aortic branch vessels), device-related reinterventions, and reintervention specifically for endoleak. Independent binary (cylindrical vs noncylindrical necks) and continuous (percentage of neck diameter change) variables were assessed. The abdominal aortic aneurysm (AAA) diameter, proximal neck length, maximal infrarenal neck angle, gender, and use of aortic extender cuffs were also assessed. RESULTS: Of 3077 GREAT patients with available proximal aortic landing zone diameter measurements available, 1765 were found to have cylindrical necks and 1312 had noncylindrical necks. The noncylindrical neck cohort had a significantly greater proportion of women (17.4% vs 12.6%; P < .001) and more severe infrarenal angulation (33.8 degrees vs 28.4 degrees ; P < .001). A total 14.7% of noncylindrical neck patients and 11.2% cylindrical neck patients underwent implantation outside of the EXCLUDER instructions for use regarding the anatomic inclusion criteria (P = .004). The procedural characteristics were similar between the two cohorts; however, noncylindrical neck patients required significantly more aortic extender cuffs (P = .004). The average follow-up was 21.2 +/- 17.5 months and 17.8 +/- 15.8 months for the cylindrical and noncylindrical cohorts, respectively (P < .001). The Cox multivariate regression models demonstrated female gender and maximum AAA diameter were significant risk factors for subsequent reintervention (overall, device-related, and endoleak-specific). Women were 2.2 times as likely to require device-related intervention during the follow-up period compared with men (P < .001). Neck shape morphology was not a significant predictor, except for device-related intervention, for which cylindrical necks (binary definition) resulted in a slightly elevated risk (1.5 times; P = .03). CONCLUSIONS: Noncylindrical neck morphology was more common in women and was associated with an increased use of aortic extender cuffs but did not increase the risk of intervention. Female gender and AAA diameter were associated with an increased need for reintervention.

Shutze, W., W. P. Shutze, Jr., P. Prajapati, G. Ogola, J. Schauer, E. Biller, N. Douville and R. A. Shutze (2018). “Postoperative continuous catheter-infused local anesthetic reduces pain scores and narcotic use after lower extremity revascularization.” Vascular 26(3): 262-270.

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Objective: Postoperative pain following lower extremity revascularization procedures is traditionally controlled with narcotic administration. However, this may not adequately control the pain and puts the patient at risk for complications from opiate use. Here we report an alternative strategy for pain management using a continuous catheter-infused local anesthetic into the operative limb. Design Retrospective case-control study. Methods: Patients undergoing lower extremity revascularization procedures using continuous catheter-infused local anesthetic were compared to similar patients undergoing similar procedures during the same time period who did not receive continuous catheter-infused local anesthetic. Records were reviewed for pain scores, narcotics consumption, length of stay, need for postoperative chest X-ray, supplemental oxygen use, wound complications, and 30-day readmission. Results: There were 153 patients (mean age 69.5 years) from September 2011 to December 2014 who underwent common femoral artery procedures, femoral-popliteal bypass, femoral-tibial bypass, popliteal aneurysm repair, popliteal to pedal bypass, popliteal artery thrombo-embolectomy, sapheno-popliteal venous bypass, or ilio-femoral bypass. There were no significant differences between the continuous catheter-infused local anesthetic (n=57) and control (n=96) groups regarding age, body mass index, cardiac history, diabetes, hypertension, and procedures performed. The continuous catheter-infused local anesthetic group showed better cumulative average pain scores, better high pain scores on postoperative days 1-3, and better average pain scores on postoperative days 2-3 (P<0.03). The continuous catheter-infused local anesthetic group had lower median narcotics consumption on postoperative days 1-2 (P=0.02). No differences were found in postoperative length of stay, urinary catheter use, number of postoperative chest X-rays, oxygen use, mobilization, or fever. Wound complications occurred in 8.8% of the continuous catheter-infused local anesthetic group and in 11.5% of controls (P=0.79). Readmission rates were 23% (continuous catheter-infused local anesthetic) and 21% (controls; P=0.84). Conclusion: Postoperative continuous catheter-infused local anesthetic reduces pain scores and pain medication use compared to standard opiate therapy in these patients, without increasing wound complication or readmission rates. Continuous catheter-infused local anesthetic appeared to have no effect on the incidence of pulmonary complications, mobilization, or fever.