Abstracts selected for presentation at the SVM 2020 Annual Scientific Sessions

Jay D. Coffman Young Investigator Award (YIA) Presentations

In honor of Dr. Jay D. Coffman (1928–2006), distinguished internist and researcher of vascular medicine and clinical cardiology, SVM sponsors an annual award in vascular medicine and biology research. The top finalists make oral presentations during the Jay D. Coffman Young Investigator Presentation.

YIA 1

JMJD3 regulates macrophage-mediated inflammation in abdominal aortic aneurysms

Frank M. Davis¹, Aaron Dendekker¹, Rachael Wasikowski¹, Amrita Joshi¹, Steve Kunkel¹, Lam C. Tsoi¹, Johann Gudjonsson¹, Katherine Gallagher¹

¹University of Michigan, Ann Arbor, MI, USA

Background: Abdominal aortic aneurysms (AAA) are characterized by inflammatory macrophage (M) infiltration. The mechanisms regulating M polarization during AAA development remain unknown. There is evidence that epigenetic enzymes, specifically the histone demethylase JMJD3, direct M polarization. The purpose of this study was to evaluate if JMJD3-mediated epigenetic modifications regulate M phenotype during AAA formation.

Methods: Single-cell sequencing was conducted on human aortic samples. For our murine model, male C57BL/6 mice were injected with a PCSK9 gain-of-function mutation AAV (D377Y). Mice were fed a saturated fat diet and infused with AngII (1 µg/kg/min) or saline for 4 weeks. AAA maximum diameters were quantified and Ms were sorted. Histone 3 lysine 27 trimethylation (H3K27me3) was evaluated by ChIP. Statistical significance was determined using ANOVA.

Results: Single-cell transcriptome analysis of human AAAs demonstrated significant upregulation of JMJD3 and inflammatory cytokines in myeloid subsets compared to controls. Ms from AngII-induced AAAs displayed increased Jmjd3 and NFB-mediated cytokine expression. AngII-induced AAA Ms had decreased levels of the Jmjd3-mediated repressive histone mark, H3K27me3, on inflammatory gene promoters. siRNA inhibition of JMJD3 reduced M-mediated inflammatory cytokine expression. To determine drivers of JMJD3 production IFN signaling was evaluated and mice with IFN receptor genetic depletion displayed reduced Jmjd3 levels. Finally, pharmacological inhibition of JMJD3 reduced AAA formation and inflammatory cytokines.

Conclusion: These results suggest JMJD3 may regulate M-mediated inflammation in human and murine AAAs as well as identify a potential target for the treatment of chronic inflammation.

YIA 2

Anticoagulant use after peripheral endovascular intervention in intermittent claudicants is associated with increased risk of major adverse limb events

Niveditta Ramkumar¹, Mark Creager¹, Philip Goodney¹, Stanislav Henkin¹

¹Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA

Background: Peripheral endovascular intervention (PVI) for peripheral artery disease (PAD) has become more common than surgical bypass. Post-procedure, dual-antiplatelet therapy is often prescribed. However, there is a lack of data regarding efficacy of anticoagulants after PVI. We sought to evaluate incidence of major adverse limb events (MALE) after PVI in patients on anticoagulants.

Methods: We analyzed index endovascular interventions for patients with intermittent claudication in the Vascular Quality Initiative (2010-2019). The exposure variable was presence of anticoagulant. We studied 1-year outcomes, including patency loss (occlusion or target lesion reintervention), MALE (any major amputation or re-intervention), and all-cause mortality, using Kaplan-Meier survival analysis and multivariable Cox regression.

Results: Among 26,240 patients with claudication, 2,394 (9.1%) were discharged on an anticoagulant (mostly vitamin K antagonist). Patients on an anticoagulant were older (69.5 vs 66.2 years, p < 0.001), were more likely to have coronary artery disease (35.7% vs 28.6%, p < 0.001), had infrapopliteal treatment (16% vs 7.3%, p < 0.001) and were more likely to be discharged without an antiplatelet agent (17% vs 4.4%, p < 0.001). Compared to those not on an anticoagulant, those who received discharge anticoagulation had a significantly higher 1-year cumulative incidence of MALE (7.3% vs 5.6%, log-rank p=0.003) and mortality (6.4% vs 2.8%, log-rank p < 0.001; Table). These effects remained after risk adjustment.

Conclusion: Use of anticoagulation after PVI for intermittent claudication is associated with higher 1-year risk of MALE and mortality. Further studies are necessary to evaluate the etiology of these effects.

YIA 2 Table.

Association of anticoagulation on discharge and adverse outcomes after endovascular intervention for intermittent claudication.

YIA 3

A deprived neighborhood environment and diminished health status gains following peripheral artery disease treatment: Insights from the PORTRAIT registry

Vittal Hejjaji¹, Zubeen Azari², Philip G. Jones¹, Carlos Mena-Hurtado³, Paul S. Chan¹, Mehdi H. Shishehbor⁴, John A. Spertus¹, Asma Ahmed⁵, Ali O. Malik¹, Kim G. Smolderen¹

¹Saint Luke's Mid America Heart Institute, Kansas City, MO, USA, ²Kansas City University-Medicine, Kansas City, MO, USA, ³Yale School of Medicine, New Haven, CT, USA, ⁴University Hospitals Cleveland Medical Center, Cleveland, OH, USA, ⁵People Tree Hospital, Bengaluru, India

Background: We examined the never before studied association between neighborhood-level socio-economic status and health status in patients with peripheral artery disease (PAD).

Methods: From 2011-2015, we recruited patients from 10 US vascular specialty clinics that presented with new or exacerbating PAD symptoms. We collected clinical and health status data at baseline and 12 months. PAD health status was assessed with the Peripheral Arterial Questionnaire Summary Score (PAQ, range 0-100; higher scores better). Patients neighborhood socioeconomic disadvantage was summarized using the Area Deprivation Index (ADI), represented as national percentile ranks (higher rank = greater deprivation). We examined the association between ADI and PAQ adjusting for 30 patient demographic, clinical and individual-level socioeconomic factors.

Results: Among 564 patients (mean age 69, 57% male), 15% lived in the least deprived areas (ADI percentiles 1-24) and 30% in most deprived areas (percentiles 75-100). Overall mean PAQ scores were 47 at baseline and 66 at 12 months. At baseline, there was no association between ADI and PAQ after adjusting for patients age and sex (p=0.54). However, at 12 months, patients in the most deprived areas reported lower change in health status (17±4.2) than those in the least deprived areas (24±0.8), despite adjustment for patient characteristics and baseline health status (see Figure).

Conclusion: In a real-world database, patients with PAD living in highly disadvantaged neighborhoods report smaller improvements in health status compared with those in the least deprived areas.

YIA 3 Figure.

Variation in health status change by area deprivation index over 12 months.

YIA 4

Characterizing cancellations, exercise duration, and results of exercise ankle brachial index testing

Gloria Kim¹, Amy Felsted¹, Kailyn Geter¹, Sandy Brown¹, Matthew A. Corriere¹

¹University of Michigan, Ann Arbor, MI, USA

Background: Ankle brachial indexes (ABI) may be performed with walking exercise when there is clinical suspicion of symptomatic PAD and resting ABI are normal or borderline. We evaluated a consecutive series of exercise ABI referrals for rates of study cancellation, completion, exercise duration, and reasons for discontinuing exercise.

Methods: 125 consecutive exercise ABI referrals were analyzed. Studies were categorized as cancelled if no exercise was attempted. Results were categorized as positive if an exercise-induced decrease in ABI was observed. Reasons for discontinuing exercise were evaluated based on leg symptoms. Exercise duration was compared between positive and negative studies using T-tests.

Results: Exercise was cancelled for 31/125 patients (25%), often for comorbidities deemed contraindications (N=10) (including coronary heart disease, CHF, and COPD), walking impairment (N=4) and symptoms of shortness of breath (N=3) or chest pain (N=3). Exercise duration was longer for negative versus positive studies (7.6±2.6 versus 6.3±2.3 minutes; P=0.015). 33% of documented reasons for exercise discontinuation were unrelated to leg symptoms (such as general fatigue, shortness of breath, and chest pain). 50/94 (53%) of studies were negative.

Conclusion: A significant proportion of exercise ABI tests are cancelled due to comorbidity, symptoms, or walking impairment. Among patients completing exercise ABI, mean duration of exercise exceeded six minutes for patients with and without positive studies. Screening based on comorbidity and symptoms may reduce cancellation of exercise ABI and related costs and administrative burdens.

Poster Presentations

Poster 101-A

Outcome heterogeneity in response to CMS-reimbursed supervised exercise therapy in PAD: An exploratory domain analysis

Mary O. Whipple¹, Julian Wolfson², Erica Schorr³, Diane Treat-Jacobson³

¹School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA, ²School of Public Health, University of Minnesota, Minneapolis, MN, USA, ³School of Nursing, University of Minnesota, Minneapolis, MN, USA

Background: Patients with lower extremity peripheral artery disease (PAD) often have severe walking limitations. Supervised exercise therapy (SET) is a proven treatment for symptomatic PAD, yet one-third of patients do not increase walking distance with treatment. It is unknown if other SET-related outcomes respond variably. The purpose of this analysis was to: 1) examine domains of SET outcomes and 2) identify characteristics associated with improved response in each domain. We hypothesized that outcomes would cluster into unique domains representing 1) walking ability, 2) physical function, and 3) symptom outlook.

Methods: N=41 adults (60 years) completed a 12-week SET program. The 6-minute walk test (6MWT), short physical performance battery, timed up and go, Walking Impairment Questionnaire (WIQ), PROMIS Mobility, and PAD Quality of Life questionnaire (PADQOL) were completed at baseline and 12 weeks. Principal component (PC) analysis identified unique domains; composite scores were calculated for each domain. Linear regression was used to examine relationships between clinical characteristics and composite scores.

Results: Three PCs accounted for 65% of variability in outcome response at 12 weeks: PAD limitations (PC1, 38.4%), confidence and mobility (PC2, 16.5%), and objective function (PC3, 10.3%). Previous revascularization and diabetes were associated with greater improvements in PC2 (p=.047) and PC3 (p=.042), respectively. Age, sex, BMI, ABI, and smoking did not predict PC scores.

Conclusion: Integrating primary measures of walking ability (e.g., 6MWT) with complementary measures (e.g., WIQ and PADQOL) may better characterize individual improvement with SET, and could provide future opportunities for tailoring programs to target specific domains.

Poster 102-B

Improvement in patient reported outcome measures following supervised exercise therapy or peripheral vascular intervention for symptomatic peripheral artery disease

Aishwarya Raja¹, Mohsin Chowdhury¹, Brett Carroll¹, Anna Krawisz¹, Alec Schmaier, PhD¹, Robert Yeh¹, Eric A. Secemsky¹

¹Beth Israel Deaconess Medical Center, Boston, MA, USA

Background: Symptomatic peripheral artery disease (PAD) is associated with severe morbidity and poor quality of life. Although data suggest that supervised exercise therapy (SET) may improve symptoms to a similar degree as peripheral vascular intervention (PVI), few studies have evaluated changes in patient reported outcomes among a real world PAD population.

Methods: Consecutive patients with symptomatic PAD referred to a single tertiary care center were treated with either PVI or SET at the discretion of the clinician. The primary outcome was the change in the Peripheral Artery Questionnaire (PAQ) summary score between baseline and 30 days following treatment. A change in PAQ of ⩾ 8 has been established as clinically meaningful.

Results: Fifteen patients have been enrolled in the study, including 9 who received SET and 6 who received PVI. Patients had similar proportion of diabetes (53.3%), renal insufficiency (20.0%), current tobacco use (13.3%) and prior peripheral revascularization (26.7%). However, patients referred for SET were notably older (73.9±9.4 vs 63.3+/-10.6 for PVI). Baseline PAQ scores were modestly lower among those referred for PVI (45.8±9.2) compared with SET (47.9±10.3). Following treatment, the mean improvement in PAQ at 30 days was 15.4±17.6 for PVI (p=0.12) and 7.0±5.7 for SET (p=0.09) (see Figure).

Conclusion: In this real world assessment of patient reported outcomes following SET or PVI for the management of symptomatic PAD, both treatments demonstrated improvement in PAQ scores at 30 days, with a larger change among those receiving PVI. Future work assessing the long-term durability of these changes is ongoing.

Poster 102-B Figure.

Poster 103-C

Identifying dietary and nutritional risk factors for symptomatic peripheral arterial disease using the UK biobank cohort study

Amy Kaufman¹, Eri Fukaya², Nicholas Leeper¹, Elsie Ross¹

¹Stanford University, Stanford, CA, USA, ²Stanford Health Care, Stanford, CA, USA

Background: Atherosclerotic peripheral arterial disease (PAD) detrimentally impacts quality of life and cardiovascular morbidity and mortality. Well-known risk factors include age, smoking, hypertension, and diabetes. The role of diet and nutrition has been relatively overlooked, despite the importance of lifestyle modifications for prevention. We sought to use the UK Biobank, which has over 100 diet/ nutrition variables, to identify risk factors associated with symptomatic PAD.

Methods: We applied machine learning (ML) analysis to nearly 500,000 individuals from the UK Biobank in an agnostic search. After identifying 71 diet/nutrition variables related to PAD risk, we applied a stringent variable selection method known as elastic net. Finally to evaluate the clinical significance of the remaining variables, we used Cox regression to estimate hazard ratios for risk of symptomatic PAD.

Results: Our final data set included 2,161 individuals with incident PAD events and 483,860 without these events. Nutritional variables associated with higher risk of PAD events were iron, folate, vitamin D3/calcium and thiamine supplementation. Cooking with lard and olive spread compared to cooking with olive oil were associated with increased risk of symptomatic PAD. Conversely higher cereal intake and supplementation with selenium, glucosamine, and cod liver oil were associated with decreased risk. Fish oil supplementation, taken by 31% of the population, was not significantly associated with decreased risk of events. See Figure.

Conclusion: Multiple dietary and nutritional factors are associated with risk of symptomatic PAD. Further work may help identify individuals at high risk of developing symptomatic PAD and assist in more personalized primary and secondary prevention.

Poster 103-C Figure.

Poster 104-D

Cardiac rehabilitation program improves outcomes in patients with peripheral arterial disease after undergoing revascularization

Farhad Sami¹, Sagar Ranka¹, Matthew Lippmann¹, Brian Weiford, Blake Boyer, Bob Whitman, Kirk Hance, Eric Hockstad, Kamal Gupta¹

¹University of Kansas Medical Center, Kansas City, KS, USA

Background: Currently there is no Medicare approval for patients with peripheral artery disease (PAD) undergoing revascularization to get cardiac rehabilitation (CR). Since PAD patients are at an even higher risk than coronary artery disease (CAD) patients, we hypothesized that PAD patients will benefit from CR after revascularization.

Methods: We conducted a pilot study to assess the feasibility (and benefit) of CR in PAD patients post revascularization and compared them to standard of care (control group). The primary endpoint was onset of claudication during 6-minute walk test (6MWT) (Table). Secondary endpoints were clinical variables and Quality of Life (QOL) measures. Standard statistical tests were used for intergroup comparisons.

Results: The study enrolled 22 subjects (CR group=12). Mean age was 59.9 and 64.9 years in CR and controls, respectively. 58.3% and 60% were female in CR and control groups, respectively. The CR group had higher prevalence of diabetes, tobacco use, CAD, hypertension, and atrial fibrillation (p=not significant). CR group had a lower incidence of claudication during the 6-MWT (0% vs 40%; p=0.01). The number of laps and distance walked by the CR group was higher (p=not significant). Mean vascular QOL score was higher in the CR group (16 vs 13; p=0.03).

Conclusion: Study findings suggest that CR improves QOL and walking ability in patients with PAD after revascularization. Larger studies are needed to confirm these findings for CR to become routine for PAD patients post revascularization (like CAD).

Poster 104-D Table.

Comparison of Outcomes between Cardiac Rehabilitation and Control Group.

Poster 105-A

The association of leg symptoms with mortality in people with a low ankle brachial index

Pooja Nayak¹, Mary McDermott²

¹University of Illinois at Chicago College of Medicine, Chicago, IL, USA, ²Northwestern University, Evanston, IL, USA

Background: Most people with PAD do not have classical intermittent claudication (IC) symptoms. Some are asymptomatic and others have atypical exertional leg symptoms. This longitudinal study assessed whether the presence and type of leg symptoms reported at baseline was associated with risk of all-cause mortality in people with and without PAD.

Methods: 1,289 patients with ABI < 0.90 and 440 with ABI 0.90-1.40 were identified from Chicago medical centers and followed for a mean of 40 months (interquartile range 26-51). Participants were categorized at baseline by leg symptoms: classic IC (n=339), always asymptomatic (no exertional leg symptoms including during the 6-minute walk, n=376), and leg pain/carry on (exertional leg pain that does not stop the participant from walking, n=132). Mortality data were obtained from proxies, physicians, medical records, and the Social Security Database.

Results: In people with ABI < 0.90, leg pain/carry was associated with lower mortality than those who were always asymptomatic (11.5 vs 26.1%). Adjusting for age, sex, race, comorbidities, ABI and other confounders, leg pain/carry on was associated with lower mortality compared to the always asymptomatic group (adjusted Hazard Ratio (aHR), 95% CI=0.43, 0.23-0.82, P=0.01). In contrast, among people with ABI 0.90-1.40, those with leg pain/carry on (aHR=4.75, 1.18-19.16, P=0.03) and those with atypical exertional leg symptoms (aHR=4.37, 1.65-11.62, P=0.003) had higher mortality than asymptomatic patients (Table).

Conclusion: In people with ABI < 0.90, asymptomatic patients had higher mortality than those who walked despite exertional leg pain, while exertional leg symptoms were associated with increased mortality in people with a normal ABI.

Poster 105-A Table.

The association of leg symptoms with mortality in people with a low ankle brachial index.

Poster 106-B

Barriers to supervised exercise therapy participation in people with peripheral artery disease

Kruti Patel¹, Mary McDermott²

¹University of Illinois College of Medicine, Chicago, Il, USA, ²Northwestern University, Evanston, IL, USA

Background: The Center for Medicare and Medicaid Services (CMS) began covering supervised exercise therapy (SET) for people with peripheral artery disease (PAD) in 2017. This study evaluated participation rates in SET and reasons for non-participation in SET among PAD patients in Chicago during 2019.

Methods: People with PAD (defined as an ankle brachial index (ABI) < 0.90, vascular laboratory evidence of PAD, or a positive heel-rise test) participating in ongoing research studies were identified from the Chicago-area community and hospital centers. Data were collected using a questionnaire administered by certified research staff.

Results: Between May and December 2019, 235 PAD patients completed the questionnaire (mean age 70 (SD=8.7), mean ABI 0.69 (SD=0.22), 94 (40%) female, and 150 (64%) black). Overall, 179/235 (77%) participants with PAD were willing to travel to a medical center 3x/week for SET. The Table shows reasons provided by PAD patients who were unwilling to travel for SET. However, 103/179 (58%) were unwilling to pay $11/session co-pay required by CMS. Of the 235, 194 (83%) reported never receiving advice from their physician to participate in SET. Of the 41/235 (17%) patients who were advised to participate, 26/41 (63%) reported receiving a SET referral, and 23/41 (56%) participated in SET. However, 17/23 (74%) patients who participated in SET did not complete a full 12 weeks.

Conclusion: Despite CMS coverage since 2017, in 2019 more than 80% of PAD patients in the Chicago area reported SET had not been recommended by their physician. Interventions to increase participation should target PAD patients perception that SET is inconvenient and costly.

Poster 106-B Table.

Reasons* Provided by PAD Patients Who were not Willing to Travel to a Medical Center 3x/Week for 12 Weeks for SET.

Poster 107-C

Descriptive epidemiology and clinical characteristics of latent versus active JAK2-Myeloproliferative Neoplasms (MPN) in splanchnic venous thrombosis: Updated analysis of pooled database

Philip A. Haddad¹, Dalia Hammoud¹, Kevin Gallagher¹

¹LSU Health Sciences Center-Shreveport/Overton Brooks VA Medical Center, Shreveport, LA, USA

Background: Splanchnic vein thromboses (SVT) often cause Budd-Chiari syndrome (BCS). JAK2-MPN is the most common cause of SVT/BCS. Endothelial cells harboring JAK2 mutations have been demonstrated in patients with BCS which may contribute to the overall prothrombotic propensity. This study attempts to describe the epidemiology and clinical characteristics of latent JAK2-MPN (LMPN), where JAK2 mutation is detected without clinical evidence of MPN, versus active JAK2-MPN (AMPN) where JAK2+ MPN is present, in patients with SVT/ BCS.

Methods: We compiled a pooled database of 90 cases with SVT/BCS. Kaplan-Meier survival curves, Cox proportional-hazards model, and Log-rank tests were used to assess the influence of demographic and clinical factors on survival.

Results: The SVT/BCS cohort consisted of 65% LMPN and 35% AMPN with median ages of 39 and 42 years respectively. The peak incidence of SVT/BCS seems to occur between ages 36-48 for LMPN and 24-36 for AMPN. Females were twice more predominant than males. The AMPN group consisted of 41% Polycythemia Vera (PV), 22% Essential Thrombocythemia, 28% Myelofibrosis (MF) and 3% others. There was no difference in the type of splanchnic vein involvement or the number of coexisting acquired or inherited conditions between the two groups. Survival of patients with BCS did not differ by their MPN status or sex. 21% of LMPN progressed to AMPN (57% ET, 21.5% PV, and 21.5% MF). The median time to progression was 55 months among those that progressed. While the median time to progression was longer for males (63 vs 39 months) this difference did not reach statistical significance.

Conclusion: This study describes for the first time the epidemiologic and clinical characteristics of patients with SVT/BSC by their MPN status. It reveals that the majority of LMPN do not progress to AMPN, indicating that LMPN prothrombotic propensity is independent of the hematologic AMPN clinical expression.

Poster 108-D

The relative impact of treatment approaches on the outcome of catastrophic antiphospholipid syndrome (CAPS): Analysis of an updated database

Philip A. Haddad¹, Dalia Hammoud¹, Kevin Gallagher¹

¹LSU Health Sciences Center-Shreveport/Overton Brooks VA Medical Center, Shreveport, LA, USA

Background: CAPS is an aggressive form of antiphospholipid syndrome causing multi-organ thrombosis and failure. A treatment approach has been adopted which consisted of anticoagulation (AC), glucocorticoids (GC), plasma exchange (PEX) and/or intravenous immunoglobulins (IG). CAPS mortality rates remain high despite this approach. Several reports have demonstrated the primary and salvage activity of Rituximab (RTX) and Eculizumab (ECL). We conducted this analysis to provide an updated description of the impact of current treatment approaches on the CAPS outcomes.

Methods: We compiled a pooled CAPS database. Frequency tables, Chi-squared tests, and Fisher's exact tests were used to assess the effect of therapeutic approaches on the clinical outcomes.

Results: Our database consisted of 453 cases. Mortality rates for the following combinations were: 37% for ACGC, 20% for ACGCPEX, 27% for ACGCIG, 31% for ACGCPEXIG, 17% for ACGCPEXIGRTX, and 20% for ACGCPEXIGRTXECL. Mortality of all RTX-based combinations was 17% whereas that of ECL-based combinations was 6%. Compared to ACGC, ACGCPEX, RTX-based, and ECL-based combinations had lower mortality. When compared to ACGCPEX+/-IG, ECL-based combinations demonstrated significant lower mortality unlike RTX-based combinations. When mortality was analyzed separately by whether or not the combinations included PEX, IG, or GC, only those that included PEX had significant lower mortality as long as RTX and/or ECL were not included.

Conclusion: Early use of ECL and RTX improves CAPS mortality. We recommend a new CAPS frontline treatment approach consisting of ACGCECL+/-RTX+ therapies targeting the underlying medical condition.

Poster 109-A

A coronary artery calcium scan is essential to identify cardiovascular risk in asymptomatic firefighters

Elizabeth V. Ratchford¹, M. Dominique Ashen¹, Kathryn A. Carson²

¹Johns Hopkins University School of Medicine, Baltimore, USA, ²Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

Background: Myocardial infarction is the number one cause of death among US firefighters (FF). Through a comprehensive CVD prevention program (CVDPP), we attempted to identify at-risk FF.

Methods: Asymptomatic FF aged 40 years without known CVD or diabetes (N=487) were recruited from fire departments in 3 counties in Maryland. The CVDPP included evaluation of blood pressure, cholesterol, BMI, glucose, medications, and a coronary calcium scan. Comprehensive prevention recommendations were sent to their primary care/occupational health providers.

Results: Results indicated 191 (39%) of FF had coronary artery calcification (CAC). On univariable logistic regression, older age, male sex, hypertension, BMI, and glucose were significantly (p < 0.05) associated with higher likelihood of having CAC. Multiple logistic regression indicated older age, male gender, taking cholesterol or hypertension medications, and higher LDL cholesterol, BMI and glucose were significantly associated with higher likelihood of having CAC. Of those with CAC, 141 (74%) were not on lipid-lowering medication. In addition, 47 (94%) of those on medication had an LDL >70. A subset (n=100) was evaluated in more detail, including family history, diet, exercise, smoking, and Atherosclerotic CVD (ASCVD) risk score. In this subset, 30 (30%) had CAC. Among these 30, 28 (93%) had an ASCVD risk score < 7.5%. Thus, if we had solely used ASCVD scores to assess risk in this subset, we would have missed identifying and treating FF with subclinical atherosclerosis.

Conclusion: Overall results suggest that a CAC scan identifies FF at increased risk for CVD. A comprehensive CVDPP is an achievable approach to help reduce CVD risk in this high-risk population.

Poster 110-B

Safety and efficacy of drug coated balloon angioplasty for the treatment of peripheral arterial disease in patients with critical limb ischemia: A systematic review and meta-analysis

Stefanos Giannopoulos^1,2, Sheila Ghanian^1,2, Sahil Parikh³, Eric A. Secemsky⁴, Peter Schneider⁵, Ehrin J. Armstrong^1,2

¹Rocky Mountain Regional VA Medical Center, Aurora. CO, USA, ²University of Colorado, Denver, CO, USA, ³Columbia University Irving Medical Center, New York, NY, USA, ⁴Beth Israel Deaconess Medical Center, Boston, MA, USA, ⁵University of California at San Francisco, San Francisco, CA, USA

Background: Patients with chronic limb threatening ischemia (CTLI) often have complex multilevel disease peripheral artery disease. Drug coated balloons (DCB) may reduce restenosis compared to other endovascular approaches, but the safety and efficacy of DCB have not been studied systematically in patients with CTLI.

Methods: A meta-analysis of randomized trials and of observational studies was conducted with the use of random effects modeling. The incidence of adverse events during a follow up of 12 months and odds ratios (OR) between DCB vs. balloon angioplasty +/-stenting (POBA) were calculated. Longer-term outcomes were determined when possible. Outcomes were also stratified by FP vs. IP interventions.

Results: For fifteen studies the primary target lesion was at the femoropopliteal segment (N = 1,151) and for nine studies the treated lesions were infrapopliteal (N = 957). The average length of femoropopliteal lesions was 120.6mm (SD: 43.7mm) and of infrapopliteal lesions was 135.4mm (SD: 53.5mm). The overall (FP and IP lesions) 12-month all-cause mortality rate was 9% (19 studies; 6%-13%; I2=76.6%), while 5% (22 studies; 2%-8%; I2= 84.7%) of the patients underwent major amputation within 1 year after the procedure. During 12-month follow up 82% (76%-87%; I2= 73.7%) and 64% (58%-70%; I2= 40.2%) of the femoropopliteal and infrapopliteal lesions remained patent respectively. A sensitivity analysis including only the infrapopliteal lesions demonstrated no difference between DCB vs POBA in terms of primary patency, TLR, major amputation or mortality during a follow up period of 12 months. However, patients with infrapopliteal lesions undergoing DCB angioplasty did have a significantly lower risk for re-occlusion [DCB: 10% (N = 20/191), POBA: 25% (N = 47/187); OR: 0.38; 95% CI: 0.210.70; p=0.002]. Limited data were available on long-term follow up, including mortality after DCB angioplasty in CTLI. See Figure.

Conclusion: DCB angioplasty of femoropopliteal and infrapopliteal lesions in patients with CTLI results in acceptable 12-month patency rates, although comparative data have not shown a patency benefit for infrapopliteal lesions. The 12-month mortality rate of DCB vs. POBA was not significantly different, but studies with longer-term outcomes are necessary to determine any association between DCB use and mortality in patients with CTLI.

Poster 110-B Figure.

Poster 111-C

Active smoking is associated with decreased rates of wound healing after endovascular treatment of critical limb ischemia

Stefanos Giannopoulos^1,2, Damianos G. Kokkinidis^1,2, Moosa Haider³, Gagan D. Singh³, Eric A. Secemsky⁴, Jay S. Giri^5,6, Joshua A. Beckman⁷, Ehrin J. Armstrong^1,2

¹Rocky Mountain Regional VA Medical Center, Aurora, CO, USA, ²University of Colorado, Denver, CO, USA, ³Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, USA, ⁴Beth Israel Deaconess Medical Center, Boston, MA, USA, ⁵Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA, ⁶Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, USA, ⁷Department of Medicine-Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA

Background: Active smoking status is known to be associated with increased mortality and decreased amputation free survival in patients with peripheral artery disease (PAD). Previous studies have shown that smoking cessation is associated with improved wound healing in diabetic ulcers, but there are few data for the association between active smoking and wound healing in critical limb ischemia (CLI).

Methods: A single center observational study was conducted. Consecutive patients with CLI who underwent endovascular interventions were included. Smoking status was assessed at the time of the intervention comparing active to no active smoking at the time of the intervention and also during follow-up visits at six, nine and twelve months after the procedure. Cox and logistic regression analyses were conducted to compare the complete wound healing rates of the two groups during follow-up.

Results: In total, 264 patients (active smokers: n=41; not active smokers: n=223) and 553 lesions were included. Active smoking was associated with reduced rates of wound healing in the 6-month univariate cox regression analysis (HR: 4.54; 95% CI: 1.41 14.28; p = 0.012). The 6-month Kaplan Meier (KM) estimates for complete wound healing were 8.9% for the active smoking group vs 34% for the non-current smoking group. Active smoking was also associated with reduced rates of wound healing in the 9-month univariate (HR: 2.32; 95% CI: 1.11- 4.76; p = 0.026) and multivariate analysis (HR: 9.09; 95% CI: 1.06 100.0; p=0.044). The 9-month KM estimates for complete wound healing were 25% in the active smoking group vs 46% in the non-active smoking group. No difference was found between the two groups in 9-month major amputation rates. The time to complete wound healing was also longer in the active smoking group (269.7 ± 187.5 days vs. 208.3 ± 115.7 days; p=0.009). See Figure.

Conclusion: Active smoking status at the time of intervention in CLI patients is associated with higher rates of lack of wound healing during both 6- and 9-month follow-up. Active smoking was associated with on average a two-month delay in the median time to wound healing. These findings emphasize the importance of smoking cessation for patients with CLI.

Poster 111-C Figure.

Kaplan Meier Survival Analysis for Lack of Wound Healing.

Poster 113-A

Anticoagulation changes following major and clinically relevant nonmajor bleeding events

Thane Feldeisen¹, Constantina Alexandris-Souphis¹, Xiaowen Kong¹, Eva Kline-Rogers¹, Scott Kaatz², Mona Ali³, Jay Kozlowski⁴, James Froehlich¹, Geoff Barnes¹

¹Michigan Medicine, Frankel Cardiovascular Center, Ann Arbor, MI, USA, ²Henry Ford Hospital, Detroit, MI, USA, ³William Beaumont Hospital, Royal Oak, MI, USA, ⁴Huron Valley-Sinai Hospital, Commerce Township, MI, USA

Background: Bleeding events are common complications of anticoagulant drugs, including both warfarin and the direct oral anticoagulants (DOACs). Many patients elect to change anticoagulant or stop all therapy after experiencing a bleeding event. Differences in medication management between warfarin- and DOAC-treated patients following a bleeding event is unknown.

Methods: Patients from six anticoagulation clinics taking warfarin or DOAC therapy who experienced an ISTH-defined major or clinically relevant non-major (CRNM) bleeding event were identified between 2016 and 2018. The primary outcome was management of the anticoagulant following bleeding (discontinue, change drug class, restart same drug class). DOAC- and warfarin-treated patients were propensity matched based on the individual elements of the CHA2DS2-VASc and HAS-BLED scores as well as the severity of the bleeding event.

Results: Of the 573 patients on warfarin therapy and 382 on DOAC therapy who experienced a major or CRNM bleeding event, most patients continued some form of anticoagulation therapy (Table). Most warfarin (449, 81.3%) and DOAC patients (324, 85.7%) restarted their previous anticoagulation (p=0.14).

Conclusion: Following an anticoagulant-related bleeding event, most patients restarted anticoagulation therapy, most often with the same type of anticoagulant that they previously were taking.

Poster 113-A Table.

Matched Data (2:1 varied ratio matching) All Bleeding Events.

Poster 114-B

Effect of recent hospitalization or surgery on pulmonary embolism treatments and outcomes: A comparative analysis

Colby D. Shanafelt¹, Tyler Mehegan¹, Abby Pribish¹, Kevin Soriano¹, Andrew Dicks¹, Anuradha Godishala¹, Eric A. Secemsky¹, Brett Carroll¹

¹Beth Israel Deaconess Medical Center, Boston, MA, USA

Background: Pulmonary embolism (PE) is a leading cause of morbidity and mortality in the United States. Recent hospitalization or surgery is a major risk factor for development of PE, yet there is minimal data examining its effect on treatment and outcomes.

Methods: We conducted a retrospective review of institutional billing codes for in-patients with acute PE from August 2012-August 2018. Data was stratified based on whether patients had a recent major medical encounter (MME), defined as surgery or hospitalization within 90 days of admission for the acute PE. Clinical characteristics, treatments and outcomes were compared between groups.

Results: 2,063 patients were hospitalized for an acute PE; 633 (30.1%) had a recent MME. Patients with a recent MME were sicker based on Charlson Comorbidity Index, though PE severity was similar between groups. Patients with a recent MME were less likely to get systemic thrombolysis (1.4% vs. 3.4%; p=0.01) and were more likely to be readmitted within 30 and 90 days (22.7% vs 15.3% and 28.1% vs. 19.9%, respectively) (Figure). There were no statistically significant differences in use of other advanced therapies, IVC filter, major bleeding events, length of stay (LOS), in-hospital mortality (IHM) or recurrent venous thromboembolism within 90 days.

Conclusion: Despite being sicker, PE patients with a recent MME had similar IHM and LOS, but experienced higher readmission rates. Optimizing post-discharge care may be particularly important in the management of these patients.

Poster 114-B Figure.

Effect of Recent Hospitalization or Surgery on Pulmonary Embolism Treatments and Outcomes.

Poster 115-C

Frequency and outcomes of low to intermediate risk atrial fibrillation patients prescribed Warfarin or direct oral anticoagulants

Spencer A. Morgan¹, Brian Haymart², Xiaowen Kong², Mona Ali³, Jay Kozlowski⁴, Eva Kline-Rogers², Scott Kaatz⁵, James Froehlich², Geoff Barnes²

¹Michigan Medicine, Ann Arbor, MI, USA, ²Michigan Medicine, Frankel Cardiovascular Center, Ann Arbor, MI, USA, ³William Beaumont Hospital, Royal Oak, MI, USA, ⁴Huron Valley-Sinai Hospital, Commerce Township, MI, USA, ⁵Henry Ford Hospital, Detroit, MI, USA

Background: The CHA2DS2-VASc score estimates stroke risk to determine need for anticoagulation (AC) in atrial fibrillation (AF) patients. Those with 0-1 non-gender risk factors per CHA2DS2-VASc are considered low risk (0 non-gender risk factor) or intermediate risk (1 non-gender risk factor), with AC not strongly recommended.

Methods: From the Michigan Anticoagulation Quality Improvement Initiative registry, we identified warfarin-treated or DOAC-treated patients with AF and 0-1 non-gender risk factors. Rates of major, clinically-relevant non-major and non-major bleeding were reported. Chi-squared tests were used to test the association between warfarin versus DOACs; clinical variables included age, gender, comorbidities, concurrent medications and HAS-BLED score.

Results: Among 4227 AF patients between 2011-2019, 585 (13.8%) AF pts had 0-1 non-gender risk factors. As shown in the Table, HAS-BLED scores were higher among warfarin patients (p < 0.01). Major bleeding was more common among warfarin-treated patients (p < 0.001), while DOAC-treated patients experienced more clinically-relevant non-major and non-major bleeding (p < 0.001).

Conclusion: Many AF patients in this cohort are at lower risk for stroke and may not meet guideline recommendations for anticoagulation. In these patients, the severity of bleeding varied based upon on the anticoagulant class given. Efforts to reduce overuse of anticoagulation in low-risk AF patients are warranted.

Poster 115-C Table.

Comparison of demographics and outcomes of low and intermediate risk AF patients treated with warfarin.

Poster 116-D

Arterial dissections in pregnancy: A nationwide cohort study

Andrew Dicks¹, Sebastian Beyer¹, Eric Secemsky¹, Brett Carroll¹

¹Beth Israel Deaconess Medical Center, Boston, MA, USA

Background: Pregnancy is a known risk factor for cardiovascular events, including arterial dissection, and can cause significant morbidity and mortality in the peripartum period. However, little is known about the risk factors, distribution, timing, and outcomes of arterial dissections in pregnancy.

Methods: The study analyzed all female patients aged 15-50 with hospitalizations associated with pregnancy and/or delivery in the Nationwide Readmissions Database between 2010-15. The primary outcome was any incident arterial dissection during pregnancy, delivery, or postpartum periods. Secondary outcomes included location of dissection, timing of dissection, and in-hospital mortality.

Results: Among 4,138,496 pregnant patients, 220 (0.005%) patients were diagnosed with a new dissection during the antepartum or postpartum period. Risk factors included older age (33 vs. 28 years), chronic hypertension (20.5% vs. 2.4%), pre-eclampsia or eclampsia (27.7% vs. 5.5%), lipid disorder (5.5% vs. 0.2%), and tobacco use (18.6% vs. 7.7%). Of the 220 patients with dissection, 61 (27.7%) dissections occurred during pregnancy, 62 (28.2%) were diagnosed during admission for delivery, and 97 (44.1%) were diagnosed in the postpartum period. The majority of postpartum dissections occurred within 30-days after delivery (see Figure). The most common locations for dissections were coronary (33.6%), vertebral (30%), aortic (22.2%), and carotid (14.5%). In-hospital mortality was less than 4.5% for all dissections, with the highest mortality rate associated with aortic dissections.

Conclusion: Arterial dissections are a rare complication of pregnancy, which occur throughout peripartum period, but most commonly postpartum. CV risk factors are more common among those that develop a dissection.

Poster 116-D Figure.

Timing of postpartum readmissions associated with new dissections. Most dissections occurred within 30 days after delivery. Vertebral and coronary dissections were the most common new dissections in the postpartum period.

Poster 117-A

Comparison of atherosclerotic burden in non- lower extremity vasculature in patients with and without peripheral artery disease using 18F- sodium fluoride imaging

Chaitanya S. Rojulpote¹, Shivaraj Patil², Karthik Gonuguntla², Pranav Karambelkar¹, Abhijit Bhattaru¹, Shadi Asadollahi¹, Thomas Werner¹, Poul Hoilund-Carlsen³, Abass Alavi¹

¹University of Pennsylvania, Philadelphia, PA, USA, ²University of Connecticut, Storrs, CT, USA, ³Odense University Hospital, Odense, Denmark

Background: Atherosclerosis is the most common cause of peripheral artery disease (PAD). We sought to compare the atherosclerotic burden in non-lower extremity arteries in patients with and without PAD using NaF-PET/CT.

Methods: We identified 5 individuals (61.8±6.6 years, 1 male, 4 females) with PAD and matched them to 5 individuals without PAD based on age and gender from the unfavorable cardiovascular risk profile group of the CAMONA trial (60±7.2 years, 1, male, 4 females). These individuals underwent PET/CT imaging 90 minutes after the injection of NaF (2.2Mbq/Kg). A uniform and standardized protocol was followed for image acquisition. The NaF uptake was measured by a trained physician by manually defining regions of interest on each axial slice and the following arteries were examined: coronary artery (CA), carotid artery (CR), ascending aorta (AS), arch of aorta (AR), descending aorta (DA), and abdominal aorta (AA). The average SUVmean (aSUVmean) was calculated for each arterial segment. Paired t-test was used for statistical analysis.

Results: The total aSUVmean was higher in the PAD group compared to the non-PAD group (6.54±0.9 vs. 5.03±0.45, p=0.01). Comparison of arterial segments revealed higher NaF uptake in CR, AS, AR, and DA in the PAD group compared to the non-PAD group (0.93±0.25 vs. 0.54±0.14, p=0.01; 1.28±0.20 vs. 0.86±1.19, p < 0.01; 1.18±0.17 vs. 0.90±0.19, p=0.03; 1.32±0.24 vs. 0.91±0.15, p=0.01). The NaF uptake in CA and AA was similar between the two groups (0.77±0.04 vs. 0.71±0.05, p=0.11; 1.07±0.28 vs. 1.12±0.30, p=0.82).

Conclusion: In our study, individuals with PAD had higher atherosclerotic burden in the carotid arteries and thoracic aorta, however a similar difference was not observed in the coronary arteries and abdominal aorta.

Poster 118-B

Length of treatment in provoked VTE patients

Mara Carrigan¹, Brian Haymart², Xiaowen Kong², Mona Ali³, Scott Kaatz⁴, Shah Vinay⁴, James Froehlich², Geoff Barnes²

¹University of Kansas, Lawrence, KS, USA, ²Michigan Medicine, Frankel Cardiovascular Center, Ann Arbor, MI, USA, ³William Beaumont Hospital, Royal Oak, MI, USA, ⁴Henry Ford Hospital, Detroit, MI, USA

Background: Guidelines recommend only 3 months of anticoagulation for most patients with provoked venous thromboembolism (VTE). We aimed to compare length of treatment (LOT) in patients with provoked VTE treated with either warfarin or a direct oral anticoagulant (DOAC).

Methods: Patients with provoked VTE were identified from the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry. Patients with additional indications for anticoagulation or who were being treatment for upper extremity VTE were excluded. LOT of 3 months was defined as 80 to 120 days. Logistic regression was used to evaluate predictors of extended treatment.

Results: A total of 578 warfarin and 228 DOAC patients with provoked VTE were identified (Table). Warfarin-treated patients more often had prior VTE (19% vs. 6.6%, p < 0.001) and antiplatelet use (31.7% vs. 23.7%, p < 0.03). The prevalence of cancer was similar in both groups. The median LOT was longer for DOAC-treated patients (180 vs 133 days, p < 0.0001). In both groups, few patients received only ~3 months of anticoagulation (both 120 days (71.1% vs. 51.6%, p < 0.001) and warfarin-treated patients more likely to receive < 80 days (28.0% vs 4.8%, p < 0.001). DOAC use (OR 2.53, 95% CI: 1.81-3.55) and prior VTE (OR 1.83, 95% CI: 1.22-2.75) predicted extended treatment after adjusting for gender, antiplatelet use, and cancer.

Conclusion: Most patients with provoked VTE, regardless of anticoagulant, received more than 3 months of anticoagulation. Treatment courses were longer for DOAC-treated patients versus warfarin-treated patients. It is unclear how low-dose DOAC therapies or patient risk factors may have influenced LOT decision-making.

Poster 118-B Table.

Patient Characteristics and Length of Treatment.

Poster 119-C

Venous thromboembolism incidence and management following meningioma resection

Samantha M. Rizzo¹, Sherwin Tavakol¹, Wenya Linda Bi¹, Umberto Campia¹, Alec Schmaier²

¹Brigham and Women's Hospital, Boston, MA, USA, ²Beth Israel Deaconess Medical Center, Boston, MA, USA

Background: Meningioma resection is associated with enhanced venous thromboembolism (VTE) risk. Optimal prophylaxis and management are not well established.

Methods: We retrospectively evaluated post-operative VTE incidence, management, and outcomes in meningioma patients treated in a single institution.

Results: Our registry included 902 meningioma patients. Of them, 80 (8.9%) had post-operative VTE: 47 (5.2%) had deep venous thrombosis (DVT) alone, 20 (2.2%) had DVT and pulmonary embolism (PE), and 13 (1.4%) had PE alone. Inpatient pharmacologic VTE prophylaxis was associated with a significant reduction in the incidence of symptomatic VTE (5.0% treated patients vs. 8.8% untreated, p < 0.05). Of all patients with VTE, 59 (74%) received therapeutic anticoagulation, either as first treatment (25, 42%), or after receiving prophylactic dose first for an average of 25.2 ± 15.8 days (34, 58%). Warfarin (51%) and apixaban (34%) were the most frequently prescribed drugs. Additionally, 8 (10%) received prophylactic anticoagulation only, 13 (16%) received no anticoagulation, and 38 (48%) received inferior vena cava filters. Two major bleeding events occurred: 1 on prophylactic and 1 on therapeutic anticoagulation. One patient died from PE. A multivariate model found the following predictors of VTE: age (OR=1.42, p=0.009), non-white race (OR=2.90, p=0.029), obesity (OR=1.90, p=0.050), history of VTE (OR=3.19, p=0.026), and inpatient pharmacologic prophylaxis (OR=0.38, p=0.006).

Conclusion: VTE was common following meningioma surgery. Pharmacologic prophylaxis significantly reduced symptomatic VTE incidence compared with observation. Delayed full anticoagulation was safe and bleeding events were uncommon.

Poster 120-D

Aspirin-free strategy versus standard term dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: A meta-analysis of randomized controlled trials

Mohammad Saud Khan^1,2, Abdelmoniem Moustafa^1,2, Abdullah Zoheb Azhar³, Abdur Rahman Khan^4,5, Sohail Ikram⁶

¹The Miriam Hospital, Providence, RI, USA, ²Warren Alpert School of Brown University, Providence, RI, USA, ³Metropolitan Hospital Center, New York, NY, USA, ⁴Massachusetts General Hospital, Boston, MA, USA, ⁵Harvard Medical School, Boston, MA, USA, ⁶University of Louisville School of Medicine, Louisville, KY, USA

Background: Dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y12 inhibitor is the standard treatment in patients undergoing percutaneous coronary intervention (PCI). However, optimal duration of DAPT continues to be a matter of debate. Recently, a short duration of DAPT (1 to 3 months) followed by single antiplatelet therapy with P2Y12 inhibitor (aspirin free strategy) has been suggested. We performed a meta-analysis of available randomized controlled trials (RCTs) to compare the aspirin free strategy with standard term DAPT in patients undergoing PCI.

Methods: Pubmed, Embase and Cochrane Central databases were searched for RCTs reporting outcomes on short term DAPT followed by P2Y12 monotherapy compared to standard term DAPT in patients undergoing PCI. The primary outcome of interest was major bleeding defined by Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding. Secondary outcomes of interest were myocardial infarction (MI), stent thrombosis (definite or probable), ischemic stroke, all-cause mortality and cardiovascular mortality. Outcomes were analysed at 12 months follow up period. A random effects model meta-analysis was performed to pool risk ratios for the outcomes.

Results: There was significant reduction in major bleeding in aspirin free strategy group compared to standard term DAPT group (RR: 0.61; 95%CI: 0.38-0.95; P=0.03) at 12 months follow up. No significant difference was identified for rest of the outcomes of MI (RR: 1.06; 95%CI: 0.90-1.25; P=0.46), ischemic stroke (RR: 1.16; 95%CI: 0.66-2.04; P=0.60), stent thrombosis (RR: 1.16; 95%CI: 0.79-1.70; P=0.46), all-cause mortality (RR: 0.87; 95%CI: 0.71-1.06; P=0.16) and cardiovascular mortality (RR: 0.76; 95%CI: 0.52-1.11; P=0.15) between the two groups (Figure).

Conclusion: Aspirin-free strategy is associated with less incidence of major bleeding with no significant difference in MI, ischemic stroke, stent thrombosis, all-cause mortality and cardiac mortality compared to standard term DAPT in patients undergoing PCI.

Poster 120-D Figure.

Forest plot comparing aspirin-free strategy and standard term dual antiplatelet therapy for the included outcomes.

Poster 121-A

Intravascular lithotripsy for treatment of severely calcified mesenteric stenosis

Mohammad Saud Khan^1,2, Muhammad Baig^1,2, Omar N. Hyder^1,2, Herbert Aronow², Peter A. Soukas²

¹The Miriam Hospital, Providence, RI, USA, ²Warren Alpert School of Brown University, Providence, RI, USA

Background: Severe vascular calcification increases complexity of percutaneous transluminal angioplasty and is associated with worse outcomes. Intravascular lithotripsy (IVL) is an emerging approach for modification of calcified plaques. Recently, the technology of IVL has been successfully utilized for modification of calcified plaques in coronary and lower extremity peripheral vascular disease with promising results. However, reports of IVL use in mesenteric vasculature is missing.

Methods: We report 2 cases of IVL use in calcific mesenteric stenosis, one in de-novo superior mesenteric artery (SMA) calcified stenosis and another in celiac artery in-stent restenosis (ISR).

Results: Case of IVL in De-novo Stenosis: A 73-year-old female with known history of mesenteric ischemia s/p stent placement in SMA (8 months prior) presented with symptoms of post prandial abdominal pain, episodes of non-bloody vomiting, decreased appetite and weight loss for past 3 months. A duplex ultrasound showed significantly elevated velocities in SMA. Selective mesenteric angiography and intravascular ultrasound showed severe concentric calcification and high-grade stenosis of proximal to mid SMA with patent previously placed SMA stent. A 5 X 60 mm shockwave lithotripsy balloon was then used to deliver 300 pulses followed by drug eluting stent placement. Repeat angiography demonstrated excellent results with less than 10% residual stenosis and no evidence of dissection or contrast extravasation (Figure). Case of IVL in In-Stent Restenosis: A 65-year-old female patient presented with recurrent post prandial pain with decreased appetite. Six months prior, she was diagnosed with mesenteric ischemia for which she underwent bare metal stent placement in celiac artery. A duplex ultrasound done showed severe restenosis of celiac stents. Selective celiac angiography was performed which revealed 90% ISR of celiac stent. In addition, celiac stent was noted to be under expanded in its midportion secondary to deep wall calcification. IVL of the celiac ISR was performed using a 6 X 60mm lithotripsy balloon with administration of 300 pulses. The previously under dilated and under expanded stent was now fully expanded and opposed to the artery. A PTFE balloon expandable covered stent was placed. Repeat angiography demonstrated an excellent result with less than 10% residual stenosis and no evidence of contrast extravasation, dissection or embolization (Figure).

Conclusion: IVL was successfully used in reducing severely calcified de-novo and in-stent restenosis without any complications in mesenteric vascular disease.

Poster 121-A Figure.

(A) Preprocedural angiography showing severe de-novo stenosis of proximal to mid superior mesenteric artery. (B) Treatment of superior mesenteric artery stenosis with shockwave intravascular lithotripsy system. (C) Post treatment angiography showing resolution of stenosis. (D) Preprocedural angiography showing severe in-stent restenosis of previously placed celiac stent along with under expansion in its midportion. (E) Treatment of celiac in-stent restenosis with shockwave intravascular lithotripsy system. (F) Post treatment angiography showing resolution of stenosis and full expansion of previously placed celiac stent.

Poster 122-B

Mesenteric artery dissection and/or inflammation

Nedaa Skeik¹, Jenna Smith², Sydney Olson², Meagan Nowariak², Jesse Manunga^2,3, Jessica Titus^2,3, Senthil Jayarajan^2,3, Aleem Mirza^2,3, Tim Sullivan^2,3

¹Vascular Medicine, Minneapolis Heart Institute, Minneapolis, MN, USA, ²Research, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA, ³Vascular Surgery, Minneapolis Heart Institute, Minneapolis, MN, USA

Background: Mesenteric artery dissection (MAD) and/or wall thickening (MWT) are uncommon with scant literature yet may have great clinical significance. Herein, we present our experience diagnosing and managing these rare arteriopathies.

Methods: From a single center retrospective database, we reviewed 1682 patients who presented with mesenteric artery (celiac, superior [SMA] and/or inferior mesenteric [IMA]) dissection (D) and/or wall thickening (WT) from Jan 2000 to Mar 2017.

Results: Average age of the 97 included patients was 55 ± 14 years, mostly men (63%). There were 18 celiac D (19%), 8 celiac WT (8%), 15 celiac D+WT (16%), 14 SMA D (14%), 7 SMA WT (7%), 7 SMA D+WT (7%), 1 IMA D (1%), 2 IMA WT (2%) and 25 with multiple arterial involvement (26%). Based on most supported diagnostic criteria, primary etiologies were segmental arterial mediolysis (SAM) (n = 16), isolated dissection (n = 16), localized vasculitis of the gastrointestinal tract (LVGT) (n = 16), extension of thoracoabdominal aortic dissection (AD) (n = 12), trauma (n = 12) and fibromuscular dysplasia (FMD) (n = 11). Most (71%) patients presented with abdominal pain, though 20% were asymptomatic. Hypertension (55%), hyperlipidemia (32%) and tobacco use (31%) were prevalent. CT angiogram was the most frequently used imaging (90%). Management included conservative (observation) (24%), medical (44%), endovascular (20%) and open repair (12%) with high survival (98%) and symptom relief (73%). Of those medically or conservatively managed, 91% had stable or improved imaging at follow-up.

Conclusion: MAD and MWT are rare and can be caused by various etiologies. Most patients improved with a conservative, medical, endovascular and/or surgical approach. Our project provides guidance for diagnosis and management of various mesenteric arteriopathies.

Poster 123-C

Safety and efficacy of dual versus triple anti-thrombotic therapy in patient with atrial fibrillation undergoing percutaneous coronary intervention: Meta-analysis

Abdelmoniem Moustafa^1,2, Mohammad Khan¹, Marwan Saad¹

¹The Miriam Hospital, Providence, RI, USA, ²Warren Alpert School of Brown University, Providence, RI, USA

Background: Patients with atrial fibrillation undergoing percutaneous coronary intervention have indications for oral anticoagulation and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor. The concurrent use of all three agents, termed triple oral antithrombotic therapy (TAT), increases the risk of bleeding. A number of prospective trials showed that omission of aspirin mitigates the risk of bleeding without affecting major adverse cardiovascular event (MACE).

ethods: The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to October 2019. Relevant randomized control trials comparing dual anti-thrombotic therapy (DAT) versus TAT were identified and a metanalysis was performed using random effect model. The safety endpoints of interest were thrombolysis in myocardial infarction criteria (TIMI) major and minor bleeding, TIMI major bleeding and intracranial bleeding. The efficacy endpoints of interest were major adverse cardiovascular events (MACE) and individual components of MACE.

Results: Six trials with 11722 patients were included. For safety endpoint, DAT was associated with significantly lower incidence of TIMI major and minor bleeding [RR: 0.58, 95% CI 0.44-0.77, p=0.0001], TIMI Major bleeding [RR: 0.55, 95% CI 0.42-0.73, p < 0.0001] as well as intracranial bleeding [RR: 0.35, 95% CI 0.16-0.73, p=0.006] compared with TAT. No significant difference was observed for MACE [RR: 0.95 (0.77-1.17) p=0.62] or any of the individual component of MACE between the two groups. See Figure.

Conclusion: Omission of aspirin from TAT in patient with AF after PCI is associated with lower risk of bleeding without compromising the efficacy in terms of mortality and cardiovascular thrombotic events.

Poster 123-C Figure.

Forest plot for safety and efficacy endpoints combined.

Poster 124-D

Comparing acute pulmonary embolism care between black and white patients: Experience of a multi-hospital academic medical center

Carlos E. Barbery¹, Tara Holder², Alexander E. Sullivan¹, Cindy Green¹, Manesh R. Patel¹, Kevin L. Thomas¹, William S. Jones¹

¹Duke University Medical Center, Durham, NC, USA, ²Vanderbilt University Medical Center, Nashville, TN, USA

Background: Studies suggest that black patients have inferior medical outcomes compared to white patients. Acute pulmonary embolism (PE) is an increasingly important cause of morbidity and mortality in modern medicine. We describe the differences in presentation and management of acute PE between black and white patients at a multi-hospital academic medical center.

Methods: All PE presentations from January 1, 2016 to June 30, 2017 were retrospectively identified using ICD-10 codes. Data was abstracted by manual chart review for all image-confirmed PEs.

Results: A cohort of 782 patients with acute PE was identified, of which 319 were black and 463 were white. Black and white patients had comparable rates of intermediate high risk (21.9% v 17.9%) and high risk (6.6% v 6.3%) PE and similar laboratory and imaging utilization. Black patients had higher BMI (32.1 v 30.3, p=0.017), were younger (60.3 y.o v 64.6 y.o, p=0.001), and were more likely to have a history of heart failure (16.0% v 7.1%, p < 0.001), while white patients had higher rates of malignancy (46.9% v 34.5%, p=0.001) and recent surgery (29.6% v 18.2%, p < 0.001). Black patients were more likely to receive systemic thrombolysis (18.2% v 6.1%, p=0.026), while white patients had a nonsignificant trend toward surgical embolectomy (1.8% v 6.1%, p=0.401). There was no difference in inpatient mortality, but black patients had longer hospital length of stay (7.6 v 6.7, p=0.024).

Conclusion: Black patients less often had traditional risk factors compared to white patients yet had similarly severe PEs. The trend towards systemic thrombolysis in black patients over other interventions may signal delayed diagnosis and subsequent rescue therapy and should be further examined.

Poster 125-A

Reasons and associated outcomes in delayed anticoagulation in venous thromboembolism

Nichole E. Brunton¹, Waldemar Wysokinski², David Hodge², Danielle Vlazny², Damon E. Houghton², Ana Casanegra²

¹Danbury Hospital, Danbury, CT, USA, ²Mayo Clinic, Rochester, MN, USA

Background: Delayed initiation of anticoagulation for acute venous thromboembolism (VTE) is associated with risk of thrombus propagation, embolization and death. Identifying barriers to therapy initiation represents an important step to improve safety and outcomes.

Methods: Consecutive patients enrolled in the Mayo Clinic VTE Registry between March 2013 and November 2019 with acute VTE were followed prospectively. Outcomes at 90 days were assessed in person, by mailed questionnaire, or scripted phone interview.

Results: Of 2355 patients enrolled, 92 (3.9%) experienced anticoagulation delay (AD) of >24h with mean delay of 7.6 days. These patients were more likely to have thrombosis of atypical location (38% vs. 9.7%, p < 0.001) or provoked event related to cancer. Most AD causes were preventable; the most frequent being delay for expert opinion. Additional delays occurred due to proximity to procedure, bleeding and thrombocytopenia (Table). At follow-up, AD patients had increased VTE recurrence (5.8% vs 1.7%, p=0.006) and clinically relevant non-major bleeding (7.0% vs 2.9%, p=0.03) compared to patients receiving anticoagulation within 24 hours. No difference in mortality or major bleeding was found. Findings remained consistent after adjusting for age and cancer.

Conclusion: AD was associated with worse clinical outcomes. While uncommon in our practice, preventable delays exist and prompt further discussion for care improvement.

Poster 125-A Table.

Reasons for delay of anticoagulation initiation.

Poster 126-B

Higher admission rates and in-hospital mortality for acute type A aortic dissection during Influenza season: A single center experience

Anna Conlon¹, Carmel Ashur², Marion Hofmann Bowman², Karen Kim², Himanshu Patel², Kim Eagle², Bo Yang²

¹University of Michigan, Ann Arbor, MI, USA, ²Michigan Medicine, Ann Arbor, MI, USA

Background: Increased incidence of type A aortic dissection (ATAAD) during winter months has been shown to be independent of climate and temperature. This association may be partially explained by an increase in flu activity during the winter months.

Methods: Monthly admissions for ATAAD at the University of Michigan were extracted from the University of Michigan Cardiac Surgery Data Warehouse and surveillance data on lab confirmed cases of influenza from the University of Michigan Infectious Disease department (UMID) were obtained. Michigan-specific influenza trends from 2009-2019 were obtained from the Center for Disease Control and Prevention (CDC) website, including data from the Influenza-like Illness Surveillance Network (ILI-net). Months were categorized as High influenza activity if the monthly average ILI, IHSP or UMID was above the corresponding yearly average and otherwise categorized as low influenza activity. Multivariable linear regression models were used to compare ATAAD rates in High influenza activity months vs. low influenza activity months and to assess associations between monthly average flu rates and monthly ATAAD, while controlling for average monthly temperature.

Results: From October 2009 to April 2019, 433 patients were admitted with ATAAD. There was a significant association between influenza activity and ATAAD, with 4.81 [95% CI 4.19-5.43] ATAADs occurring during high influenza activity months and 3.47 [95% CI: 3.00-3.93] occurring during low influenza activity months (p < 0.001). This association remained significant after adjusting for monthly temperature, with an estimated increase of 1.25 (95% CI: 0.19-2.30, p=0.021) ATAADs in high influenza activity months compared to low influenza activity months (see Figure). When comparing ATAAD rates with each individual marker of flu activity, significantly higher monthly admission rates for ATAAD occurred during months with high rates of ILI (p=0.015), but no significant association was found between ATAAD and IHSP influenza rates (p=0.051) or UMID influenza rates (p=0.090). There was a positive, but non-significant increasing trend in ATAADs with increasing lab confirmed flu cases (p=0.14). Significantly higher in-hospital mortality and 30-day mortality occurred in patients presenting during high influenza activity months vs. low influenza activity months, with In-hospital mortality rates of 5.79% vs. 10.99%, respectively (p=0.024) and 30-day mortality rates of 5.44% vs. 9.68, respectively (p=0.048).

Conclusion: We demonstrate a positive association between regional influenza activity and admission rates for ATAAD that is independent of temperature, suggesting that influenza infection could be a triggering event in ATAAD. If so, quality improvement projects to increase influenza vaccination rates are needed, as this rate is lower in patients with thoracic aortic aneurysms compared to other cardiovascular diseases (data not shown).

Poster 126-B Figure.

Monthly Aortic Dissection Rate by Influenza activity. Dark gray = high flu activity months (n = 202). Light gray = low flu activity months (n = 253).

Poster 127-C

Fact or fiction: Electrocardiographic findings associated with right ventricular dysfunction in patients with acute pulmonary embolism

Alexander E. Sullivan¹, Tara Holder², Manesh R. Patel¹, Terry Fortin¹, William S. Jones¹

¹Duke University Medical Center, Durham, NC, USA, ²Vanderbilt University Medical Center, Nashville, TN, USA

Background: New electrocardiographic (ECG) findings- S1Q3T3, ST-elevation (STE) in aVR with and without ST-depression (STD) in V4-V6, isolated STD in V4-V6, and right bundle branch block (RBBB)- have been described in association with acute pulmonary embolism (PE) and new right ventricular dysfunction (RVD). We examined this association in a large, retrospective cohort of consecutive patients with acute PE at a multi-hospital academic center.

Methods: Patients with ICD-10 codes for acute PE from January 1, 2016 to June 30, 2017 were identified and included if imaging-confirmed acute PE was diagnosed during index hospitalization. Two physicians blinded from other patient information reviewed ECGs completed within 24 hours of PE diagnosis and coded ECG findings.

Results: A cohort of 472 patients with acute PE and both ECGs and echocardiographic assessment of the RV was identified. Evidence of RVD was present in 227 (48.1%) patients while new S1Q3T3 was seen in 45 (9.5%) patients, STE in aVR in 32 (6.8%) patients, STD in V4-V6 in 19 (4.0%) patients, STE in aVR with STD in V4-V6 in 12 (2.5%) patients, RBBB in 18 (3.8%) patients (Table). Overall incidence of proximal PE on CT was low with rates ranging from 38.9%-58.3% amongst patients with these ECG findings. All five ECG findings had poor sensitivity for RVD but new S1Q3T3 had the strongest positive likelihood ratio (4.99, 2.38-10.49) for RVD.

Conclusion: Classic ECG findings are uncommon in patients with acute PE and are insensitive for RVD. While new S1Q3T3 had the highest likelihood ratio for RVD, ECGs should not be used to screen for RVD and have low clinical utility compared to modern echocardiography.

Poster 127-C Table.

Associations Between ECG findings and Right Ventricular Dysfunction.

Poster 128-D

The value of platelet-to-lymphocyte ratio in predicting deep venous thrombosis among adult patients who underwent venous duplex study in a tertiary medical center

Marion D. Lagmay¹, Jonathan James G. Bernado¹, Renelene Macabeo¹, Richard Henry Tiongco, II¹

¹St. Luke's Medical Center - Global City, Taguig City, Metro Manila, Philippines

Background: Thrombotic disorders are pro-inflammatory as much as they are hemostatic. The platelet-to-lymphocyte ratio (PLR) is a novel marker that integrates hemostasis and inflammation and is a more stable parameter than the individual parameters alone. The study aims to determine the association of PLR and the presence of acute-subacute, lower extremity DVT among adult patients.

Methods: This was a cross-sectional study utilizing chart review including adult patients who underwent venous duplex study from July 2015 to June 2019 in a tertiary medical center. PLR was calculated based on a CBC done within 24 hours of the venous duplex scan. PLR values of >149 was considered positive for DVT.

Results: 179 were included for the DVT group and 1106 were included for those without DVT. 33% of patients with DVT had a PLR value of >149 vs 25% of those patients without DVT (p-value 0.02). The probability that the PLR 149 when the patient has DVT is 33% while the probability that a patient will not have DVT given that the PLR is < 149 was 75.2%. The PPV of having DVT given that a patient had a PLR of 149 was almost 18% and the NPV was 87.4%. See Table.

Conclusion: This study demonstrated that an elevated PLR is associated with DVT. Further studies are needed to validate the use of PLR for its use in screening for lower extremity DVT.

Poster 128-D Table.

Association of PLR to DVT.

Poster 129-A

Prevalence of thoracic outlet syndrome and thrombus resolution in patients with primary upper extremity deep vein thrombosis: A phlebographic study

Alejandro D. Godoy¹, Romina Montivero¹, Aldo Tabares¹

¹Hospital Privado Universitario De Cordoba, Cordoba, Argentina

Background: Upper extremity deep vein thrombosis (UEDVT) accounts for 3-5 % of all cases of DVT. Most UEDVT cases are secondary to central vein cannulation or cancer, whereas the remaining cases are considered primary or spontaneous. Thoracic Outlet Syndrome (TOS) is considered a contributing factor in some primary UEDVT. We studied the prevalence of TOS and thrombus resolution by functional venography in a cohort of patients with primary UEDVT

Methods: A retrospective study was conducted at the Hospital Privado Cordoba, Argentina from January 1 2008 to 31 December 2019. UEDVT patients were identified by searching the radiology databases. A positive result for TOS was considered when vein compression was present at 90 degrees abduction or less

Results: A total of 334 upper limb venograms were performed; 294 were excluded: 5 negative venograms, 3 Arterio-venous malformations, 36 catheter placement, 250 AVF for hemodialysis A total of 40 patients with primary UEDVT were evaluated, 28 (70%) patients were women with a median age of 38 years. A venographic diagnosis of TOS was present in 29 (72.5 %) patients. Among patients with TOS-positive, 14 (35%) received oral contraceptives as compared with 0 patients in TOS-negative p = 0.04, 8 (20%)TOS- positive patients had thrombophilia and 1 (2.5%) TOS-negative p = 0.39 Follow up venography showed complete recanalization 17/32 (52%);complete recanalization was present in 12 (37.5%) of the TOS-positive patients and 5 (16%) of TOS-negative p = 1.

Conclusion: In the cohort of patients with unprovoked UEDVT studied, a high prevalence of TOS was found. TOS in conjunction with oral contraceptives and thrombophilia might precipitate UEDVT. Following anticoagulant therapy, complete recanalization occurs in approximately 50% of patients.

Poster 130-B

Atrial fibrillation and adverse clinical outcomes in acute aortic syndromes

Samantha M. Rizzo¹, Julia E. Snyder¹, Ruth Morrison¹, Amita Patel¹, Alec Schmaier², Gregory Piazza¹, Samuel Z. Goldhaber¹, Umberto Campia¹

¹Brigham and Women's Hospital, Boston, MA, USA, ²Beth Israel Deaconess Medical Center, Boston, MA, USA

Background: Atrial fibrillation (AF) has been described as a surrogate marker for adverse clinical outcomes. Using our Acute Aortic Syndromes (AAS) database, we assessed the prevalence of AF in patients with AAS and evaluated its impact on stroke and in-hospital mortality.

Methods: We retrospectively evaluated patients with AAS at a single tertiary care center. We identified patients with AF on presenting electrocardiogram.

Results: Our database included 260 patients with AAS from January 2015 to January 2020: 125 (48%) Stanford Type A and 135 (52%) Type B. Twenty-seven (10.4%) patients presented with AF: 12 (9.6%) had Type A AAS and 15 (11.1%) had Type B. Four (33.3%) Type A patients with AF experienced stroke as a complication of AAS compared to 17 (15.0%) Type A patients without AF. Type A patients with AF had a higher in-hospital mortality rate than Type A patients without AF (66.7% vs. 17.7%, p=0.0001). In Type B patients with AF, none suffered a stroke during hospitalization, but 11 (9.2%) Type B patients without AF experienced stroke. Three (20.0%) Type B patients with AF died in-hospital, compared to 11 (9.2%) Type B patients without AF (see Figure).

Conclusion: In Type A AAS patients, AF was associated with higher rates of in-hospital mortality. Type B AAS patients with AF did not have a significantly higher rate of in-hospital mortality and had a lower absolute number of strokes compared with Type B patients without AF. The unexpected finding of no strokes with AF in Type B AAS may be related to the low number of events in our cohort or it may describe an AF paradox in this population. Further study is needed to confirm our findings.

Poster 130-B Figure.

Stroke and In-Hospital Mortality in Acute Aortic Syndromes Patients with and without Atrial Fibrillation.

Poster 131-C

Pulmonary artery elastance: A useful risk stratification tool for patients with acute pulmonary embolism

Hayaan Kamran¹, Jean-Pierre Iskandar¹, Gustavo Heresei¹, Marcelo Gomes¹, John Bartholomew¹, Serge Harb¹, Joseph M Delehanty², Scott J. Cameron¹

¹Cleveland Clinic, Cleveland, OH, USA, ²University of Rochester, Rochester, NY, USA

Background: We previously reported that risk stratification tools including the Pulmonary Embolism Severity Index (PESI) can under-estimate short-term patient mortality in the context of right ventricular (RV) dysfunction caused by acute pulmonary embolism (PE). We hypothesized that echocardiographic assessment of RV and pulmonary artery (PA) mismatch at the time of presentation may predict clinical decompensation in high risk PE.

Methods: We analyzed the last random 80 patients presenting to our hospital with high risk acute PE. Patient clinical variables were examined in the context of the PESI score which does not account for RV dysfunction and the BOVA score which does. Echocardiographic assessment of pulmonary artery elastance (PAE) was determined from PA systolic pressure (PASP), Stroke Volume (SV) and adjusted to tricuspid annular plane systolic excursion (TAPSE) for each patient.

Results: 38 patients with acute PE had complete variables of which 24 received only anticoagulation (AC) and 14 required advanced therapeutics (AT) including systemic/catheter-assisted thrombolysis/surgical embolectomy. PESI and BOVA scores between AT vs. AC patients were: 118 ± 11 vs. 105 ± 9, p=0.34 and 3.6 ± 0.5 and 3.7 ± 0.5, P=0.91, respectively. PAE was elevated in patients who became sicker and required AT vs. AC alone (1.5 ± 0.2 vs. 0.9 ± 0.2 mmHg.mL-1, p=0.022). Normalized to TAPSE, a similar observation was made for AI vs AC (1.1 ± 0.2 vs 0.7 ± 0.2 mmHg.mL-1/cm, p=0.023). See Figure.

Conclusion: Noninvasive assessment of pulmonary artery elastance may be a better early marker predicting sicker patients with acute PE in whom the PESI score or BOVA score may under-estimate their true risk.

Poster 131-C Figure.

Comparative analysis of initial PESI, BOVA scores and pulmonary artery elastance of patients presenting with pulmonary embolism.

Poster 132-D

The teachable art of vascular medicine

Hayaan Kamran¹, Deborah Hornacek¹, Doran S. Mix², Colin M. Wright², Scott J. Cameron¹

¹Cleveland Clinic, Cleveland, OH, USA, ²University of Rochester, Rochester, NY, USA

Background: Vascular medicine is a sub-specialty to which medical trainees are given limited exposure. Common historical and physical exam (PE) components of vascular medicine are overlooked or misunderstood. Hypothesis: a focused lecture on the PE would makes trainees aware of knowledge gaps and improve understanding.

Methods: A lecture detailing historical signs and PE elements was presented to medical students (MS, n=531), internal medicine residents (IMR, n=53) and cardiology fellows (CVF, n=45) by multiple choice quiz (MCQ) pre- and post-lecture. The MCQ elicited common findings in patients with peripheral artery disease (PAD), chronic venous insufficiency (CVI), and lymphedema. Categorical data were assessed for statistical significance by chi-square and Fischers exact test.

Results: MS, IMR, and CVF scored better on the post-lecture quiz compared to pre-lecture quiz. (91% vs 31.2% respectively, p < 0.01. PAD was the poorest understood disorder. On the pre-lecture MCQ, IMR answered fewer questions correctly compared to MS and CVF which did not reach statistical significance (22.6% vs 30.9%, p=0.21 and 22.6% vs 45.2%, p=0.055, respectively.). CVF scored highest in the pre- and post-lecture MCQ with 100% correct responses in the latter.

Conclusion: Medical trainees are generally unaware of physical manifestations of common vascular diseases, with knowledge gaps carried forward into residency and fellowship. An interactive didactic session enhanced familiarity with the PE pertinent to vascular pathology.

Poster 133-A

Real world outcomes in a veteran population of claudicants referred for supervised exercise therapy: A pilot project

S. Elissa Altin¹, Marabel D. Schneider², Heidi Keefe³, Mary Martin-O'Brien³, Christine Coppola³, Ysanne Johnson³, Sasanka Jayasuriya⁴, Judith Meadows^1,3

¹Yale University, New Haven, CT, USA, ²Yale University School of Medicine, New Haven, CT, USA, ³VA Connecticut, West Haven, CT, USA, ⁴Ascension — Columbia St. Mary's Hospital, Milwaukee, WI, USA

Background: Supervised exercise therapy (SET) is a Class I guideline recommendation for patients with claudication. Since institution of the MISSION Act (Maintaining Internal Systems and Strengthening Integrated Outside Networks), patients in a vascular clinic at Veteran Health Administration (VHA)-Connecticut have been referred for SET at civilian centers.

Methods: Of 68 consecutive patients evaluated between March 2019 and January 2020 in this ongoing prospective, cohort study of patients with claudication, 67 patients were referred for SET prior to any revascularization. One-third (n=23) declined SET due to copayment, interference with work schedule, and inadequate transportation. Patients undergo sub-maximal exercise treadmill testing (ETT) prior to and at completion of SET. Subgroup statistical analysis with unpaired t-test was used due to the small, heterogeneous sample size of this pilot population.

Results: Both patient groups accepting and declining SET showed comparable rates of medical therapy: anti-platelet or anticoagulation therapy (94% vs. 82%), high-intensity statin (100% vs. 96%), ACEi or ARB (72% vs. 65%). Average lowest ABI values were similar in patients completing and declining SET (0.70 vs. 0.73). Baseline sub-maximal exercise treadmill testing (ETT) showed a mean peak functional tolerance of 3.2 metabolic equivalents of task (METs). At this interim analysis, 18 patients have completed SET and undergone repeat ETT with improvement of 60% to 5.1 METs. In a subgroup with ABI 0.65 (n=9), there was an 81% improvement in METs compared to 60% of those with ABI > 0.65 (n=9) (p = 0.25). Of 6 patients with inflow disease (defined as iliac and/or CFA disease) with or without outflow disease (defined as SFA and/or popliteal disease) there was a 59% improvement in METs, compared to 75% improvement in METs in those patients with isolated outflow disease (p = 0.31).

Conclusion: This pilot study confirms that all patients completing SET demonstrate an improvement in METs achieved. Interestingly, there is a trend towards greatest benefit of SET in patients with ABI 0.65 and those with outflow disease in absence of inflow disease.

Poster 134-B

Safety and efficacy of combined lithoplasty with adjunctive drug coated balloon angioplasty in the treatment of common femoral artery disease

Muhammad Baig¹, Hafiz Imran², Mohammad Khan³, Omar N. Hyder^1,3, Shafiq Mamdani², Peter A. Soukas¹

¹Warren Alpert Medical School of Brown University, Providence, RI, USA, ²Brown University, Providence, RI, USA, ³The Miriam Hospital, Providence, RI, USA

Background: Surgical endarterectomy is the gold standard for treatment of calcified common femoral artery (CFA) disease. Endovascular therapy is an alternative in the high-risk surgical patient, albeit with lower intermediate patency rates. Although CFA stenting achieves comparable patency rates, stent fracture, thrombosis and compromise of future access site remain concerns. Lithoplasty balloons capable of altering the compliance of calcified lesions may be a safe and effective adjuvant treatment for CFA disease.

Methods: The goal of this study was to determine the safety and feasibility of combined intravascular lithoplasty (IVL) and drug coated balloon angioplasty (DCB) in the treatment of calcified CFA stenotic disease. We reviewed all patients at our institution with Rutherford class III claudication or critical limb ischemia who underwent endovascular treatment of >50% calcified CFA stenoses with adjuvant balloon lithoplasty. Procedural success was defined as < 30% residual stenosis without need for bailout stenting in the CFA. Major adverse events were assessed at 30 days and 6 months.

Results: We reviewed 33 patients who underwent balloon lithoplasty of calcified CFA disease. Twenty-three patients had complete follow-up data and were included in the final analysis. Patients had an average age of 73+7 years. Pre-procedure initial ABI was 0.61+0.26 and initial angiographic stenosis was 75+14%. Six (26%) patients required concomitant atherectomy prior to IVL. On average 200+100 pulses were delivered via IVL balloon to the stenotic lesion. IVL was followed by drug coated balloon angioplasty. Final residual stenosis was less than 30% in all cases. One (4.3%) patient developed a non-flow limiting dissection after IVL/DCB not requiring intervention. One (4.3%) patient required bailout stenting for flow limiting dissections in non-CFA vessels. ABI at 1-month post-procedure was 1.0+0.32 and ABI at 6-month was 0.91+0.52. Five (21.7%) patients required target vessel revascularization within 6 months of initial intervention.

Conclusion: Intravascular lithoplasty of calcified CFA disease is safe with low rates of procedural complication and need for bailout stenting. Target vessel revascularization, however, remains high with over a fifth of patient requiring re-intervention by 6 months.

Poster 135-C

Peripheral arterial disease patient and health status profiles across vascular specialty settings: Insights from the PORTRAIT registry

Asma Ahmed¹, Yuanyuan Tang², Vittal Hejjaji², Carlos Mena-Hurtado³, David M. Safley², John A. Spertus², Qurat Ul Ain Jelani³, Clementine Labrosciano⁴, Kim G. Smolderen²

¹People Tree Hospital, Bengaluru, India, ²Saint Luke's Mid America Heart Institute, Kansas City, MO, USA, ³Yale School of Medicine, New Haven, CT, USA, ⁴University of Adelaide, Adelaide, SA, Australia

Background: To formally evaluate the quality and outcomes of peripheral artery disease (PAD) care, risk-adjusted measures are needed to ensure that they reflect the quality of care, rather than the severity of the case mix. We sought to compare patient, clinical and health status (physical limitation, symptoms and quality of life) characteristics of patients with PAD across the specialties of vascular surgery (VS), interventional and general cardiology, and vascular medicine (VM) to underscore the need for risk adjustment in comparing providers care.

Methods: Between 2011-2015, we recruited patients with new or worsening claudication from four different types of PAD specialty clinics. Patient characteristics, cardiovascular risk, disease severity, and health status at enrollment were measured and compared. Disease-specific health status was measured with the Peripheral Artery Questionnaire.

Results: Among 797 patients with PAD (mean age 68.6±9.7; male 58.1%), 50 (6.2%) were managed by VS, 530 (66.4%) by interventional, 150 (18.8%) by general cardiologists and 67 (8.4%) by VM specialists. VM patients were older, more commonly women and had more co-morbidities. VS and interventional cardiologists managed patients with more severe symptoms, while VM providers managed a higher proportion of bilateral disease. At baseline, VM patients reported to have better health status (Table).

Conclusion: In a multi-center US registry, we found substantial differences in the socio-demographic, clinical and patient-reported health status characteristics in symptomatic patients with PAD.

Poster 135-C Table.

Patient characteristics and management of strategies based on provider type.

Poster 137-A

Evaluation of changing vena cava filter use from 2016 through 2019: A single institution quality improvement project

Damon E. Houghton¹, Laurie Rupkalvis¹, Ann Comstock¹, Lisa Peterson¹, Ian McPhail¹, Robert McBane¹, Haraldur Bjarnason¹, Erica Knavel¹

¹Mayo Clinic, Rochester, MN, USA

Background: In the United States, vena cava filter (VCF) use has been declining since 2010. We have observed a significant decline in insertions at our institution since 2016.

Methods: A quality improvement project at Mayo Clinic, Rochester Minnesota, tracks VCF placements. Type of VCF insertions and specific reasons for insertion were recorded from 1/1/2016 through 12/31/2019.

Results: A total of 698 VCFs were placed in 695 patients: 2016 (n=243); 2017 (n= 156); 2018 (n=156); 2019 (n=120). Mean age was 62 (SD 16.4) and 59.2% were male. VCFs inserted were mostly retrievable (85.1%) and were mostly placed for treatment (78.4%) indications (acute VTE within 3 months). The most commonly inserted VCF type was the Argon Option Elite (67.3%) followed by the VenaTech (14.6%) and Gunther Tulip (12.0%). Analyzing by year of placement (Table), no significant difference was observed in the use of retrievable vs. permanent filters (p=0.16) or prophylactic vs. treatment indications (p=0.26). No difference was observed in the age (p=0.17) or sex (p=1.0) and year of placement. Differences were observed for treatment indications (bleeding, post-operative, other) however, these differences do not account for the downward trend in insertions. For prophylactic indications, insertions in non-trauma patients may be decreasing as the frequency of placements for trauma within this category has increased (p=0.051). Comparing 2019 to 2016, there were fewer permanent VCFs placed (9.2% vs. 17.7%, p=0.03) and prophylactic VCFs (15.0% vs. 23.5%, p=0.06).

Conclusion: We observed a >50% reduction in VCF insertions from 2016 to 2019 that is difficult to attribute to any single change in clinical practice. The reduction in number of prophylactic VCFs mirrored the reduction in VCFs placed for treatment indications and there was a similar reduction in both retrievable and permanent filter types.

Poster 137-A Table.

Poster 138-B

Quality review and education as method of improving guideline adherence for medication prescription and outcomes among vascular interventionalists performing non-cardiac vascular surgeries

Alejandro Perez¹, Shih-Ting Chiu¹, Amy Manning¹, Brant W. Ullery¹

¹Providence Heart Institute-Oregon, Portland, OR, USA

Background: Medical management of patients undergoing non-cardiac vascular procedures often sub-optimally follow evidence based guidelines. We hypothesized that feedback to practitioners in regards to outcomes and medications prescribed would improve care.

Methods: With conversion to new database in 2015 that allowed for more comprehensive tracking of vascular surgery outcomes, a decision was made to share these data with practitioners on regular basis as well as relay medications prescribed at discharge. Carotid and abdominal aortic surgeries were evaluated. The most frequent format for presentation of data was vascular morbidity and mortality conference. Medications included in presentations were antiplatelet and statin therapies. Comparisons were made between adherence to guideline based therapies 2 years before and 2 years after new database implementation. ACE inhibitor/aldosterone receptor blocker (ARB) therapy prescribing data were not included in these presentations. SAS Enterprise Guide 7.1 and R 3.6.1 software used for analysis.

Results: 826 patients were evaluated. 400 patients were in pre new database implementation and 426 were included after implementation. No significant difference found with prescribing of ACE inhibitors/ARB, changing only from 47 to 48%. There was difference with univariate analysis of antiplatelet and statin prescribing. Antiplatelet prescribing improved from 89 to 93%, Odds Ratio (OR) = 1.7 (95% confidence interval, 1-2.8) and statin prescribing improved from 74 to 86%, OR= 2.1 (95% confidence interval, 1.5-3). Access site and bleeding complications also demonstrated improvement. See Figure.

Conclusion: Regular feedback to vascular practitioners improves adherence to guideline based therapies and can improve surgical outcomes.

Poster 138-B Figure.

Impact of quality review and education on medication management and surgical outcomes in vascular surgery patients.

Poster 139-C

Sex differences in platelet activation following plant-based nitrate consumption

Matthew Godwin¹, Joshua Gorski², Zachary Hilt², Shalini Shah², Annelise Hamer², Craig Morrell², Scott J. Cameron¹

¹Cleveland Clinic, Cleveland, OH, USA, ²University of Rochester, Rochester, NY, USA

Background: Platelet activation plays a role in thrombotic disorders. Nitric oxide (NO) may have a beneficial effect on platelets. An inorganic-rich nitrate (NO3-) diet is converted to nitrite (NO2-) in the gut to release NO. We hypothesized that capsules containing NO3- may increase blood and platelet NO2- -to-NO production to suppress activation in a manner similar to a plant based diet.

Methods: NO3- was administered in a double-blinded, randomized manner to 22 healthy people (10 women, 12 men), each subject presenting twice for 44 total encounters. Saliva and blood NO3- concentration were assessed by the Greiss Reaction. Platelet activation as dose-response curves was assessed by flow cytometry and laser microscopy. Platelet NO production was assessed by confocal microscopy and quantified by flow cytometry. Platelet surface receptor density was determined by fluorescently-tagged receptor antibodies.

Results: Oral NO3- increased saliva and plasma NO2-/ NO3- compared to placebo (303 ± 62 vs. 65 ± 21; P=0.002 and 188 ± 9.5 vs 32 ± 3.1; P=4x10^-11, respectively) as well as platelet NO production by 2.2-fold in males and by 11.2-fold in females (p < 0.0001). Females platelets were more reactive than males platelets by several orders of magnitude following blinded placebo administration. NO3- decreased spontaneous platelet activation in female subjects by two-fold (P=0.03) but not male subjects (P=0.73). Agonist-induced platelet activation was dose-dependently augmented in male platelets by NO3- compared to placebo, and attenuated in female platelets compared to placebo in a manner not explained by changes in surface receptor density. Platelet count, hemoglobin, and WBC count were unaffected by BE. See Figure.

Conclusion: We describe a divergent effect of oral nitrate ingestion on platelet NO production and platelet reactivity in males and females, potentially involving a complex interaction between the microbiome and/or free radical production. Women are typically under-represented in cardiovascular investigations. We suggest that nitrate intake and its effect on platelet reactivity and thrombosis in those subscribing to a plant-based diet should be evaluated prospectively in men and women.

Poster 139-C Figure.

Poster 140-D

Platelet reactivity in response to P2Y12, thromboxane, and PAR1 agonists among patients with acute ischemic stroke and large vessel occlusion

Matthew T. Bender¹, Tarun Bhalla¹, Thomas Mattingly¹, Scott J. Cameron², Craig Morrell¹

¹University of Rochester Medical Center, Rochester, NY, USA, ²Cleveland Clinic, Cleveland, OH, USA

Background: We previously reported that the platelet phenotype changes in vascular disease which may affect the responsiveness to antiplatelet medications. Platelet signal transduction pathways at the time of thrombotic stroke have never been extensively evaluated. We hypothesized that platelet signaling at the time of acute stroke may differ depending on which antithrombotic agents are administered.

Methods: Platelets were isolated and washed from consenting patients presenting with stroke. Platelet activation was evaluated by flow cytometry (surface p-selectin, mean fluorescence intensity [MFI]) following stimulation for agonists for the P2Y12 receptor (ADP), thromboxane receptor (U46619), and PAR1 (TRAP6).

Results: Patients (19 total) were mostly female (58%) and Caucasian (84%) with mean age 78 years. Stroke etiology was: atrial fibrillation (58%). Pre-intervention antithrombotic agents/thrombolytics were: Aspirin (53%); clopidogrel (6%); tPA (53%); Heparin, Coumadin, or DOACs (11%). Platelets were more reactive through the thromboxane receptor (7.3-fold) than PAR1 (3.4-fold) or ADP (2.4-fold). Women had greater platelet reactivity than men. Aspirin therapy decreased the platelet response to thromboxane (5.2-fold vs. 7.3-fold), and tPA administration decreased the platelet response to a PAR1 agonist (2.5-fold vs. 3.4-fold). Patients taking clopidogrel therapy showed a minimal response to a P2Y12 receptor agonist (1.2-fold vs. 2.4-fold) and a decreased response to a thromboxane agonist (3.5-fold vs. 7.3-fold). See Figure.

Conclusion: At the time of acute thrombotic stroke, platelet signaling appears to favor thromboxane receptor signaling with residual platelet activity. With past data indicating aspirin protects against stroke only in women when use for primary prevention, and recent data suggesting a sex-specific divergent response to low dose aspirin therapy, our data should be evaluated in a larger population using different doses of antiplatelet agents.

Poster 140-D Figure.

Mean fluorescence intensity fold-increase by escalating agonist dose, Male vs. Female.

Poster 141-A

Treatment

-risk paradox for the receipt of guideline-recommended medical therapy in patients with critical limb ischemia and comorbid chronic kidney disease: insights from the VQI registry

Fiorella Llanos-Chea^1,2, Kim Smolderen¹, Qurat Ul Ain Jelani¹, Maria Trejo³, Craig Parzynski¹, Jeffrey Turner^1,2, Herbert Aronow⁴, Sameer Nagpal^1,2, Carlos Mena-Hurtado¹

¹Yale School of Medicine, New Haven, CT, USA, ²Yale New Haven Hospital, New Haven, CT, USA, ³University of Connecticut, Storrs, CT, USA, ⁴Warren Alpert Medical School of Brown University, Providence, RI, USA

Background: Critical limb ischemia (CLI) is the most advanced expression of peripheral artery disease (PAD). Ensuring the delivery of guideline-recommended medical therapy (GRMT) is critical in this population to mitigate their cardiovascular risk. It is unclear whether the prescription of GRMT varies by the presence of other critical comorbid conditions, such as chronic kidney disease (CKD), and whether practices vary across different sites.

Methods: A prospectively collected cohort of 27,474 patients was derived from the endovascular module of the Vascular Quality Initiative (VQI) registry. All patients had CLI (Rutherford 4-6) and were enrolled between January 2016 to April 2019 from 237 sites. CKD was defined as a GFR < 60 mL/min/1.73 m2 or need for renal replacement therapy. GRMT was defined as the use of an antiplatelet, statin, and angiotensin converting enzyme inhibitor in those with hypertension. Detailed patient characteristics and medications prescribed both on admission and at the time of discharge, after a peripheral vascular intervention (PVI) were registered. Receipt of GRMT across sites were summarized by CKD status and median odds ratios (MORs) for site variability were calculated.

Results: A total of 47% (n= 12, 922) had comorbid CKD. Mean age was 69.4 ± 11.7 years and 41% were female. Patients with CKD vs. no CKD had a worse cardiovascular risk profile (more hypertension, diabetes, coronary artery disease, prior smoking, and stroke) and a more history of prior PVIs (all p < 0.05). Moreover, pre and post endovascular intervention, CKD vs. no CKD patients were less likely to receive GRMT (p < 0.001). Significant variability across sites was observed in the delivery of GRMT to patients on both the CKD and no CKD groups, before (MOR: 1.33, CI 1.28-1.39) and after an intervention (MOR: 1.36, CI 1.30-1.41). See Figure.

Conclusion: GRMT rates in patients with CLI undergoing peripheral vascular intervention are suboptimal. In addition, a risk-treatment paradox exists across vascular centers for patients with CLI who present with comorbid CKD, thereby undermining the ability to properly mitigate their cardiovascular risk.

Poster 141-A Figure.

(a) Overview of Receipt of Guideline-Recommended Medical Therapy Before and After the Endovascular Procedure for the Overall Cohort and by CKD Status. (b) Site Variability of GRMT by CKD Status.

Poster 142-B

The impact of pulmonary embolism response team activation on outcomes of pulmonary embolism

Merry E. Barnett¹, Randy Ramcharitar¹, Alexandra Kadl¹, Andrew Mihalek¹, Sula Mazimba¹, Aditya Sharma¹

¹University of Virginia, Charlottesville, VA, USA

Background: Implementation of pulmonary embolism response teams (modeled after rapid response teams for acute myocardial infarction) have been shown to improve mortality associated with PE. Studies of patients with acute MI have shown that medical care and patient outcomes are impacted by facility arrival times. No similar studies have been performed for patients with PE.

Methods: Using our institutions Pulmonary Embolism Response Team (PERT) logs, a database was created to examine differences in medical care and mortality for PE patients diagnosed during normal business hours (weekdays from 7 AM to 5 PM) versus off hours (weeknights from 5 PM to 7 AM and weekends). The study cohort included 68 patients who underwent PERT activation within 48 hours of arrival at our institution from October 2018 to October 2019.

Results: The study cohort was composed predominantly of obese, older, Caucasian males with an average PESI of 105. Of the patients included, 70.5% experienced PERT activation during non-business hours. The average time from PERT activation to treatment decision was similar for patients with PERT activations during normal business hours and off hours (1:14 ± 1:45 vs 1:15 ± 1:26, p = 0.97). More patients with PERT activations during business hours underwent catheter-based interventions than those presenting after hours (40% vs 18.7%, p = 0.06), but statistical significance was not attained. No significant differences were noted in mortality for patients presenting during business hours and off hours (20% vs 20.1%, p = 0.9). See Table.

Conclusion: Despite fewer advanced interventions for patients diagnosed with PE during non-business hours, patients diagnosed with PE after hours had similar overall mortality rates as patients diagnosed during normal business hours.

Poster 142-B Table.

Baseline characteristics and outcomes for PE patients presenting during normal business hours versus off hours.