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Background The purpose of this study was to assess whether increased body mass index (BMI) negatively affects assisted reproductive technology (ART) outcomes among gestational carriers. Methods A retrospective matched case-control cohort, including all gestational carrier (GC) cycles performed at CReATe Fertility Centre (Toronto, ON, Canada) between 2003 and 2016. Setting A Canadian fertility clinic, with a large surrogacy program. Patients All gestational carriers that had undergone a cycle completed to a transfer at our clinic, and had BMI and outcome data available, were matched by BMI to infertile patients treated at our clinic during the same years provided they had undergone a cycle completed to a transfer, and had outcomes data available. Interventions None. Main outcome measures Clinical pregnancies rates, miscarriage rates and live birth rates. Results BMI was not a reliable prediction factor of any of the measured outcomes. Importantly, the gestational carrier population had better outcomes and a significantly lower overall incidence of maternal, fetal and neonatal complications when compared with infertile patients, treated at our clinic during the same years. Conclusion BMI is not a reliable predictor of outcomes among gestational carriers.

Patients who undergo vascular surgery are burdened by high early readmission rates. We examined the frequency and cause of early readmissions after elective and emergent admission to the vascular surgery service at our institution to identify modifiable targets for quality improvement.Over a 5-year period, all patients admitted and readmitted to the vascular surgery service were identified. Medical records were then individually reviewed to identify baseline characteristics from the index admission and the most responsible diagnosis for readmission within 28 days of discharge.Of a total of 3324 patients, 421 (12.7%) were readmitted to our institution within 28 days of discharge. Forty-seven were found to have more than 1 readmission following their index admission. The readmission rate ranged from 11.8% to 14.1% over the 5-year study period, resulting in an average readmission rate of 12.7%. There were similar rates for men (12.9%) and women (12.3%). Of the readmitted cases, 236 (63.1%) were unplanned readmissions. The most common diagnoses for unplanned readmissions were worsening of peripheral arterial disease status including complications related to peripheral bypass graft (30.9%), surgical site infections (15.3%) and nonsurgical infections (14.8%).To reduce readmission rates effectively, institutions must identify highrisk patients. In our study cohort, the most frequent pathology resulting in readmission was peripheral arterial disease. The most frequent preventable reason for readmission was surgical site infection. Interventions focused on early assessment of clinical status and wounds in addition to avoidance of infectious complications could help reduce readmission rates. Preventive resources can be efficiently targeted by focusing on subgroups at risk for readmission.Les patients soumis à une chirurgie vasculaire présentent malheureusement un taux élevé de réadmission précoce. Nous avons analysé la fréquence et les causes de réadmission précoce après une admission urgente ou non urgente au service de chirurgie vasculaire afin d’identifier les facteurs modifiables en vue d’améliorer la qualité des soins.Sur une période de 5 ans, tous les patients admis, puis réadmis au service de chirurgie vasculaire ont été identifiés. On a ensuite passé en revue individuellement les dossiers médicaux pour relever les caractéristiques de base à l’admission initiale et le diagnostic ayant le plus probablement justifié la réadmission dans les 28 jours suivant le congé.Sur un total de 3324 patients, 421 (12,7 %) ont été réadmis à notre établissement dans les 28 jours suivant leur congé. Quarante-sept ont été réadmis plus d’une fois après leur hospitalisation initiale. Le taux de réadmission a varié de 11,8 % à 14,1 % pendant la période de 5 ans de l’étude, le taux moyen de réadmission étant de 12,7 %. Les taux étaient similaires chez les hommes (12,9 %) et les femmes (12,3 %). Parmi les cas réadmis, 236 (63,1 %) étaient imprévus. Les diagnostics ayant le plus souvent justifié une réadmission imprévue étaient aggravation de la maladie artérielle périphérique (y compris complications au niveau de pontages artériels périphériques) (30,9 %), infection du site opératoire (15,3 %) et infections non chirurgicales (14,8 %).Pour réduire efficacement les taux de réadmission, les établissements doivent identifier les patients à haut risque. Dans notre cohorte, la pathologie ayant le plus souvent mené à une réadmission était la maladie artérielle périphérique. La raison évitable la plus fréquente était l’infection du site opératoire. Les interventions axées sur une évaluation rapide de l’état clinique et de l’état des plaies, ainsi que la prévention des complications infectieuses pourraient contribuer à réduire les taux de réadmission. Des mesures préventives pourraient cibler judicieusement les groupes à risque de réadmission.

Background Advances in vitrification techniques have enabled planned oocyte cryopreservation ('Planned OC'). Objectives To explore the cost-efficiency and utilisation of planned OC, as well as patients' perspectives on the process. Search strategy A systematic search in PubMed/MEDLINE, Embase, Cochrane Database and PsychINFO, for all relevant studies published between January 2007 and December 2019. Selection criteria The protocol followed PRISMA guidelines in PECO format, and was registered with PROSPERO. Data collection and analysis Two independent reviewers evaluated all manuscripts for inclusion eligibility. Authors were contacted for missing data. Included studies were assessed for risk of bias and for heterogeneity. Weighted effects were measured and plotted. Main results The search yielded 12 545 records, of which 43 were included. Planned OC is cost-efficient at 35, assuming 60% utilisation; and at 37 assuming utilising donor sperm when necessary. At 38 it is cost-efficient to defer planned OC in favour of undergoing 2 IVF cycles. Currently, utilisation of banked-oocytes within 22-58 months, is up to 15%. Nine percent of warmed banked oocytes result in life births. Online resources and treating physicians are equally important sources of information regarding planned OC. Most patients think planned OC is ideal before age 35 and are not fully aware of what the process entails and tend to overestimate the success rates. The main barrier to wider endorsement of planned OC is being wary of potential health implications or of limited success. Conclusion Planned OC is an adequate method for preserving fertility. However, knowledge gaps result in under-utilisation leading to reduced cost-efficiency. Tweetable abstract Identifying facilitators and barriers for wider adoption of banking oocytes can enhance the cost-efficiency of this modality.

Endovascular aneurysm repair (EVAR) is associated with decreased perioperative morbidity and mortaliy in comparison with open repair, and thus octagenarians are traditionally offered EVAR given their age and medical comorbidities. The aim of this study was to investigate outcomes and predictors of complications associated with EVAR in octogenarians.We conducted a retrospective chart review of consecutive patients aged 80 years and older who received an EVAR between August 2010 and January 2017 at a single centre in Toronto, Ontario. We conducted univariate comparisons and then completed logistic regression to determine predictors of complications. We used Kaplan-Meier analysis to explore survival times.A total of 154 octogenarians underwent an EVAR during the study period for an infrarenal aneurysm with a mean size of 64.8 (standard deviation [SD] 12.7) mm. The mean age of the patients was 84.1 (SD 3.7) years, and most patients (81%) were men. Eighteen patients presented with a ruptured abdominal aortic aneurysm (AAA). Ninety-five (62%) patients sustained a complication. Fifty percent of patients experienced an intraoperative complication. A majority of these (77%) resulted in an endoleak, with type II endoleaks requiring no further intervenion being the most common (58%, n = 45). The remaining complications (n = 70) occurred postoperatively, with myocardial ischemia (n = 24) and dysrhythmias (n = 10) being the most common. Past aortic surgery (χ2 = 8.62, p = 0.014, Cramer V = 0.27) was found to be a multivariate predictor of complications. Most patients (88%) continued follow-up to an average of 20.9 months. Twenty-one patients (13%) died. Nine of these deaths (43%) occurred during the index admission and involved a ruptured AAA. Past aortic surgery was the only predictor of vascular complications. The mean survival time after EVAR was 57.63 months for patients without events.Endovascular aneurysm repair in octogenarians is a suitable form of therapy with acceptable short- and long-term results in the elective setting. Past aortic surgery was a predictor of complications in this population.La réparation endovasculaire de l’anévrisme (REVA) est associée à une diminution de la morbidité et de la mortalité périopératoires comparativement à la chirurgie ouverte, c’est pourquoi on offre habituellement la REVA aux octogénaires, compte tenu de leur âge et de leurs comorbidités. Le but de cette étude était d’analyser l’issue de la REVA et les prédicteurs de complications chez les octogénaires.Nous avons procédé à une analyse rétrospective des dossiers de patients de 80 ans et plus consécutifs soumis à une REVA entre août 2010 et janvier 2017 dans un établissement de Toronto, en Ontario. Nous avons effectué des comparaisons univariées, puis une analyse de régression logistique pour dégager les prédicteurs de complications. C’est l’analyse de Kaplan–Meier qui a permis d’explorer la survie.En tout, pendant la période de l’étude, 154 octogénaires ont subi une REVA pour un anévrisme infrarénal dont la dimension moyenne était de 64,8 mm (écart-type [É.-T.] 12,7 mm). L’âge moyen des patients était de 84,1 ans (É.-T. 3,7 ans) et la majorité des patients (81 %) étaient des hommes. Dix-huit patients ont présenté une rupture d’anévrisme de l’aorte abdominale (AAA). Quatre-vingt-quinze patients (62 %) ont connu une complication. Cinquante pour cent des patients ont eu une complication peropératoire. Une majorité des complications (77 %) ont causé des endofuites, le plus fréquemment de type II, ne nécessitant pas d’autres interventions (58 %, n = 45). Les autres complications (n = 70) sont survenues en période postopératoire et les plus fréquentes ont été l’ischémie myocardique (n = 24) et la dysrythmie (n = 10). Des antécédents de chirurgie à l’aorte (χ2 = 8,62, p = 0,014, test V de Cramer = 0,27) se sont révélés être un prédicteur multivarié de complications. La plupart des patients (88 %) ont maintenu le suivi pendant une durée moyenne de 20,9 mois. Vingt-et-un patients (13 %) sont décédés. Neuf de ces décès (43 %) se sont produits pendant l’admission index et impliquaient une rupture de l’AAA. Des antécédents de chirurgie à l’aorte ont été le seul prédicteur des complications vasculaires. La survie moyenne après la REVA a été de 57,63 mois pour les patients n’ayant présenté aucune complication.La REVA est une forme de traitement qui convient aux octogénaires et qui donne des résultats acceptables à court et à long terme dans un contexte de chirurgie non urgente. Des antécédents de chirurgie à l’aorte se sont révélés être un prédicteur de complications dans cette population.

The Vascular Quality Initiative (VQI) is a national cooperative quality-improvement initiative designed to evaluate processes of care and outcomes in vascular surgery. The purpose of this report is to show the utility of such a database to provide insight into the standard of care provided, to highlight areas of local quality improvement, to benchmark our data against local, regional and national trends, and to ultimately improve safety in Canadian patients undergoing vascular surgery. We present the history of the database, its spread in the Canadian health care system and examples of quality improvements achieved from analyses of data recorded and retrieved from the VQI. Using the VQI, our institution was able to decrease the length of stay after endovascular aneurysm repair, decrease the contrast volume in endovascular aneurysm repair, save on costs, and provide medium-term outcome data on peripheral vascular interventions and smoking cessation strategies. The VQI is a powerful tool to improve patient safety and quality in vascular surgery. Its ability to create local regional improvement groups fosters a quality-focused culture and is important for Canadian patients.La Vascular Quality Initiative (VQI) est une initiative de collaboration nationale axée sur l’amélioration de la qualité, conçue pour évaluer les processus de soins et les résultats en chirurgie vasculaire. Le but du présent rapport est de montrer l’utilité d’une telle base de données pour situer les normes de soins actuelles, mettre en lumière les secteurs d’amélioration de la qualité locale, évaluer nos données à la lumière des tendances locales, régionales et nationales et ultimement, améliorer la sécurité des patients canadiens de chirurgie vasculaire. Nous retraçons l’historique de cette base de données, son adoption par le système de santé canadien et donnons des exemples d’améliorations de la qualité obtenues grâce à l’analyse des données enregistrées et récupérées à partir de la base VQI. Cette base de données nous a permis d’abréger les séjours hospitaliers après la réparation endovasculaire des anévrismes, d’épargner sur les coûts et de compiler les résultats à moyen terme des interventions vasculaires périphériques et des stratégies d’abandon du tabagisme. La VQI est un outil puissant pour améliorer la sécurité des patients et la qualité de la chirurgie vasculaire. Sa capacité de créer des groupes loco-régionaux d’amélioration de la qualité favorise une culture axée sur la qualité et est importante pour les patients canadiens.

Objectives Choosing an optimal amputation level requires balance between maximizing limb salvage while minimizing chances of non-healing wounds and re-amputation. Our aim was to assess the long-term outcome for minor amputations in patients with peripheral vascular disease. Methods A retrospective study of minor amputations between January 1, 2005 and December 31, 2015 was performed. Electronic medical records of eligible patients were examined to extract demographics, co morbidities and clinical data. Results Within the study period, 220 patients underwent 296 primary minor amputations in 244 lower extremities. Wound healing was achieved in 18.2% (54 of 296 amputations) and 43.6% (129 of 296 amputations) at 90 days and 365 days, respectively. Rates of progression to major amputation were 16.4% (40 or 244 limbs) and 21.7% (53 of 244 limbs) at 90 days and 365 days, respectively. In the final multivariate model, lower ipsilateral posterior tibial waveforms predicted poor 90-day healing (OR = 2.22, p = 0.01) as well as limb loss (OR = 3.02, p = 0.02) in a dose-response manner. In the final logistic regression model, emergency department admission (OR = 0.20, p Conclusion This study shows that a majority of foot amputees require ongoing care for non-healing wounds and a proportion necessitate conversion to major amputation. Adequate vascularization is essential to promote and maintain healing.

Background The perioperative period provides a critical window to address opioid use, particularly in patients with a history of chronic pain and presurgical opioid use. The Toronto General Hospital Transitional Pain Service (TPS) was developed to address the issues of pain and opioid use after surgery. Aims To provide program evaluation results from the TPS at the Toronto General Hospital highlighting opioid weaning rates and pain management of opioid-naïve and opioid-experienced surgical patients. Methods Two hundred fifty-one high-risk TPS patients were dichotomized preoperatively as opioid naïve or opioid experienced. Outcomes included pain, opioid consumption, weaning rates, and psychosocial/medical comorbidities. Results Six months postoperatively, pain and function were significantly improved. Opioid-naïve and opioid-experienced patients reduced consumption by 69% and 44%, respectively. Forty-six percent and 26% weaned completely. Consumption at hospital discharge predicted weaning in opioid-naïve patients. Pain catastrophizing, neuropathy, and recreational drug use predicted weaning in opioid-experienced patients. Conclusions The TPS enabled almost half of opioid-naïve patients and one in four opioid-experienced patients to wean. The TPS successfully targets perioperative opioid use in complex pain patients.

Smoking is the single most important modifiable risk factor for patients with vascular disease. The aim of this study was to determine the prevalence of smoking and cessation rates among patients undergoing vascular surgery in a Canadian center.As part of the Vascular Quality Initiative, a prospectively maintained database was used to identify the patients undergoing vascular surgery between 2010 and 2013. Smoking prevalence data were collated preprocedure, postprocedure, and at year follow-up after intervention at a median of 13 months (mean = 14.4 ± 7.8 months). Cessation rates at 13-month follow-up were assessed to determine any statistically significant univariate factors. These factors were then used to build a model through backwards logistic regression. Multicollinearity was tested by assessing both variance inflation factors and tolerance.Overall, 624 patients had complete follow-up data. Of these, 209 (33.5%) were smokers presurgically. At 1-year follow-up, of those 209 patients who were smokers preoperatively, 87 (41.6%) had stopped smoking while 122 (58.4%) had not. Patients who were male and aged70 years were more likely to be smokers preoperatively (P = 0.001 and P 0.001, respectively). Cessation rates were increased in those aged70 years (P = 0.005) and in those with chronic obstructive pulmonary disease (P = 0.016). Gender was also statistically associated, with cessation rates higher in females (P = 0.011).More than one-third of patients who underwent surgery in a Canadian vascular center continue to smoke. Uniquely, we report a statistically significant association between gender and postoperative cessation rates.

Introduction: A proportion of hemodialysis patients exhaust all options for arteriovenous access in upper extremities. Arteriovenous thigh grafts are a potential vascular access option in such patients. Methods: We performed a retrospective study of all thigh arteriovenous access grafts placed between 1995 and 2015. The clinical, demographic patient information and patency of each thigh graft was determined from the time of surgical creation placement until abandonment, transfer to other modality, or center or end of study, and the reason for access failure documented. Results: In total, 44 patients received 49 thigh arteriovenous accesses. The average age was 60 years (13–79 years); Half (53%) of the patients (n = 24) were female and 61% of the patients (n = 30) of arteriovenous accesses were left-sided. The cumulative proportion surviving (primary patency rates) at 12, 24, and 28 months were 43% (standard error = 9%), 33% (standard error = 9%), and 13% (standard error = 9%), respectively. The cumulative proportion of surviving grafts at 12, 24, and 48 months were 61% (standard error = 8%), 58% (standard error = 9%), and 31% (standard error = 13%), respectively. In total, 37 revisions were performed in 22 patients to maintain patency or eradicate infection. Infection occurred in 20 patients (39%) of thigh grafts requiring 16 patients (80% of those affected) to be removed; 14 patients had grafts (33.3%) that served as the lone hemodialysis arteriovenous access during the patients’ lifetime on dialysis. Conclusion: Arteriovenous thigh graft access is used infrequently, but they have an acceptable patency. Some accesses require revisions and they have a high infection rate. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.

The impact of aneurysm thrombus characteristics on type 2 endoleak rate following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is unclear. The purpose of this study is to determine the impact of pre-operative aneurysm thrombus volume and density on the incidence of type 2 endoleak following EVAR for infrarenal AAA.A retrospective analysis was completed on all patients who underwent standard EVAR at an academic medical institution between May 1, 2010 and June 1, 2016 with a minimum follow-up period of 12 months. The final analysis included 170 patients. Thrombus volume and density were determined by analyzing pre-operative computed tomography angiography (CTA) scans using the TeraRecon plaque analysis module. The number and diameter of patent infrarenal aortic branch vessels were also identified. Type 2 endoleak was diagnosed by post-operative CTA, duplex ultrasound, or angiography.Over a median follow-up period of 29 months, 88 (51.8%) of 170 patients had a type 2 endoleak. The thrombus volume as a proportion of the infrarenal aorta volume was significantly lower in patients with type 2 endoleak (odds ratio [OR] 0.034, 95% confidence interval [CI] 0.005-0.291, P = 0.002). The number of patent lumbar arteries was significantly greater in patients with type 2 endoleak (OR 1.45, 95% CI 1.16-1.56, P 0.0005). Both variables independently predicted the incidence of type 2 endoleak in a multivariate analysis. Thrombus density was not related to the incidence of type 2 endoleak.A lower ratio of thrombus volume/infrarenal aorta volume and a higher number of patent lumbar arteries were associated with an increased incidence of type 2 endoleak. A multivariate logistic regression model was generated to pre-operatively predict the risk of type 2 endoleak. This model can guide the stratification of patients for intensity of endoleak surveillance following EVAR and consideration of pre-operative treatment.

Living donor liver resections are associated with significant postoperative pain. Epidural analgesia is the gold standard for postoperative pain management, although it is often refused or contraindicated. Surgically placed abdominal wall catheters (AWCs) are a novel pain modality that can potentially provide pain relief for those patients who are unable to receive an epidural. A retrospective review was performed at a single center. Patients were categorized according to their postoperative pain modality: intravenous (IV) patient-controlled analgesia (PCA), AWCs with IV PCA, or patient-controlled epidural analgesia (PCEA). Pain scores, opioid consumption, and outcomes were compared for the first 3 postoperative days. Propensity score matches (PSMs) were performed to adjust for covariates and to confirm the primary analysis. The AWC group had significantly lower mean morphine-equivalent consumption on postoperative day 3 [18.1 mg, standard error (SE) = 3.1 versus 28.2 mg, SE = 3.0; P = 0.02] and mean cumulative morphine-equivalent consumption (97.2 mg, SE = 7.2 versus 121.0 mg, SE = 9.1; P = 0.04) in comparison with the IV PCA group; the difference in cumulative-morphine equivalent remained significant in the PSMs. AWC pain scores were higher than those in the PCEA group and were similar to the those in the IV PCA group. The AWC group had a lower incidence of pruritus and a shorter hospital stay in comparison with the PCEA group and had a lower incidence of sedation in comparison with both groups. Time to ambulation, nausea, and vomiting were comparable among all 3 groups. The PSMs confirmed all results except for a decrease in the length of stay in comparison with PCEA. AWCs may be an alternative to epidural analgesia after living donor liver resections. Randomized trials are needed to verify the benefits of AWCs, including the safety and adverse effects. Liver Transpl 21:478–486, 2015. © 2015 AASLD.

Vascular complications (VCs) remain a significant cause of morbidity in transcatheter aortic valve implantation (TAVI) patients and are associated with worse outcomes. This research analysed the incidence, impact, and predictors of VCs in transfemoral cases.A retrospective chart review was performed of 388 consecutive TAVI patients between January 2007 and April 2015, which included 237 transfemoral cases. Major and minor VCs were characterised according to the Valve Academic Research Consortium (VARC) guidelines. Logistic regression was completed to identify predictors of VCs.While VCs occurred in 68 (28.7%) cases, only seven (3.38%) were classified as major complications. Twenty-six (10.9%) of these complications occurred intra-operatively, with four being major (1.6%) and 22 minor (9.3%). Post-operative VCs occurred in 42 cases (17.2%), with three (1.3%) being major. Procedures to correct VCs occurred in 10 (4.2%) cases, with the majority (90%) being surgical and the remainder being treated by endovascular techniques. Nine surgical procedures, predominantly embolectomy, were performed to correct post-operative complications. Female gender was a predictor of all major VCs (B = -2.1, p .006). Further, a logistic regression analysis found that when the largest sheath was located on the left side, there were increased minor post-operative complications (B = -0.99, p = .007). Dissections and haematomas made up the majority of VCs. Thirty day mortality was six patients (n = 2.5%), and peri-operative VCs were significantly correlated with 30 day mortality (p = .001, R = 0.21). The 30 day readmission rate comprised nine patients (3.8%), with three (1.3%) due to VCs, including haematomas and groin infections.VCs contribute to operative morbidity in TAVI patients. This study demonstrated low major VC rates over an eight year period. Left sided location of largest sheath size and female gender were predictors of VC.

Objectives: This study assessed the safety and efficacy of cyanoacrylate glue embolization (CGE) for the treatment of refluxing varicose veins. Methods: A prospective registry was created starting January 2014 for all patients with refluxing varicose veins undergoing CGE at a single center. Neither tumescent anesthesia nor postinterventional compression stockings were incorporated into the treatment. All patients underwent clinical examination and duplex ultrasound evaluation at 2 and 6 months postprocedure. Results: CGE was performed in 67 patients or 103 extremities with 108 vein segments. Target vein segments included 82.4% (89 of 108) great saphenous veins, 12.0% (13 of 108) short saphenous veins, and 5.6% (6 of 108) accessory saphenous veins. The treated segment lengths had a range from 12 cm to 63 cm. Technical success, defined as complete closure of the refluxing vein immediately after the procedure diagnosed by duplex ultrasound, occurred in 100% (108 of 108) of vein segments. The procedure was well tolerated, with only 10.4% (7 of 67) of patients experiencing venospasm. Ultrasound results were available for 80.6% (54 of 67) and 46.3% (31 of 67) of patients at 2 and 6 months, respectively. Only one of 108 target vein segments demonstrated recanalization. The target vein segment occlusion rate at 6 months was 96.8% (30 of 31). No cellulitis or postprocedural paresthesia was reported. No serious adverse events, including deep vein thrombosis, occurred. Conclusions: CGE of refluxing varicose veins is safe and effective without the use of compression stockings or tumescent anesthesia at 6 months.

Objectives Postoperative stump pain after major lower limb amputation is a significant impediment to the recovery of amputees. The vast majority of patients require opioid analgesics following surgery, which are associated with opioid-related side-effects. Here, we investigate whether intraoperative placement of a peripheral nerve stump catheter followed by continuous infusion of local anesthetic is as effective at pain control as current analgesic practices. If beneficial, this procedure could potentially reduce post-amputation opioid consumption and opioid-related adverse effects. Methods A retrospective chart review was conducted of 198 patients over a 4-year period who had undergone a major lower limb amputation for indications related to peripheral vascular disease. Postoperatively, 102 patients received a perineural catheter were compared to 96 patients who did not. The primary outcomes of this study were the amount of morphine equivalents used in the first 72 hours postoperatively and postoperative pain intensity in the first 24 hours. Results A total of 198 lower-limb amputations were selected for analyses. Multiple regression analyses indicated that perineural catheter use was associated with a lower cumulative postoperative opioid consumption over the first 72 hours but not postoperative pain scores at 24 hours. Perineural catheter use led to a 40% reduction in opioid use during the first 72 hours postoperatively. Mixed model repeated measures analysis demonstrated that this opioid reduction was consistent over time. Other variables related to total opioid use included age, pre-surgical chronic pain, pre-surgical opioid use, patient-controlled analgesia. Conclusions Continuous perineural infusions of local anesthetic are a safe and effective method for reducing post-amputation opioid analgesic medications after major lower limp amputation.