Outcomes of one-stage and two-stage aneurysm repair in arteriovenous fistulae.

OBJECTIVE: Maintenance of long-term arteriovenous access is important in long-term care for patients with end-stage renal disease. Arteriovenous access is associated in the long term with the development of fistula aneurysms (FAs). This study aims to evaluate the outcomes of staged FA treatment in dialysis access arteriovenous fistulae (AVF). METHODS: A retrospective review of all patients over a 12-year period with primary autogenous AVF was undertaken at a single center. Patients undergoing elective open aneurysm repair were identified and were categorized into three groups: single FA repair (single, control group) and staged and unstaged repair of two FAs (staged and unstaged). A staged repair was a procedure in which the initial intent was to treat both aneurysms in the AVF and in which the most symptomatic aneurysm was treated first. When the incision from the first surgery had healed, the second symptomatic aneurysm in the AVF was treated. An unstaged repair was a procedure in which the initial intent was to repair both symptomatic aneurysms simultaneously. All patients had a fistulogram before the FA repair. Thirty-day outcomes, cannulation failure, line placement, reintervention, and functional dialysis (continuous hemodialysis for 3 consecutive months) were examined. RESULTS: Five hundred twenty-seven patients presented with FA that met requirements for open intervention; 44% underwent single FA repair, whereas the remaining 34% and 22% underwent staged and unstaged repair of two FAs, respectively. The majority of patients were diabetic and Hispanic. Ninety-one percent of the patients required percutaneous interventions of the outflow tract (37%) and the central veins (54%). Thirty-day major adverse cardiovascular events were equivalent across all modalities. Thirty-day morbidity and early thrombosis (<18 days) were significantly higher in the unstaged group (4.3%) compared with the two other groups (1.3% and 2.1%, single and staged, respectively), which led to an increased need for a short-term tunneled catheter (8.9%) compared with the two other groups (3.4% and 4.4%, single and staged, respectively), Unstaged repair resulted in an increased incidence of secondary procedures (5.0%) compared with the two other groups (2.6% and 3.1%, single and staged, respectively). Functional dialysis at 5 years was equivalent in the single and staged groups but was significantly decreased in the unstaged group. CONCLUSIONS: Open interventions are successful therapeutic modalities for FAs, but unstaged rather than staged repair of two concurrent FAs results in a higher early thrombosis, an increased secondary intervention rate, and a need for a short-term tunneled central line. Staged and single FA repairs have equivalent results. In the setting of two symptomatic FAs, staged repair is recommended.

Pedal medial arterial calcification influences the outcomes of isolated infra-malleolar interventions for chronic limb-threatening ischemia.

OBJECTIVE: Inframalleolar disease is present in most diabetic patients presenting with tissue loss. Inframalleolar (pedal) artery disease and pedal medial arterial calcification (pMAC) are associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). This study aimed to examine the impact of pMAC on the outcomes after isolated inframalleolar (pedal artery) interventions. METHODS: A database of lower extremity endovascular intervention for patients with tissue loss between 2007 and 2022 was retrospectively queried. Patients with CLTI were selected, and those undergoing isolated inframalleolar intervention on the dorsalis pedis and medial and lateral tarsal arteries and who had foot x-rays were identified. X-rays were assessed blindly for pMAC and scored on a scale of 0 to 5. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention to treat analysis by the patient was performed. Amputation-free survival (survival without major amputation) was evaluated. RESULTS: A total of 223 patients (51% female; 87% Hispanic; average age, 66 years; 323 vessels) underwent isolated infra-malleolar intervention for tissue loss. All patients had diabetes, 96% had hypertension, 79% had hyperlipidemia, and 63% had chronic renal insufficiency (55% of these were on hemodialysis). Most of the patients had Wound, Ischemia, and foot Infection (WIfI) stage 3 disease and had various stages of pMAC: severe (score = 5) in 48%, moderate (score = 2-4) in 31%, and mild (score = 0-1) in 21% of the patients. Technical success was 94%, with a median of one vessel treated per patient. All failures were in severe pMAC. Overall, major adverse cardiovascular events was 0.9% at 90 days after the procedure. Following the intervention, most patients underwent a planned forefoot amputation (single digit, multiple digits, ray amputation, or trans-metatarsal amputation). WIfI ischemic grade was improved by 51%. Wound healing at 3 months was 69%. Those not healing underwent below-knee amputations. The overall 5-year amputation-free survival rate was 35% ± 9%. The severity of pMAC was associated with decreased AFS. CONCLUSIONS: Increasing severity of pMAC influences the technical and long-term outcomes of infra-malleolar intervention in diabetes. Severe pMAC is associated with amputation and should be considered as a variable in the shared decision-making of diabetic patients with CLTI.

Management of depth to achieve timely arteriovenous fistula utilization.

OBJECTIVE: Failure to achieve timely arteriovenous fistulae (AVFs) utilization due to excessive depth (>6 mm) remains an ongoing concern for dialysis access. This study evaluates the outcomes of radiocephalic (RCF) and brachiocephalic (BCF) fistula elevation required for access utilization. METHODS: A retrospective review of all patients undergoing first-time autologous access over 10 years was undertaken. RCF and BCF were analyzed, and cases of initial access failure due to depth alone were selected for study. Primary and staged brachio-basilic AVF were excluded. Outcomes of early thrombosis, line placement, maturation (successful progression to hemodialysis [HD), reintervention, and functional dialysis (continuous HD for 3 consecutive months) were examined. RESULTS: From January 2012 to December 2022, 1733 patients (67% female; mean age, 61 ± 14 years) underwent autologous AVF placement. Of these, 298 patients (17%) had depth-related AVF access issues (BCF, 71% and RCF, 29%). Nineteen percent of these AVFs underwent a primary balloon-assisted maturation (BAM), and 2% had side branch coil embolization before consideration for elevation. The average time to intervention for depth was 11 ± 4 weeks after primary creation. During elevation, side branch ligation occurred in 38% of cases, and 15% underwent intraoperative BAM, The pre-elevation depth was 8.2 ± 3.1 mm, and the mean post-elevation depth was 4.7 ± 2.9 mm (P = .002). Early thrombosis (<18 days) occurred in 4% of cases. There was no mortality, and the 30-day major adverse cardiac event rate was 2%, with a 30-day morbidity of 5%, which was driven by wound issues. Six percent of the AVFs underwent follow-up BAM within 3 months. Mean maturation of the AVFs was 74% ± 3% vs 72% ± 3% (P = .58) for the elevation vs no-elevation groups at 24 weeks, respectively. However, there was an increase in tunneled central line placement in pre-emptive fistula patients due to the delay in maturation (elevation, 17% vs no-elevation, 8%; P = .008). There was a mean successful access time of 6 ± 3 weeks after elevation (16 ± 4 weeks after access creation). There was a median of 2.4 secondary interventions per year after elevation compared with a median of 2.7 secondary interventions per year without elevation. Mean access functionality was 68% ± 8% vs 75% ± 8% at 3 years for the elevation vs no-elevation groups, respectively (P = .25). CONCLUSIONS: Elevation of deep BCF and RCF occurs late after placement but can be successfully achieved with low morbidity and satisfactory long-term functionality. It results in an increase in tunneled central line placement in pre-emptive fistula patients. Elevation is a valuable adjunct to AVF maturation and enhances an autologous access policy.

Comparison of Open and Endovascular Aneurysm Repair in Native Arteriovenous Fistulas.

BACKGROUND: Arteriovenous accesses develop aneurysms (FA) during their active use, resulting in pain, erosion, bleeding, and difficulty in cannulation. This study aims to evaluate the outcomes of open and endovascular management of single FA in arteriovenous fistulas (AVF). METHODS: A retrospective review of all upper extremity primary AVFs over 12 years was undertaken at a single center. Patients undergoing elective open and endovascular repair of a single FA were identified. Thirty-day outcomes, cannulation failure, line placement, re-intervention, and functional dialysis (continuous hemodialysis) for 3 consecutive months were examined. RESULTS: Three hundred and seventy nine patients presented with a single FA that met the requirements for intervention: 126 (33%) underwent endovascular repair, and the remainder 253 (67%) underwent open repair. Preoperative fistulogram identified anatomically significant issues in 91% of the cases, and these were treated by balloon angioplasty: 10% within the fistula tract, 44% within the outflow tract, and 47% in the central veins. In open repair, 57% underwent plication, 35% underwent resection and re-anastomosis, and the remainder (8%) underwent interposition grafting. In endovascular repair, successful placement of a stent was achieved in all cases with 1 ± 2 (mean ± standard deviation [SD]) covered stents (diameter: 6 -8 mm) placed, achieving successful exclusion of the FA. The combination of early thrombosis and cannulation failures led to the greater need for a tunneled central line in endovascular repair (6.5% vs. 2.4%; endovascular versus open repair; P = 0.04). As a result, the mean time for establishing renewed access in the index AVF was significantly higher in endovascular repair (2 ± 3 vs. 2 ± 2 weeks, mean ± SD; endovascular open repair versus open repair; P = 0.001). In follow-up, there were more secondary interventions per year in the endovascular compared to open repair groups (3.1 vs. 1.4 secondary interventions per year; endovascular versus open repair; P = 0.04). Median functional dialysis durations were superior in the open repair (48 ± 6%, mean + standard error) compared to the endovascular repair at 5 years. (26 ± 7%; P = 0.03). CONCLUSIONS: Open repair results in a more rapid return to access use, lower need for a tunneled central line, lower secondary re-intervention rates, and superior functional dialysis durations compared to endovascular repair. Open FA repair should be considered for symptomatic single FA repairs before endovascular FA repair.

Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism.

BACKGROUND: Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS: A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS: In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS: The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.

Influence of a Novel Morphology-Driven Classification on Limb Salvage after Isolated Tibial Intervention for Chronic Limb Threatening Ischemia.

BACKGROUND: Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI. METHODS: A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated Infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300mm (1 point) and poor pedal runoff score (1 point). Patients were then divided into three groups: low-risk (0 or 1 points), moderate-risk (2 points), and high-risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-orientated outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated. RESULTS: 1607 patients (55% male, average age 60 years, 3846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic. origin Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day Major Amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate-risk and high-risk exceeded the goal threshold. For the OPG. Freedom from MALE was 60±5%, 46±5%, and 22±9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± SEM; p =0.008. Overall amputation-free survival (AFS) was 55±5%, 37±6%, and 18±7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± SEM; p=0.003). CONCLUSIONS: Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI.

Obesity drives secondary procedures to achieve access maturation in end-stage renal disease.

BACKGROUND: Establishing long-term arteriovenous access is an important component in the long-term care of a patient with end-stage renal disease. The increasing frequency of obesity is reported to impact the access management of end-stage renal disease patients. This study aims to evaluate the outcomes of arteriovenous fistulae (AVF) in obese and nonobese patients. METHODS: A retrospective review of all patients over ten years with primary autogenous AVF (radiocephalic, brachiocephalic, and brachial-basilic) was undertaken at a single center. Patients were subcategorized by body mass index into nonobese, class I, II, and III obesity. Outcomes of maturation (successful progression to hemodialysis), reintervention, functional dialysis (continuous hemodialysis for 3 consecutive months), and patency were examined. RESULTS: From January 1999 to December 2019, 2311 patients (67% female; mean age, 61 ± 15 years) underwent primary AVF placement (12% radiocephalic, 53% brachiocephalic, and 35% brachial basilic). Forty-one percent were nonobese, 29% had class I obesity, 19% had class II obesity, and 11% had class III obesity. The majority of patients were diabetic and Hispanic. The 30-day major adverse cardiovascular event rate was elevated in class II (0.20%) and class III (0.50%) obesity compared with class I obesity (0.15%) and nonobese (0.05%). The 30-day morbidity rate was higher in all classes of obesity (0.5% vs0.3% vs 0.2% vs 0.05% for class III vs class II vs class I obesity and nonobese, respectively). Early thrombosis was significantly increased in class II (9%) and class III obesity (12%) compared with class I obesity (5%) and nonobese (3%). There was a two-fold increase in procedures to effect maturation in class II (51%) and class III (74%) obesity compared with class I obesity (22%) and nonobese (34%). Secondary patency at 3 years was significantly lower in class III (62 ± 4%) and class II (79 ± 3%) compared with class I obesity (87 ± 2%) and nonobese (93 ± 4%). All classes of obesity required significantly more secondary Interventions per year compared with nonobese (3.9 vs 3.1 vs 2.5 vs 1.4 secondary interventions per year for class III vs class II vs class I obesity and nonobese, respectively). CONCLUSIONS: Advancing obesity class is associated with an increased number of procedures to achieve AVF maturation and is associated with poorer patency and functionality as the category of obesity advances.

An analysis of vascular surgery education publications reveals an educational shortage.

BACKGROUND: As vascular surgery training continues to evolve with the growth of integrated vascular surgery residency (0+5) programs and the consolidation of fellowship programs, optimizing all aspects of the education for vascular surgery trainees, both fellows and 0+5 residents, has become increasingly important. In the present study, we aimed to determine the prevalence, quality, and content of vascular surgery education publications across journals. METHODS: Journal websites (n = 26) and PubMed were queried to identify vascular surgery education publications from 2012 to 2021. The publications were organized into 11 content categories: (1) curriculum, (2) simulation, (3) trainee assessment, (4) program evaluation, (5) wellness/burnout, (6) diversity/inclusion, (7) mentorship/career, (8) case outcomes, (9) perceptions of training, (10) social media, and (11) other. Publication interactivity and quality were measured via PlumX data and Medical Education Research Study Quality Instrument scores. The data were analyzed via univariate analysis and linear regression. RESULTS: A total of 115 vascular surgery education publications (0.2% [interquartile range (IQR), 0.04%-0.5%] of total publications) were identified from the selected journals. The Journal of Vascular Surgery had the highest proportion (0.8%) of vascular surgery education publications, followed by the Journal of Surgical Education (0.7%) and Annals of Vascular Surgery (0.6%). Vascular surgery journals constituted most (79%) of the publications. Of the authors, 15% (IQR, 0%-25%) had a master's or doctorate degree in education. Senior authors were more often identified as male gender (77%), and more first authors (41%) were identified as female gender. An interactivity analysis showed that there were 10.3 citations (IQR, 12), 33.1 captures (IQR, 34), and 8.4 social media interactions (IQR 14) per publication. The educational quality had a median Medical Education Research Study Quality Instrument score of 11 (IQR, 9-12.5), with 49% of publications having a score greater than the median. Publications on training (44% curriculum and 20% simulation) were significantly more frequent than other topics (P < .001), with no change in the publication content over 10 years (P = .29). The volume of vascular surgery education publications did not change during the study period (P = .13) despite the ongoing changes in the educational environment. CONCLUSIONS: Despite the increasing importance placed on vascular surgery education by national vascular societies, publications on vascular surgery education have remained sparse among all journals. Also, the vascular surgery educational content has not changed during the past 10 years, with a primary focus on curriculum and simulation training. Further promotion of vascular surgery educational research is required to increase the quality, volume, and diversity of education publications.

A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery.

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

Factors associated with successful median arcuate ligament release in an international, multi-institutional cohort.

OBJECTIVE: Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure. METHODS: The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up. RESULTS: For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval [CI], 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio [HR], 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure. CONCLUSIONS: No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.

Acute Kidney Injury Following Revascularization in Patients With Chronic Limb-Threatening Ischemia and Non-Dialysis-Dependent Chronic Kidney Disease: Insights From the NSQIP Database at 30-Day Follow-Up.

BACKGROUND: Patients with chronic limb-threatening ischemia (CLTI) and chronic kidney disease (CKD) are at risk of developing renal injury following revascularization. We aimed to compare the risk of adverse renal events following endovascular revascularization (ER) or open surgery (OS) in patients with CLTI and CKD. METHODS: A retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) databases (2011-2017) was performed including patients with CLTI and non-dialysis-dependent CKD, comparing ER to OS. The primary outcome was a composite of postprocedural kidney injury or failure within 30 days. Thirty-day mortality, major adverse cardiac and cerebrovascular events (MACCE), amputation, readmission or target lesion revascularization (TLR) were compared using multivariate logistic regression and propensity-score matched analysis. RESULTS: A total of 5009 patients were included (ER: 2361; OS: 3409). The risk for the composite primary outcome was comparable between groups (odds ratio [OR]: 0.78, 95% confidence interval (CI): 0.53-1.17) as for kidney injury (n=54, OR: 0.97, 95% CI: 0.39-1.19) or failure (n=55, OR: 0.68, 95% CI: 0.39-1.19). In the adjusted regression, a significant benefit was observed with ER for the primary outcome (OR: 0.60, p=0.018) and renal failure (OR: 0.50, p=0.025), but not for renal injury (OR: 0.76, p=0.34). Lower rates of MACCE, TLR, and readmissions were observed after ER. Thirty-day mortality and major amputation rates did not differ. In the propensity score analysis, revascularization strategy was not associated with renal injury or failure. CONCLUSIONS: In this cohort, the incidence of renal events within 30 days of revascularization in CLTI was low and comparable between ER and OR. CLINICAL IMPACT: In a cohort of 5009 patients with chronic limb-threatening ischemia and non-end-stage chronic kidney disease (CKD), postprocedural kidney injury or failure within 30 days was comparable between patients submitted to open or endovascular revascularization (ER). Lower rates of major adverse cardiac and cerebrovascular events, target lesion revascularization, and readmissions were observed after endovascular revascularization. Based on these findings, ER should not be avoided due to fear of worsening renal function in CKD patients with chronic limb-threatening ischemia. In fact, these patients benefit more from ER regarding cardiovascular outcomes with no increased risk of kidney injury.

Systematic review of vascular surgery recruitment strategies for medical students and general surgery residents.

OBJECTIVES: Recruitment into the vascular surgery specialty is an imperative as the specialty faces significant demographic changes. Due to the changing dynamics in vascular surgery training pathways, we sought to review current literature on recruitment strategies and their effectiveness with medical students and general surgery residents. METHODS: A systematic search, following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, was performed by searching MEDLINE, EMBASE, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Education Resources Information Center (ERIC) databases for studies on vascular surgery recruitment methods for medical students and general surgery residents from inception of databases to December 31, 2021. Reports in English discussing recruitment strategies were included. Reports lacking recruitment method data and those with insufficient data were excluded. RESULTS: Ten reports met inclusion criteria and studied a total of 688 participants. Seven reports (70%) employed simulation, didactic, or online courses. The remaining 30% of studies included data on mentorship, research, or other interventions. Most of the studies (50%) reported data for medical students (MS1-MS4). Interventions specific to residents or both students and residents comprised the other 50% of studies. Simulation and didactic courses increased interest in vascular surgery by a median of 50% (interquartile range, 38%-64%) for both medical students and residents. Importantly, without reinforcement, interest was seen to decrease over time. CONCLUSIONS: Recruitment interventions are useful in increasing student interest in vascular surgery. Early exposure to simulated vascular surgery procedures and mentorship are cited as common reasons for entering the field. Further studies on recruitment strategies focused on long-term outcomes are required.

Perioperative care in open aortic vascular surgery: A consensus statement by the Enhanced Recovery After Surgery (ERAS) Society and Society for Vascular Surgery.

The Society for Vascular Surgery and the Enhanced Recovery After Surgery Society formally collaborated and elected an international, multidisciplinary panel of experts to review the literature and provide evidence-based recommendations related to all the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites) for aortic aneurysm and aortoiliac occlusive disease. Structured around the Enhanced Recovery After Surgery core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

How Competitive are Integrated Vascular Surgery Residency Programs? A Ten-Year Comparison Using a Normalized Competitive Index.

BACKGROUND: Integrated vascular surgery residency (VS) programs have increased in popularity and offer an accelerated track compared to the traditional fellowship pathway. We sought to create a simple metric for medical students to better assess the competitiveness of VS training programs compared to general surgery (GS) programs. METHODS: GS and VS programs were compared using the National Resident Matching Program match data from 2012 to 2021. Applicant metrics (board scores, research output and experiences, work experiences, and volunteer experiences) from 2015 to 2019 were obtained using the Association of American Medical Colleges Report on Residents. A competitive index (CI) was created (number of programs ranked per applicant divided by match rate) for each specialty and normalized (NCI) to a value of 1 to improve longitudinal comparisons. NCI and number of programs ranked per applicant were plotted across time and a linear regression was performed to evaluate a 10-year trend. RESULTS: The match rate of both specialties was 52% and was similar for GS and VS programs. CI was higher for VS compared to GS (18.4 ± 3.0 vs. 14.5 ± 0.4; P < 0.001). The number of programs ranked per applicant was higher in VS compared to GS (9.4 vs. 7.7, P < 0.05). The linear regression revealed increasing NCI and number of programs ranked per applicant over time for VS programs compared to GS with all R2 > 0.61 (P < 0.001). CONCLUSIONS: Matching into a VS programs is becoming increasingly competitive. The average CI was approximately 27% higher for VS programs compared to GS programs despite similar match rates. As VS programs continue to evolve, NCI may be a more useful metric for applicants.

Quality Assessment of Online Resources for Thoracic Outlet Syndrome Patients.

BACKGROUND: The internet has become a leading resource for patients, to research information about their medical conditions. Access to inaccurate information can lead to miscommunication, poor patient satisfaction and effect shared decision-making with the provider. This study seeks to evaluate the quality and readability of patient resources that appear in the top search results for Thoracic Outlet Syndrome (TOS). METHODS: Searches were performed for "TOS" and "Thoracic Outlet Syndrome" on the search engines Google ©, Yahoo ©, and Bing©, and on the meta-search platforms Yippy© and Dogpile©. Websites were screened for exclusion and evaluated by 2 reviewers for accountability, interactivity, structure/organization, and content. Exclusion criteria included duplications, no original content on TOS, resources not intended for patients, foreign language, and inaccessible websites. Reviewers came to a consensus on scoring discrepancies. Four indices were used to evaluate readability. Statistical analysis was performed using the Rstudio with ANOVA. RESULTS: In total, 44 websites met inclusion criteria. There were 25 hospital/healthcare organization websites (57%), 11 open access (25%), 5 government agency (11%), 2 professional medical society (5%), and 1 industry sponsored (2%). Median scores were 5.00 out of 16.00 for Accountability (interquartile range IQR: 1.50-8.75), 1.50 out of 5.00 for Interactivity (IQR:1.50-1.50), 3.00 out of 4.00 for Structure/Organization (IQR: 2.00-3.13), 10.00 out of 25.00 for Content (IQR: 7.90-12.63) and 20.25 out of 50.00 for Total Score (IQR: 16.73-27.75). Websites performed well-describing TOS with 98% of websites providing a definition, 90% providing an etiology, 93% providing description or images of the anatomy, 98% providing symptoms of neurogenic TOS, 93% providing symptoms of venous TOS, and 93% providing symptoms of arterial TOS. Physical therapy was the most discussed treatment option (91%) followed by decompression surgery (86%), thrombolysis (41%), vascular repair (39%), interscalene injections (18%), and embolectomy (11%). There was no significant difference across website types for any category other than accountability where Open Access scored the highest (Table II). Readability was difficult with median Flesch Reading Ease formula score correlating to a college level (IQR: 10th-12th grade-college), median Flesch-Kincaid Grade Level of 10 (IQR: 9th-12th grade), median Standardized Measure of Gobbledygook (SMOG) grade of 10 (IQR: 9th-11th grade), and median Dale-Chall Readability Formula Score correlating to 11th-12th grade (IQR: 11th to 12th-college grade level). There was no significant difference between website types for readability. CONCLUSIONS: The top web results for TOS have varying degrees of quality with a clear gap in certain areas of information. While websites performed well-explaining the disease, they lacked discussion of the full scope of treatment that may be offered. In addition, readability was poor across all website types which will not help patients' understanding of their condition. Providers should take into account the variability in websites when entering into shared decision-making discussions with patients.

Deep Venous Arterialization for Chronic Limb Threatening Ischemia in Atherosclerosis Patients - A Meta-Analysis.

BACKGROUND: Venous arterialization is an upcoming and novel alternative in chronic limb threatening ischemia (CLTI) patients in the absence of standard revascularization options. The aim of this study is to systematically review and analyze outcomes of venous arterialization. METHODS: A systematic literature search was performed in 5 databases using the PRISMA methodology. Inclusion criteria were English language original research papers on CLTI patients treated with venous arterialization. EXCLUSION CRITERIA: absence of CLTI due to atherosclerosis, duplicate study or reporting of patients, meeting abstract only. Quality and risk of bias were evaluated. Meta-analysis was performed using random effects model on articles that have a sample size of equal or greater than 10. RESULTS: Twelve studies included 442 patients that underwent treatment for 445 limbs (374 patients and 377 limbs underwent venous arterialization while remainder underwent traditional bypass and served as control subjects). Average age was 66 [18 studies, range 37 -91 years], 68% were male [271/366, 15 studies] and 67% diabetic [271/406, 16 studies]). Most limbs (88%, 352/398, 16 studies) had tissue loss. Pooled 30-day mortality was 3.7% (95%-confidence interval [CI] 0.8 -6.6%), 30-day morbidity was 15.5% (95%-CI 3.2 -27.8%), 30-day major adverse cardiovascular event was 5.2% (95%-CI 1.7 -8.6%) and 30-day major adverse limb event was 16.7% (95%-CI 1.5 -31.9%). Pooled 1-year limb-salvage rate was 79.0% (95%-CI 68.7 -90.7) and 1-year survival rate was 85.7% (95%-CI 76.2 -96.4). Studies quality varied significantly across studies. CONCLUSION: Venous arterialization has an acceptable a 1-year limb salvage rate of 79%, however, this is based on low levels of evidence. More randomized controlled trials or high-quality cohort studies are needed to further define the effectiveness of this procedure for CLTI.

Management of Arterio-Venous Fistula Side Branches During Maturation: Ligation or Coil Embolization.

OBJECTIVE: Failure of maturation of arteriovenous fistulae (AVF) remains an ongoing concern for dialysis access. One etiology is the presence of side branches that divert flow from the main AVF channel. This study aims to evaluate the outcomes of endovascular and open surgical interventions for AVF side branches in the setting of maturation failure. METHODS: A retrospective review of all patients within a 10-year period with primary radio cephalic and brachiocephalic AVF was undertaken, and 380 cases of maturation failure related to branch diversion were selected for the study. Fifty-four percent and 48% of the AVF in the ENDO and OPEN groups respectively have concomitant stenosis further along in the flow path that required intervention by balloon angioplasty at the same time as a side branch intervention. All patients underwent duplex imaging or a fistulogram before intervention. Indications were low flow (<600 mL/min) or failure to increase in size (<6 mm diameter) in all cases. Interventions were divided into endovascular (coil embolization; ENDO) and surgical (branch ligation; OPEN) interventions. Outcomes of maturation (successful progression to hemodialysis (HD)), re-intervention, and functional dialysis (continuous HD for three consecutive months) were examined. RESULTS: From January 2008 to December 2018, 187 patients (49^ of all cases with side branches; 65% female, age of 57 ± 18 years; mean ± SD) with poorly maturing radiocephalic (70%) and brachiocephalic AVF (30%) underwent intervention due to the presence of accessory venous branches only. Indications were failure to mature in 54% and low flow in 46%. The average time to intervention due to failure to mature was 5 ± 4 weeks (mean ± SD) after primary access placement. Eighty-one had coil embolization and 106 had open branch ligation. Technical success was 90% in ENDO and 100% in OPEN. Technical ENDO failures had a secondary open branch ligation but were considered failures for analysis. Repeat interventions by balloon-assisted maturation were required in 45% of all the cases with no difference between ENDO and OPEN. Recannulation of the ENDO branches occurred in 10% of the cases requiring repeat intervention. Sixty one percent of isolated endovascular (n = 49) and 64% of isolated open (n = 68) matured to successful cannulation (P = 0.84). Median functional dialysis durations remained equivalent between ENDO (2.6 years) and OPEN (2.8 years) groups (P = 0.12). CONCLUSION: There is an improved maturation rate following the ENDO group compared to OPEN interventions while both ENDO and OPEN modalities demonstrated similar long-term functionality.

Quality Analysis of Online Resources for Patients with Peripheral Artery Disease.

BACKGROUND: The burden of peripheral artery disease is significant for public health but the readily available on-line information on the disease is poorly studied. This study seeks to evaluate the quality and readability of patient resources and identify gaps that appear in the top search results for peripheral artery disease. METHODS: Internet searches were performed for "PAD" and "Peripheral Artery Disease" and "PVD" on three search engines and two metasearch engines. The top 30 websites from each search engine were compiled, screened, and evaluated across four categories of information to assess overall quality: accountability, interactivity, structure, and content. Four indices were used to evaluate readability of the text for the viewer. Statistical analyses was performed using Rstudio with ANOVA. RESULTS: Sixty-three websites met inclusion criteria, of which 25 were open access (34.9%), 30 were from hospital/healthcare organization (48%), 5 were from a governmental agency (8%), 4 were industry sponsored (6%), and 2 were from professional medical societies (3%). Median total quality score was 19 out of 47 (IQR, 15 -30): of the components of this score, accountability was 5 out of 17 (2 -10), interactivity was 2 out of 5 (2.0 -2.0), site structure was 3 out of 4 (2.5 -3.0), and site content was 11 out of 21 (7 -14). Total score varied significantly by organization type (P = 0.007). Open access (30, 17 -34, median, IQR) and governmental agency (30, 29 -31) websites scored the highest while hospital/healthcare organization (16, 14v21) websites scored the lowest. Overall readability was low with a median Flesch-Kincaid Grade Level Score of 10.7 (IQR, 10 -12). Using this index, only one website (1.6%) was written below the recommended 6th grade reading level. CONCLUSION: Freely available online patient education materials for peripheral artery disease are poor, have varying quality, and are largely written at a level higher than that of an average US adult thus depriving the patient from understanding the existing information. We recommend that the vascular surgery community re-examine the current offering and provide improved readable websites to patients to facilitate patient education and shared decision making.

Extent of heel ulceration influences the outcomes in patients with isolated infrapopliteal limb threatening critical ischemia.

BACKGROUND: The aim of the present study was to assess the effects of the extent of heel ulceration on the outcomes of limb threatening critical ischemia due to isolated infrapopliteal disease. METHODS: A retrospective review identified 989 patients with isolated infrapopliteal disease and heel ulceration treated from 2001 to 2018. The heel was defined as the back of the foot, extending from the Achilles tendon to around the plantar surface and covering the apex of the calcaneum bone. Heel ulceration was categorized into three groups by area: <5 cm2, 5 to 10 cm2, and >10 cm2. The interventions were endovascular, open bypass, major amputation, and wound care. An intention-to-treat analysis by patient group was performed. The 30-day outcomes and amputation-free survival (AFS; survival without a major amputation) were evaluated. RESULTS: Of the 989 patients, 384 (58% male; average age, 65 years; n = 768 vessels) had undergone isolated endovascular tibial intervention, 124 (45% male; average age, 59 years) had undergone popliteal tibial vein bypass for limb threatening critical ischemia, 219 (52% male; average age, 67 years) had undergone major amputation, and 242 (49% male; average age, 66 years) had received wound care. No difference was found in the 30-day major adverse cardiac events in the endovascular and open bypass groups, with significantly more events in the major amputation group (P = .03). The 30-day major adverse limb events and 30-day amputation rates were equivalent between the open bypass and endovascular groups. The 5-year AFS rate was superior in the open bypass group (37% ± 8%; mean ± standard error of the mean) compared with the endovascular group (27% ± 9%; P = .04). The wound care group had a 5-year AFS rate of 20% ± 9%, which was not significantly different from that of the endovascular group. Patients with heel ulcers of <5 cm2 had better AFS (47% ± 8%) than those with 5- to 10- cm2 heel ulceration (24% ± 9%). Heel ulcers >10 cm2 were associated with markedly worse 5-year AFS outcomes (0% ± 0%). The presence of end-stage renal disease, osteomyelitis, uncontrolled diabetes (hemoglobin A1c >10%), and/or frailty combined with a heel ulcer >10 cm2 were predictive of poor AFS. CONCLUSIONS: An increasing heel ulcer area combined with osteomyelitis and systemic comorbidities was associated with worsening 30-day outcomes and 5-year AFS, irrespective of the therapy chosen.

Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries.

Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.