Open E-survey on the Use and Perception of Chatbots in Vascular Surgery.

Objective: Large language models and artificial intelligence (AI) based chatbots have brought new insights in healthcare, but they also raise major concerns. Their applications in vascular surgery have scarcely been investigated to date. This international survey aimed to evaluate the perceptions and feedback from vascular surgeons on the use of AI chatbots in vascular surgery. Methods: This international open e-survey comprised 50 items that covered participant characteristics, their perceptions on the use of AI chatbots in vascular surgery, and their user experience. The study was designed in accordance with the Checklist for reporting Results of Internet E-Surveys and was critically reviewed and approved by international members of the European Vascular Research Collaborative (EVRC) prior to distribution. Participation was open to self reported health professionals specialised (or specialising) in vascular surgery, including residents or fellows. Results: Of the 342 individuals who visited the survey page, 318 (93%) agreed to participate; 262 (82.4%) finished the survey and were included in the analysis. Most were consultants or attending physicians (64.1%), most declared not having any training or education related to AI in healthcare (221; 84.4%), and 198 (75.6%) rated their knowledge about the abilities of AI chatbots between average to very poor. Interestingly, 95 participants (36.3%) found that AI chatbots were very useful or somewhat useful in clinical practice at this stage and 229 (87.4%) agreed that they should be systematically validated prior to being used. Eighty participants (30.5%) had specifically tested it for questions related to clinical practice and 59 (73.8%) of them experienced issues or limitations. Conclusion: This international survey provides an overview of perceptions of AI chatbots by vascular surgeons and highlights the need to improve knowledge and training of health professionals to better evaluate, define, and implement their use in vascular surgery.

Effects of timing of repair on mortality following thoracic endovascular aortic repair for blunt thoracic aortic injury.

OBJECTIVES: Blunt thoracic aortic injuries (BTAI) are traditionally treated as emergencies with most fixed within 24 hours of arrival by thoracic endovascular aortic repair (TEVAR) regardless of grade of injury. However, the optimal timing of repair remains debated. METHODS: All patients with grade 2 and 3 BTAI enrolled in the Aortic Trauma Foundation prospective multi-center registry from 2015 to 2022 were categorized dependent on timing of repair (ER=Early Repair<24 hours, LR=Late Repair>24 hours). Chi-square/Fisher's exact tests were used to compare patient/operative factors and logistic regression analysis was performed to identify factors related to 30-day mortality. RESULTS: 222 Grade 2 and 3 BTAI treated by TEVAR were analysed, with 179 in the ER group (81%). There was no difference between the groups regarding Injury Severity Score (ISS), Glasgow Coma Scale (GCS), age, or gender. Those in ER were more likely to have a widened mediastinum and a shorter distance from the left subclavian artery to the injury. 30-day in-hospital mortality occurred in 14 patients (6%); 2 of which were aortic-related. 30-day mortality was associated with a higher baseline incidence of CAD/PVD/previous cardiac revascularisation; lower systolic blood pressure, GCS, hemoglobin, platelet count and blood pH; and higher lactate and ISS on arrival. On multivariate regression analysis, lower haemoglobin, higher ISS, and Grade 3 BTAI were associated with 30-day mortality (p<0.05), although time to TEVAR was not. DISCUSSION: In selected patients, delay in performance of TEVAR for Grade 2 & 3 BTAI may be possible. Further research is necessary to identify other factors predictive of success.

Treating deep venous insufficiency with a novel implantable device.

Chronic venous insufficiency (CVI) is increasing in prevalence on a global scale. Current treatment options are limited to improving venous return, ablation of refluxing veins, and reducing outflow obstruction. A new bioprosthetic device, the VenoValve, may bridge the gap of treatment for patients with chronic venous insufficiency who have failed prior treatment. We demonstrate the treatment of a 72-year-old man with bilateral venous insufficiency and leg wounds using this device in his left femoral vein via an open anterior surgical approach. The patient had no postoperative complications, and a patent valve at 6 months. The VenoValve may be a viable option for patients with advanced chronic venous insufficiency.

A Bibliometric Analysis on Adherence to Reporting Standards for Endovascular Treatment of Chronic Lower Extremity Peripheral Artery Disease.

BACKGROUND: The treatment of chronic limb-threatening ischemia (CLTI) involves a broad spectrum of therapies including many new and emerging techniques. To standardize the results of studies examining this pathology and to allow critical analysis and comparison between studies, the Society for Vascular Surgery (SVS) recommended reporting standard guidelines for the endovascular management of CLTI in 2016. Research studies that do not adhere to complete reporting standards are often more ambiguous in impact and external validity, leading to bias and misinformation that has potentially damaging effects on clinical decision-making. We thus sought to examine adherence to and factors associated with noncompliance with these recommended guidelines. METHODS: A literature database search was conducted to include all clinical trials, randomized controlled trials, and retrospective comparative studies written in English examining the endovascular treatment of peripheral artery disease (PAD)/CLTI from January 2020 to August 2022. Systematic reviews, case reports, and meta-analysis were excluded. The manuscripts were reviewed for adherence with the SVS guidelines (overall and by guideline subcategories based on demographics, treatment methods, and outcomes), and factors associated with this adherence were determined. These data were used to calculate descriptive and comparative statistics. RESULTS: Fifty-four manuscripts were identified from this time frame. On average, articles reviewed reported on 42.0% of the SVS reporting standards (range, 25.0-65.2%, Fig 1) with 74.1% of articles (n = 40) not adhering to at least 50.0% of the standards. Manuscripts most completely followed guidelines regarding "patient factors" and were least likely to demonstrate adherence to the description of CLTI and study complications. Within the guideline subcategories, complete adherence to guidelines was not demonstrated in any manuscript in stent trials, disease outcome measures, technical outcome measures, patient factors and critical limb ischemia description, and complete adherence rates within the other subcategories was low (range, 5.6-18.6%). Studies conducted within the United States and those with industry sponsorship were more likely to adhere to >50% of the reporting standards (P < 0.05). Journal impact factor, year of publication, and number of authors had no correlation to the percent adherence to guidelines in specific categories or adherence overall. CONCLUSIONS: Adherence to reporting standard guidelines for endovascular treatment of lower extremity PAD specifically outlined by the SVS is suboptimal regardless of the quality of the journal the research is published in. Increasing adherence to reporting standards to provide a framework for comparison of studies across techniques used should be prioritized by authors, journal editors, and vascular societies.

Factors Associated With Tobacco Cessation Advice Recall and Quit Rates in Vascular Surgery Patients. A Single Center Study.

OBJECTIVES: Smoking is an important modifiable risk factor in all vascular diseases and verbal advice from providers has been shown to increase rates of tobacco cessation. We sought to identify factors that will improve tobacco cessation and recall of receiving verbal cessation advice in vascular surgery patients at a single institution. METHODS: The study is a retrospective cohort study. Patients seen in outpatient vascular surgery clinic who triggered a tobacco Best Practice Advisory (BPA) during their office visits over a 10-month period were contacted post-clinic and administered surveys detailing smoking status, cessation advice recall, and validated scales for nicotine dependence and willingness to quit smoking. This BPA is a "hard stop" that requires providers to document actions taken. Charts were reviewed for tobacco cessation documentation. Nine-digit zip-codes identified the area deprivation index, a measure of socioeconomic status. Univariate analysis was used to identify factors associated with cessation and advice recall. RESULTS: One hundred out of 318 (31.4%) patients responded to the survey. Epic Slicer Dicer found 97 BPA responses. To dismiss the BPA, 89 providers (91.8%) selected "advised tobacco cessation" and "Unable to Advise" otherwise. Of the 318 patients, 115 (36.1%) had cessation intervention documented in their provider notes and 151 (47.5%) received written tobacco cessation advice. Of survey respondents, 70 recalled receiving verbal advice, 27 recalled receiving written advice, 28 reported receiving offers of medication/therapy for cessation. 55 patients reported having tobacco cessation plans, and among those 17 reported having quit tobacco. Recall of receiving written advice (P < .001) and recall of receiving medication/therapy (P = .008) were associated with recall of receiving verbal cessation advice. CONCLUSIONS: Providing patients with tobacco cessation medication/therapy and written tobacco cessation education during office visits is associated with increased patients' recall of tobacco cessation advice. Vascular surgeons should continue to provide directed tobacco cessation advice.

Intravascular Ultrasound May Not Impact Graft Sizing in Endovascular Repair of Blunt Thoracic Aortic Injury.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for severe blunt thoracic aortic injuries (BTAI). Successful outcomes rely on accurate endograft sizing, but initial imaging may underestimate aortic diameters. This study examines the impact of intravascular ultrasound (IVUS) on endograft sizing and clinical outcomes in BTAI patients. METHODS: A prospectively collected multi-institutional dataset from the Aortic Trauma Foundation was analyzed. Patients with BTAI undergoing TEVAR with IVUS were compared to patients who underwent TEVAR alone. Demographics and operative variables were compared, focusing on IVUS effects on endograft sizing by examining maximal proximal and distal aortic diameter on initial CT imaging compared to the graft diameters used during TEVAR. RESULTS: 293 patients underwent TEVAR for BTAI with IVUS utilized in 124 cases (42.3%). The average graft size in the IVUS and non-IVUS groups were similar proximally (26.91 ± 4.3 mm IVUS vs 27.77 ± 4.7 mm non-IVUS, P = 0.116) and distally (25.96 ± 4.7 mm IVUS vs 26.51 ± 4.7 mm non-IVUS). IVUS did not impact the difference between graft size and initial CT measurements proximally (4.32 ± 4.8 mm IVUS vs 4.23 ± 3.9 mm non-IVUS, P = 0.859) or distally (4.17 ± 5.9 mm IVUS vs 4.50 ± 4.3 mm non-IVUS, P = 0.606). Although delayed hemorrhagic and ischemic stroke occurred less frequently in IVUS patients (0.8% IVUS vs 7.1% non- IVUS, P = 0.024), in-hospital mortality was similar between groups (5.6% IVUS vs 7.7% non-IVUS, P = 0.581). CONCLUSIONS: IVUS is not associated with significant changes in endograft sizing compared to sizing based on CT scan alone in BTAI patients. IVUS was not associated with differences in mortality but was associated with a decrease in delayed hemorrhagic and ischemic stroke. Routine IVUS in BTAI patients may not be necessary for accurate sizing, but there may be a relationship between IVUS and stroke.

A national census for the off-label treatment of complex aortic aneurysms.

OBJECTIVE: Despite regulatory challenges, device availability, and rapidly expanding techniques, off-label endovascular repair of complex aortic aneurysms (cAAs) has expanded in the past decade. Given the lack of United States Food and Drug Administration-approved endovascular technology to treat cAAs, we performed a national census to better understand volume and current practice patterns in the United States. METHODS: Targeted sampling identified vascular surgeons with experience in off-label endovascular repair of cAAs. An electronic survey was distributed with institutional review board approval from the University of Rochester to 261 individuals with a response rate of 38% (n = 98). RESULTS: A total of 93 respondents (95%) reported off-label endovascular repair of cAAs. Mean age was 45.7 ± 8.3 years, and 84% were male. Most respondents (59%) were within the first 10 years of practice, and 69% trained at institutions with a high-volume of off-label endovascular procedures for complex aortic aneurysms with or without a physician-sponsored investigational device exemption (PS-IDE). Twelve respondents from 11 institutions reported institutional PS-IDEs for physician-modified endografts (PMEGs), in-situ laser fenestration (ISLF), or parallel grafting technique (PGT), including sites with PS-IDEs for custom-manufactured devices. Eighty-nine unique institutions reported elective off-label endovascular repair with a mean of 20.2 ± 16.5 cases/year and ∼1757 total cases/year nationally. Eighty reported urgent/emergent off-label endovascular repair with a mean of 5.7 ± 5.4 cases/year and ∼499 total cases/year nationally. There was no correlation between high-volume endovascular institutions (>15 cases/year) and institutions with high volumes of open surgical repair for cAAs (>15 cases/year; odds ratio, 0.7; 95% confidence interval, 0.3-1.5; P = .34). Elective techniques included PMEG (70%), ISLF (30%), hybrid PMEG/ISLF (18%), and PGT (14%), with PMEG being the preferred technique for 63% of respondents. Techniques for emergent endovascular treatment of complex aortic disease included PMEG (52%), ISLF (40%), PGT (20%), and hybrid-PMEG/ISLF (14%), with PMEG being the preferred technique for 41% of respondents. Thirty-nine percent of respondents always or frequently offer referrals to institutions with PS-IDEs for custom-manufactured devices. The most common barrier for referral to PS-IDE centers included geographic distance (48%), longitudinal relationship with patient (45%), and costs associated with travel (33%). Only 61% of respondents participate in the Vascular Quality Initiative for complex endovascular aneurysm repair, and only 57% maintain a prospective institutional database. Eighty-six percent reported interest in a national collaborative database for off-label endovascular repair of cAA. CONCLUSIONS: Estimates of off-label endovascular repair of cAAs are likely underrepresented in the literature based on this national census. PMEG was the most common technique for elective and emergent procedures. Under-reported off-label endovascular repair of cAA outcomes data appears to be limited by non-standardized PS-IDE reporting to the United States Food and Drug Administration, and the lack of Vascular Quality Initiative participation and prospective institutional data collection. Most participants are interested in a national collaborative database for endovascular repair of cAAs.

Practice Patterns and Barriers to Vascular Genetic Testing Among Vascular Surgeons.

INTRODUCTION: Engaging patients living with or at risk of aortic dissection via the Aortic Dissection Collaborative, physician education in vascular genetics was identified as a research priority. We surveyed vascular surgeons to characterize practice patterns, motivations, and barriers regarding aortopathy genetic testing. METHODS: An anonymous 27-question survey was distributed on social media platforms between November and December 2022. Domains included demographics, vascular genetic education, testing attitudes and utilization, and experience in treating patients with genetic vascular aortopathies. The analysis included summary statistics and unpaired t-test to compare responses by interest in incorporating testing and practice type. RESULTS: A total of 171 vascular surgeons from 15 countries responded to the survey (23% trainees). Over half received vascular genetics education during training (59%), and most (86%) were interested in incorporating genetic testing into their practice. Academic surgeons were more likely to have cared for a patient with a known genetic aortopathy over the past year than surgeons in hospital-based and private practices (83% vs. 56% vs. 27%; P < 0.01), to have ever made a referral to a medical geneticist (78% vs. 51% vs. 9%; P < 0.01), and have access to genetic counselors or geneticists (66% vs. 46% vs. 0%; P < 0.01). Barriers to genetic testing were rated as more significant by surgeons in nonacademic practices, with top barriers being insurance coverage of testing, cost of genetic testing, and access to genetic counselors. Evidence-based professional society guidelines were the strongest rated motivating factor for testing incorporation among respondents. CONCLUSIONS: Vascular surgeon attitudes are not major barriers to incorporating genetic testing for patients with aortopathies; however, practical challenges regarding genetic testing and counseling are barriers to implementation especially for vascular surgeons in nonacademic practices. Future efforts should focus on evidence-based society guidelines, continuing medical education to increase adoption, and facilitating access to genetic counseling.

Early survival benefit of a low-profile endograft in blunt traumatic aortic injury.

OBJECTIVE: The aim of this study was to demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury. METHODS: A prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 centers in the United States between 2017 and 2021. The primary endpoint was 30-day all-cause mortality. RESULTS: The cohort was mostly male (74%), with a mean age of 42.4 ± 17.2 years, and treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3, and 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42%, and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent endograft. Technical success was 98% (one early type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% confidence interval [CI] of 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through 4 years (95% CI, 86.6%-99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, was 98.0% at 30 days and 95.8% from 6 months to 4 years (95% CI, 84.3%-98.9%). There were no strokes and one case of paraplegia (2%) during follow-up. CONCLUSIONS: RelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury.

Characterization of long-term survival in Medicare patients undergoing arteriovenous hemodialysis access.

BACKGROUND: Patients undergoing arteriovenous (AV) access creation for hemodialysis often have significant comorbidities. Our goal was to quantify the long-term survival and associated risks factors for long-term mortality in these patients to aid in optimization of goals and expectations. METHODS: The Vascular Implant Surveillance and Interventional Outcomes Network Vascular Quality Initiative Medicare linked data was used to assess long-term survival in the HD registry. Demographics, comorbidities, and interventions were recorded. Because the majority of hemodialysis patients are provided Medicare, Medicare linkage was used to obtain survival data. Multivariable analysis was used to identify independent associations with mortality. RESULTS: There were 13,945 AV access patients analyzed including 10,872 (78%) AV fistulas and 3073 (22%) AV grafts. The median age was 67 years and 56% of patients were male. Approximately one-third had a prior AV access and 44.7% had prior tunneled dialysis catheters. Patients receiving an AV fistula, compared with AV grafts, were more often younger, male, White, obese, independently ambulatory, preoperatively living at home, and less often have a prior AV access and tunneled dialysis catheters (P < .05 for all). The 5-year mortality overall was 62.9% with 61.2% for AV fistulas and 68.8% for AV grafts (P < .001). On multivariable analysis for 5 year mortality, nonambulatory status (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.53-1.83; P < .001), lower extremity access (HR, 1.67; 95% CI, 1.35-2.05; P < .001), human immunodeficiency virus or acquired immunodeficiency syndrome (HR, 1.44; 95% CI, 1.13-1.82; P < .001), White race (HR, 1.43; 95% CI, 1.35-1.51; P < .001), congestive heart failure (HR, 1.33; 95% CI, 1.26-1.41; P < .001), chronic obstructive pulmonary disease (HR, 1.23; 95% CI, 1.15-1.31; P < .001), and AV graft placement (HR, 1.12; 95% CI, 1.02-1.23, P = .016) were most associated with poor survival. Factors associated with improved survival were never smoking (HR, .73; 95% CI, 0.67-0.79; P < .001), prior/quit smoking (HR, .78; 95% CI, 0.72-0.84; P < .001), preoperative home living (HR, .75; 95% CI, 0.68-0.83; P < .001), and hypertension (HR, .89; 95% CI, 0.8-0.99; P = .03). CONCLUSIONS: Long-term survival in Medicare patients undergoing AV access creation is poor with nearly two-thirds of patients having died at 5 years. There are many modifiable risk factors that may improve survival in these patients and give an opportunity for transplantation.

Fourth-Year Medical Students' Perceptions of Vascular Surgery: Can We Improve the Pipeline?

BACKGROUND: Since their inception, Integrated Vascular Surgery Residency (IVSR) programs have expanded widely and attracted highly competitive medical students by offering a more focused approach to learning both open surgical and endovascular techniques. However, despite substantial modifications to the training paradigm, a shortage of vascular surgeons is still projected through 2050. We aimed to gather and analyze fourth-year medical students' knowledge and perceptions of vascular surgery (VS) to further inform strategies for recruiting future vascular surgeons. METHODS: We sent anonymous electronic questionnaires to fourth-year medical students at 7 allopathic and 3 osteopathic medical schools, with questions detailing demographics, specialty preferences, and exposure to and perceptions of VS. Descriptive statistics were obtained, and responses were compared between students applying to surgical specialties (SS) and nonsurgical specialties (NSS). RESULTS: Two hundred eleven of 1,764 (12%) participants responded (56% female). 56% reported VS exposure, most commonly during the third year. 64 (30%) planned to apply to SS. 57% of respondents reported knowledge of the management of vascular disease, and 56% understood procedures performed by vascular surgeons. Ranking the importance of factors in choosing specialties, SS selected "experiences gained during medical school rotations" (P < 0.05), "types and/or variety of treatment modalities used in this field" (P < 0.001), and "interest in the pathology or disease processes treated" (P < 0.05) as highest priorities. NSS preferred "lifestyle (work-life balance) as an attending" (P < 0.001). Only 7% of all respondents believed vascular surgeons have a good work-life balance, with a larger percentage of SS (P < 0.001) agreeing. Stratified by gender, female students rated "limited ability of childbirth during residency and/or postponement of family plans" (P < 0.05), "gender-related concerns, such as discrimination at work or unfair career possibilities" (P < 0.001), and "fear of unfair competition" (P < 0.05) as potential negative aspects of VS careers. 55% of respondents believed the IVSR makes VS more appealing. CONCLUSIONS: Medical students perceive poor quality of life and work-life balance as deterring factors to a career in VS. Opportunities exist to educate students on the pathologies treated, procedures performed, and attainable quality of life available in our field. We should also continue to develop recruitment strategies to stimulate student interest and increase early exposure in VS.

Exploring the perception of venous disease within vascular surgery.

BACKGROUND: Biases and gender disparities influence career pathways within medicine, and vascular surgery is no exception. Venous disease comprises an estimated 1% to 3% of total health care expenditures. However, its value among vascular surgeons is poorly understood. This study aims to investigate the factors that influence vascular surgeons' current perceptions of superficial and deep venous disease treatments. METHODS: An anonymous survey was distributed electronically to practicing vascular surgeons in December 2021. The respondents were stratified by gender and practice breakdown. A venous-heavy practice was defined as a practice with venous work comprising ≥25% of the total volume. Changes in practice patterns over the respondent's career were also explored. Descriptive, univariate, and multivariate analyses were performed using STATA (StataCorp). RESULTS: A total of 315 practicing vascular surgeons responded, with 81.5% from the United States. Their mean age was 46.6 ± 9.6 years, and most identified as men (63.3%). The race and ethnicity breakdown was as follows: White (non-Hispanic), 63.0%; Asian or Asian Indian, 17.1%; Hispanic, Latinx, or Spanish, 8.4%; Black, 1.6%; and unknown, 9.9%. The practice settings were academic for 47.0%, private practice for 26.5%, hospital employed for 23.3%, and other for 3.2%. The female respondents were significantly younger (P < .0001), with fewer years in practice (P < .0001) and were more likely to perceive a gender bias within a career encompassing venous disease compared with the male respondents (P = .02). Of the 315 participants, 143 (45.4%) had a venous-heavy practice. No differences were found in age or gender between the venous-heavy and venous-light practices. Those with a venous-heavy practice had significantly more years in practice statistically (P = .02), had sought more venous training after graduation (P < .0001), were more likely to be in private practice (P < .0001), and were more likely to desire a practice change (P = .001) compared with those with a venous-light practice. Overall, 74.3% of respondents indicated that venous work might be less "valued" than arterial work in the field of vascular surgery. On multivariable regression, the predictors for the perception of venous work being less valued were female gender (odds ratio, 2.01; 95% confidence interval, 1.14-4.03) and completion of a vascular surgery fellowship (odds ratio, 2.0; 95% confidence interval, 1.15-3.57). CONCLUSIONS: Vascular surgeons overwhelmingly perceived the management of venous disease to be of less value than that of arterial disease, particularly by women and fellowship-trained vascular surgeons. The prevalence of venous disease, as measured by its proportion of the U.S. healthcare budget, cannot be overstated. Thus, efforts to elevate the importance of chronic venous disease within the scope of vascular surgery practices are essential to ensure patients are provided with appropriate specialty care.

Impact of Flow Reversal Duration on Neurological Outcomes of Transcarotid Artery Revascularization (TCAR).

BACKGROUNDS: Flow reversal is a key component of transcarotid artery revascularization (TCAR). However, the impact of flow reversal duration on neurological outcomes and the duration of flow reversal which optimizes TCAR's outcomes is not known. We evaluated the association of flow reversal time with the intraoperative and postoperative neurological outcomes of TCAR. METHODS: We studied all patients undergoing TCAR from September 2016 to October 2021. The exposure of interest was the duration of flow reversal. Multivariable logistic and fractional polynomial models were used to study the impact of flow reversal duration on in-hospital stroke, intraoperative neurological change/intolerance and stroke/death following TCAR and to identify the flow reversal time above which significant perioperative neurological events occur. RESULTS: The study included 19,462 patients with mean age of 73.4 years who were mostly Caucasian (91%) and male (63%). The mean flow reversal time was 10.7 minutes, and the overall stroke rate was 1.4%. The odds of intraoperative neurological change increased by 3.6% per minute increase in flow reversal time (odds ratio (OR), 1.04; 95%, 1.01-1.06; P < 0.002). Flow reversal duration >10 minutes was associated with 78% increased odds of neurological changes compared to flow reversal duration <10 minutes. There was no significant association between flow reversal duration and stroke, and stroke/death in the first 5 minutes after initiation of flow reversal. The odds of stroke increased by 2.7% per minute increase in flow reversal time >5 minutes (OR, 1.03; 95%, 1.01-1.04; P < 0.001), with flow reversal duration >10 minutes associated with 38% increased odds of stroke compared to flow reversal duration ≤10 minutes (OR, 1.37, 95% confidence interval (CI), 1.09-1.73, P = 0.006). The odds of stroke/death increased by 2.5% per minute increase in flow reversal time >5 minutes (OR, 1.03; 95%, 1.01-1.04; P < 0.001). Flow reversal duration >10 minutes was associated with 25% increased odds of stroke/death compared to flow reversal duration <10 minutes (OR, 1.25, 95% CI, 1.01-1.53, P = 0.038). Symptomatic status did not modify outcomes. CONCLUSIONS: Our findings suggest that outcomes following TCAR are optimal if the duration of flow reversal is minimized. A clinical cutoff time of 10 minutes is suggested by this study and recommended as a guide. Further studies targeted at the flow reversal component of TCAR are needed to solidify the evidence regarding the clinical effects of temporarily induced retrograde cerebral blood flow during TCAR.

Postoperative complications and their association with post-traumatic stress disorder in academic vascular surgeons.

OBJECTIVES: Postoperative complications are an inherent component of surgical practice. This study seeks to address their association with emotional responses of academic vascular surgeons. METHODS: An anonymous electronic survey was sent to all vascular surgery program directors in North America with a request to disseminate to their faculty. The survey captured data on demographics and practice type and used imbedded validated measures to determine emotional responses to postoperative complications and to assess coping mechanisms. Univariate analysis was performed to determine differences between those who reported at least partial symptoms of post-traumatic stress disorder (PTSD) following their worse major complication over the previous year and those who did not. Multivariable logistic regression analysis was performed for all covariates found significant on univariate analysis, and those deemed clinically relevant. RESULTS: The survey was distributed to 267 faculty at 128 institutions in the United States and 10 institutions in Canada and completed by 65 participants (response rate, 32%). Twenty of 65 (31%) identified as female, and the total group had a mean age of 47 ± 10.2 years. Most respondents (43/65; 66%) reported a major complication within 3 months of the survey, with the majority of respondents (45/65; 69%) reporting the outcome of patient mortality. Of respondents, 20 of 65 (31%) demonstrated at least partial symptoms of PTSD in response to the worst complication from the previous year, with 12 of 65 (19%) meeting the clinical diagnosis of PTSD. Respondents in the PTSD group were more likely to criticize/blame themselves following the complication (P = .0028); less likely to identify the complication as "expected" (P = .048) or to believe causes of their complications were due to others/external factors; and more likely to identify as a female (55% vs 20%; P = .008). Regarding support following major complications, most respondents (57/65; 88%) desired the ability to discuss details of the case with a respected peer. The most common external pressure influencing their emotional responses to complications was maintaining reputation and a sense of honor (66%). Gender differences persisted on multivariate analysis (P = .016). CONCLUSIONS: Emotional responses following major postoperative complications in vascular surgery are common and may pose a risk for PTSD. This may occur more commonly following complications that are unexpected or in cases in which the cause of the complication was due to a perceived or actual surgical mistake. The ubiquitous nature and severity of the emotional toll of major complications for vascular surgeons is poorly described and under-recognized. Gender-related differences may exist, and most surgeons desire a support network of respected peers with whom to discuss complications.

Depression screening in patients with vascular disease.

OBJECTIVES: Major depression is associated with increased morbidity and mortality in vascular surgery patients. The US Preventive Services Task Force and American Heart Association recommend routine depression screening for adults, especially those with cardiovascular disease. Since routine depression screening has not been implemented in most vascular surgery clinics across the nation, we sought to determine the feasibility of depression screening and understand the prevalence and predictors of depression in patients presenting to a single institution's vascular surgery clinic over a 4 month period. METHODS: From June to September 2020, vascular surgery clinic patients were administered a 26-item survey that included validated scales for depression (PHQ-9), pain, frailty, alcohol dependence, and nicotine dependence. Although not validated, the Rosenberg Self-Esteem Scale was also administered. Patient charts were reviewed for demographic information and medical history. 9-digit patient zip codes were used to determine Area Deprivation Index, a measure of socioeconomic status. Univariate and multivariate analyses were performed to understand the factors associated with increased depression prevalence in the study population. RESULTS: A total of 140 (36.4%) of 385 patients met study inclusion criteria. 35.7% of them screened positive for mild to severe depression (PHQ-9 scores ≥5). On univariate analysis, major depression was significantly associated with lower socioeconomic status (p = 0.007), higher frailty (p < 0.001), lower self-esteem (p < 0.001), higher daily pain (p < 0.001), health problems that interfere with social activities (p < 0.001), fatigue (p < 0.001), unmarried status (p = 0.031), and lack of primary care provider (p = 0.048). Multivariate analyses significantly predicted higher frailty (B= 0.487, p = 0.007) and lower self-esteem (B= -0.413, p < 0.001) in patients with depression. Depression was not associated with gender, age, employment status, smoking status, alcohol use, or type of vascular disease. COCLUSIONS: More than one-third of vascular surgery clinic patients have comorbid depression. Higher frailty and lower self-esteem are significant risk factors for depression. Prevention and early identification of frailty may improve outcomes. Depression screening in vascular surgery clinics is feasible and could be useful in determining which patients may benefit from more frequent follow-up and monitoring for associated comorbidities. Vascular surgeons may play an important role in screening for depression and referring patients for psychotherapy and/or pharmacotherapy.

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.