Comprehensive review of virtual assistants in vascular surgery.

Virtual assistants, broadly defined as digital services designed to simulate human conversation and provide personalized responses based on user input, have the potential to improve health care by supporting clinicians and patients in terms of diagnosing and managing disease, performing administrative tasks, and supporting medical research and education. These tasks are particularly helpful in vascular surgery, where the clinical and administrative burden is high due to the rising incidence of vascular disease, the medical complexity of the patients, and the potential for innovation and care advancement. The rapid development of artificial intelligence, machine learning, and natural language processing techniques have facilitated the training of large language models, such as GPT-4 (OpenAI), which can support the development of increasingly powerful virtual assistants. These tools may support holistic, multidisciplinary, and high-quality vascular care delivery throughout the pre-, intra-, and postoperative stages. Importantly, it is critical to consider the design, safety, and challenges related to virtual assistants, including data security, ethical, and equity concerns. By combining the perspectives of patients, clinicians, data scientists, and other stakeholders when developing, implementing, and monitoring virtual assistants, there is potential to harness the power of this technology to care for vascular surgery patients more effectively. In this comprehensive review article, we introduce the concept of virtual assistants, describe potential applications of virtual assistants in vascular surgery for clinicians and patients, highlight the benefits and drawbacks of large language models, such as GPT-4, and discuss considerations around the design, safety, and challenges associated with virtual assistants in vascular surgery.

e-Health and environmental sustainability in vascular surgery.

e-Health technology holds great promise for improving the management of patients with vascular diseases and offers a unique opportunity to mitigate the environmental impact of vascular care, which remains an under-investigated field. The innovative potential of e-Health operates in a complex environment with finite resources. As the expansion of digital health will increase demand for devices, contributing to the environmental burden of electronics and energy use, the sustainability of e-Health technology is of crucial importance, especially in the context of increasing prevalence of cardiovascular diseases. This review discusses the environmental impact of care related to vascular surgery and e-Health innovation, the potential of e-Health technology to mitigate greenhouse gas emissions generated by the health care sector, and to provide leads to research promoting e-Heath technology sustainability. A multifaceted approach, including ethical design, validated eco-audits methodology and reporting standards, technological refinement, electronic and medical devices reuse and recycling, and effective policies is required to provide a sustainable and optimal level of care to vascular patients.

Case report of spontaneous coronary artery dissection in a 50­year­old man.

BACKGROUND: Spontaneous Coronary Artery Dissection (SCAD) is an acute coronary event of uncertain origin. SCAD occurs when the coronary artery wall dissects non-traumatically and non-atherosclerotically, leading to the formation of an intramural hematoma or intimal tear, ultimately compressing and restricting the true lumen, or even occluding it. The management of SCAD remains controversial despite modern imaging techniques. In addition to supportive drug therapy, percutaneous coronary intervention (PCI) is another option that can be used as an effective treatment modality. CASE PRESENTATION: We describe A 50-year-old male with SCAD presented to the hospital emergency department complaining of chest pain. Coronary angiography incidentally showed spiral dissection from the proximal to distal right coronary artery (RCA). Three overlapping coroflex stents were deployed from the distal to the proximal RCA. CONCLUSIONS: To stabilize the coronary artery in Acute Coronary Syndrome (ACS) patients due to SCAD, prompt interventions such as stenting and angioplasty are needed. However, it is necessary to pay attention to the clinical condition of patients and quick diagnosis for the recovery of patients and reduction of complications.

Decision making in the frail vascular surgery patient: A scoping review.

Increasing evidence highlights the adverse impact of frailty and reduced physiologic reserve on surgical outcomes. Therefore, identification of frailty is essential for older adults being evaluated for vascular surgery procedures. Numerous frailty assessment tools are available to quantify the level of frailty and assist in preoperative decision making for these older patients. This review evaluates traditional and novel frailty metrics for their scientific validation, limitations, and clinical utility in vascular surgery decision-making.

Appropriate Use Criteria Committees: The professional society role in the development and implementation of Appropriate Use Criteria.

Vascular surgeons have the ability to manage and intervene on numerous vascular diseases of both the arterial and venous systems. With the growing number of interventions available as endovascular technology evolves, it is important to determine when a procedure is safely indicated for a vascular surgery patient. Appropriate Use Criteria (AUC) offer synthesized clinical information and practice standards that can aid clinicians in making these management decisions. Professional societies, such as the Society for Vascular Surgery, bring experts in the field together to collaborate and create AUC for various vascular diseases and interventions. It is essential to publish these criteria in peer-reviewed journals, as well as make them available on public websites so the information is available to vascular surgeons and interventionalists from other specialties who also treat patients with vascular disease. Cardiology, interventional radiology, and interventional nephrology are some other specialties that perform procedures for vascular disease, and vascular interventions by nonsurgeon specialists continue to increase. The Society for Vascular Surgery has published AUC on intermittent claudication, carotid disease, and abdominal aneurysm management. These are intended to guide practice, but also have highlighted areas for improvement that would allow for more universal implementation of AUC in vascular patient care across medical specialties. Increased intersocietal participation and perhaps inclusion of government and other payer participation will allow professional society-sponsored AUC to evolve, resulting in coordinated, appropriate care for vascular surgery patients.

Racial Disparities in Outcomes of Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction Secondary to Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a rare cause of ST-segment elevation myocardial infarction (STEMI), predominantly affecting women. Because primary percutaneous coronary intervention (PPCI) is reserved for a select group of patients, vulnerable and minority patients may experience delays in appropriate management and adverse outcomes. We examined the racial differences in the outcomes for patients with SCAD who underwent PPCI for STEMI. Records of patients aged ≥18 years who underwent PPCI for SCAD-related STEMI between 2016 and 2020 were identified from the National Inpatient Sample database. Clinical, socioeconomic, and hospital characteristics were compared between non-White and White patients. Weighted multivariate analysis assessed the association of race with inpatient mortality, length of stay (LOS), and hospitalization costs. The total weighted estimate of patients with SCAD-STEMI who underwent PPCI was 4,945, constituting 25% non-White patients. Non-White patients were younger (56 vs 60.7 years, p <0.001); had a higher prevalence of diabetes, acute renal failure, and obesity; and were more likely to be uninsured and be in the lowest income group. Inpatient mortality (7.7% vs 8.4%, p = 0.74) and hospitalization costs ($34,213 vs $31,858, p = 0.27) were similar for non-White and White patients, and the adjusted analysis did not show any association between the patients' race and inpatient mortality (odds ratio 0.60, 95% confidence interval [CI] 0.32 to 1.13, p = 0.11) or hospitalization costs (ß [ß coefficient]: 215, 95% CI -4,193 to 4,623, p >0.90). Similarly, there was no association between the patients' race and LOS (incident rate ratio 1.20, 95% CI 1.00 to 1.45, p = 0.054). The weighted multivariate analysis showed that age; clinical co-morbidities such as diabetes, acute renal failure, valvular dysfunction, and obesity; low-income status; and hospitalization in the western region were associated with adverse outcomes. In conclusion, our study does not show any differences in inpatient mortality, LOS, and hospitalization costs between non-White and White patients who underwent PPCI for SCAD-related STEMI.

Retrospective analysis of 1,203 cases of referral to a quaternary vascular surgery outpatient clinic within the Unified Health System, São Paulo, Brazil.

OBJECTIVE: Through a retrospective analysis of 1,203 cases of referral from primary healthcare units to a specialized quaternary vascular surgical service, the findings of this study revealed a high proportion of inappropriate referrals, which may represent a substantial subutilization of this highly complex service. Consequently, in this study, we aimed to evaluate 1,203 cases of referral to a quaternary vascular surgical service, in São Paulo, Brazil, over a 6-year period, to assess the appropriate need for referral; in addition to the prevalence of surgical indications. METHODS: In this retrospective analysis, we reviewed the institutional records of participants referred from Basic Healthcare Units to a vascular surgical service inside the Brazilian Unified Health System, between May 2015 and December 2020. Demographic and clinical data were collected. The participants were stratified, as per the reason for referral to the vascular surgical service, previous imaging studies, and surgical treatment indications. Referral appropriateness and complementary examinations were evaluated for each disease cohort. Finally, the prevalence of cases requiring surgical treatment was defined as the outcome measure. RESULTS: Of the 1,203 referrals evaluated, venous disease was the main reason for referral (53%), followed by peripheral arterial disease (19.4%). A considerable proportion of participants had been referred without complementary imaging or after a long duration of undergoing an examination. Referrals were regarded as inappropriate in 517 (43%) cases. Of these, 32 cases (6.2%) had been referred to the vascular surgical service, as the incorrect specialty. The percentage of referred participants who ultimately underwent surgical treatment was 39.92%. Carotid (18%) and peripheral arterial diseases (18.4%) were correlated with a lower prevalence of surgical treatments. CONCLUSION: The rate of referral appropriateness to specialized vascular care from primary care settings was low. This may represent a subutilization of quaternary surgical services, with low rates of surgical treatment.

Risk factors for post-operative portal vein stenosis in pediatric liver transplantation: a single center case-control study.

PURPOSE: The incidence of post-transplant poral vein stenosis (PVS) is higher in pediatric liver transplantation, probably resulting from various portal vein (PV) reconstruction methods or other factors. METHODS: 332 patients less than 12 years old when receiving liver transplantation (LT) were enrolled in this research. Portal vein reconstruction methods include anastomosis to the left side of the recipient PV trunk (type 1, n = 170), to the recipient left and right PV branch patch (type 2, n = 79), using vein graft interposition (type 3, n = 32), or end-to-end PV anastomosis (type 4, n = 50). The incidence of PVS was analyzed in terms to different PV reconstruction methods and other possible risk factors. RESULTS: PVS occurred in 35 (10.5%) patients. Of the 32 patients using vein graft, 20 patients received a cryopreserved vein graft, 11 (55%) developed PVS, while the remaining 12 patients received a fresh iliac vein for PV interposition and none of them developed PVS. 9 patients whose liver donor was under 12 years old developed PVS, with an incidence of 18.8%. CONCLUSION: Cryopreserved vein graft interposition and a liver donor under 12 are independent risk factors for PVS in pediatric LT.

Radiation-induced cutaneous vasculopathy of the breast: a rare case report.

BACKGROUND: Radiation therapy is often indicated as part of the treatment for breast cancer and is therefore used frequently worldwide. Vasculopathy is a general term used to describe any condition that affects blood vessels. We present a case report of a patient who presented with vasculopathy as a rare late side effect of radiation therapy to the breast. CASE PRESENTATION: This 66-year-old woman was initially treated with breast-conserving surgery for early-stage receptor-positive left breast carcinoma. She received postoperative radiation therapy and hormonal treatment with tamoxifen. She developed sudden spontaneous painless ecchymosis spread over the whole irradiated area 1.5 years after finishing her radiation therapy. Tumor relapse was excluded. There was no associated vasculitis. The cause was presumed to be multifactorial. She had a history of smoking and was known to have hyperlipidemia. She had undergone several surgical treatments at the left breast one year after her initial breast-conserving treatment and was taking tamoxifen. Anti-inflammatory medicine and treatments increasing local blood flow were prescribed. The ecchymosis resolved completely within one month. CONCLUSIONS: Vasculopathy can occur as a rare late side effect of radiation therapy. It can be reversible. Prevention begins with carefully treating precipitating factors.

Venous compression syndromes in females: A descriptive review.

Venous compression syndromes have been described, yet the role of sex is poorly understood. Although iliac vein compression has been discussed more often with the advent of newer technologies, research has fallen short on defining epidemiology, best practices for evaluation and treatment, and differences in responses to treatment between men and females. The authors report on iliac vein compression, nonthrombotic renal vein compression, and other venous compression syndromes in females. Literature searches of PubMed were performed using the following keywords: females/females and May Thurner, venous stenting, venous outcomes, deep venous disease, deep venous compression, venous stenting, renal vein compression, renal vein surgery/stent, popliteal vein entrapment, venous thoracic vein entrapment, and popliteal vein entrapment. The articles prompted the authors to research further as the referenced articles were reviewed. Sex representation has not been addressed adequately in the research of venous compression syndromes, making the discussion of best treatment options and long-term outcomes difficult. More specific understanding of epidemiology and response to interventions will only come from research that addresses these issues directly, understanding that some of these syndromes occur rarely.

Predictors of Multi-Vessel Identification, Outcome, and Optimal Surgical Timing for Microvascular Decompression in Hemifacial Spasm.

OBJECTIVES AND BACKGROUND: Hemifacial spasm (HFS) is a disabling condition that imposes significant burden upon patients. Microvascular decompression (MVD) surgery is the most effective and long-lasting treatment for HFS, but outcomes following this surgery may vary based on a variety of clinical and operative factors. A more thorough understanding of the variables that impact patient outcome after MVD surgery is needed. METHODS: A systematic review and meta-analysis of Medline, Embase, and Central was conducted (n = 2108 screened; n = 86 included) with the goal of determining the impact of the following variables on outcome: duration of disease, geographic location, intraoperative use of an endoscope, and intraoperative finding of single versus multi-vessel neurovascular compression. RESULTS: Most cases of hemifacial spasm occur on the left side (53.9%, p < 0.001) and are more common in women than men (66.5% versus 33.5%, p < 0.0001). The offending vessel frequencies were: 40.8% anterior inferior cerebellar artery [AICA], 24.9% posterior inferior cerebellar artery [PICA], 17.2% multiple vessels, and 4.7% vertebral artery [VA]. Multiple vessel combinations involved: 26.5% PICA + AICA, 24.6% PICA + VA, 23.1% AICA + VA, and 4.7% AICA + PICA + VA. Relative to the Americas, AICA was less frequent in Europe (p = 0.005), while PICA more frequent in Europe (p = 0.009) and Asia (p < 0.0001). With endoscope assistance, frequency of multiple vessels identified was 31.7% (versus 14.7% with non-endoscopic, p = 0.005), and 27.4% for AICA (43.5% with non-endoscopic, p = 0.003). Spasm improvement was 94.1% near discharge and 96.0% at maximum follow-up. Complications occurred in 16.5% of cases, with spasm recurrence in 2.4%. Greatest frequency of spasm improvement (p < 0.0001) and lowest spasm recurrence rates (p = 0.0005) were reported in series from Asia. For every additional month of pre-operative spasm, the effect size of post-operative improvement decreased (p = 0.04). With every subsequent postoperative month, the effect size of spasm improvement increased (p = 0.0497). The frequency of spasm improvement was significantly higher in series published after 2005 (94.4% versus 97.4%, p = 0.005). CONCLUSION: Clinical outcomes following MVD for HFS have improved since 2005. Consideration should be given to earlier operation (shorter disease duration) and use of an endoscope may increase detection of multiple offending vessels. Further studies are needed to understand regional differences in culprit vessel incidence and surgical outcomes in the Americas, Europe, and Asia.

Preoperative Assessment of Patients with Vascular Disease.

Patients with vascular disease represent a particularly high-risk surgical population. Many of the comorbidities that contribute to their vascular presentation impact a number of vascular beds or other organ systems. As a result, these patients have the highest rates of cardiac and pulmonary complications among patients with noncardiac surgery. The vascular surgeon is in a unique position to help evaluate and treat many of these conditions to not only reduce the perioperative risk but also to improve the patient's overall health. This article presents a comprehensive review of the common preoperative evaluations that have a high impact on patients with vascular disease.