Neck radiation is not associated with increased risk of perioperative adverse events after transcarotid artery revascularization or transfemoral carotid artery stenting.

OBJECTIVE: It is unclear whether patients with prior neck radiation therapy (RT) are at high risk for carotid artery stenting (CAS). We aimed to delineate 30-day perioperative and 3-year long-term outcomes in patients treated for radiation-induced stenotic lesions by the transfemoral carotid artery stenting (TFCAS) or transcarotid artery revascularization (TCAR) approach to determine comparative risk and to ascertain the optimal intervention in this cohort. METHODS: Data were extracted from the Vascular Quality Initiative CAS registry for patients with prior neck radiation who had undergone either TCAR or TFCAS. The Student t-test and the χ2 test were used to compare baseline patient characteristics. Multivariable logistic regression and Cox Hazard Proportional analysis were used to compare perioperative and long-term differences between patients with and without prior neck radiation following TCAR and TFCAS. Kaplan-Meier estimator was used to determine the incidence of 3-year adverse events. RESULTS: A total of 72,656 patients (TCAR, 40,879; TFCAS, 31,777) were included in the analysis. Of these, 4151 patients had a history of neck radiation. Patients with a history of neck radiation were more likely to be younger, white, and have fewer comorbidities than patients with no neck radiation history. After adjustment for confounding factors, there was no difference in relative risk of 30-day perioperative stroke (P = .11), death (P = .36), or myocardial infarction (MI) (P = .61) between TCAR patients with or without a history of neck radiation. The odds of stroke/death (P = .10) and stroke/death/MI (P = .07) were also not statistically significant. In patients with prior neck radiation, TCAR had lower odds for in-hospital stroke/death/MI (odds ratio, 0.59; 95% confidence interval [CI], 0.35-0.99; P = .05) and access site complications than TFCAS. At year 3, patients with prior neck radiation had an increased hazard for mortality after TCAR (hazard ratio [HR], 1.24; 95% CI, 1.02-1.51; P = .04) and TFCAS (HR, 1.33; 95% CI, 1.12-1.58; P = .001). Patients with prior neck radiation also experienced an increased hazard for reintervention after TCAR (HR, 2.16; 95% CI, 1.45-3.20; P < .001) and TFCAS (HR, 1.67; 95% CI, 1.02-2.73; P<.001). CONCLUSIONS: Patients with prior neck radiation had a similar relative risk of 30-day perioperative adverse events as patients with no neck radiation after adjustment for baseline demographics and disease characteristics. In these patients, TCAR was associated with reduced odds of perioperative stroke/death/MI as compared with TFCAS. However, patients with prior neck radiation were at increased risk for 3-year mortality and reintervention.

Large-Diameter Fenestrated Endograft Repair of Abdominal Aortic Aneurysms Is Not Associated With Medium-Term Outcomes.

INTRODUCTION: Recent data suggests that infrarenal abdominal aortic aneurysm (AAA) endovascular repair (EVAR) with large diameter grafts (LGs) may have a higher risk of endoleak and reintervention. However, this has not been studied extensively for fenestrated endovascular aneurysm repair (fEVAR). We, therefore, sought to evaluate the outcomes of patients undergoing fEVAR with large-diameter endografts. METHODS: Patients from the national Vascular Quality Initiative registry who underwent fEVAR for intact juxtarenal AAA were identified. Patients with genetic causes for aneurysms, those with prior aortic surgery, and those undergoing repair for symptomatic or ruptured aneurysms were excluded. Rates of endoleaks and reintervention at periprocedural and long-term follow-up timepoints (9-22 mo) were analyzed in grafts 32 mm or larger (LG) and were compared to those smaller than 32 mm (small diameter graft). RESULTS: A total of 693 patients (22.8% LG) were identified. Overall, demographic variables were comparable except LG exhibited a more frequent history of coronary artery disease (32.9% versus 25.4%, P = 0.037). There were no significant differences in the rates of endoleak at procedural completion. Overall survival at 5 y was no different. The rate of reintervention at 1 y was also no different (log-rank P = 0.86). CONCLUSIONS: While graft size appears to have an association with outcomes in infrarenal aneurysm repair, the same does not appear to be true for fEVAR. Further studies should evaluate the long-term outcomes associated with LG which could alter the approach to repair of AAA with large neck diameters traditionally treated with standard infrarenal EVAR.

Review of Malpractice Litigation in the Diagnosis and Treatment of Venous & Lymphatic Disease.

BACKGROUND: Malpractice claims involving nonthrombotic venous and lymphatic diseases and interventions have not been reported previously. We investigated common reasons for litigation, medical specialties involved, patient injuries, and case outcomes in malpractice litigation involving venous and lymphatic disease. METHODS: Litigation cases entered into the Westlaw database from June 8th, 1984 to February 15th, 2018 were analyzed. Search terms included relevant words and phrases related to nonthrombotic venous, thoracic outlet syndrome, and lymphatic disease and treatment. Data on physician specialty, malpractice claims, and patient injuries jury outcomes, amount awarded to the plaintiff, and jury fees were collected and compared for each category. RESULTS: A total of 144 cases were identified. 41 cases involved varicose veins, 11 spider veins, 35 thoracic outlet syndrome (TOS), 17 other venous diseases, and 40 lymphatic diseases. Physician defendants were frequently vascular surgeons (23%) and general surgeons (15%). The majority of litigation claims involved "post-procedure complication" (77%), "lack of informed consent" (25%), "failure to diagnose & treat" (15%), and "intraoperative complications" (13%). The most common injuries were skin damage (27.8%), nerve damage (25%), and lymphedema (24%). Patient death occurred in 6% of cases. Out of venous malpractice cases with post-procedure complications, stab phlebectomy (27%) was the most common intervention followed by foam sclerotherapy (21%), rib resection (21%), laser spider vein removal (5%), and endovenous laser ablation therapy (EVLT)(3%). Of varicose vein cases, 15% included deep vein thrombosis or pulmonary embolism as post-procedure complications. In TOS rib resections, 65% of cases referenced nerve damage and 12% involved arterial injury. For lymphatic disease cases, general surgeons were frequently identified defendants (25%). Lymphedema (93%) and lymphangitis (7%) occurred as post-procedure complications after breast, gynecologic, orthopedic, and radiation procedures. A majority of complications occurred after breast cases (40%). Verdicts overall ruled in favor of the defendant in 71% (102/144) of cases and the plaintiff in 20% (29/144) of cases. Out of cases ruled in favor of the plaintiff, 31% were lymphatics, 24% varicose veins, and 24% TOS cases. Only 8% (12/144) of cases were settled and one outcome was unknown. The mean award was $820,193 (standard deviation SD $1,226,008, Range $12,853 - $6,500,000). CONCLUSIONS: The majority of venous and lymphatic litigation cases involve claims of post-procedure complications. Venous complications occurred after open and endovascular treatment of varicose veins, spider vein treatment, and surgical management of TOS. Lymphedema occurred after breast, oncology, and orthopedic procedures. These cases reflect opportunities for intervention to help potentially prevent litigation.

Panel composition and disparities in the topics of presentation in vascular surgery conferences.

BACKGROUND: Previous studies identified gender disparities in surgical conference presenters and moderators. We sought to assess disparities in the representation of women in terms of speakers and moderators, but with particular emphasis on panels and topics of discussion at vascular surgery conferences. METHODS: Data regarding presenters and moderators from the Southern Association of Vascular Surgery, Western Vascular Society, Vascular and Endovascular Surgical Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery conferences was obtained from online meeting archives and via email correspondence. Scientific session speakers, moderators, and panelists were identified by sex. Specific vascular topics for each discussion were also identified. Keynote speakers or special guests were excluded. RESULTS: Compared to men, women were less often presenters (18% versus 82%, p < .002) and moderators (16% versus 84%, p < .001) of conference sessions. Women were most likely to present on dialysis access and least likely to present on venous disease overall. Women were more likely to present on aortic (24% vs 19%; p < .013) and cerebrovascular disease (33% vs 27%; p < .021) at regional compared to national conferences. Of panels assessed, 68% were all-male. Subgroup analysis suggests that some improvements have been made over time. CONCLUSIONS: Significant disparities persist in the topics presented and in panel composition suggesting potential areas for improvement in equity. Further study should focus on evaluating trends in the training level of the presenter and the topics presented, and assessing parity in structural factors that impact research presentation opportunities.

Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patients.

INTRODUCTION: Asymptomatic patients with a remote history of transient ischemic attack (TIA) or stroke are not well studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic patients, patients with a remote history of neurologic symptoms, and asymptomatic patients. METHODS: Data from patients in the Vascular Quality Initiative database who underwent TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) were analyzed. Symptomatic status was defined as TIA and/or stroke occurring within 180 days before the procedure. Asymptomatic status was divided into patients with no history of TIA/stroke (asymptomatic) and patients with a history of TIA/stroke occurring more than 180 days before the procedure (remote history of neurologic symptoms). The Student t-test and Pearson χ2 test were used to compare baseline patient characteristics and outcomes. Multivariate logistic regression was used to adjust for significant between-group differences in baseline characteristics. RESULTS: There were 7158 patients who underwent TCAR (symptomatic: 2574, asymptomatic: 3689, and asymptomatic with a remote history of neurologic symptoms: 895) and 18,023 patients who underwent TFCAS (symptomatic: 6195, asymptomatic: 10,333, and asymptomatic with a remote history of neurologic symptoms: 1495). Regardless of symptom status, the mean patient age was 73 years for TCAR and 69 years for TFCAS. A total of 64% of patients in the study were male and 36% of patients were female. The mean long-term follow-up data ranged between 208 and 331 days within the three patient groups. Carotid stenosis patients with a remote history of neurologic symptoms had higher rates of TIA, stroke, TIA/stroke, stroke/death, and stroke/death/myocardial infarction than asymptomatic patients, and these rates were similar to those of symptomatic patients. Comparing TCAR and TFCAS among patients with a remote history of neurologic symptoms, there were statistically significant reductions in the odds of stroke/death (odds ratio: 0.46, 95% confidence interval: 0.27-0.84, P = .011) and stroke/death/myocardial infarction (odds ratio: 0.51, 95% confidence interval: 0.30-0.87, P = .013) after TCAR. This was likely driven by the increased rate of death after TFCAS in patients with a remote history of neurologic symptoms (0.9%) compared with asymptomatic patients (0.6%). CONCLUSIONS: Asymptomatic patients with a remote history of TIA/stroke do not have the same outcomes as asymptomatic patients without a history of TIA/stroke and are at higher risk of adverse in-hospital events. Patients with a remote history of TIA/stroke have increased risk of in-hospital death after TFCAS and may benefit from TCAR.

Vascular Surgeons as Expert Witnesses in Malpractice Litigation.

BACKGROUND: This study investigates the role of vascular surgeons as expert witnesses in United States' malpractice claims. MATERIALS AND METHODS: We reviewed the Westlaw database from 1999 through 2014 using the search terms "vascular" and "surgeon". Case defendant, plaintiff, allegation, and verdict were compiled. Surgeon expert witness demographic data including age, practice duration, scholarly impact (H-index) and practice setting were reviewed using faculty websites, state licensing boards, and Scopus database. RESULTS: A total of 785 cases were identified, Three-hundred seventy-seven with a vascular surgeon as the plaintiff or defense expert witness. Vascular surgeons were defense experts in One-hundred thirty one (34.75%) cases, plaintiff experts in One-hundred eighteen (31.3%), both plaintiff and defense experts in Ninty six (25.46%), or unspecified in Thiry two cases (8.29%). Two-hunder eighty three individual expert witnesses were identified. Vascular surgeon experts who testified 4 or more times were likely to be plaintiff experts (32.5% versus 18.7%, P <0.05). Mean years of practice (23.5 versus 24.2, P = 0.10) between plaintiff and defense experts was comparable. Plaintiff experts were more likely in non-academic practice (64.4% versus 52.5%, P <0.05) with lower scholarly impact (H-index 12.8 versus 16.7, P <0.05). CONCLUSIONS: A small percentage of vascular surgeons were experts in multiple cases, especially as plaintiff witnesses. Vascular surgeons as plaintiff's witnesses have similar years of age, work less in an academics, and have lower scholarly impact than defense witnesses. While national organizations provide guidelines defining expert witness qualifications, the required credentials vary by State. Development of minimum qualifications nationally may improve consistency in expert credentialing and lead to more ethical trial representation.

Comparison of Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting Based on High Risk Anatomic Characteristics.

BACKGROUND: Anatomic details affecting the adverse outcomes following carotid artery stenting have not been well characterized. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients stratified by degree of lesion calcification and aortic arch type. METHODS: Data from patients in the Society for Vascular Surgery's Vascular Quality Initiative database undergoing TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) and had non-missing grading on carotid artery calcification or aortic arch type was analyzed. Degree of calcification was stratified into 3 groups: none, ≤ 50% calcification, and >50% calcification. Arch type was stratified as Type I, Type II, and Type III. RESULTS: A total of 9,868 patients (TCAR: 4,224; TFCAS: 5,644) were included in the calcification analysis. TCAR patients were generally older, white, smokers, and had more comorbidities than TFCAS patients. Among the symptomatic patients, there was no difference in rates of stroke, stroke/transient ischemic attack (TIA), and myocardial infarction (MI) by calcification severity between TCAR and TFCAS. However, there was a trend towards increased risk in all 3 events with higher calcification only after TFCAS. Symptomatic patients with severe (>50%) calcification had lower rates of death (TCAR: 0.9% vs. TFCAS: 2.8%, P = 0.013), stroke/death (TCAR: 2.7% vs. TFCAS: 5.8%, P = 0.006), stroke/death/MI (TCAR: 3.3% vs. TFCAS: 6.5%, P = 0.007), and postop complications (TCAR: 6.0% vs. TFCAS: 12.4%, P < 0.001) after TCAR compared to TFCAS. Furthermore, TCAR had lower risk of mortality at all degrees of calcification compared to TFCAS. Similar findings were noted among asymptomatic TCAR patients with >50% calcification, in which the rates of death (TCAR: 0.4% vs. TFCAS: 1.1%, P = 0.080) and stroke/death (TCAR: 1.5% vs. TFCAS: 3.1%, P = 0.029) were reduced. A comparison of TCAR to TFCAS by arch type showed that rates of stroke/death after TCAR were similar regardless of arch complexity (Type I: 2.6% vs. Type II: 2.8%), but increased after TFCAS with complex, high risk anatomy (Type I: 4.2% vs. Type II: 5.2%). CONCLUSIONS: While increased calcification increased rates of adverse events after TFCAS, this trend was not observed after TCAR, which also had lower rates of death and stroke/death among patients with severe calcification. Furthermore, TCAR had lower risk of mortality than TFCAS across all degrees of calcification. TFCAS was associated with increased risk of stroke/death with complex aortic arch anatomy, however, rates of stroke/death after TCAR were similar regardless of arch complexity. Our results suggests that TCAR should be preferentially considered in revascularization of patients with anatomy considered high-risk for TFCAS.

Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations.

OBJECTIVE: The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease. METHODS: Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation. RESULTS: TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality. CONCLUSIONS: TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.

The 100 most cited articles in the diagnosis and management of peripheral artery disease.

OBJECTIVE: Peripheral artery disease (PAD) is a highly prevalent disease that places major lifestyle limitations and mortality risk on affected individuals. As the understanding of the disease has grown in the medical community, it is unknown which literature has made the greatest impact on the knowledge of PAD. We performed a bibliometric analysis using the number of citations as an indication of impact to analyze the top 100 most influential articles on PAD management. METHODS: A retrospective search of the Web of Science (Thomson Reuters, New York, NY) database for English-only publications was conducted in November 2020. We identified initial references from the database using the search terms "Peripheral Arterial Disease," "Peripheral Vascular Disease," "Claudication," "Critical Limb Ischemia," "Chronic Limb Threatening Ischemia," "Rest Pain," "Ischemic Ulcer," "Toe Gangrene," "Ankle Brachial Index," and "Leg Ischemia" in Web of Science Core Collections. Articles were ranked based on the number of citations and then analyzed based on citation count and average number of citations per year. Additional metrics included the overall average number of publications per year, the journals, journal discipline, author (including degree and gender), institution, country, topic area, and the level of evidence. RESULTS: The most popular articles were published between 1959 and 2017, with 46,716 citations in total (average 27.26 citations/y). The most popular article had 2225 citations in total and was Rutherford's "Recommended standards for reports dealing with lower extremity ischemia: Revised version." Peak years of citations were 2016, 2014, and 2018 (2753, 2674, and 2639 citations, respectively). Top journals for the most cited publications were Circulation, Journal of Vascular Surgery, and the Lancet with 21, 13, and 7 articles, respectively. A majority of articles originated from the United States (58 articles), followed by the United Kingdom (15 articles) and Germany (13 articles). Major topic areas of interest and trends in the progressive understanding of PAD were noted. Top areas of focus included surgical interventions (29%), therapeutic angiogenesis (15%), epidemiological studies in PAD (14%), and diagnosis and evaluation (13%). In the top cited literature, 48% (14/29) of surgical articles investigated endovascular interventions for PAD. CONCLUSIONS: Overall, PAD research has evolved from basic epidemiological studies to advanced management with continued investigation toward future, improved treatments for PAD.

The current state of vascular surgery presence and educational content in Google and YouTube internet search results.

BACKGROUND: Information on the internet regarding vascular disease has not been extensively assessed. Our goal was to compile and appraise the information available via Google and YouTube searches regarding various topics of interest for vascular surgeons (VS) and related procedures with a focus on the role of the VS. METHODS: The Google and YouTube platforms were independently queried for 25 keywords/phrases relating to common vascular diagnoses and procedures by two separate researchers from March to July 2019. Paid advertisements or a Society for Vascular Surgery (SVS) webpage or affiliated video in the first 25 results was documented. Results were reviewed for information regarding the responsible medical specialty and the target audience, and disease-related information (screening, risk factors, risk reduction, diagnostic testing, operative treatment, alternative treatment, follow-up, complications, and recovery). RESULTS: From the Google search, 357 unique domains of 1241 total webpages were identified with 75% directed toward the public. An SVS page was present in 56% of the first-page results and least likely to be present in searches for claudication, gangrene, carotid stent, rib resection, and thrombolysis. VS were mentioned as referral physicians in 56% of the 68% of websites that mentioned a specialty, endovascular specialists/interventional radiology in 20%, and cardiothoracic surgeons in 19%. Only 4% of the websites contained information from all categories, with the greatest number for aortic dissection. Advertisements were present in 18% of all searches (most commonly for "varicose vein," "varicose vein surgery," and "inferior vena cava filter"). From YouTube, 1247 search results (613 unique videos) were evaluated with 64% directed toward the public. An SVS affiliated video was present in 36% of searches. In the 47% of videos where a specialty was mentioned, 56% mentioned VS, interventional radiology in 10%, and cardiothoracic surgeons in 7%. Only 0.24% of the videos contained information from all categories. The greatest number of content categories was in videos related to peripheral arterial disease. Across both platforms, dialysis access searches yielded results with the least number of content categories. CONCLUSIONS: Patient-related information regarding vascular surgical topics is readily available on the internet, but the content is highly variable and not comprehensive. Only half of the searches mention VS as the referral physician of choice or authority for these medical conditions. Further efforts should focus on developing the online presence of vascular surgery, improving the quality of education of vascular disease on the internet, and directing patients to the vascular specialists to treat these conditions.

Acute thrombotic manifestations of coronavirus disease 2019 infection: Experience at a large New York City health care system.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel coronavirus that has typically resulted in upper respiratory symptoms. However, we have encountered acute arterial and venous thrombotic events after COVID-19 infection. Managing acute thrombotic events from the novel virus has presented unprecedented challenges during the COVID-19 pandemic. In our study, we have highlighted the unique treatment required for these patients and discussed the role of anticoagulation for patients diagnosed with COVID-19. METHODS: The data from 21 patients with laboratory-confirmed COVID-19 disease and acute venous or arterial thrombosis were collected. The demographics, comorbidities, home medications, laboratory markers, and outcomes were analyzed. The primary postoperative outcome of interest was mortality, and the secondary outcomes were primary patency and morbidity. To assess for significance, a univariate analysis was performed using the Pearson χ2 and Fisher exact tests for categorical variables and the Student t test for continuous variables. RESULTS: A total of 21 patients with acute thrombotic events met our inclusion and exclusion criteria. Most cases were acute arterial events (76.2%), with the remainder venous cases (23.8%). The average age for all patients was 64.6 years, and 52.4% were male. The most prevalent comorbidity in the group was hypertension (81.0%). Several markers were markedly abnormal in both arterial and venous cases, including an elevated neutrophil/lymphocyte ratio (8.8) and D-dimer level (4.9 µg/mL). Operative intervention included percutaneous angiography in 25.00% of patients and open surgical embolectomy in 23.8%. Most of the patients who had undergone arterial intervention had developed a postoperative complication (53.9%) compared with a 0% complication rate after venous interventions. Acute kidney injury on admission was a factor in 75.0% of those who died vs 18.2% in the survivors (P = .04). CONCLUSIONS: We have described our experience in the epicenter of the pandemic of 21 patients who had experienced major thrombotic events from infection with COVID-19. The findings from our cohort have highlighted the need for increased awareness of the vascular manifestations of COVID-19 and the important role of anticoagulation for these patients. More data are urgently needed to optimize treatment and prevent further vascular complications of COVID-19 infections.

Perioperative Opioid and Nonopioid Prescribing Patterns in AVF/AVG Creation.

BACKGROUND: To evaluate postoperative opioid prescribing patterns in patients undergoing hemodialysis access creation. METHODS: Operative logs were reviewed to identify patients undergoing creation of arteriovenous fistula (AVF) or graft (AVG) from September 2016 to January 2018. Immediate postoperative opioid prescriptions were compared for ambulatory patients versus inpatients. Opioid prescriptions at the time of discharge for inpatients were recorded. Rates of opioid prescribing were standardized by conversion to morphine milligram equivalents (MMEs). Opioid use postoperatively and at the time of discharge based on anesthetic technique, general anesthesia versus regional or local anesthesia with sedation were compared. Alternative pain medications administered and pain scores were recorded. Comparisons were made between the percentage of opioid use and doses administered between AVF and AVG patient groups, ambulatory and inpatients, and type of anesthetic technique used. Statistical analysis was performed with chi-square and t-tests. RESULTS: We identified 164 patients undergoing AV access creation but not receiving chronic opioid therapy. A significantly higher percentage of inpatients received opioids in the immediate postoperative period than ambulatory patients (AVF: 72% vs. 19%, P < 0.001; AVG: 62% vs. 25%, P = 0.001). Overall, all AVG patients were more likely to be discharged with an opioid prescription than all AVF patients (37% vs. 8%, P < 0.001). Of AVG patients managed in the ambulatory setting, 48% were discharged with an opioid prescription. The mean total opioid postoperative dose prescribed to inpatients was significantly higher than that prescribed to ambulatory patients for both fistulas (28.73 MMEs vs. 1.27 MMEs, P < 0.001) and grafts (22.11 MMEs vs. 2.16 MMEs, P = 0.005). General anesthesia patient groups were more likely to receive opioids postoperatively than local anesthesia with sedation patients for both AVF (54% vs. 24%, P = 0.027) and AVG creation (61% vs. 17% P < 0.001). Postoperative alternative medication use in the hospital was low with 18% acetaminophen and 1% nonsteroidal anti-inflammatory drug use for AVF patient groups and 24% acetaminophen and 0% nonsteroidal anti-inflammatory drug use for AVG patient groups. The percentage of patients reporting postoperative pain in the recovery room and on the inpatient units was comparable between ambulatory and inpatient settings (AVF: 21% vs. 28%, P = 0.534; AVG: 23% vs. 44%, P = 0.061). CONCLUSIONS: A higher percentage of inpatients undergoing hemodialysis access received opioids when compared with ambulatory patients in the immediate postoperative period. Inpatients were prescribed higher mean doses than ambulatory patients. AVG patient groups were prescribed more opioids than AVF patient groups. Alternative analgesic agent use was low, suggesting an opportunity for improved pain control and opioid reduction. Dialysis access creation represents an opportunity to improve on opioid prescribing patterns.

Ambulatory Status following Major Lower Extremity Amputation.

BACKGROUND: The ability to ambulate following major lower extremity amputation, either below (BKA) or above knee (AKA), is a major concern for all prospective patients. This study analyzed ambulatory rates and risk factors for nonambulation in patients undergoing a major lower extremity amputation. METHODS: A retrospective review of 811 patients who underwent BKA or AKA at our institution between January 2009 and December 2014 was conducted. Demographic information and co-morbid conditions, including the patients' functional status prior to surgery, at 6 months, and at latest follow up were recorded. Following exclusion criteria, 538 patients were included. Patients who were either independent or used an assistive device were considered ambulatory, while those who were completely wheelchair-dependent or bed-bound were considered nonambulatory. RESULTS: Pre-operatively, 83.1% of BKA patients were ambulatory, significantly more so than those undergoing AKA (44.9%, P < 0.0001). At 6-month follow-up these percentages dropped to 58.0% and 25.2%, respectively, for all patients. For patients who were ambulatory pre-operatively, 182/246 (73.9%) of BKA and 32/51 (62.7%) of AKA remained so post-amputation. Of those patients with both 6-month and greater than 1-year follow-up, there was no change in ambulatory status between the 2 time periods. On multivariable logistic regression, age greater than 70 years and female sex were associated with nonambulation post-operatively (P = 0.001, P = 0.015, respectively). None of the co-morbid conditions recorded (diabetes, renal insufficiency, end-stage renal disease, peripheral vascular disease, or body mass index > 35) was found to have a statistically significant correlation with post-operative ambulation using multivariable analysis. CONCLUSIONS: The majority of ambulatory patients undergoing a major amputation were able to remain ambulatory. Patients who failed to ambulate 6 months after their amputation, failed to resume ambulating. Age greater than 70 and female sex were found to have a statistically significant association with becoming nonambulatory following surgery.

A Propensity-Matched Analysis of Endovascular Intervention versus Open Nonautologous Bypass as Initial Therapy in Patients with Chronic Limb-Threatening Ischemia.

OBJECTIVES: Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention. METHODS: We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models. RESULTS: A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P < 0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization. CONCLUSIONS: An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.

Trends in Ethnicity, Race, and Sex Among Psychiatry and Non-psychiatry Residency Applicants, 2008-2019.

OBJECTIVE: The objective of this study was to examine trends in racial/ethnic and gender representation among US psychiatry residency applicants compared with non-psychiatry applicants. METHODS: Using publicly available applicant data, racial/ethnic and gender distributions of psychiatry residency applicants from 2008 to 2019 were examined and compared with non-psychiatry residency applicants. Both longitudinal trends within both cohorts and cross-sectional, between-group differences were examined. RESULTS: From 2008 to 2019, the percentage of female, American Indian/Alaskan Native (AIAN), Black, Hispanic, and Native Hawaiian/Other Pacific Islander (NHPI) psychiatry and non-psychiatry residency applicants increased (p<.001). Within each year, Black and Asian applicants comprised a larger percentage of psychiatry applicants compared with non-psychiatry applicants (p<.001). Between 2008 and 2019, Black psychiatry and non-psychiatry applicants increased from 9.1% to 11.6% and 6.6% to 7.6%, respectively; Asian psychiatry and non-psychiatry applicants decreased from 39.5% to 30.5% and 27.5% to 26.6%, respectively; White psychiatry and non-psychiatry applicants increased from 26.7% to 38.2% and 42.7% to 49.2%, respectively. CONCLUSIONS: Racial/ethnic and gender characteristics of US psychiatry residency applicants represent the future of the US psychiatric workforce. The US psychiatry residency applicant pool has become increasingly diverse from 2008 to 2019. Initiatives should work to enhance representation of psychiatry applicants from historically marginalized backgrounds, and simultaneously to recruit and retain a diverse psychiatric workforce following residency training.

Gender disparities in academic vascular surgeons.

OBJECTIVE: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery. METHODS: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis. RESULTS: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001). CONCLUSIONS: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery.

Common Reasons for Malpractice Lawsuits Involving Pulmonary Embolism and Deep Vein Thrombosis.

BACKGROUND: Pulmonary embolism and deep vein thrombosis are common clinical entities, and the related malpractice suits affect all medical subspecialties. Claims from malpractice litigation were analyzed to understand the demographics of these lawsuits and the common reasons for pursuing litigation. METHODS: Cases entered into the Westlaw database from March 5, 1987, to May 31, 2018, were reviewed. Search terms included "pulmonary embolism" and "deep vein thrombosis." RESULTS: A total of 277 cases were identified. The most frequently identified defendant was an internist (including family practitioner; 33%), followed by an emergency physician (18%), an orthopedic surgeon (16%), and an obstetrician/gynecologist (9%). The most common etiology for pulmonary embolism was prior surgery (41%). The most common allegation was "failure to diagnose and treat" in 62%. Other negligence included the failure to administer prophylactic anticoagulation while in the hospital (18%), failure to prescribe anticoagulation on discharge (8%), failure to administer anticoagulation after diagnosis (8%), and premature discontinuation of anticoagulation (2%). The most frequently claimed injury was death in 222 cases (80%). Verdicts were found for the defendant in 57% of cases and for the plaintiff in 27% and settled in 16%. CONCLUSIONS: The most frequently cited negligent act was the failure to give prophylactic anticoagulation, even after discharge. The trends noted in this study may potentially be addressed and therefore prevented by systems-based practice changes. The most common allegation, "failure to diagnose and treat," suggests that first-contact doctors such as emergency physicians and primary care practitioners must maintain a high index of suspicion for deep vein thrombosis/pulmonary embolism.

The Prevalence and Utility of Vascular Surgery Training Programs' and Vascular Societies' Social Media Presence.

BACKGROUND: There is a paucity of information describing the adoption of social media by the vascular surgery community and social media's effectiveness. We evaluated current trends in social media use by all accredited vascular surgery training programs (VSTPs) in the United States and National and Regional Vascular Societies (NVS) in comparison to hospital/institutions and general surgery programs (GSPs). METHODS: Four major social media platforms (Twitter, Facebook, Instagram, and YouTube) were individually searched for VSTPs, affiliated hospital/institution, affiliated GSP, and NVS profiles (31 societies). Social media presence was evaluated for quantitative and qualitative variables (likes/followers/posts and content) on each platform. Statistical analysis was performed utilizing a two-sample t-test, exact McNemar's and Fischer's exact test, as appropriate, with alpha set at 0.05. RESULTS: Social media accounts were found for 31% of VSTP. VSTP with both fellowship and integrated positions had a greater social media presence than integrated only (45% vs. 10%, P = 0.042) and fellowship only (45% vs. 26%, P = 0.044) programs. For integrated programs, an increase in residency positions filled in the 2019 match was associated with the use of social media (P = 0.002). VSTP social media presence was largest on Twitter (24%) with 232 total posts and 0.32 posts/day. 52% of NVS had a social media platform, with the highest prevalence on Facebook (42%) and highest utilization on Twitter (1422 posts, 0.47 posts/day). Hashtags were used for postings by 78% of VSTP and 100% of NVS. VSTP had a lower overall social media presence than their institutions and GSP (31% vs. 96% and 65%, P < 0.001). Twitter was used by VSTP significantly less than the institutions and GSP (24% vs. 87% and 57%, P < 0.001). Facebook and Instagram were used less by VSTP than institutions or GSP (10% vs. 93% and 26% P < 0.001, 4% vs. 76% and 24% P < 0.001 respectively). YouTube channels were the least used platform in VSTP compared with institutions (3% vs. 92%, P < 0.001), but comparable to GSP (3% vs. 10%, P = 0.062). Regarding content, VSTP accounts were used for comments on academic activity of residents/physicians, faculty research, patient education, and commendations. CONCLUSIONS: There is relative underuse of social media by VSTP in comparison to their associated institutions and general surgery programs. VSTP may modify their approach to recruitment by utilizing the follower base of institutions, surgery programs, and NVS or by leveraging established institutional marketing programs. Adoption of social media may provide vascular surgery increased exposure for trainee and patient recruitment and specialty brand recognition.

Malpractice Litigation for Compartment Syndrome.

BACKGROUND: The aim of this study was to analyze litigation involving compartment syndrome to identify the causes and outcomes of such malpractice suits. A better understanding of such litigation may provide insight into areas where clinicians may make improvements in the delivery of care. METHODS: Jury verdict reviews from the Westlaw database from January 1, 2010 to January 1, 2018 were reviewed. The search term "compartment syndrome" was used to identify cases and extract data on the specialty of the physician defendant, the demographics of the plaintiff, the allegation, and the verdict. RESULTS: A total of 124 individual cases involving the diagnosis of compartment syndrome were identified. Medical centers or the hospital was included as a defendant in 51.6% of cases. The most frequent physician defendants were orthopedic surgeons (45.96%) and emergency medicine physicians (20.16%), followed by cardiothoracic/vascular surgeons (16.93%). Failure to diagnose was the most frequently cited claim (71.8% of cases). Most plaintiffs were men, with a mean age of 36.7 years, suffering injuries for an average of 5 years before their verdict. Traumatic compartment syndrome of the lower extremity causing nerve damage was the most common complication attributed to failure to diagnose, leading to litigation. Forty cases (32.25%) were found for the plaintiff or settled, with an average award of $1,553,993.66. CONCLUSIONS: Our study offers a brief overview of the most common defendants, plaintiffs, and injuries involved in legal disputes involving compartment syndrome. Orthopedic surgeons were most commonly named; however, vascular surgeons may also be involved in these cases because of the large number of cases with associated arterial involvement. A significant percentage of cases were plaintiff verdicts or settled cases. Failure to diagnosis or delay in treatment was the most common causes of malpractice litigation. Compartment syndrome is a clinical diagnosis and requires a high level of suspicion for a timely diagnosis. Lack of objective criteria for diagnosis increases the chances of medical errors and makes it an area vulnerable to litigation.

Digital Footprint of Vascular Surgery Training Programs in the United States and Canada.

BACKGROUND: The digital footprint of vascular residency and fellowship programs may have an impact on an applicant's likelihood of selecting a given program. This may include content and accessibility of a particular program's website as well as its social media presence. The goal of this study is to evaluate the online presence of all accredited vascular surgery training programs in the United States and Canada. METHODS: A list of accredited vascular surgery training programs in the United States was obtained from the Accreditation Council for Graduate Medical Education and the Society for Vascular Surgery websites. Canadian program websites were sourced from the Canadian Society for Vascular Surgery website. Each program website was individually queried. A systematic Google search of each program was carried out to determine website accessibility. Thirty-one individual content and quality metrics were used to appraise the websites. Three major social media platforms (Twitter, Facebook, and Instagram) were individually searched for program profiles. RESULTS: A total of 105 independent vascular surgery fellowship programs in the 5 + 2 paradigm and 55 integrated vascular surgery residency programs in the 0 + 5 paradigm were identified in the United States. An additional 10 Canadian programs were also identified, including 10 integrated residency programs and 4 independent fellowships. Ninety-nine percent of integrated residency and fellowship programs were accessible through Google search. Program description was also almost universally available. Significant differences between US and Canadian programs were observed including the mention of salary information (43% vs. 10%, P = 0.039), clinic responsibilities (38% vs. 90%, P = 0.001), teaching responsibilities (34% vs. 100%, P < 0.0001), program director contact information (47% vs. 80%, P = 0.045), mention of journal club (52% vs. 100%, P = 0.003), research requirements (50% vs. 90%, P = 0.014), and past and current research (30% vs. 70%, P = 0.009 and 37% vs. 80%, P = 0.008, respectively). Additionally, there were significant differences in mention of institutions from which trainees came from (48% vs. 10%, P = 0.021), mention of hybrid operating room (42% vs. 100%, P = 0.0003), advertised medical student rotations (25% vs. 90%, P < 0.0001), and finally social media presence (13% vs. 70%, P < 0.0001). CONCLUSIONS: The overall digital footprint of the majority of training programs in the United States was small, unlike their Canadian counterparts. Although the vast majority of websites for vascular surgery training programs were accessible via simple internet searches, they lacked information that could have been important to applicants. Additionally, the significant underuse of social media platforms by American vascular surgery programs indicated a potential missed opportunity to target the millennials who make up most of the applicant pool to these programs.