The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms.

The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms (PAAs) leverage the work of a panel of experts chosen by the Society for Vascular Surgery to review the current world literature as it applies to PAAs to extract the most salient, evidence-based recommendations for the treatment of these patients. These guidelines focus on PAA screening, indications for intervention, choice of repair strategy, management of asymptomatic and symptomatic PAAs (including those presenting with acute limb ischemia), and follow-up of both untreated and treated PAAs. They offer long-awaited evidence-based recommendations for physicians taking care of these patients.

Burnout in the Plastic Surgeon: Implications and Interventions.

A career as a plastic surgeon is both rewarding and challenging. The road to becoming a surgeon is a long arduous endeavor and can bring significant challenges not only to the surgeon but their family. A study by the American College of Surgeons (ACS) suggested that over 40% of surgeons experience burnout and a recent survey of American Society of Plastic Surgeons (ASPS) showed that more than one-fourth of plastic surgeons have signs of professional burnout. Burnout is a state of physical and mental exhaustion. The three main components of burnout are emotional exhaustion, depersonalization, and reduced personal accomplishment. Exhaustion occurs as a result of emotional demands. Depersonalization refers to a cynical, negative or a detached response to patient care. The reduced accomplishment refers to a belief that one can no longer work effectively. There has been a recent explosion in the literature characterizing burnout within the surgical profession. Reports of burnout, burnout victims, and burnout syndrome are filling the medical literature, books, blogs, and social media across all different specialties. Burnout in a plastic surgeon has negative and potentially fatal repercussions to the surgeon, their family, their patients, their staff, colleagues, coworkers, and their organization. To date, there are a limited number of publications addressing burnout in the plastic surgery community. The goals of this paper are to review the symptoms of burnout, its effect on plastic surgeons, and discuss potential solutions for burnout prevention and physician wellness.

Surgeon and medical student response to patient death.

BACKGROUND: Virtually all surgeons will experience patient death in their practice. Despite this, little is known about how surgeons cope with patient death or its potential adverse impact on surgeons' well-being. Education on how to respond to loss is not often incorporated into current wellness curricula in surgical training. In light of the ongoing COVID-19 pandemic and the significant hospital-related mortality, understanding surgical provider response to patient loss takes on unique import. METHODS: A retrospective analysis was performed following administration of a 10-item survey that assessed healthcare provider (HCP) experience with patient death, activities used to cope with patient loss, and symptoms HCPs experienced. Participants included surgical faculty, residents, surgical advance practice providers and medical students on their surgical clerkship. Demographic characteristics were recorded: age, gender, academic level. Chi-squared test or Fisher exact test compared proportionality between those that did and did not experience patient loss. Logistic regression generated odds ratios examining impact of patient loss on symptoms experienced and activities engaged in after patient loss. RESULTS: Fifty-six (75%) respondents experienced patient death. Common responses were to talk with colleagues (71%) and seek comfort from family/friends/partner (55%). Most respondents did not report symptoms related to patient death (53%); burnout was the most common symptom reported (36%). Respondents were less likely to seek interpersonal support for COVID-19-related death (P<0.008). Only 49% of participants received education on coping with patient death. CONCLUSIONS: Few surgeons receive training related to patient death. Optimal coping strategies are unknown but may mitigate potential negative impacts, including burnout. The data presented here also suggests the need to establish medical education designed to mitigate the distress associated with patient loss.

Radiation exposure in endovascular procedures.

BACKGROUND: The introduction of percutaneous techniques to treat patients with peripheral vascular disease has placed the vascular surgeon in the unique role as the fluoroscopy supervisor overseeing the radiation protection for patient, self, staff, and trainee. Since radiation is an invisible threat in endovascular interventions, attention to protection may be challenging for the surgeon to understand and enforce. METHODS: General endovascular radiation considerations for endovascular aneurysm repair (EVAR) and peripheral interventions are reviewed. RESULTS: Peripheral atherectomy has the highest estimated skin doses of all endovascular procedures. Renal interventions, visceral balloon angioplasty and stenting, and embolization procedures are some of the procedures that have the highest peak skin doses. Patients with high body mass index (BMI) have been found to have up to three times higher peak skin doses than patients with normal BMI. CONCLUSION: The degree of radiation exposure is dependent on the type of endovascular procedure, the patient's body habitus, and also the safety habits of the surgeon. Radiation exposure needs addressed in an informed consent process as is required for other procedures. Radiation exposure risks also need monitoring just as a surgeon monitors individual morbidity and mortality.

Beyond the Technical: Determining Real Indications for Vascular Access and Hemodialysis Initiation in End-Stage Renal Disease.

Determining valid indications for vascular access creation and hemodialysis initiation in end-stage renal disease requires utilization of verified prognostication tools and recognition of triggers to initiate serious conversations, and implementation of concurrent palliative care and/or hospice care is recommended. Establishment of a multi-disciplinary team that includes consideration of interventionalists in the pre-dialysis medical situation is important. A "catheter best" approach may be the most appropriate for some patients to meet goals of care.

Effects of a standardized emergency department protocol on after-hours use of venous duplex ultrasound.

OBJECTIVE: Vascular laboratory (VL) venous duplex ultrasound is the "gold standard" for diagnosis of lower extremity deep venous thrombosis (DVT), which is linked to many morbid conditions. Decreasing night and weekend use of VL services in the emergency department (ED) represents a potentially viable means of reducing costs as skilled personnel must remain on call and receive a wage premium when activated. We investigated the effects of workflow changes that required ED providers to use a computerized decision-making tool, integrated into the electronic medical record, to calculate a Wells score for each patient considered for an after-hours venous duplex ultrasound study for suspected DVT. METHODS: The rate of VL use and study positivity before and after implementation of the decision-making tool were examined in addition to measures of ED throughput, rate of concomitant pulmonary embolism, disposition of examined patients from the ED, observed thrombus distribution in duplex ultrasound studies positive for DVT, and calculated personnel costs of after-hours VL use. RESULTS: A total of 391 after-hours, ED-initiated venous duplex ultrasound studies were obtained during the 4-year study period (n = 213 before intervention, n = 178 after intervention; P = .12). Whereas the period immediately after the start of the intervention saw a decrease in VL use, this was not sustained. Studies performed after the intervention were not more likely to be positive for acute DVT (12.2% vs 18%; P = .1179). The average Wells score was 2.8 (range, 0-6). VL personnel were called in 347 times during the 4-year period, with a total cost of $14,643.40. Nurse-ordered studies were significantly more likely to be positive, with 22% revealing acute DVT compared with 12% for physician-ordered studies (P = .042). The intervention resulted in significant improvements in ED throughput, with time between triage and study request falling from 226 minutes to 165 minutes (P < .001). Observed thrombus distribution revealed involvement of the most proximal external iliac system in a minority of cases (11%), whereas most thrombi (89%) were limited to the femoropopliteal, calf, and superficial venous systems. CONCLUSIONS: A requirement for ED providers to document a Wells score before obtaining an after-hours venous duplex ultrasound study resulted in only a transient decrease in VL use but improved ED throughput. Studies ordered by nurses were significantly more likely to be positive, possibly as a result of consistent protocol adherence compared with the physicians. Future studies may warrant investigation into this provider variance.

Competency champions in the clinical competency committee: a successful strategy to implement milestone evaluations and competency coaching.

OBJECTIVES: To create a clinical competency committee (CCC) that (1) centers on the competency-based milestones, (2) is simple to implement, (3) creates competency expertise, and (4) guides remediation and coaching of residents who are not progressing in milestone performance evaluations. DESIGN: We created a CCC that meets monthly and at each meeting reviews a resident class for milestone performance, a competency (by a faculty competency champion), a resident rotation service, and any other resident or issue of concern. SETTING: University surgical residency program. PARTICIPANTS: The CCC members include the program director, associate program directors, director of surgical curriculum, competency champions, departmental chair, 2 at-large faculty members, and the administrative chief residents. RESULTS: Seven residents were placed on remediation (later renamed as coaching) during the academic year after falling behind on milestone progression in one or more competencies. An additional 4 residents voluntarily placed themselves on remediation for medical knowledge after receiving in-training examination scores that the residents (not the CCC membership) considered substandard. All but 2 of the remediated/coached residents successfully completed all area milestone performance but some chose to stay on the medical knowledge competency strategy. CONCLUSIONS: Monthly meetings of the CCC make milestone evaluation less burdensome. In addition, the expectations of the residents are clearer and more tangible. "Competency champions" who are familiar with the milestones allow effective coaching strategies and documentation of clear performance improvements in competencies for successful completion of residency training. Residents who do not reach appropriate milestone performance can then be placed in remediation for more formal performance evaluation. The function of our CCC has also allowed us opportunity to evaluate the required rotations to ensure that they offer experiences that help residents achieve competency performance necessary to be safe and effective surgeons upon completion of training.

Safety, feasibility, and outcome of retrievable vena cava filters in high-risk surgical patients.

OBJECTIVE: Retrievable vena cava filters (rVCFs) are being used frequently in the perioperative setting for preventing pulmonary embolism. The indications and safety profile for placement of preoperative retrievable vena cava filters (rVCFs) remains undefined, however. This study sought to determine the safety, feasibility, and outcome of rVCFs in bariatric surgery patients, who are known as a high-risk population for periprocedural deep vein thrombus (DVT) or pulmonary embolus, or both. METHODS: Between June 1, 2004, and October 1, 2005, protocols were developed and implemented at a tertiary referral hospital for placement of rVCFs in 59 consecutive high-risk patients undergoing laparoscopic gastric bypass or duodenal switch if they met any of the following criteria: body mass index >55 kg/m(2), hypercoagulable state, severe immobility, venous stasis, or previous history of DVT or pulmonary embolus. Using both Site-Rite (Bard Access Systems, Salt Lake City, Utah) ultrasound and fluoroscopy, Günther Tulip (Cook, Inc., Bloomington, Ind) rVCFs were placed immediately after general anesthesia, just preceding the bariatric procedure. The internal jugular vein was the preferred approach, followed by the femoral vein. Retrieval was performed after the fourth postoperative week. RESULTS: During a 16-month period, 60 rVCFs were placed in 61 attempts, 57 through the internal jugular vein and three through the femoral vein. Six patients refused the retrieval attempt. Of the remaining 54 rVCFs, the primary retrieval success was 90% (49/54), with all failures due to severe filter tilt. The secondary retrieval success was 100% (3/3). The two remaining patients refused secondary retrieval attempt. The mean +/- standard deviation dwell time of the rVCFs was 63 +/- 30 days. No procedure complications occurred in placement or retrieval. One patient developed a clinical pulmonary embolism with the filter in place while not receiving postoperative anticoagulation. No patients died. The mean body mass index of the patients was 61 +/- 10 kg/m(2). CONCLUSION: Placement and retrieval of retrievable vena cava filters in high-risk bariatric surgery patients is safe, feasible, and offers potential clinical benefit to patients requiring short-term protection from pulmonary embolism.