Multi-Level Thrombotic/Embolic Burden and Its Role in Sex-Related Outcomes in Acute Limb Ischemia (ALI).

INTRODUCTION: The impact of sex upon outcomes in acute limb ischemia (ALI) remains disputed. We aim to quantify the effect of sex upon amputation-free survival (AFS) after a percutaneous-first approach for ALI. METHODS: Two-center retrospective review of ALI managed via a percutaneous-first approach. Demographics, comorbidities, and clinical characteristics were analyzed (Table I). The Kaplan-Meier and Cox regression were used to estimate AFS, limb-salvage and overall survival. RESULTS: Over nine years, 170 patients (87, 51% males; median age 67 IQR 59, 77 years) presented with ALI. Rutherford Classification was I in 56 (33%); IIa in 85 (50%); IIb in 20 (12%) and III in 9 (5%). Thirty-day mortality, major amputation rate and fasciotomy rates were 8% (N=13); 6.5% (N=11), and 4.7% (N=8), respectively. Among revascularized limbs, 92% were patent at 30 days. Length of stay was 7 (IQR 3-11) days. Complications included 13 bleeding episodes (8%), 4 cases of atrial fibrillation (2%), and 3 re-thrombosis/clot extension events (1.7%). No differences were noted in complication rates when stratified by sex. Females were older than males (median age 70 IQR 62, 79 vs 65 IQR 56, 76 years; p=0.02) and more likely to present with atrial fibrillation (20.5% vs 8%, p 0.02); and hyperlipidemia (72% vs 57%, p = 0.04). Females also more frequently presented with multi-level thrombotic/embolic burden compared to males (56% vs 43%; p=0.03), and required both aspiration thrombectomy and thrombolysis (27% versus 14%; p 0.02). Kaplan-Meier estimated median AFS, limb salvage, and overall survival were 425 (IQR 140, 824 days); 314 (IQR 72, 727 days); and 342 (IQR 112, 762 days). When stratified by sex, females had worse survival (median 270 IQR 92, 636 versus 406 IQR 140, 937 days; p=0.005); and limb salvage (median 241 IQR 88, 636 versus 363 IQR 49, 822 days; p=0.04) compared to males. Univariate Cox regression showed female sex (HR = 1.46 95% CI 1.04-2.05; p=0.03); multi-level thrombotic/embolic burden (HR 1.64 95% CI 1.17-2.31; p=0.004) and Rutherford Class (HR 1.37 95% CI 1.08-1.73; p=0.009) predicted major amputation/death. By multivariable Cox regression, multi-level thrombotic/embolic burden (HR 1.54 95% CI 1.09-2.17; p=0.01), Rutherford Class (HR 1.34 95% CI 1.07-1.69; p=0.01), and female Sex (HR = 1.45 95% CI 1.03-2.05; p=0.03) were each independently predictive of major amputation/death. CONCLUSIONS: A percutaneous-first strategy is safe and efficacious in the overall ALI population. Similar to prior works, female versus male ALI patients in our cohort have higher rates of mortality and major amputation. In our multivariable model, multi-level thrombotic/embolic burden was independently associated with a greater than 45% increased hazard of major amputation/ death at last follow up. Further prospective analysis is warranted to elucidate the underlying factors contributing to the higher prevalence of multi-level thrombotic/embolic burden in female ALI patients, and to further define the optimal percutaneous-first approach for ALI in consideration of patient sex and extent of clot burden.

Characterization of tibial velocities by duplex ultrasound in severe peripheral arterial disease and controls.

BACKGROUND: The relationship between tibiopopliteal velocities and peripheral arterial disease (PAD) severity is not well understood. We sought to characterize tibiopopliteal velocities in severe PAD and non-PAD control patients. METHODS: Patients with an arterial duplex ultrasound (DUS) examination with PAD evaluated during a 5-year period were retrospectively compared with non-PAD controls. Control DUS examinations were collected sequentially during a 6-month period, retrospectively. PAD patients included those with lifestyle-limiting intermittent claudication warranting revascularization and patients with critical limb ischemia, defined as ischemic rest pain, gangrene, or a nonhealing ischemic ulcer. For each, tibial and popliteal artery peak systolic velocity (PSV) was measured at the proximal, mid, and distal segment of each artery, and a mean PSV for each artery was calculated. Mean PSV, ankle-brachial indices, peak ankle velocity (PAV), average ankle velocity (AAV), mean tibial velocity (MTV), and ankle-profunda index (API) were compared between the two groups using independent t-tests. PAV is the maximum PSV of the distal peroneal, posterior tibial (PT), or anterior tibial (AT) artery; AAV is the average PSV of the distal peroneal, PT, and AT arteries; MTV is calculated by first averaging the proximal, mid, and distal PSV for each tibial artery and then averaging the three means together; API is the AAV divided by proximal PSV of the profunda. RESULTS: DUS was available in 103 patients with PAD (68 patients with critical limb ischemia and 35 patients with intermittent claudication) and 68 controls. Mean ankle-brachial index in the PAD group was 0.64 ± 0.25 compared with 1.08 ± 0.09 in controls (P = .006). Mean PSVs were significantly lower in PAD patients than in controls at the popliteal (64.6 ± 42.2 vs 76.2 ± 29.6; P = .037), peroneal (34.3 ± 26.4 vs 53.8 ± 23.3; P < .001), AT (43.7 ± 31.4 vs 65.4 ± 25.0; P < .001), and PT (43.4 ± 42.3 vs 74.1 ± 30.6; P < .001) and higher at the profunda (131.5 ± 88.0 vs 96.2 ± 44.8; P = .001). Tibial parameters including PAV (52.6 ± 45.0 vs 86.9 ± 35.7; P < .001), AAV (37.4 ± 26.4 vs 64.5 ± 21.7; P < .001), MTV (41.7 ± 30.4 vs 65.4 ± 21.7; P < .001), and API (0.43 ± 0.45 vs 0.75 ± 0.30; P < .001) were significantly lower in the PAD group than in controls. Nonoverlapping 95% confidence interval reference ranges were established for severe PAD and non-PAD controls. CONCLUSIONS: This study aims to characterize lower extremity arterial PSVs and ankle parameters in severe PAD and non-PAD controls. These early criteria establish reference ranges to guide vascular laboratory interpretation and clinical decision-making.

Radiology Resident Ownership Scale (RROS): Adapting a Validated Measure of Patient Care Ownership to the Radiology Context.

RATIONALE AND OBJECTIVES: The aim of this study was to develop a validated instrument to measure radiology residents' sense of psychological ownership of patient care. MATERIALS AND METHODS: A previously validated measure of patient care ownership was adapted through a two-step process of expert review and revision by six academic radiology faculty. An online, anonymous survey was distributed to 64 residents and fellows at the end of three consecutive four-week long rotations. We calculated Cronbach's α to determine the scale's internal consistency, performed exploratory factor analysis to identify possible subscales, and conducted bivariate and correlational analysis to establish construct validity. RESULTS: The 11-item ownership scale demonstrated good internal consistency (Cronbach's α = 0.93), and three subscales were identified corresponding to assertiveness, conscientiousness, and confidence/perceived competence. Sense of ownership was significantly associated with training level, prior experience in the type of rotation, stress, sleep, burnout, peer support, relationships with clinical staff, and recognition by department. We found no significant association between ownership and age, gender, type of rotation, site of rotation, type of residency, perceived interruption frequency, or remote work frequency. CONCLUSION: The radiology resident patient care ownership scale demonstrates good internal consistency and preliminary evidence of validity. After further validation, we expect the scale to be a valuable tool in evaluating interventions aimed at increasing radiology residents' sense of ownership.

Successful treatment of a rare 6.5-cm true profunda femoris artery aneurysm with aneurysmectomy and interposition bypass.

Profunda femoris artery aneurysms (PFAAs) are rare and account for only 0.5% of all peripheral artery aneurysms. Potential complications include compression of surrounding nerves and veins, limb ischemia, and rupture. Currently there are no guidelines on the management of true PFAAs, and suggested treatment modalities include endovascular, open, and hybrid approaches. We report a case of an 82-year-old male with a history of aneurysmal disease who presented with a symptomatic 6.5-cm PFAA. He underwent successful aneurysmectomy and interposition bypass, which remains an effective method for treatment of this rare pathology.

Virtual medical student education and recruitment during the COVID-19 pandemic.

Due to the immediate need for social distancing, as well as widespread disruption in clinical practices, brought on by the novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, medical student education rapidly shifted to a virtual format, which resulted in a variety of innovative and remotely accessible practices to address new restrictions on face-to-face education. Educators approached curriculum design seeking to replicate as much of the in-person experience as possible, and were faced with overcoming the challenges of replacing the innately hands-on nature of surgery with virtual operative and skills experiences. Restrictions on in-person visiting electives expedited the role of virtual education as a notable opportunity for medical student education and recruitment, with a variety of approaches to engaging undergraduate medical learners, including the use of live-streaming operative cases, virtual didactic curricula, and a rise in podcasts; web-based conferences; and virtual journal clubs. In addition to education, virtual outreach to medical students has become an essential tool in trainee recruitment and selection, and ongoing application of novel educational platforms will allow for new opportunities in multi-institutional collaboration and exchange with a multitude of benefits to future vascular surgery trainees. Our aim was to outline the resources and practices used to virtually teach and recruit medical students and the benefits of virtual rotations to the program and students.