Intraoperative Pedal Pressure Changes Offers Another Quantitative Assessment for Revascularization.

BACKGROUND: Lower extremity angiography is one of the most prevalent vascular procedures performed, generally via the contralateral common femoral artery. The use of retrograde pedal artery access to perform angiography has long been reserved as a "bail-out" technique to help cross chronic total occlusions that were not amenable from an antegrade approach. Recently, there have been reports and discussions involving increased utilization of pedal access for primary revascularization. The purpose of this study is to describe the outcomes of pedal access as a primary approach and to propose a novel evaluation of distal perfusion changes associated with interventions using direct pressure measurements. METHODS: A retrospective observational study evaluating all patients who underwent lower extremity angiography via retrograde pedal access between December 1, 2020, and June 30, 2021, within a single health-care system spanning 3 hospitals was performed. Demographics, comorbidities, procedural indications, and details were all recorded. Hemodynamic measurements were obtained and recorded upon initial pedal access and post intervention with a pressure transducer connected directly to the access sheath. Outcomes were analyzed with paired t-test. RESULTS: Twenty-eight angiograms using primary pedal access for endovascular intervention were performed during the study period. Most patients were African American (75%) females (57.1%) with hypertension (89.3%), hyperlipidemia (78.6%), diabetes (85.7%), coronary artery disease (64.3%), and current tobacco users (57.1%). The most prevalent indication for angiography was nonhealing wounds (67.9%). Pedal access was mostly achieved via the anterior tibial artery (79%). Sixty-three vessels were treated during the 28 angiograms (averaging 2.3 vessels per angiogram), most commonly the superficial femoral (27%), anterior tibial (25%), and popliteal (22%) arteries. Balloon angioplasty with or without stenting (98.5%) was predominately performed with an overall technical success rate of 94%. The mean preintervention and postintervention pressures were 36.5 mm Hg (standard deviation [SD] 25.7) and 83.4 mm Hg (SD 19.5), respectively. The mean change in pressure after intervention was 46.9 mm Hg (SD 23.3) (Table 3). There was a statistically significant difference detected between preintervention and postintervention pressure (P < 0.001) (Figure 1). There were no major amputations or adverse cardiovascular events at a mean first follow-up duration of 89 days. Six of the total 28 patients (21.4%) underwent repeat endovascular intervention on the ipsilateral extremity within a median of 45 (interquartile range 22.5-62.3) days. CONCLUSIONS: Primary pedal access is a viable option for performing lower extremity angiographic interventions. A significant increase in pedal artery pressure can be observed after angiographic intervention from retrograde pedal artery access. Further studies are necessary to define the clinical prognostic importance of these findings in relation to wound healing rates.

The Society for Vascular Surgery Objective Performance Goals for Critical Limb Ischemia are attainable in select patients with ischemic wounds managed with wound care alone.

BACKGROUND: To set therapeutic benchmarks, in 2009 the Society for Vascular Surgery defined objective performance goals (OPG) for treatment of patients with chronic limb threatening ischemia (CLTI) with either open surgical bypass or endovascular intervention. The goal of these OPGs are to set standards of care from a revascularization standpoint and to provide performance benchmarks for 1 year patency rates for new endovascular therapies. While OPGs are useful in this regard, a critical decision point in the treatment of patients with CLTI is determining when revascularization is necessary. There is little guidance in the comprehensive treatment of this patient population, especially in the nonoperative cohort. Guidelines are needed for the CLTI patient population as a whole and not just those revascularized, and our aim was to assess whether CLTI OPGs could be attained with nonoperative management alone. METHODS: Our cohort included patients with an incident diagnosis of CLTI (by hemodynamic and symptomatic criteria) at our institution from 2013-2017. The primary outcome measured was mortality. Secondary outcomes were limb loss and failure of amputation-free survival. Descriptive statistics were used to define the 2 groups - patients undergoing primary revascularization and patients undergoing primary wound management. The risk difference in outcomes between the 2 groups was estimated using collaborative-targeted maximum likelihood estimation. RESULTS: Our cohort included 349 incident CLTI patients; 60% male, 51% white, mean age 63 +/- 13 years, 20% Rutherford 4, and 80% Rutherford 5. Most patients (277, 79%) underwent primary revascularization, and 72 (21%) were treated with wound care alone. Demographics and presenting characteristics were similar between groups. Although the revascularized patients were more likely to have femoropopliteal disease (72% vs. 36%), both groups had a high rate of infrapopliteal disease (62% vs. 57%). Not surprisingly, the patients in the revascularization group were less likely to have congestive heart failure (34% vs. 42%), complicated diabetes (52% vs. 79%), obesity (19% vs. 33%), and end stage renal disease (14% vs. 28%). In the wound care group, 2-year outcomes were 65% survival, 51% amputation free survival, 19% major limb amputation, and 17% major adverse cardiac event. The wound care cohort had a 13% greater risk of death at 2 years; however, the risk of limb loss at 2 years was 12% less in the wound care cohort. CONCLUSIONS: A comprehensive set treatment goals and expected amputation free survival outcomes can guide revascularization, but also assure that appropriate outcomes are achieved for patients treated without revascularization. The 2-year outcomes achieved in this cohort provide an estimate of outcomes for nonrevascularized CLTI patients. Although multi-center or prospective studies are needed, we demonstrate that equal, even improved, limb salvage rates are possible.

Performance of Viabahn balloon-expandable stent compared with self-expandable covered stents for branched endovascular aortic repair.

OBJECTIVE: The objective of this study was to compare the performance between the Viabahn balloon-expandable stent (VBX; Viabahn [W. L. Gore & Associates, Flagstaff, Ariz]) and a covered self-expandable stent (SES; Fluency [Bard Peripheral Vascular, Tempe, Ariz]) used as bridging stents for directional branches during fenestrated or branched endovascular aneurysm repair of complex aortic aneurysms. METHODS: Patients with thoracoabdominal aortic aneurysms (type I-IV) or pararenal aortic aneurysms either at high risk for open repair or unsuitable for endovascular repair with commercially available devices were prospectively enrolled in a physician-sponsored investigational device exemption trial. Descriptive statistics of the cohort included demographics, risk factors, and anatomic and device characteristics. Individual branches were grouped as either VBX or SES and had data analyzed for primary patency, branch-related type I or type III endoleaks, branch instability, branch-related secondary intervention, and branch-related aortic rupture or death. Categorical variables were expressed as total and percentage, and continuous variables were expressed as median (interquartile range). Kaplan-Meier curves were used to estimate long-term results. Groups were compared with the log-rank test. P value <.05 was considered statistically significant. RESULTS: During the period from July 2012 through June 2019, there were 263 patients treated for complex aortic aneurysm (thoracoabdominal aortic aneurysm) with fenestrated or branched endografts. The devices used were either custom-manufactured devices or off-the-shelf p-Branch or t-Branch (Cook Medical, Bloomington, Ind) devices. The median age was 71 years (interquartile range, 66-79 years); 70% were male, and 81% were white. The most common cardiac risk factors were smoking (92%), hypertension (91%), hyperlipidemia (78%), and chronic obstructive pulmonary disease (52%). The total number of vessels incorporated into the repair was 977, with branches representing 18.4% (179 branches). Among these 179 branches, the celiac artery, superior mesenteric artery, right renal artery, and left renal artery received 54 (30%), 56 (31%), 38 (21%), and 31 (18%) branches, respectively. VBX and SES groups represented 96 (54%) and 81 (46%) of the branches implanted. The celiac artery, superior mesenteric artery, right renal artery, and left renal artery received VBX as a bridging stent in 40%, 46.7%, 33.8%, and 32.2% respectively. The overall cohort survival rate was 78.5% at 24 months. There was no branch-related rupture or mortality. Primary patency at 24 months (VBX, 98.1%; SES, 98.6%; log-rank, P = .95), freedom from endoleak (VBX, 95.6%; SES, 98.6%; log-rank, P = .66), freedom from secondary intervention (VBX, 94.7%; SES, 98.1%; log-rank, P = .33), and freedom from branch instability (VBX, 95.6%; SES, 97.2%; log-rank, P = .77) were similar between groups. CONCLUSIONS: This initial experience with VBX stents demonstrated excellent primary patency and similarly low rates of branch-related complications and endoleaks, with no branch-related aortic rupture or death. Our results demonstrate that in a high-volume, experienced aortic center, the VBX stent is a safe and effective bridging stent option during branched endovascular aortic repair. Multicenter studies with a larger cohort and longer follow-up are necessary to validate these findings.

Poor glycemic control is associated with significant increase in major limb amputation and adverse events in the 30-day postoperative period after infrainguinal bypass.

OBJECTIVE: Understanding modifiable risk factors to improve surgical outcomes is increasingly important in value-based health care. There is an established association between peripheral artery disease (PAD), diabetes, and limb loss, but less is known about expected outcomes after revascularization relative to the degree of glycemic control. The purpose of this study was to determine the association between hemoglobin A1c (HbA1c) management in diabetics and surgical outcomes after open infrainguinal bypass. METHODS: The Vascular Quality Initiative infrainguinal bypass module was used to identify adult patients (≥18 years) with a history of diabetes who underwent bypass for PAD between 2011 and 2018. Exclusion criteria included missing or illogical HbA1c values and if the indication for the limb treated was not PAD. Patients were categorized by preoperative HbA1c levels as low severity/controlled (<7.0%), high severity (7.0%-10.0%), and very high severity (>10.0%). Primary outcomes were 30-day incidence of major adverse cardiac events (MACEs), major adverse limb events (MALEs), ipsilateral amputation, and 1-year all-cause mortality. Thirty-day outcomes were calculated using multivariable regression to compute odds ratios; hazard ratios were calculated for all-cause mortality. All analyses were adjusted for demographics, comorbidities, and clinical characteristics. RESULTS: The final sample included 30,813 operations (27,988 unique patients): 17,517 (57%) nondiabetic patients, 5194 patients with low-severity/controlled diabetes, and 8102 (26%) patients with poorly controlled diabetes, including 5531 (70%) treated with insulin. There were 6439 (21%) patients with high-severity HbA1c values and 1663 (5%) patients with very-high-severity HbA1c values. Those with a very high HbA1c level were more likely to be nonwhite, insulin dependent, and active smokers. Compared with nondiabetics, patients with very-high-severity HbA1c had an 81% increase in MACEs and 31% increase in MALEs, whereas patients with high-severity HbA1c only had a 49% increase in MACEs and a 12% increase in MALEs. Each one-step increase in severity category (eg, low to high to very high) was associated with an average 29% increase in the odds of MACEs and an 8% increase in the odds of MALEs. CONCLUSIONS: Uncontrolled diabetes with an HbA1c value >10.0% was associated with significantly worse 30-day surgical outcomes. Patients with incrementally better glycemic control (HbA1c level of 7.0%-10.0%) did not suffer the same rate of complications, suggesting that preoperative attempts at improving diabetes management even slightly could lead to improved surgical outcomes in open infrainguinal bypass patients.

Renal volumes and estimated glomerular filtration rate changes after fenestrated-branched endovascular aortic repair.

OBJECTIVE: To describe changes in renal volumes (RV) and renal function after fenestrated-branched endovascular repair (F-BEVAR) for complex aortic aneurysms. METHODS: The data from patients enrolled in a physician-sponsored investigational device exemption clinical trial for endovascular treatment of complex aortic aneurysms from July 2012 to April 2017 were retrospectively analyzed. Descriptive statistics were calculated using the mean ± standard deviation. The mean estimated glomerular filtration rate (eGFR) and RV were calculated at baseline and 6, 12, and 18 months after F-BEVAR. Variable distributions were evaluated for skewness, and all models required log-transformation. Linear models using generalized estimating equations were used to assess the association between the RV and eGFR over time after adjustment for relevant covariates. We used Kaplan-Meier life-table analysis to calculate survival and branch patency. RESULTS: A total of 139 patients were followed up for 18 months or until death. The mean age was 71 ± 8 years (70% male). The most common risk factor was hypertension (92%). Chronic kidney disease (CKD; eGFR <60 mL/min) was present in 56 patients (40%). Thirty-one patients (22%) had ≥1 accessory renal artery. Of these 31 accessory arteries, 27 (87%) were embolized or covered. On average, the eGFR had decreased over time compared with baseline, with a median change of -4.4 mL/min (interquartile range [IQR], -11.4 to 4.9 mL/min), -2.6 mL/min (IQR, -11.9 to 6.5 mL/min), and -3.4 mL/min (IQR, -11.9 to 5.5 mL/min) at 6, 12, and 18 months postoperatively, respectively. Similarly, the RV had decreased from baseline by 8% ± 17%, 10% ± 17%, and 11% ± 22% at 6, 12, and 18 months, respectively. An increase in the baseline patient age of 5 years was estimated to be associated with a 3% (95% confidence interval [CI], 0.2%-6.0%) decrease in the mean eGFR during the follow-up period, collapsing over time. This change is similar to the natural history of renal deterioration with age. We estimated that an increase in the log-RV of 1 U would be associated with an estimated 26% (95% CI, 3%-52%) increase in the mean eGFR. Preexisting CKD did not affect the average change in RV. Of the 56 patients with previous CKD, 9 (16.1%) showed improvement in the eGFR to >60 mL/min. The median follow-up period was 17.9 months (IQR, 6.3-24.8). The Kaplan-Meier survival rate at 1 and 2 years was 84.7% (95% CI, 78.3%-91.1%) and 78.8% (95% CI, 71.0%- 86.6%), respectively. CONCLUSIONS: The RV and eGFR decreased in patients undergoing repair at the rates expected for patients with complex aortic disease. The eGFR correlated with the RV. Most of the decline in renal function occurred within the first 6 months postoperatively, after which, the renal function had stabilized.

Stenting of superior mesenteric and celiac arteries does not increase complication rates after fenestrated-branched endovascular aneurysm repair.

OBJECTIVE: This study compared complications in patients undergoing fenestrated-branched endovascular aneurysm repair (F-BEVAR) without and with stenting of the superior mesenteric artery (SMA) or celiac artery (CA), with particular attention to the length of coverage above the CA. METHODS: A retrospective review was performed of a prospectively maintained database of patients treated with F-BEVAR for thoracoabdominal aortic aneurysms between July 2012 and May 2017. Data included demographics, risk factors, comorbidities, preoperative aneurysm characteristics, procedural data, and outcomes. Patients were grouped as follows: group 1, no SMA or CA stent; group 2, SMA or CA stent and <5 cm of coverage above the CA; and group 3, SMA or CA stent and ≥5 cm of coverage above the CA. Complications measured included death, myocardial infarction, respiratory failure, stroke or transient ischemic attack, paraplegia, acute kidney injury, mesenteric ischemia, and vascular complications. Individual and composite complications were compared between groups. RESULTS: There were 223 patients who had data analyzed (group 1, 53 [24%]; group 2, 101 [45%]; and group 3, 69 [31%]). Mean age was 72 years (76% male). There was no difference in patients' characteristics between groups, except for hypertension (less common in group 2) and history of previous aortic surgery (more common in group 3). Group 2 (15%) and group 3 (90%) had higher spinal drain use than group 1 (2%; P < .0001). Mean operative time was longer in groups 2 and 3 compared with group 1 (group 1, 224 minutes; group 2, 253 minutes; and group 3, 313 minutes; P < .0001). Group 1 had more intraoperative complications, without difference in the technical success and mortality rates. Failure to deliver a bridging stent occurred in only 3 of 695 vessels (0.4%) intended, without difference between groups (P = .79). The incidence of major complications (individually and composite analysis) was similar between groups. On 30-day computed tomography angiography, there was no difference in type I or type III endoleaks (2%, 3%, and 6%) and branch patency (98%, 99%, and 99%) for groups 1, 2, and 3, respectively. At 3 years of follow-up, there was no difference in survival, stent patency, and branch instability. Group 3 had a higher reintervention rate compared with groups 1 and 2 (P < .0001); however, there was no difference between groups 1 and 2 (P = .31). CONCLUSIONS: Patients who needed SMA or CA incorporation with stents during F-BEVAR for aortic repair had more complex procedures, as assessed by operative time, brachial access, number of vessels incorporated, and spinal drain use. However, the extension of the repair did not affect the outcomes, demonstrated by similar mortality and morbidity rates between groups.

A systematic review of enhanced recovery after surgery for vascular operations.

BACKGROUND: Patients undergoing vascular operations face high rates of intraoperative and postoperative complications and delayed return to baseline. Enhanced recovery after surgery (ERAS), with its aim of delivering high-quality perioperative care and accelerating recovery, appears well suited to address the needs of this population. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review to characterize the use and effectiveness of ERAS in all types of vascular and endovascular operations. We queried MEDLINE (through PubMed), Embase, Web of Science, Scopus, ProQuest Dissertations and Theses Global, Cochrane Central Register of Controlled Trials, Prospero, and Google Scholar. Two reviewers independently completed screening, review, and quality assessment. Eligible articles described the use of ERAS pathways for vascular operations from January 1, 1997, through December 7, 2017. Details regarding patients' demographics and use of the ERAS pathway or selected ERAS components were extracted. When available, results including perioperative morbidity, mortality, and in-hospital length of stay were collected. The studies with control groups that evaluated ERAS-like pathways were meta-analyzed using random-effects meta-analysis. RESULTS: In the final analysis, 19 studies were included: four randomized controlled trials and 15 observational studies. By Let Evidence Guide Every New Decision (LEGEND) criteria, the two good-quality studies are randomized controlled trials that evaluated a specific part of an ERAS pathway. All other studies were considered poor quality. Meta-analysis of the five studies describing ERAS-like pathways demonstrated a reduction in length of stay by 3.5 days (P = .0012). CONCLUSIONS: Based on systematic review, the use of ERAS pathways in vascular surgery is limited, and existing evidence of their feasibility and effectiveness is low quality. There is minimal poor- to moderate-quality evidence describing the use of ERAS pathways in open aortic operations. There is scarce, poor-quality evidence related to ERAS pathways in lower extremity operations and no published evidence related to ERAS pathways in endovascular operations. Although the risk of bias is high in most of the studies done to date, all of them observed improvements in length of stay, postoperative diet, and ambulation. It is reasonable to consider the implementation of ERAS pathways in the care of vascular surgery patients, specifically those undergoing open aortic operations, but many of the details will be based on limited data and extrapolation from other surgical specialties until further research is done.

Outcomes and complications after fenestrated-branched endovascular aortic repair.

OBJECTIVE: To report the outcomes of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aortic aneurysms with fenestrated and/or branched devices. METHODS: This study represents a retrospective analysis of a prospectively maintained database of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aneurysms between July 2012 and July 2017. Subjects included high-risk patients for open repair and patients with unsuitable anatomy for either standard endovascular aneurysm repair or Zenith (Cook Medical, Bloomington, Ind) fenestrated device. Aneurysm classification was based upon Crawford classification. We included the pararenal and paravisceral aneurysms in the type IV aneurysm group, because the repair of these aneurysms usually involved treatment of all four visceral branches. The endografts implanted were custom manufactured devices or off-the-shelf devices based on the Cook Zenith platform. Variables analyzed included preoperative demographics and comorbidities, anatomic aneurysmal characteristics, procedural details, and perioperative complications. RESULTS: One -hundred fifty patients with a mean age of 71 ± 7.9 years were treated; 69% were male. Tobacco use (93%) and hypertension (91%) were the most common risk factors. Fifty-seven patients (38%) had a history of previous aortic repair. The mean aneurysm diameter was 62 ± 12 mm and 14 (9%) aneurysms were associated with chronic dissection. A total of 573 visceral vessels were incorporated (celiac artery/superior mesenteric artery [287 vessels], renal arteries [275 vessels], and 11 additional vessels) and 539 were stented. The celiac artery/superior mesenteric artery received a fenestrated design in 76.1% of cases. Branch designs were used in the renal artery in 13.2%, with the remainder treated with fenestrations. Spinal cord drainage was used in 51% of patients (76/150). The mean operative time, fluoroscopy time, and estimated blood loss were 283 ± 89 minutes, 83 ± 38 minutes, and 417 ± 404 mL, respectively. There were five patients (3.3%) with intraoperative complications, resulting in one intraoperative death. The early mortality was 2.7% (4/150). Major complications included respiratory failure in 7% (10/150), stroke and myocardial infarction in 0.7% each (1/150), and paraplegia in 2.7% (4/150). Acute kidney injury occurred in 4.7% of patients (7/150), two of whom required temporary dialysis. Thirty-nine percent of patients experienced at least one complication. Early branch vessel patency was 99.8% (525/526). Survival, primary, and primary-assisted branch patency at 2 years of follow-up were 79%, 97%, and 99%, respectively. CONCLUSIONS: Endovascular repair of complex aneurysms is safe and effective when performed in a high-volume center experienced in aortic disease management. Branch vessels patency and the low incidence of paraplegia and mortality support expanded use to treat most complex thoracoabdominal aortic aneurysms.

Cigarette smoking intensity informs outcomes after open revascularization for peripheral artery disease.

OBJECTIVE: Cigarette smoking is the leading risk factor for peripheral artery disease (PAD). Existing literature often defines smoking history in broad categories of current, former, and never smokers, which may not sufficiently identify patients at the highest risk for poor outcomes. The purpose of this study was to examine the use of more informative categorization of smoking and to determine the association with important revascularization outcomes. METHODS: We conducted a retrospective review of all patients undergoing open lower extremity revascularization for symptomatic PAD, defined as claudication (Rutherford 3) or critical limb ischemia (Rutherford 4-6), during a 5-year period (2013-2017). Smoking history, demographics, and comorbidities were abstracted from electronic health records from seven hospitals within our health care system. Smoking history was defined by intensity (packs/day), duration (years), pack-year history, and cessation time. Outcomes included major adverse limb events (MALEs), death, limb loss, and amputation-free survival. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals (CIs) for each parameter adjusted for patients' demographics and comorbidities. Cumulative incidence is reported for outcomes at 30, 180, and 365 days of follow-up. RESULTS: We identified 693 patients undergoing open lower extremity revascularization for PAD (66% critical limb ischemia; 46% diabetes). The 1-year cumulative incidence of MALEs was 29.9% (95% CI, 26.4-33.9), whereas the 1-year incidence of death was 9.8% (95% CI, 7.5-12.7). The broad classification of current and former smokers identified no statistically significant differences in any measured outcomes. Patients who smoked more than one pack/day had 1.48 (95% CI, 1.01-2.16) times increase in risk of MALEs at 1 year compared with patients who smoked one or fewer packs/day. Patients who smoked more than one pack/day also had the highest 1-year amputation incidence (12.7%). Each of the four parameters was associated with increased risk of poor outcomes, although small sample size limited the precision of our estimates. CONCLUSIONS: We found that smoking intensity is particularly informative of outcomes of patients undergoing open lower extremity revascularization for symptomatic PAD. These findings lay the groundwork for future research on relevant smoking history parameters and benefits of smoking reduction and cessation for clinicians to discuss with patients and to better understand and inform patients of intervention risks and expected outcomes.

Evaluating the Ergonomics of Surgical Residents During Laparoscopic Simulation: A Novel Computerized Approach.

BACKGROUND: Assessment of residents' body positioning during laparoscopy has not been adequately investigated. This study presents a novel computer vision technique to automate ergonomic evaluation and demonstrates this approach through simulated laparoscopy. METHODS: Surgical residents at a single academic institution were video recorded performing tasks from the Fundamentals of Laparoscopic Surgery (FLS). Ergonomics were assessed by 2 raters using the Rapid Upper Limb Assessment (RULA) tool. Additionally, a novel computer software program was used to measure ergonomics from the video recordings. All participants completed a survey on musculoskeletal complaints, which was graded by severity. RESULTS: Ten residents participated; all performed FLS in postures that exceeded acceptable ergonomic risks as determined by both the human and computerized RULA scores (P < .001). Lower-level residents scored worse than upper-level residents on the human-graded RULA assessment (P = .04). There was no difference in computer-graded RULA scores by resident level (P = .39) and computer-graded scores did not correlate with human scores (P = .75). Shoulder and wrist position were the greatest contributors to higher computer-graded scores (P < .001). Self-reported musculoskeletal complaints did not differ at resident level (P = .74); however, all residents reported having at least 1 form of musculoskeletal complaint occurring "often." CONCLUSIONS: Surgery residents demonstrated suboptimal ergonomics while performing simulated laparoscopic tasks. A novel computer program to measure ergonomics did not agree with the scores generated by the human raters, although it concluded that resident ergonomics remain a concern, especially regarding shoulder and wrist positioning.

Reinvigorating an Academy of Medical Educators Using Ecological Systems Theory.

The educational framework of communities of practice postulates that early learners join medical communities as social networks that provide a common identity, role modeling and mentorship, and experiential learning. While being elected into a medical society is an honor, member engagement in these groups can falter if the society membership is seen as an honorific rather than one requiring continuing participation. As an example, Academies of Medical Educators have been established by many academic medical centers to encourage collaboration, skill development, professional identity formation, and scholarship. The University of North Carolina established the Academy of Educators in 2006 to create a diverse community of educators to promote the scholarship, teaching skills, and professional identity of educators. Despite rapid growth to over 500 members, we had less than 30 participants at events over the 2017-2018 academic year. To increase member engagement and participation, our academy leadership team used Bronfenbrenner's Ecological Systems Theory to design interventions at each layer of environmental influence, specifically at the microsystem, mesosystem, exosystem, macrosystem, and chronosystem levels. In this paper, we describe the multipronged approach used to increase the University of North Carolina Academy of Medical Educators event attendance from 30 to 1,000 faculty participants over the course of one academic year (2018-2019). This paper provides a model as to how medical societies can use ecological systems theory as a natural and comprehensive approach to plan and improve their member engagement and experience.

Aberrant Right Subclavian Artery to Esophageal Fistula: A Rare Case and Its Management.

A 29-year-old woman underwent esophageal stent placement after developing esophageal stenosis in the setting of tracheoesophageal fistula repair in childhood. The patient developed hemoptysis from an esophageal to aberrant right subclavian artery fistula; this was managed with several staged procedures involving arterial stent placement, carotid-to-subclavian bypass, and aberrant subclavian artery ligation. The patient then underwent pericardial patch repair of her perforated esophagus. This case illustrates the importance of understanding congenital anatomy and frequent associations, such as tracheoesophageal fistula and aberrant right subclavian artery; furthermore, it demonstrates the importance of multidisciplinary care for complex cases.

Peak Performance: A Communications-Based Leadership and Teamwork Simulation for Fourth-Year Medical Students.

BACKGROUND: Medical education has traditionally been rooted in the teaching of health and disease processes, with little attention to the development of teamwork and leadership competencies. OBJECTIVE: In an era of value-based health care provided by high-functioning teams, new approaches are needed to develop communication, leadership, and teamwork skills for medical students. DESIGN: We designed and piloted a simulation-based educational activity called Peak Performance that linked a workbook, which focused on self-reflection on communication and leadership skills, with professional coaching. The simulation scenario placed students in the role of an upper-level resident on an inpatient service, followed by a small group debrief with students, a clinical faculty member, and a professional executive coach. After the debriefing session, students were invited to complete a self-reflection workbook within 1 week of the initial simulation. The final element of the curriculum was an individualized session with an executive coach. Peak Performance was offered to all fourth-year medical students enrolled in the Social and Health Systems Science required course at the University of North Carolina School of Medicine. RESULTS: Pre-/post-self-assessments of leadership competencies were completed by students. Pre-simulation self-assessment scores ranged from 3.72 to 4.33 on a 5-point scale. The lowest scores were in "Managing Conflict" and "Managing Others." The highest score was in "Self-Awareness." The post-simulation scores decreased in every competency, with "Managing Others" dropping significantly from 3.72 pre-simulation to 3.36 post-simulation (0.31, P < .05). Satisfaction with the curriculum was high, as reflected by a Net Promoter Score of 91% ("excellent" > 50%). CONCLUSIONS: A novel simulation-based educational activity linked to professional coaching is a feasible and impactful strategy to develop leadership, communication, and teamwork skills in medical students. Student insight and self-awareness increased as evidenced by a decrease in competency self-assessment after guided reflection and individualized coaching.

Operative strategies for inferior vena cava repair in oncologic surgery.

OBJECTIVE: Tumor involvement of the inferior vena cava (IVC) can result from primary caval leiomyosarcoma, local invasion by retroperitoneal malignant neoplasm, or metastases. Whereas ligation of the IVC may be well tolerated if collateral circulation can be adequately preserved, collaterals must often be ligated during oncologic resection. Reconstruction of the IVC may be performed by primary repair, patch angioplasty, or interposition graft. The purpose of our study was to describe different strategies of IVC reconstruction and to measure outcomes associated with IVC reconstruction among patients with retroperitoneal malignant disease. METHODS: All patients undergoing IVC reconstruction at our quaternary care hospital between November 2004 and February 2018 were identified using billing data (Current Procedural Terminology code 34502). Patients who underwent resection of the IVC for tumor involvement were enrolled in our study; data were collected on demographics, operative intervention, type of reconstruction, postoperative course, and 1-year outcomes. Patency rates were assessed by reviewing postoperative imaging including computed tomography, magnetic resonance imaging, ultrasound, and venography. Two-year mortality and patency were calculated using Kaplan-Meier analysis methods. RESULTS: We identified 52 (46% female) patients who underwent IVC reconstruction for retroperitoneal malignant disease. The mean age was 53.6 years (range, 23-80 years). Procedures performed included primary repair (n = 17 [33%]), patch angioplasty (n = 18 [35%]), and interposition grafting (n = 17 [33%]). The mean length of stay was 16 days and did not vary significantly by group. Patients undergoing interposition graft were discharged on aspirin 81 mg daily. The 30-day survival rate was 96.2% (95% confidence interval [CI], 90.9-100), 1-year survival rate was 75.1% (95% CI, 62.8-87.4), and 2-year survival rate was 64.7% (95% CI, 50.5-78.9). There were no intraoperative deaths. The 30-day primary patency rate was 96% (95% CI, 90.7-100.0), 1-year primary patency rate was 88.8% (95% CI, 79.4-98.2), and 2-year primary patency rate was 77.5% (95% CI, 63.0-92.0). Seven patients (14%) developed nonocclusive thrombus within the IVC, and 16 patients (30%) developed postoperative symptoms of venous obstruction. CONCLUSIONS: IVC reconstruction is a safe option for patients requiring IVC resection during oncologic surgery as evidenced by 1-year survival of 75% and 1-year primary patency approaching 90%. The overall rate of postoperative thrombus development was low and similar across all groups. In the management of primary and secondary retroperitoneal malignant disease with IVC infiltration, IVC reconstruction should be considered to achieve appropriate oncologic resection while minimizing possible complications from caval interruption.

Percutaneous thrombectomy using a novel single-session device for acute ilio-caval deep vein thrombosis.

A 53-year-old man developed acute left leg pain and edema 2 weeks after lumbar interbody fusion. A computed tomography venogram demonstrated acute thrombosis extending from the deep veins of the calf all the way to and including the common iliac vein owing to external compression of common iliac vein secondary to extruded bone graft material. Endovascular intervention without the use of thrombolysis was performed using a novel percutaneous mechanical thrombectomy system (ClotTriever, Inari Medical, Irvine, Calif), allowing clot removal in single session. Clot removal and stenting were performed with resolution of symptoms and only mild swelling with prolonged standing at the 6-month follow-up.

A case of aneurysmal dilation of a brachial artery after venous outflow resection.

Dilation throughout the brachial artery in the setting of an arteriovenous fistula is a common occurrence, but focal aneurysmal dilation is not often visualized. Progressive enlargement of a focal arterial segment warrants intervention before negative sequelae. We present the case of a 38-year-old man with history of left upper extremity brachiocephalic fistula who had an enlarged brachial artery and progressive aneurysmal dilation of the distal aspect after ligation and excision of a dilated venous outflow component. The patient was successfully treated with resection and end-to-end reconstruction of the brachial artery, with resolution of pain and improvement in the functionality of his extremity. This case highlights the possible challenges encountered in such situations, when the anatomy is so distorted that it is difficult to clearly delineate on preoperative imaging.

Limited adoption of abdominal aortic aneurysm screening guidelines associated with no improvement in aneurysm rupture rate.

BACKGROUND: Screening for abdominal aortic aneurysms can prevent life-threatening rupture. The Screening Abdominal Aortic Aneurysms Very Efficiently Act was implemented in 2007. This provides for a one-time abdominal aortic aneurysm screening. We hypothesize that the Screening Abdominal Aortic Aneurysms Very Efficiently Act has increased the screening rate and identified more abdominal aortic aneurysms, leading to fewer ruptured abdominal aortic aneurysms. METHODS: Centers for Medicare and Medicaid Services data were used to estimate the number of Medicare enrollees eligible for screening and the number screened. The Nationwide Inpatient Sample database was queried for discharges involving abdominal aortic aneurysm rupture and/or repair from the years 2000 to 2015 to assess national trends in abdominal aortic aneurysm admissions. The main outcomes were abdominal aortic aneurysm screening rates and standardized yearly incidence of abdominal aortic aneurysm rupture and abdominal aortic aneurysm repairs (stratified by open and endovascular). RESULTS: The number of patients screened increased from 9,884 (2007) to 95,243 (2015). The screening rate increased from 0.2% (2007) to 1.4% (2015) (P < .001) of eligible patients. The number of abdominal aortic aneurysm ruptures increased slightly after the initiation of the Screening Abdominal Aortic Aneurysms Very Efficiently Act from 8.3 per 100,000 to 9.4 per 100,000 (incidence rate ratio 1.12, 95% confidence interval 1.06-1.19). The average yearly change in abdominal aortic aneurysm ruptures was not significant (95% confidence interval -0.01 to 0.00, P = .30). The number of open abdominal aortic aneurysm repairs declined, while endovascular repairs increased during the study period. CONCLUSION: The Screening Abdominal Aortic Aneurysms Very Efficiently Act has increased the number of patients being screened; however, screening rates remain low. The number of patients presenting with rupture has not decreased. Screening strategies need to be reassessed or made more widely available for this legislation to have an impact.

Incidence of venous leg ulcer healing and recurrence after treatment with endovenous laser ablation.

BACKGROUND: The Effect of Surgery and Compression on Healing and Recurrence (ESCHAR) trial previously reported that patients with venous leg ulcers treated with saphenous stripping experienced a significantly reduced incidence of ulcer recurrence compared with patients treated with compression therapy. Most patients with leg ulcers and saphenous insufficiency are currently treated with endovenous thermal ablation (EVTA), but little information is available on the long-term results after EVTA in Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class 5 (C5) and class 6 (C6) patients. METHODS: We retrospectively reviewed all CEAP C5 or C6 patients treated with EVTA to define the incidence of ulcer healing and recurrence. Patients with active ulcers were managed weekly in a comprehensive wound center until healed. After healing, patients were treated with compression stockings and returned at 6-month intervals for follow-up. Time to healing and time to ulcer recurrence were determined by Kaplan-Meier survival analysis. Risk factors were assessed to determine their association with ulcer recurrence. RESULTS: EVTA of the great saphenous vein (n = 146), small saphenous vein (n = 20), or both (n = 7) was performed on 173 limbs with active (n = 72) or healed (n = 101) ulcers. Deep venous insufficiency was present in 54 cases (31.2%). Concomitant phlebectomy was performed in 59 limbs (34%). Median follow-up time was 25.2 months after EVTA. Venous ulcers healed after EVTA in 57% of cases at 3 months, 74% at 6 months, and 78% at 12 months. Ulcers recurred in 9% of patients at 1 year after EVTA, 20% at 2 years, and 29% at 3 years of follow-up. Ulcers recurred significantly more often in patients with deep venous insufficiency and in patients who did not undergo phlebectomy of associated varicose veins at the time of EVTA. CONCLUSIONS: Ulcers recurred in a minority of CEAP clinical C5 and C6 patients after EVTA of the saphenous veins. Ulcer recurrence was less frequent in patients without concomitant deep venous reflux and in those treated with phlebectomy of varicose veins at the time of EVTA. We suggest consideration of phlebectomy at the time of EVTA for patients with C5 and C6 venous insufficiency, particularly in those with isolated superficial venous insufficiency.

Standardized, Interdepartmental, Simulation-Based Central Line Insertion Course Closes an Educational Gap and Improves Intern Comfort with the Procedure.

Central line placement is a common procedure, routinely performed by junior residents in medical and surgical departments. Before this project, no standardized instructional course on the insertion of central lines existed at our institution, and few interns had received formal ultrasound training. Interns from five departments participated in a simulation-based central line insertion course. Intern familiarity with the procedure and with ultrasound, as well as their prior experience with line placement and their level of comfort, was assessed. Of the 99 interns in participating departments, 45 per cent had been trained as of October 2015. Forty-one per cent were female. The majority (59.5%) had no prior formal ultrasound training, and 46.0 per cent had never placed a line as primary operator. Scores increased significantly, from a precourse score mean of 13.7 to a postcourse score mean of 16.1, P < 0.001. All three of the self-reported measures of comfort with ultrasound also improved significantly. All interns reported the course was "very much" helpful, and 100 per cent reported they felt "somewhat" or "much" more comfortable with the procedure after attendance. To our knowledge, this is the first hospital-wide, standardized, simulation-based central line insertion course in the United States. Preliminary results indicate overwhelming satisfaction with the course, better ultrasound preparedness, and improved comfort with central line insertion.

Classification of anatomic involvement of the iliocaval venous outflow tract and its relationship to outcomes after iliocaval venous stenting.

OBJECTIVE: Iliocaval venous obstruction (ICVO) includes a wide spectrum of iliac vein and vena cava obstructive patterns but anatomic classification is lacking, making comparisons of treatment modalities difficult. The purpose of this study was to propose an anatomic classification for ICVO based on patterns of venous obstruction and to correlate severity to clinically relevant outcomes. METHODS: A multi-institutional retrospective evaluation of patients with ICVO who underwent venous stenting procedures was performed to identify anatomic patterns of iliocaval obstruction. The sites of venous disease were categorized on the basis of computed tomography or magnetic resonance venography supplemented by contrast venography or intravascular ultrasound. Proposed anatomic classification was defined as follows: type I, stenosis of a single venous segment; type II, stenosis of multiple venous segments; type III, occlusion of a single venous segment; and type IV, occlusion of multiple venous segments. Anatomic segments included in the classification scheme were defined as inferior vena cava, common iliac vein, external iliac vein, and common femoral vein. All patients underwent attempted stenting to re-establish normal iliocaval outflow. Outcomes, including initial procedural success and rethrombosis rates within 6 months, were determined for each type of ICVO. RESULTS: A consecutive 120 patients with ICVO underwent venography and attempted intervention. The type of ICVO was well distributed across all categories, with type I involvement identified in 42.5% of cases, type II in 19.2%, type III in 13.3%, and type IV in 25%. Procedural success was achieved significantly more often in types I and II ICVO (P = .02). Stent reocclusion was more frequent in type IV ICVO (26.7%) than in type I (7.8%) or type II ICVO (4.3%) (P = .009). CONCLUSIONS: On the basis of a proposed anatomic classification, the diversity of ICVO may be stratified according to the severity of venous involvement. The anatomic classification was found to correlate to the technical success and short-term patency of venous intervention. Prospective evaluation is required to further validate the utility of this new anatomic classification system.