Machine learning-based prediction of abdominal aortic aneurysms for individualized patient care.

OBJECTIVE: The United States Preventative Services Task Force guidelines for screening for abdominal aortic aneurysms (AAA) are broad and exclude many at risk groups. We analyzed a large AAA screening database to examine the utility of a novel machine learning (ML) model for predicting individual risk of AAA. METHODS: We created a ML model to predict the presence of AAAs (>3 cm) from the database of a national nonprofit screening organization (AAAneurysm Outreach). Participants self-reported demographics and comorbidities. The model is a two-layered feed-forward shallow network. The ML model then generated AAA probability based on patient characteristics. We evaluated graphs to determine significant factors, and then compared those graphs with a traditional logistic regression model. RESULTS: We analyzed a cohort of 10,033 patients with an AAA prevalence of 2.74%. Consistent with logistic regression analysis, the ML model identified the following predictors of AAA: Caucasian race, male gender, advancing age, and recent or past smoker with recent smoker having a more profound affect (P < .05). Interestingly, the ML model showed body mass index (BMI) was associated with likelihood of AAAs, especially for younger females. The ML model also identified a higher than predicted risk of AAA in several groups, including female nonsmokers with cardiac disease, female diabetics, those with a family history of AAA, and those with hypertension or hyperlipidemia at older ages. An elevated BMI conveyed a higher than expected risk in male smokers and all females. The ML model also identified a complex relationship of both diabetes mellitus and hyperlipidemia with gender. Family history of AAA was a more important risk factor in the ML model for both men and women too. CONCLUSIONS: We successfully developed an ML model based on an AAA screening database that unveils a complex relationship between AAA prevalence and many risk factors, including BMI. The model also highlights the need to expand AAA screening efforts in women. Using ML models in the clinical setting has the potential to deliver precise, individualized screening recommendations.

Vascular In-person for Students In the match Trial: An investigation of postinterview site visits to address the limitations of virtual interviews.

PURPOSE: The graduate medical education community implemented virtual residency interviews in response to travel restrictions during the COVID-19 pandemic, and this approach has persisted. Although many residency applicants wish to visit in-person prospective training sites, such opportunities could bias programs toward those who are able to meet this financial burden, exacerbating equity concerns. One proposed solution is to offer applicants the opportunity to visit only after a program's rank list is "locked," avoiding favoritism to applicants who visit, but allowing applicants to experience some of the camaraderie, geography, and local effects of an in-person visit. As debate about the optimal format of residency interviews continues, it is important to investigate whether in-person program visits, completed after program rank list certification, provide meaningful benefits to applicants in the residency match process. METHODS: All vascular programs entering the 2023 integrated vascular surgery residency match were invited to participate. Programs agreed to certify their National Resident Matching Program rank lists by February 1, 2023. Applicants then had the opportunity to visit the programs at which they interviewed. The particulars of the visit were determined by the individual programs. Applicants completed their standard rank list and locked on the standard date: March 1, 2023. Applicants then completed a survey regarding the impact of the visits on their rank order list decision-making. Program directors (PDs) completed a survey regarding their experiences as well. Data were collected using REDCap. RESULTS: Twenty-one of the 74 (28%) programs participated. Nineteen PDs completed the postinterview site visit survey (response rate 90%). Applicants interviewing at the participating programs (n = 112) were informed of the study, offered the opportunity to attend postinterview site visits, and received the survey. Forty-seven applicants responded (response rate 42%). Eighty-six percent of applicants stated that the visit impacted their rank list. Most important factors were esprit de corps of the program (86%), the faculty/trainees/staff (81%), and the physical setting (62%). Seventy-one percent of those participating spent ≤$800 on their visit. Eighty-one percent were satisfied with the process. Twenty-one percent of PDs would have changed their rank list if they could have based on the applicants' in-person visit. Sixty-three percent of the visit sessions cost the programs ≤$500, and 63% were satisfied with the process. CONCLUSIONS: This study is the first to document the impact of in-person site visits by applicants on a graduate medical education match process in one specialty. Our results suggest that this process provides meaningful data to applicants that helped them with their decision-making evidenced by most altering their rank lists, while avoiding some of the critical equity issues that accompany traditional in-person interviews. This may provide a model for future interview processes for residency programs.

Vascular complications secondary to resuscitative endovascular balloon occlusion of the aorta placement at a Level 1 Trauma Center.

OBJECTIVE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to manage severe hemorrhagic shock. Popularized in medical care during military conflicts, the concept has emerged as a lifesaving technique that is utilized around the United States. Literature on risks of REBOA placement, especially vascular injuries, are not well-reported. Our goal was to assess the incidence of vascular injury from REBOA placement and the risk factors associated with injury and death among these patients at our institution. METHODS: We performed a retrospective cohort study of all patients who underwent REBOA placement between September 2017 and June 2022 at our Level 1 Trauma Center. The primary outcome variable was the presence of an injury related to REBOA insertion or use. Secondary outcomes studied were limb loss, the need for dialysis, and mortality. Data were analyzed using descriptive statistics, χ2, and t-tests as appropriate for the variable type. RESULTS: We identified 99 patients who underwent REBOA placement during the study period. The mean age of patients was 43.1 ± 17.2 years, and 67.7% (67/99) were males. The majority of injuries were from blunt trauma (79.8%; 79/99). Twelve of the patients (12.1%; 12/99) had a vascular injury related to REBOA placement. All but one required intervention. The complications included local vessel injury (58.3%; 7/12), distal embolization (16.7%; 2/12), excessive bleeding requiring vascular consult (8.3%; 1/12), pseudoaneurysm requiring intervention (8.3%; 1/12), and one incident of inability to remove the REBOA device (8.3%; 1/12). The repairs were performed by vascular surgery (75%; 9/12), interventional radiology (16.7%; 2/12), and trauma surgery (8.3%; 1/12). There was no association of age, gender, race, and blunt vs penetrating injury to REBOA-related complications. Mortality in this patient population was high (40.4%), but there was no association with REBOA-related complications. Ipsilateral limb loss occurred in two patients with REBOA-related injuries, but both were due to their injuries and not to REBOA-related ischemia. CONCLUSIONS: Although vascular complications are not unusual in REBOA placement, there does not appear to be an association with limb loss, dialysis, or mortality if they are addressed promptly. Close coordination between vascular surgeons and trauma surgeons is essential in patients undergoing REBOA placement.

Femoral vein translocation for complex hemodialysis access.

OBJECTIVE: Vascular access is difficult in patients without suitable arm veins and prior graft infections. The use of femoral vein translocation (FVT) to the upper extremity or contralateral lower extremity for hemodialysis access may be associated with low infection rates and high patency rates. FVT is used for patients without central venous occlusion who have failed prior access either owing to graft infection or repetitive graft thrombosis. The largest case series consists of 30 cases. The objective of this study is to determine the infection incidence, primary patency, primary-assisted patency, and secondary patency rates among FVTs. METHODS: A retrospective chart review was performed on all patients who underwent FVT by a single vascular practice over a 10-year period (2013-2023). Study variables included length to last follow-up (months), prior access, prior graft infection, comorbid conditions, primary patency, primary-assisted patency, secondary patency, postoperative steal syndrome, postoperative graft infection, postoperative harvest site complication, and postoperative lower extremity compartment syndrome. RESULTS: A total of 131 FVTs were performed from 2013 to 2023; 126 patients (47% male, 53% female; 76% Black, 24% White) with a mean age of 52 ± 14 years and a mean body mass index of 29 ± 8 had at least 1 month of follow-up and were included for analysis. The median follow-up was 46 months (interqurtile range, 19-72 months). The mean number of prior permanent accesses was 2.5 ± 1.4. Forty-eight percent of patients had prior graft infections. The primary, primary-assisted, and secondary patency rates were 66%, 93%, and 98%, respectively, at 6 months; 43%, 85%, and 96% at 12 months; 25%, 70%, and 92% at 24 months; 16%, 61%, and 88% at 36 months; and 14%, 56%, and 82% at 48 months. Postoperative steal syndrome and postoperative access infection requiring excision was observed 16% and 5% of patients, respectively. Harvest site complications requiring an additional procedure occurred in 19% of cases. Three patients developed lower extremity compartment syndrome postoperatively, requiring fasciotomy. Six patients developed chronic lower extremity edema after femoral vein harvest. The mean procedure time and hospital length of stay were 197 ± 40 minutes and 3.5 ± 2.8 days, respectively. CONCLUSIONS: FVT is associated with low infection rates and high long-term patency rates. Significant postoperative complications include steal syndrome and harvest site complications. FVT remains a viable option for patients who have failed prior access owing to graft infection or repetitive graft thrombosis.

Perception of shared learning environment differs between vascular surgery and general surgery residents.

BACKGROUND: An enriching learning environment is integral to resident wellness and education. Integrated vascular (VS) and general surgery (GS) residents share 18 months of core GS rotations during the postgraduate years 1-3 (PGY1-3); differences in their experiences may help identify practical levers for change. METHODS: We used a convergent mixed-methods design. Cross-sectional surveys were administered after the 2020 American Board of Surgery In-Training Examination and Vascular Surgery In-Training Examination, assessing eight domains of the learning environment and resident wellness. Multivariable logistic regression models identified factors associated with thoughts of attrition between categorical PGY1-3 residents at 57 institutions with both GS and VS programs. Resident focus groups were conducted during the 2022 Vascular Annual Meeting to elicit more granular details about the experience of the learning environment. Transcripts were analyzed using inductive and deductive logics until thematic saturation was achieved. RESULTS: Surveys were completed by 205 VS and 1198 GS PGY1-3 residents (response rates 76.8% for VS and 82.5% for GS). After adjusting for resident demographics, PGY level, and program type, GS residents were more likely than their VS peers to consider leaving their programs (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.37-4.99). This finding did not persist after adjusting for differences in perceptions of the learning environment, specifically: GS residents had higher odds of mistreatment (OR: 1.99, 95% CI: 1.36-2.90), poorer work-life integration (OR: 2.88, 95% CI: 1.41-5.87), less resident camaraderie (OR: 3.51, 95% CI: 2.26-5.45), and decreased meaning in work (OR: 2.94, 95% CI: 1.80-4.83). Qualitative data provided insight into how the shared learning environment was perceived differently: (1) vascular trainees expressed that early specialization and a smaller, more invested faculty allow for an apprenticeship model with early operative exposure, hands-on guidance, frequent feedback, and thus early skill acquisition (meaning in work); (2) a smaller program is conducive to closer relationships with co-residents and faculty, increasing familiarity (camaraderie and work-life integration); and (3) due to increased familiarity with program leadership, vascular trainees feel more comfortable reporting mistreatment, allowing for prompt responses (mistreatment). CONCLUSIONS: Despite sharing a learning environment, VS and GS residents experience training differently, contributing to differential thoughts of attrition. These differences may be attributable to intrinsic features of the integrated training paradigm that are not easily replicated by GS programs, such as smaller program size and higher faculty investment due to early specialization. Alternative strategies to compensate for these inherent differences should be considered (eg, structured operative entrustment programs and faculty incentivization).

Reported pain at work is a risk factor for vascular surgery trainee burnout.

BACKGROUND: Work-related pain is a known risk factor for vascular surgeon burnout. It risks early attrition from our workforce and is a recognized threat to the specialty. Our study aimed to understand whether work-related pain similarly contributed to vascular surgery trainee well-being. METHODS: A confidential, voluntary survey was administered after the 2022 Vascular Surgery In-Service Examination to trainees in all Accreditation Council for Graduate Medical Education-accredited vascular surgery programs. Burnout was measured by a modified, abbreviated Maslach Burnout Inventory; pain after a full day of work was measured using a 10-point Likert scale and then dichotomized as "no to mild pain" (0-2) vs "moderate to severe pain" (3-9). Univariable analyses and multivariable regression assessed associations of pain with well-being indicators (eg, burnout, thoughts of attrition, and thoughts of career change). Pain management strategies were included as additional covariables in our study. RESULTS: We included 527 trainees who completed the survey (82.2% response rate); 38% reported moderate to severe pain after a full day of work, of whom 73.6% reported using ergonomic adjustments and 67.0% used over-the-counter medications. Significantly more women reported moderate to severe pain than men (44.3% vs 34.5%; P < .01). After adjusting for gender, training level, race/ethnicity, mistreatment, and dissatisfaction with operative autonomy, moderate-to-severe pain (odds ratio, 2.52; 95% confidence interval, 1.48-4.26) and using physiotherapy as pain management (odds ratio, 3.06; 95% confidence interval, 1.02-9.14) were risk factors for burnout. Moderate to severe pain was not a risk factor for thoughts of attrition or career change after adjustment. CONCLUSIONS: Physical pain is prevalent among vascular surgery trainees and represents a risk factor for trainee burnout. Programs should consider mitigating this occupational hazard by offering ergonomic education and adjuncts, such as posture awareness and microbreaks during surgery, early and throughout training.

The role of vascular surgeons in the management of pediatric bone tumors.

OBJECTIVES: The objective of this study was to review the outcomes of a multidisciplinary approach to the surgical management of pediatric bone tumors with blood vessel involvement over a 14- year period. METHODS: A retrospective review was conducted of all pediatric bone tumor resections performed with the assistance of vascular surgery at our institution between January 2006 and January 2021. Inclusion criteria for the study included the presence of a vascular surgeon at the operative resection and radiographic evidence of major blood vessel involvement. RESULTS: From 2006 to 2021, 117 patients underwent a bone tumor resection by a single orthopedic surgeon/vascular surgeon team. Sixty were malignant tumors, and 57 were benign. Of the 117 procedures, 5.1% (6/117) required reconstruction of an artery; five in malignant cases and one in benign. No venous reconstructions were undertaken in this study. Ligation of a major artery without reconstruction was performed in 8.8% (5/57) of malignant and 1.7% (1/60) of benign resections. Despite this vessel-sparing approach, microscopic margins were clear in all cases. Local recurrence occurred in a single patient in the malignant group at 61 months. CONCLUSIONS: The ideal management of pediatric bone tumors with major blood vessel involvement remains poorly defined. Our results demonstrate that even in the setting of radiographic evidence of vessel involvement, a multidisciplinary team of vascular and orthopedic surgeons can employ a vessel-sparing approach with minimal blood loss, excellent limb salvage, and minimal local recurrence.

Persistent racial discrimination among vascular surgery trainees threatens wellness.

OBJECTIVE: Racial/ethnic discrimination is one form of mistreatment and a known risk factor for physician burnout. In the present study, we aimed to characterize the forms and identify the sources of racial/ethnic discrimination among vascular surgery trainees. METHODS: We performed a cross-sectional study of U.S. vascular surgery trainees who had voluntarily participated in an anonymous survey administered after the 2021 Vascular Surgery In-Training Examination. The primary outcome measures were self-reported mistreatment and sources of mistreatment between race and ethnicity groups. We used χ2 tests and logistic regression for bivariate and multivariable analyses, respectively. RESULTS: Representing all 123 vascular surgery training programs, 510 trainees (66.9% men) participated in the survey (83.6% response rate). Most of the trainees had self-identified as White (53.1%), followed by Asian (24.4%), Hispanic/Latinx (7.6%), Black (4.2%), and other/prefer not to say (10.8%). No significant differences were found in the self-reported duty hour violations among the groups. Black (56.3%) and Asian (36.3%) trainees reported higher rates of racial/ethnic discrimination compared with the White, Hispanic/Latinx, and other/prefer not to say groups (P < .001). Patients and their families were reported as the most common source (74.7%). Other reported sources of discrimination included nurses or staff (60%), attendings (37.4%), co-residents (31.3%), and administration (16.9%). Regarding specific forms of racial discrimination, Black and Asian trainees reported the highest rates of different standards of evaluation (20% and 5.9%, respectively), being mistaken for a nonphysician (50.0% and 5.9%, respectively), slurs and/or hurtful comments (13.3% and 5.9%, respectively), social isolation (13.0% and 1.0%, respectively), and being mistaken for another trainee of the same race/ethnicity (60.0% and 33.7%, respectively). Only 62.5% of Black trainees reported their program/institution would take their mistreatment report seriously compared with the White (88.9%), Hispanic/Latinx (88.2%), Asian (83.2%), and other/prefer not to say (71.4%) trainees (P = .01). On multivariable analysis, female gender (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.44-4.33), Asian race (OR, 6.9; 95% CI, 3.53-13.3), Black race (OR, 13.6; 95% CI, 4.25-43.4), and training in the Southeastern United States (OR, 3.8; 95% CI, 1.17-12.80) were risk factors for racial/ethnic discrimination. CONCLUSIONS: The results from the survey revealed that racial/ethnic discrimination persists in surgical training programs, with Asian and Black trainees reporting higher rates than other racial and ethnic groups. Overall, patients and family members were the most common source of racial/ethnic discrimination. However, faculty, staff, and co-trainees also contributed to racial/ethnic discrimination. Further interventions that optimize diversity, equity, and inclusion strategies and policies to address all forms of racial/ethnic discrimination with faculty, staff, and patients within the hospital are critically needed.

Defining sources and ramifications of mistreatment among female vascular surgery trainees.

OBJECTIVE: Mistreatment among vascular surgery trainees is a known risk factor for physician burnout. This study aims to characterize forms of and identify sources of mistreatment. METHODS: This is a cross-sectional study of United States vascular surgery trainees who voluntarily participated in an anonymous survey administered after the 2021 Vascular Surgery In-Training Examination. The primary outcome measures were self-reported mistreatment and sources of mistreatment between genders. Logistic regression was used for multivariable analysis. RESULTS: Representing all 125 vascular surgery training programs, 510 trainees (66.9% male) participated in the survey (83.6% response rate). Mistreatment was reported by 54.8% of trainees, with twice as many women reporting as men (82.3% vs 41.0%; P < .001). Women reported higher rates of being shouted at (44.1% vs 21.1%; P < .001); repeatedly reminded of errors (24.3% vs 16.1%; P = .04); ignored/treated hostilely (28.9% vs 10.5%; P < .001); subjected to crude/sexually demeaning remarks, stories, jokes (19.2% vs 2.1%; P < .001); evaluated by different standards (29.3% vs 2.1%; P < .001); and mistaken for a non-physician (75.2% vs 3.5%; P < .001). Among trainees reporting bullying, attendings were the most common source (68.5%). Patients and their families were the most common source of sexual harassment (66.7%), gender discrimination (90.4%), and racial discrimination (74.4%). Compared with men, women identified more patients and families as the source of bullying (50.0% vs 29.7%; P = .005), gender discrimination (97.2% vs 50.0%; P < .001), and sexual harassment (78.4% vs 27.3%; P = .003). Compared with men, women more frequently felt unprepared to respond to the behavior in the moment (10.4% vs 4.6%; P = .002), did not know how to report mistreatment at their institution (7.6% vs 3.2%; P = .04), and did not believe that their institution would take their mistreatment report seriously (9.0% vs 3.9%; P = .002). On multivariable analysis, female gender was an independent risk factor for both gender discrimination (odds ratio, 56.62; 95% confidence interval, 27.89-115) and sexual harassment (odds ratio, 26.2; 95% confidence interval, 3.34-14.8) when adjusting for children, training year, relationship status, and training program location. CONCLUSIONS: A majority of vascular surgery trainees experience mistreatment during training. Sources and forms of abuse are varied. Understanding the sources of mistreatment is critical to guide intervention strategies such as faculty remediation and/or sanctions; allyship training for staff, residents, and faculty; and institutional procedures for patient-initiated abuse.

The vascular surgery in-training examination predicts performance on qualifying examination.

OBJECTIVE: Vascular surgery trainees participate in the vascular surgery in-training examination (VSITE) during each year of their training. Although the VSITE was developed as a low-stakes, formative examination, performance on that examination might correlate with the pass rates for the Vascular Surgery Board written qualifying examination (VQE) and oral certifying examination (VCE) and might, therefore, guide both trainees and program directors. The present study was designed to examine the ability of the VSITE to predict trainees' performance on the VQE and VCE. METHODS: All first-time candidates of the Vascular Surgery Board VQE and VCE were analyzed from 2016 to 2020, including those from both the integrated and independent training pathways. VSITE scores from the final year of training were associated with the VQE scores and the probability of passing the VQE and VCE both. Linear and logistic regression models were used to determine the ability of VSITE results to predict the VQE scores and the probability of passing each board examination. RESULTS: VSITE scores available for the 559 candidates (69.3% male; 30.7% female) who had completed the VQE and 369 candidates (66.7% male; 33.3% female) who had completed both the VQE and the VCE. The linear regression model results for the final year of training showed that the VSITE scores explained 34% of the variance in the VQE scores (29% for the integrated and 37% for the independent trainees). Logistic regression demonstrated that the final year VSITE scores were a significant predictor of passing the VQE for both integrated and independent trainees (P < .001). A VSITE score of 500 during the final year of training predicted a VQE passing probability of >90% for each group of candidates. The probability of passing the VQE decreased to 73% for candidates from integrated programs, 61% for candidates from independent programs, and 64% for the whole cohort when the score was 400. The VSITE scores were a significant predictor of passing the VCE only for the candidates from independent programs (odds ratio, 1.01; 95% confidence interval, 1.00-1.02; P < .01), for whom a VSITE score of 400 correlated with an 82% probability of passing the VCE. CONCLUSIONS: VSITE performance is predictive of passing the VQE for trainees from both integrated and independent training paradigms. Vascular surgery trainees and training programs should optimize their preparation and educational efforts to maximize performance on the VSITE during their final year of training to improve the likelihood of passing the VQE. Further analysis of the predictive value of VSITE scores during the earlier years of training might allow the board certification examinations to be administered earlier in the final year of training.

Malpractice allegations against vascular surgeons: Prevalence, risk factors, and impact on surgeon wellness.

OBJECTIVE: The contemporary medicolegal environment has been linked to procedure overuse, health care variation, and higher costs. For physicians accused of malpractice, there is also a personal toll. The objective of this study was to evaluate the prevalence of and risk factors for involvement in medical malpractice lawsuits among United States vascular surgeons, and to examine the association between these allegations with surgeon wellness. METHODS: In 2018, the Society of Vascular Surgery (SVS) Wellness Task Force conducted a confidential survey of active members using a validated burnout assessment (Maslach Burnout Index) embedded into a questionnaire. This survey included questions related to medical errors and malpractice litigation. De-identified demographic, personal, and practice-related characteristics were assessed in respondents who reported malpractice allegations in the preceding 2 years, then compared with those without recent medicolegal litigation. Risk factors for malpractice allegations were identified (χ2, Kruskal-Wallis tests), and the association between malpractice allegations with wellness was examined. Multivariate logistic regression models were developed to identify independent risk factors for malpractice accusations. RESULTS: Of 2905 active SVS members, 871 responses from practicing vascular surgeons were analyzed. A total of 161 (18.5%) were named in a malpractice lawsuit within 2 years. Malpractice allegations were significantly associated with surgeon burnout (odds ratio, 1.47; 95% confidence interval, 1.01-2.15; P = .041), but not with self-reported depression or suicidal ideation. The nature of malpractice claims included procedural errors (23.1%), failure to treat (18.8%), and error/delay in diagnosis (16.9%). Twenty percent of claims were settled prior to trial, and 19% were dismissed. Defendant vascular surgeons reported a "fair" resolution in 26.4% of closed cases. By unadjusted analysis, factors significantly associated with recent malpractice claims included mean age (51.7 ± 10.0 vs 49.3 ± 11.2 years; P = .0044) and mean years in practice (18.0 ± 10.7 vs 15.2 ± 11.8; P = .0007). Multivariate analysis revealed independent variables associated with malpractice allegations, including on-call frequency (P = .0178), recent medical errors (P = .0189), and male surgeons (P = .045). CONCLUSIONS: Malpractice allegations are common for vascular surgeons and are significantly associated with surgeon burnout. Nearly 20% of survey respondents reported being named in a lawsuit within the preceding 2 years. Our findings underscore the need for SVS initiatives to provide counseling and peer support for vascular surgeons facing litigation.

Prevalence and risk factors for burnout in U.S. vascular surgery trainees.

OBJECTIVE: Burnout and suicidality are known risks for vascular surgeons above other surgical subspecialties, with surgical trainees at risk for exposure to factors that increase burnout. This study aimed to inform initiatives to improve wellness by assessing the prevalence of hazards in vascular training (mistreatment, duty-hour violations) and the rates of wellness outcomes (burnout, thoughts of attrition/specialty change/suicide). We hypothesized that mistreatment and duty-hour violations would predispose trainees to increased burnout. METHODS: We performed a cross-sectional study of residents and fellows enrolled in accredited United States vascular surgery training programs using a voluntary, confidential survey administered during the 2020 Vascular Surgery In-Training Examination. The primary outcome assessed was burnout symptoms reported on a weekly basis or more frequently. The rates of wellness outcomes were measured. The association of mistreatment and duty hours with the primary outcome was modeled with multivariable logistic regression. RESULTS: A total of 475 residents and fellows who were enrolled in one of 120 vascular surgery training programs completed the survey (84.2% response rate). Of 408 trainees completing burnout survey items, 182 (44.6%) reported symptoms of burnout. Fewer trainees reported thoughts of attrition (n = 42 [10.0%], specialty change (n = 35 [8.4%]), or suicide (n = 22 [4.9%]). Mistreatment was reported by 191 vascular trainees (47.3%) and was more common in female trainees (n = 63 [48.5%] reporting monthly or more frequently) compared with male trainees (n = 51 [18.6%]; P < .001). Duty-hour violations were also more commonly reported by female trainees (n = 31 [21.4%] reporting 3+ months in violation) compared with male trainees (n = 50 [16.2%]; P = .002). After controlling for race/ethnicity, postgraduate year, program type, and geography, female trainees were less likely to report burnout (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28-0.86). Trainees experiencing mistreatment monthly or more were three times more likely to report burnout (OR, 3.09; 95% CI, 1.78-5.39). Frequency of duty-hour violations also increased the odds of reporting burnout (1-2 months in violation: OR, 2.09; 95% CI, 1.17-3.73; 3+ months in violation: OR, 3.95; 95% CI, 2.24-6.97). CONCLUSIONS: Nearly one-half of vascular surgery trainees reported symptoms of burnout, which was associated with frequency of mistreatment and duty-hour violations. Interventions to improve well-being in vascular surgery must be tailored to the local training environment to address trainee experiences that contribute to burnout.

A Novel Clinically Based Classification System for the Profunda Femoris Artery and the Circumflex Femoral Arteries.

BACKGROUND: The profunda femoris artery (PFA) supplies important collateral branches to both the ipsilateral internal iliac artery and the distal superficial femoral artery (SFA). The size and patency of these collateral pathways can determine the risk of pelvic malperfusion, spinal cord ischemia, and lower extremity limb loss following vascular interventions. Despite its importance, the anatomy of the PFA is rarely characterized in clinical studies involving the pelvic or lower extremity circulation. This discussion may be limited by the lack of a comprehensive classification system. Our objective was to describe the most common PFA anatomic variants and present a classification system based on its branching patterns. METHODS: We dissected 155 fixed and nonfixed femoral artery systems from 88 cadavers. Seventy-seven female and 78 male femoral exposures were performed. Vessel diameters, branch configurations, and relative distances between the inguinal ligament, PFA, lateral circumflex femoral artery (LCFA), and medial circumflex femoral artery (MCFA) were recorded. RESULTS: The mean diameters of the common femoral artery, SFA, and PFA were 10.3 mm, 8.0 mm, and 6.9 mm in males and 8.9 mm, 6.9 mm, and 6.1 mm in females, respectively (P < 0.05). The mean distances from the inguinal ligament for PFA, MCFA, and LCFA were 41 mm, 41.7 mm, and 52.5 mm, respectively. No significant differences were noted relative to laterality or fixation. We developed a clinically applicable classification system based on the orientation of the PFA, LCFA, and MCFA. Six PFA, 5 LCFA, and 5 MCFA variations were identified and ranked by frequency. The 5 most common combinations accounted for 56.1% of our cadaver series. CONCLUSIONS: The anatomic orientation of the PFA and its branches is highly variable. We propose a novel classification system of this rich collateral system to facilitate consistent communication in academic and clinical vascular surgery.

Point-of-care ultrasound for identification of ruptured infrarenal abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysms (rAAA) are associated with high mortality rates and require prompt diagnosis with subsequent intervention. CT scan is considered the gold standard for diagnosis, however, in the acute setting ultrasound may be a reasonable diagnostic test for certain patients. We report a case that demonstrates the utility of point-of-care ultrasound (PoCUS) in diagnosing rAAA for a patient in extremis. Also, we provide a brief review of literature for the diagnosis of rAAA with ultrasound.

Evaluating the prevalence of abdominal aortic aneurysms in the United States through a national screening database.

OBJECTIVE: The U.S. Preventative Services Task Force guidelines for abdominal aortic aneurysm (AAA) screening are based mainly on studies of older Caucasian males from non-U.S. POPULATIONS: This study was designed to analyze the findings of a large, all-inclusive AAA screening program in the United States. METHODS: Screening events were held nationally by a U.S. nonprofit organization between 2001 and 2017. AAA screening was offered regardless of risk profile. Participants filled out a demographics form with known comorbidities. Significant risk factors were determined using logistic regression with backward stepwise variable selection. Odds ratios (OR) are reported with 95% confidence intervals (CIs). RESULTS: A total of 9457 screened participants (47% male) were analyzed. The mean age was 67 ± 9 years with 40.8% between 65 and 75 years old. Most participants were Caucasian (83.4%), followed by African American (13.1%). Screened risk factors included hypertension (58.1%), hyperlipidemia (54.9%), smoking (52.0%), cardiac disease (29.2%), diabetes mellitus (18.4%), a family history of AAA (22.4%) or brain aneurysms (8.6%), and body mass index (26.9 ± 5.28). Overall, 267 participants (2.82%) were found to have an AAA (>3 cm). Those ages 65 to 75 had a prevalence of 2.98%. In a fully adjusted, multivariate logistic regression, there was an increased risk of AAA in males (OR, 3.24; 95% CI, 2.39-4.40), current smokers (OR, 3.28; 95% CI, 2.36-4.54), previous smokers (OR, 1.86; 95% CI, 1.41-2.47), cardiac disease (OR, 1.30; 95% CI, 1.01-1.68), family history of AAA (OR, 1.60; 95% CI, 1.20-2.14), and advancing age (P < .0001). Female ever smokers 65 to 75 years old had a prevalence of 1.7%. Male smokers 45 to 54 and 55 to 64 years old had a prevalence of 3.37% and 4.43%, respectively. There was an increased risk of AAA in females with morbid obesity (OR, 5.54; 95% CI, 1.34-22.83 in never smokers and OR, 5.61; 95% CI, 1.04-30.15 in smokers), female smokers with hypertension (OR, 3.22; 95% CI, 1.21-8.58), males with cardiac disease (OR, 2.06; 95% CI, 1.08-3.90 in never smokers and OR, 1.48; 95% CI, 1.05-2.09), male smokers with a family history of AAA (OR, 1.69; 95% CI, 1.61-2.46), and current smokers (OR, 6.33; 95% CI, 2.62-15.24 for females and OR, 2.50; 95% CI, 1.70-3.65 for males). CONCLUSIONS: This study shows that there remain high-risk groups outside the current guidelines that would likely benefit from AAA screening. Risk factors for AAA include male gender, smoking, cardiac disease, family history of AAA, and advancing age. The most significant risk factor is current smoking status.

A modern appraisal of current vascular surgery education.

OBJECTIVE: Although general program requirements and curriculum content outlines are provided by the Accreditation Council for Graduate Medical Education, Association for Program Directors in Vascular Surgery, and Vascular Surgery Board of the American Board of Surgery, there is no single format for delivery of this content. The delivery of these defined educational components is, thus, likely to differ from site to site. The curriculum committee of the Association of Program Directors in Vascular Surgery was tasked with formalizing the content of the Vascular Surgery Surgical Council on Resident Education curriculum modules, and, therefore, we sought to appraise the current status of vascular educational programs in U.S. training programs before its implementation. METHODS: Program directors (PDs) of 112 U.S. vascular surgery residency and fellowship training programs were contacted via email and asked to participate in an anonymous electronic survey. This survey evaluated the educational components of individual programs, including vascular specific conferences, use of other training modalities, and determination of who was involved in the creation of these programs. RESULTS: Of the 112 PDs offered the survey, 80 (71%) responded. Most (42 of 80; 53%) have both an integrated vascular residency and a fellowship with the remaining being solely fellowship (31 of 80; 39%) or integrated residencies (7 of 80; 9%). The majority (79 of 81; 98%) of programs hold at least one vascular conference per week, with 75% (60 of 81) holding more than one each week. The total time spent in conference averaged 2.6 hours/wk, and the most common educational components of the weekly conferences were review of upcoming (48 of 79, 61%) or recently completed surgical cases (30 of 79; 38%), lectures on vascular disease processes (40 of 79; 51%), and review of book chapters from vascular surgery textbooks (27 of 78; 35%). PDs are responsible for creating the schedule at 50% (39 of 78) of the programs with most remaining programs relying on trainees (18 of 78; 23%) and assistant PDs (17 of 78; 22%). Vascular trainees present the majority of material at most programs' conferences (64 of 77; 83%). The majority of PDs feel that trainees should independently study 4 hours or more per week (51 of 79; 65%), but only 25% (20 of 79) believe that trainees actually spend this amount of time studying (P = .0001). Only 13 of 80 (16%) programs currently use a preformatted standardized vascular curriculum, but 64 of 80 (80%) believe that there is a need for the creation of this product and 72 of 80 (90%) would most likely use it. CONCLUSIONS: There is a significant variation in vascular surgery educational programs with considerable dependence on trainees to create the curriculum. The majority of PDs in vascular surgery support the creation of a standardized vascular curriculum and would use it if made.

Physical pain and musculoskeletal discomfort in vascular surgeons.

OBJECTIVE: Work-related pain and disability have been reported in the literature among surgeons. This national survey was designed to identify the prevalence and severity of these symptoms in vascular surgeons. METHODS: A survey was emailed to the 2910 members of the Society for Vascular Surgery. Physical pain was evaluated based on body part, and type of vascular procedure performed using the Borg 0 to 10 pain scale. Wellness questions were also queried. RESULTS: A total of 775 of Society for Vascular Surgery members responded, with a 26.6% response rate. Retirees were excluded from the study (n = 39). Among those actively working (n = 736), surgeons have been practicing surgery, on average, for 17.2 ± 11.6 years, with a mean age of 51.4 ± 10.9 years, and 83.6% are male. After a full day of open surgery, the majority of the responding vascular surgeons are in a moderately strong amount of pain (mean score, 4.4 ± 2.3). After a full day of endovascular procedures, most vascular surgeons are in a moderately strong amount of pain (mean score, 3.9 ± 2.4). Pain after open surgery is greatest in the neck, and after endovascular surgery pain is highest in the lower back. Surgeons performing endovenous procedures demonstrated the lowest pain scores (2.0 ± 2.0). In total, 36.9% (242/655, 81 missing responses) have sought medical care for work-related pain, with 8.3% (61/736) taking time away from the operating room. Of those, 26.2% (193/736) report pain severe enough that it interferes with sleep. Seventy-two (10%) required surgery or other significant medical procedures. Of the 39 retirees, 26% ended their careers owing to physical disabilities from work-related pain. Out of the entire cohort, 52.7% (334/633,103 missing responses) feel that physical discomfort will affect the longevity of their careers. Additionally, we found that high work-related physical discomfort is significantly associated with burnout (burnout vs no burnout; P < .0001). CONCLUSIONS: Our study shows that the majority of practicing vascular surgeons responding to the survey are in pain after a day of operating. Addressing work-related pain serves to improve the lives and careers of vascular surgeons and enhance surgical longevity.

The impact of the COVID-19 pandemic on vascular surgery practice in the United States.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to widespread postponement and cancelation of elective surgeries in the United States. We designed and administered a global survey to examine the impact of COVID-19 on vascular surgeons. We describe the impact of the pandemic on the practices of vascular surgeons in the United States. METHODS: The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons is an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force disseminated April 14 to 24, 2020. This analysis focuses on pattern changes in vascular surgery practices in the United States including the inpatient setting, ambulatory, and vascular laboratory setting. Specific questions regarding occupational exposure to COVID-19, adequacy of personal protective equipment, elective surgical practice, changes in call schedule, and redeployment to nonvascular surgery duties were also included in the survey. Regional variation was assessed. The survey data were collected using REDCap and analyzed using descriptive statistics. RESULTS: A total of 535 vascular surgeons responded to the survey from 45 states. Most of the respondents were male (73.1%), white (70.7%), practiced in urban settings (81.7%), and in teaching hospitals (66.8%). Almost one-half were in hospitals with more than 400 beds (46.4%). There was no regional variation in the presence of preoperative COVID-19 testing, COVID-19 OR protocols, adherence to national surgical standards, or the availability of personal protective equipment. The overwhelming majority of respondents (91.7%) noted elective surgery cancellation, with the Northeast and Southeast regions having the most case cancellations 94.2% and 95.8%, respectively. The Northeast region reported the highest percentage of operations or procedures on patients with COVID-19, which was either identified at the time of the surgery or later in the hospital course (82.7%). Ambulatory visits were performed via telehealth (81.3%), with 71.1% having restricted hours. More than one-half of office-based laboratories (OBLs) were closed, although there was regional variation with more than 80% in the Midwest being closed. Cases performed in OBLs focused on critical limb ischemia (42.9%) and dialysis access maintenance (39.9%). Call schedules modifications were common, although the number of call days remained the same (45.8%). CONCLUSIONS: Vascular surgeons in the United States report substantial impact on their practices during the COVID-19 pandemic, and regional variations are demonstrated, particularly in OBL use, intensive care bed availability, and COVID-19 exposure at work.

Vascular surgeon wellness and burnout: A report from the Society for Vascular Surgery Wellness Task Force.

INTRODUCTION: Physician burnout has been linked to medical errors, decreased patient satisfaction, and decreased career longevity. In light of the increasing prevalence of cardiovascular disease, vascular surgeon burnout presents a legitimate public health concern owing to the impact on the adequacy of the vascular surgery workforce. The aims of this study were to define the prevalence of burnout among practicing vascular surgeons and identify factors that contribute to burnout to facilitate future Society for Vascular Surgery (SVS) initiatives to mitigate this crisis. METHODS: In 2018, active SVS members were surveyed electronically and confidentially using the Maslach Burnout Inventory. The survey was tailored to explore specialty-specific issues, and to capture demographic and practice-related characteristics. Emotional exhaustion (EE) and depersonalization (DP) were analyzed as dimensions of burnout. Consistent with convention, surgeons with a high score on the DP and/or EE subscales of the Maslach Burnout Inventory were considered to have at least one manifestation of professional burnout. Risk factors associated with symptoms of burnout were identified using bivariate analyses (χ2, Kruskal-Wallis). Multivariate logistic regression models were developed to identify independent risk factors for burnout. RESULTS: Of 2905 active SVS members, 960 responded to the survey (34% participation rate). After excluding retired surgeons and incomplete submissions, responses from 872 practicing vascular surgeons were analyzed. The mean age was 49.7 ± 11.0 years; the majority of respondents (81%) were male. Primary practice settings were academic (40%), community practice (41%), veteran's hospital (3.3%), active military practice (1.5%), or other. Years in practice averaged 15.7 ± 11.7. Overall, 41% of respondents had at least one symptoms of burnout (ie, high EE and/or high DP), 37% endorsed symptoms of depression in the past month, and 8% indicated they had considered suicide in the last 12 months. In unadjusted analysis, factors significantly associated with burnout (P < .05) included clinical work hours, on-call frequency, electronic medical record and documentation requirements, work-home conflict, and work-related physical pain. On multivariate analysis, age, work-related physical pain and work-home conflict were independent predictors for burnout. CONCLUSIONS: Symptoms of burnout and depression are common among vascular surgeons. Advancing age, work-related physical pain, and work-home conflict are independent predictors for burnout among vascular surgeons. Efforts to promote vascular surgeon well-being must address specialty-specific challenges, including the high prevalence of work-home conflict and occupational factors that contribute to work-related pain.

Global vascular surgeons' experience, stressors, and coping during the coronavirus disease 2019 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges for health care systems globally. We designed and administered a global survey to examine the effects of COVID-19 on vascular surgeons and explore the COVID-19-related stressors faced, coping strategies used, and support structures available. METHODS: The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons was an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force. The survey analysis evaluated the effects of COVID-19-related stressors on vascular surgeons measured using the Generalized Anxiety Disorder 7-item scale. The 28-item Brief Coping Orientation to Problems Experienced inventory was used to assess the active and avoidant coping strategies. Survey data were collected using REDCap (Research Electronic Data Capture) from April 14, 2020 to April 24, 2020 inclusive. Additional qualitative data were collected using open-ended questions. Univariable and multivariable analyses of the factors associated with the anxiety levels and qualitative analysis were performed. RESULTS: A total of 1609 survey responses (70.5% male; 82.5% vascular surgeons in practice) from 58 countries (43.4% from United States; 43.4% from Brazil) were eligible for analysis. Some degree of anxiety was reported by 54.5% of the respondents, and 23.3% reported moderate or severe anxiety. Most respondents (∼60%) reported using active coping strategies and the avoidant coping strategy of "self-distraction," and 20% used other avoidant coping strategies. Multivariable analysis identified the following factors as significantly associated with increased self-reported anxiety levels: staying in a separate room at home or staying at the hospital or a hotel after work (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.08-1.79), donning and doffing personal protective equipment (OR, 1.81; 95% CI, 1.41-2.33), worry about potential adverse patient outcomes due to care delay (OR, 1.47; 95% CI, 1.16-1.87), and financial concerns (OR, 1.90; 95% CI, 1.49-2.42). The factors significantly associated with decreased self-reported anxiety levels were hospital support (OR, 0.83; 95% CI, 0.76-0.91) and the use of positive reframing as an active coping strategy (OR, 0.88; 95% CI, 0.81-0.95). CONCLUSIONS: Vascular surgeons globally have been experiencing multiple COVID-19-related stressors during this devastating crisis. These findings have highlighted the continued need for hospital systems to support their vascular surgeons and the importance of national societies to continue to invest in peer-support programs as paramount to promoting the well-being of vascular surgeons during and after the COVID-19 pandemic.