Impact of "Defensive Medicine" on the Costs of Diabetes and Associated Conditions.

BACKGROUND: Geographic variation in health care spending is typically attributed to differences in patient health status and provider practice patterns. While medicolegal considerations (i.e., "defensive medicine") anecdotally impact health care spending, this phenomenon is difficult to measure. The purpose of this study was to explore the association between the medicolegal environment and Medicare costs for diabetes and associated conditions of interest to vascular surgeons. Specifically, we hypothesized that an adverse medicolegal environment is associated with higher per capita Medicare costs for diabetic patients. METHODS: Medicare data including the most recent (2018) Medicare Geographic Variation Public Use Files and Chronic Conditions Data Files were linked to National Practitioner Data Bank files from the preceding 5 years (2013-2017), in addition to the US census data and American Medical Association workforce statistics. The state-level medicolegal environment was characterized by K-means clustering across a panel of metrics related to malpractice payment magnitude and prevalence. Per capita Medicare spending for diabetes was compared across 5 distinct medicolegal environments. Costs were standardized and risk-adjusted to account for known geographic variation in health care costs and patient population. Analysis of variance was applied to unadjusted data, followed by multivariate regression modeling. Readmission rates, per capita imaging studies, per capita tests, per capita procedures, and lower extremity amputation rates were compared between the least litigious quintile from the K-means clustering and the 2 most litigious quintiles. RESULTS: The median unadjusted Medicare per capita expenditure on diabetic patients was $15,963 ($14,885-$17,673), ranging from $13,762 (Iowa) to $21,865 (D.C.). A 1.6-fold variation persisted after payment standardization. Cluster analysis based on malpractice-related variables yields 5 distinct medicolegal environments, based on litigation frequency and malpractice payment amounts. Per capita spending on diabetes varied, ranging from $15,799 in states with low payments and infrequent litigation to $18,838 in states with the most adverse medicolegal environment (P < 0.05). After cost standardization and risk adjustment with multiple linear regression, malpractice claim prevalence (per 100 physicians) remained an independent predictor of states with the highest diabetes mellitus spending (P = 0.022). Moreover, diabetic patients in states with adverse medicolegal environments had more procedures, imaging studies, and readmissions (P < 0.05 for all) but did not have significant differences in amputation rates compared to less litigious states. CONCLUSIONS: An adverse medicolegal environment is independently associated with higher health care costs but does not result in improved outcome (i.e. amputation rate) for diabetic Medicare beneficiaries. Across states, a 1% increase in lawsuits/100 physicians was associated with a >10% increase in risk-adjusted standardized per capita costs. These findings demonstrate the potential contribution of "defensive medicine" to variation in health care utilization and spending in a population of interest to vascular surgeons.

Procedure Reimbursement, Inflation, and the Declining Buying Power of the Vascular Surgeon (2011-2021).

PURPOSE: The purpose of this study was to evaluate trends in Medicare reimbursement for common vascular procedures over the last decade. To enrich the context of this analysis, vascular procedure reimbursement is directly compared to inflation-adjusted changes in other surgical specialties. METHODS: The Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary file was utilized to identify the 20 procedures most commonly performed by vascular surgeons from 2011-2021. A similar analysis was performed for orthopedic, general, and neurological surgeons. The Centers for Medicare & Medicaid Services Physician-Fee Schedule Look-Up Tool was queried for each procedure, and reimbursement data was extracted. All monetary data was adjusted for inflation to 2021 dollars utilizing the consumer price index. Average year-over-year and total percentage change in reimbursement were calculated based on adjusted data for included procedures. Comparisons to other specialty data were made with ANOVA. RESULTS: From 2011-2021, the average, unadjusted change in reimbursement for vascular procedures was -7.2%. Accounting for inflation, the average procedural reimbursement declined by 20.1%. The greatest decline was observed in phlebectomy of varicose veins (-50.6%). Open arteriovenous fistula revision was the only vascular procedure with an increase in inflation-adjusted reimbursement (+7.5%). Year-over-year, inflation-adjusted reimbursement for common vascular procedures decreased by 2.0% per year. Venous procedures experienced the largest decrease in average adjusted reimbursement (-42.4%), followed by endovascular (-20.1%) and open procedures (-13.9%). These changes were significantly different across procedural subgroups (P < 0.001). During the same period, the average adjusted change in reimbursement for the 20 most common procedures in orthopedic surgery, general surgery, and neurosurgery was -11.6% vs. -20.1% for vascular surgery (P = 0.004). CONCLUSION: Medicare reimbursement for common surgical procedures has declined over the last decade. While absolute reimbursement has remained relatively stable for several procedures, accounting for a decade of inflation demonstrates the true diminution of buying power for equivalent work. The most alarming observation is that vascular surgeons have faced a disproportionate decrease in inflation-adjusted reimbursement in comparison to other surgical specialists. Awareness of these trends is a crucial first step towards improved advocacy and efforts to ensure the "value" of vascular surgery does not continue to erode.

Practice Patterns of Vascular Surgery's "1%".

BACKGROUND: Public focus on health care spending has increased attention on variation in practice patterns and overutilization of high-cost services. Mainstream news reports have revealed that a small number of providers account for a disproportionate amount of total Medicare payments. Here, we explore variation in Medicare payments among vascular surgeons and compare practice patterns of the most highly reimbursed surgeons to the rest of the workforce. METHODS: 2016 Medicare Provider Utilization Data were queried to identify procedure, charge, and payment data to vascular surgeons, identified by National Provider Identification taxonomy. Commonly performed services (>10/year) were stratified into categories (endovascular, open surgery, varicose vein, evaluation and management, etc.). Practice patterns of vascular surgeons comprising the top 1% Medicare payments (n = 31) were compared with the remainder of the workforce (n = 3,104). RESULTS: In 2016, Medicare payments to vascular surgeons totaled $589 M. 31 vascular surgeons-1% of the workforce-received $91 million (15% of total payments). Practice patterns of the 1% differed significantly from the remainder of vascular surgeons (P < 0.05), with endovascular procedures accounting for 85% of their reimbursement. Specifically, the 1% received 49% of total Medicare payments for atherectomy ($121 M), 98% of which were performed in the office setting. CONCLUSIONS: One percentage of vascular surgeons receive an inordinate amount of total Medicare payments to the specialty. This discrepancy is due to variations in volume, utilization, and site of service. Disproportionate use of outpatient atherectomy in a small number of providers, for example, raises concerns regarding appropriateness and overutilization. Given current scrutiny over health care spending, these findings should prompt serious discussion regarding the utility of personal and societal self-regulation.

Dose reduction using digital fluoroscopy versus digital subtraction angiography in endovascular aneurysm repair: A prospective randomized trial.

OBJECTIVE: Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) vs the standard technique using digital subtraction angiography (DSA). METHODS: Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard treatment DSA cohort or a DF cohort in which two or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose-area product (DAP) and cumulative air kerma. Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization). RESULTS: For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Of the 26 DF patients, 5 (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than in the DSA cohort (132 vs 174 Gy·cm2; P = .04). When patients were separated by number of DSA acquisitions (two or fewer vs three or more), mean DAP decreased 41% (109 vs 185 Gy·cm2; P = .005) and cumulative air kerma decreased 40% (578 vs 964 mGy; P = .004). CONCLUSIONS: In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.

Patient and institutional factors associated with postoperative opioid prescribing after common vascular procedures.

OBJECTIVE: Overprescription of postoperative opioid medication is a major contributor to the opioid abuse epidemic in the United States. Research into prescribing practices has suggested that patients be limited to 7 days or <200 morphine milligram equivalents (MME) after surgical procedures. Our aim was to identify patient or institutional factors associated with increased opioid prescriptions. METHODS: Opioid naive patients from an integrated health system undergoing one of nine surgical and endovascular procedures tracked within the Vascular Quality Initiative from 2015 to 2017 were identified and matched to their discharge and refill opioid prescriptions. Discharge opioid prescriptions were converted to MME. The primary outcome was discharge MME >200, and secondary outcomes were procedure-specific top-quartile opioid prescription and medication refills. Multivariable logistic regression was used to assess patient and perioperative factors associated with each outcome. RESULTS: Among 1546 opioid naive patients, 739 (48%) received a discharge opioid prescription; median MME was 0 (interquartile range, 0-150), and 349 (23%) had >200 MME. Among those with a discharge prescription, median MME was 180 (interquartile range, 150-300). MME varied by procedure (P < .001), with highest MME after suprainguinal bypass (median, 225) and infrainguinal bypass (200) and lowest MME after carotid artery stenting, carotid endarterectomy, and percutaneous peripheral vascular intervention (all medians of 0). On multivariable analysis, factors associated with MME >200 included younger patient age (<65 vs ≥ 80 years; odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.6; P < .001), treating institution B vs A (OR, 3.50; 95% CI, 2.42-5.07; P < .001) and C vs A (OR, 3.90; 95% CI, 2.66-5.74; P < .001), procedure-specific top-quartile length of stay (OR, 1.45; 95% CI, 1.01-2.08; P = .047), and prior tobacco use (OR, 1.60; 95% CI, 1.07-2.37; P = .02). The same variables along with current tobacco use and lack of preoperative aspirin were associated with procedure-specific top-quartile MME at discharge. Chronic beta-blocker use was protective of top-quartile MME. Based on the observed variability, an institutional standard for opioid prescribing has been developed for standardization. CONCLUSIONS: Opioid prescriptions at discharge vary with the invasiveness of vascular surgical procedures. Less than 25% of patients receive >200 MME. Variation by center represents a lack of standardization in prescribing practices and an opportunity for further improvement based on developed guidelines. Patient factors and procedure type can alert clinicians to patients at risk of higher than recommended MME.

Physical discomfort, professional satisfaction, and burnout in vascular surgeons.

OBJECTIVE: Vascular surgeons may experience physical discomfort during open and endovascular procedures. We aimed to understand and quantify the timing, severity, and location of the pain, as well as to identify how pain correlates with other factors. METHODS: An electronic survey was distributed to 1164 members of the Society for Clinical Vascular Surgery during the summer of 2016. There were 1089 (93.6%) surveys that were successfully delivered and 263 responses received (response rate of 24.2%). The survey was designed to quantify pain before, during, and after surgical procedures using the modified Borg scale. Questions aimed at determining surgeon workload, type of practice, burnout, and professional satisfaction were also included. RESULTS: Of the 263 total responses, 184 responders were male (82.1%). Workload data revealed that more than 87% of surgeons operate 3 or more days per week and 4 or more hours per day. Lead garments were worn by 48.4% these surgeons every day, with 91.4% wearing lead at least once per week. Pain was present in 74.7% of surgeons before beginning an operation, in 92.3% during an operation, and in 96.8% at completion. Before, during, and after surgery, 12.2% of vascular surgeons (n = 32) experience at least moderate pain. Years in practice had no effect on these results, and although not reaching statistical significance, there was a trend correlating surgeons who wear lead experiencing more pain immediately after performing an operation (P = .090). Of these surgeons, 31.4% acknowledged seeking medical help, although only 4.4% reported pain to their institutions. Professional satisfaction among vascular surgeons was inversely correlated with pain. Those expressing satisfaction with their profession had less pain before and two days after performing surgery (P ≤ .005). Self-reported burnout among surgeons positively correlated with increased pain. Burned out surgeons reported more pain while performing surgery (P ≤ .001), immediately after performing surgery (P ≤ .001), and persistent pain (P ≤ .001). CONCLUSIONS: Physical discomfort during the performance of daily duties by vascular surgeons is ubiquitous. Our survey shows a correlation between self-reported workplace burnout and an increased severity of work-related pain. Additional studies are needed to determine the causality of these correlations and what potential interventions can be undertaken to decrease all work-related pain.

Natural history and management outcomes of segmental arterial mediolysis.

BACKGROUND: Segmental arterial mediolysis (SAM) is a poorly understood, nonatherosclerotic, noninflammatory disease resulting from arterial medial degeneration. Patients may present with aneurysm, dissection, stenosis, or bleeding from visceral or renal arteries. Treatment algorithms are poorly characterized. METHODS: A retrospective review of all patients diagnosed with SAM was performed at our institution. Patients were identified by established criteria that include clinical presentation in combination with radiographic and serologic findings. Demographics, presenting symptoms, diagnostic evaluation, management, and outcomes were reviewed. RESULTS: There were 117 patients diagnosed with SAM between 2000 and 2016; 67.5% (n = 79) were male. Mean age was 52.7 years (range, 23.4-90 years); 69.2% (n = 81) presented with acute abdominal pain, 22.2% (n = 26) with flank pain, and 19.7% (n = 23) with back pain; 15.4% (n = 18) had abdominal pain longer than 30 days; 13.7% (n = 16) had acute hypertension, and 5.1% (n = 6) were hypotensive; 10.3% (n = 12) were asymptomatic. There were 93 (79.5%) dissections and 61 (52.1%) aneurysms. Hemorrhage was seen in 10 (8.5%). The celiac axis was affected in 54.7% (n = 64), renal arteries in 49.6% (n = 5 8), superior mesenteric artery in 43.6% (n = 51), and inferior mesenteric artery in 2.6% (n = 3). After diagnosis of SAM, aspirin was prescribed in 60.7% (n = 71). Statins were prescribed in 29.9% (n = 35). Antihypertensive medications were prescribed in 65% (n = 76), including beta blockers in 42.7% (n = 50); 40.2% (n = 47) of patients were prescribed anticoagulation. Interventions were performed in 26 (22%) patients; 13 had endovascular intervention only, 9 open surgery only, and 4 open and endovascular interventions. Of the 17 patients undergoing endovascular intervention, 19 procedures were performed, most commonly embolization (78.9% [n = 15]), followed by stenting (10.5% [n = 2]). Of the 13 patients undergoing open surgery, 14 procedures were performed, including arterial bypass (50% [n = 7]) and splenectomy with aneurysm ligation (15.4% [n = 2]). Other surgery involved thrombectomy (21.4% [n = 3]) and angioplasty (14.3% [n = 2]). Only 11.5% (n = 3) experienced a perioperative complication, including one hematoma, one abscess, and one death secondary to ongoing hemorrhage. Follow-up imaging was performed in 96.6% (n = 112). Mean follow-up was 1258 days (range, 2-5017 days). Of these, 27.7% (n = 31) had regression, 43.8% (n = 49) stability, and 28.6% (n = 32) progression. Average time between initial diagnosis and progression was 666 days. CONCLUSIONS: SAM is an uncommon disease that may require intervention; it is therefore important that the vascular surgery community be aware of this disease. Follow-up imaging is required to monitor for disease progression.

Current surgical management of carotid body tumors.

BACKGROUND: Carotid body tumors (CBTs) are rare. Management guidelines may include genetic testing for succinate dehydrogenase (SDH) mutations. We performed an institutional review of the surgical management of CBT. METHODS: A retrospective analysis (1994-2015) of CBT excisions at our institution was performed. Data obtained included demographics, genetic testing (if performed), intraoperative details, postoperative morbidity, and long-term outcomes. Data from the first CBT excision were included in patients with bilateral tumors. Genetic testing was routinely offered in patients with a family history of CBT or multiple paragangliomas. RESULTS: A total of 183 CBTs (124 female [67.7%]) were excised. A neck mass was present in 106 patients (57.9%), 24 patients (12.1%) presented with tenderness or neck pain, and 3 (1.6%) presented with cranial nerve dysfunction. Computed tomography (57.9%) or magnetic resonance imaging (51.3%) were the most commonly used imaging modalities. Preoperative angiography was performed in 73 patients (39.8%), and 62 of them (84.5%) underwent embolization or internal carotid balloon occlusion testing, or both. Mean tumor diameter was 3.2 cm (range, 0.6-7.2 cm). There were 71 (38.8%), 75 (41%), and 37 (20.2%) Shamblin type 1, 2, and 3 tumors, respectively. Average operating time was 224 minutes (range, 52-696 minutes). Average blood loss was 143.9 mL (range, 10-2000 mL). Arterial reconstruction with an interposition graft was required in 10, and patch angioplasty was performed in four. Cranial nerve injury was permanent in 10 (5.5%), and the rate of stroke was 1% (n = 2). A total of 382 lymph nodes were excised, and all were benign. There were no deaths ≤30 days. Only one patient presented with malignant disease 2 years after CBT excision, and this patient did not undergo genetic testing. Thirty-four (18.6%) had a family history of CBT. SDH testing was performed in 18 patients, and 17 tested positive. Positive genetic testing had a correlation with earlier age at operation (P < .0001). Mean age at diagnosis of patients with SDH mutations was 38.0 years, and patients without known SDH mutations presented at a mean age of 50.3 years. In patients with SDH mutations, tumor diameter, operating time, blood loss, and distribution of Shamblin type 1, 2, and 3 lesions were not significantly different compared with the control group. CONCLUSIONS: CBT can be treated with minimal morbidity and mortality; however, the subgroup of patients with positive SDH mutations may represent a variant group of younger patients. Vascular surgeons should be aware of genetic testing to identify patients and family members who should undergo additional preoperative testing and monitoring for other paragangliomas. Concomitant lymph node dissection does not appear to add value in absence of clinic suspicion for malignancy.

Surgical and medical management of extracranial carotid artery aneurysms.

OBJECTIVE: Extracranial carotid artery aneurysms (ECCAs) are extremely rare with limited information about management options. Our purpose was to review our institution's experience with ECCAs during 15 years and to discuss the presentation and treatment of these aneurysms. METHODS: A retrospective review of patients diagnosed with ECCAs from 1998 to 2012 was performed. Symptoms, risk factors, etiology, diagnostic methods, treatments, and outcomes were reviewed. RESULTS: During the study period, 141 aneurysms were diagnosed in 132 patients (mean age, 61 years; 69 men). There were 116 (82%) pseudoaneurysms and 25 (18%) true aneurysms; 69 (49%) aneurysms were asymptomatic, whereas 72 (52%) had symptoms (28 painless masses; 10 transient ischemic attacks; 10 vision symptoms; 9 ruptures; 8 strokes; 4 painful mass; 1 dysphagia; 1 tongue weakness; 1 bruit). Causes of true aneurysms included fibromuscular dysplasia in 15 patients, Ehlers-Danlos syndrome in three, Marfan syndrome in one, and uncharacterized connective tissue diseases in two. Of 25 true aneurysms, 11 (44%) were symptomatic; 15 (60%) true aneurysms underwent open surgical treatment, whereas 10 (40%) were managed nonoperatively. Postoperative complications included one stroke during a mean follow-up of 31 months (range, 0-166 months). No aneurysms managed nonoperatively required intervention during a mean follow-up of 77 months (range, 1-115 months). Of 116 pseudoaneurysms, 60 (52%) were symptomatic; 33 (29%) pseudoaneurysms underwent open surgery, 18 (15%) underwent endovascular intervention, and 65 (56%) were managed medically. Pseudoaneurysm after endarterectomy (28 patients; 24%) presented at a mean of 82 months from the surgical procedure. Mean follow-up for all aneurysms was 33.9 months. One (0.7%) aneurysm-related death occurred (rupture treated palliatively). No patient undergoing nonoperative management suffered death or major morbidity related to the aneurysm. Nonoperative management was more common in asymptomatic patients (71%) than in symptomatic patients (31%). CONCLUSIONS: ECCAs are uncommon and may be manifested with varying symptoms. All segments of the carotid artery are susceptible, although the internal is most commonly affected. Open surgical intervention was more common in patients with symptoms and with true aneurysms. Patients with pseudoaneurysms were more likely to undergo endovascular intervention. Nonoperative treatment is safe in selected patients.

Spiral vein graft for internal jugular bypass in a patient with multiple sclerosis and suspected chronic cerebrospinal venous insufficiency.

Chronic cerebrospinal venous insufficiency (CCSVI) has been implicated as a contributing factor to multiple sclerosis (MS). This theory is strongly debated within the neurology and radiology communities. This report presents the case of a 45-year-old man with known MS and suspected CCSVI who had undergone previous internal jugular angioplasty and stenting. The patient reported dramatic improvement of symptoms after intervention. The stent thrombosed despite antithrombotic medication, and several endovascular interventions failed to restore long-term patency. Open venous reconstruction of the internal jugular vein was performed with a spiral graft from the saphenous vein. The patient's symptoms improved for several weeks until the venous reconstruction occluded. This case is the first reported open venous reconstruction for suspected CCSVI.

Elimination of pneumothorax and hemothorax during placement of implantable venous access ports using ultrasound and fluoroscopic guidance.

Implantable venous access ports are essential for patients requiring chronic venous access. Ultrasound guided catheter placement has been recognized as a valuable adjunct for reducing complications during placement of access ports in the radiology and critical care medicine literature. We reviewed the medical records of patients undergoing insertion of implantable venous access ports from June 2006 through June 2009. All procedures were performed using ultrasound guidance with the internal jugular vein as the access site. There were 500 implantable venous access ports placed and included for review. There were no post-procedure pneumothoraces or hemothoraces. Carotid puncture was documented in 4 (0.8%)cases. Routine use of ultrasound guidance during placement of implantable venous access ports has eliminated the complications of pneumothorax and hemothorax during placement of internal jugular venous access ports on our vascular surgery service. Elimination of these complications and decreased use of chest x-rays should also provide increased cost savings for this procedure.

Endovascular retrieval of a TrapEase permanent inferior vena cava filter from the aorta.

Intra-aortic inferior vena cava filter placement is a rare event. We describe a case in which a permanent vena caval filter was retrieved from the aorta with endovascular techniques. Knowledge of filter design, catheters, and available wires is important to perform this procedure safely.

Comparison of open and endovascular repair of inflammatory aortic aneurysms.

OBJECTIVE: Inflammatory abdominal aortic aneurysms (IAAAs) have been traditionally managed with open repair. Endovascular aneurysm repair (EVAR) was approved September of 1999. Some authors have suggested that EVAR is not an acceptable option for management of an IAAA. However, several recent reports have suggested EVAR is a reasonable management option in these patients. The purpose of our study was to review our experience with the contemporary management of IAAA involving both open and endovascular approaches. METHODS: A retrospective review of all patients undergoing repair of IAAAs from 1999 to 2011 was conducted at three geographically separate institutions. Basic demographics, diagnostic workup, treatment, and outcomes were reviewed. RESULTS: Between 1999 and 2011, 69 patients underwent surgical repair of IAAAs, 59 by open repair and 10 by EVAR. Eighty-three percent of patients were men with a mean age of 67. Aneurysm size was similar in both groups (6.3 cm open repair vs 5.9 cm EVAR). Follow-up for the open group was a mean of 42.6 months and 33.6 months for the EVAR group. Periaortic fibrosis decreased from a mean of 5.4 mm to 2.7 mm after EVAR. Hydronephrosis was present preoperatively in one patient and did not change after EVAR. Aneurysm size decreased in seven patients (70%) who underwent EVAR. Two patients had no change with one lost to follow-up. Mean aneurysm size decrease after EVAR was 1.12 cm (17.8%). There were no aneurysm-related deaths or major morbidities in the EVAR group. Twenty-two patients (37%) in the open surgical group suffered major complications, including myocardial infarction, renal failure, lower extremity amputation, sepsis, and prolonged ventilation. CONCLUSIONS: Endovascular repair for IAAA results in successful management with improvement of periaortic inflammation. EVAR should be considered as first-line therapy in which anatomic parameters are favorable.

A randomized prospective multicenter trial of a novel vascular sealant.

BACKGROUND: Increasing use of anticoagulant medications, particularly antiplatelet therapies, can increase the difficulty in obtaining adequate suture line hemostasis. Multiple vascular sealants have been used as adjuncts to surgical procedures, but none of them have been universally successful. The aim of this study was to evaluate the safety and effectiveness of a new prophylactic vascular sealant in arterial surgery. METHODS: A randomized prospective multi-institutional trial was undertaken comparing ArterX Vascular Sealant (AVS) with Gelfoam Plus during open arterial reconstruction. RESULTS: Three hundred thirty-one anastomotic sites in 217 patients were randomized. One hundred one of 167 (60.5%) anastomotic sites in the AVS group achieved immediate hemostasis compared with 65 of 164 (39.6%) in the control group (P = 0.001). In anastomoses with polytetrafluoroethylene grafts, 105 of 167 (62.5%) in the AVS group achieved immediate hemostasis compared with 56 of 164 (34.0%) in the control group (P < 0.001). No significant differences were noted in morbidity or mortality. Operative time was significantly less in the AVS group compared with the control group (3.2 vs. 3.8 hours, P < 0.01). CONCLUSION: Use of AVS results in superior hemostatic effectiveness compared with Gelfoam Plus, with no difference in safety. Although no cost analysis was performed, cost savings likely resulted from significantly decreased operative time.

Surgical and reconstructive outcomes in primary venous leiomyosarcoma.

OBJECTIVE: Primary venous leiomyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL. METHODS: A retrospective review was performed of patients who had resection of PVL at three centers between 1990 and 2018. Patient demographics, comorbidities, intraoperative data, survival, and graft-related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS: Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the inferior vena cava (IVC) and 16 (23%) had peripheral PVL. The mean follow-up for the series was 55.0 months (range, 1-217 months). Fifty-one patients (96%) with IVC-PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within 30 days of surgery. Five patients (9%) required early reintervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within 30 days. Five-year survival was 57.5% for IVC-PVL and 70.0% for peripheral PVL. Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (P = .624) at 5 years. CONCLUSIONS: PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions, suggesting that aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long-term outcomes.

The minimally invasive management of visceral artery aneurysms and pseudoaneurysms.

OBJECTIVE: Minimally invasive methods (MIMs) are now available for the management of visceral artery aneurysms and pseudoaneurysms (visceral artery aneurysms [VAA]). The purpose of this study was to review our 10-year experience with the MIM of treating VAA. METHODS: All patients evaluated from June 1999 to June 2009 with VAAs were reviewed. Demographics, therapy, and results were analyzed. RESULTS: MIM was attempted in 185 aneurysms in 176 patients. Initial intervention was successful in 98% ofaneurysms. Sixty-three (34%) aneurysms were located in the splenic artery, 56 (30%) in the hepatic, 28 (15%) in the gastroduodenal, 16 (8.6%) in the pancreaticoduodenal, six (3.2%) in the superior mesenteric, four (2.1%) in the gastric, four (2.1%) in the celiac, four (2.1%) in the gastroepiploic, two (1%) in the inferior mesenteric, and one (0.5%) in the middle colic artery. Pseudoaneurysms were more common than true aneurysms (64% vs 36%). Bleeding was the indication for intervention in 86 aneurysms (46%). Initial treatment was successful in 177 aneurysms (98%). Reintervention was required in five (3%) aneurysms within 30 days. Coiling was used alone in 139 aneurysms (75%) and in combination with at least one other technique in 20 (11%) cases. Thirty-day aneurysm-related mortality was 3.4% (six deaths). Five additional deaths occurred during 30-day follow-up, although none was related to complications of the aneurysms (2.8%). CONCLUSIONS: MIM for visceral artery aneurysms can be used alone or in combination to effectively treat VAAs in elective or emergent conditions.

Surgical management of tumors invading the aorta and major arterial structures.

BACKGROUND: This study investigates surgical management of tumors arising from or involving the aorta and major arterial structures. METHODS: A retrospective single institutional review was conducted of patients undergoing arterial resection for tumors involving the aorta or major arterial structures between January 1992 and May 2009 at a tertiary care center. Patients with tumors abutting arteries without necessitating resection and those involving only venous structures were excluded. Patients were analyzed in groups by vessel involvement: aorta, carotid, external/common iliac, internal iliac, superficial femoral, and miscellaneous. RESULTS: Sixty patients were identified and included for review. The iliac arteries were most often resected, and sarcomatous pathology was most common (37 patients, 62%). Twelve patients underwent aortic resection, with eight (67%) of these undergoing graft reconstruction, one (8%) graft patch, and two (17%) primary repair. None of the 17 patients undergoing internal iliac resection underwent reconstruction, whereas the majority of patients in all other groups underwent reconstruction. Thirty-day mortality (TDM) was 0% in all groups, except the aortic (2/12, 17% TDM), and internal iliac arteries (1/17, 6% TDM). Estimated blood loss varied widely and was not significantly different between vessel groups (p = 0.280). Overall, 44 of 60 (73%) patients had negative margins. Fourteen patients (23%) returned to the operating room, most for wound infection or dehiscence. Mean follow-up was 20.25 months (range: 0.5-122.0 months, SD: 23 months). Forty patients were followed up for more than 1 year. Thus, with an overall median follow-up of 12.25 months, overall survival was 60% with disease-free survival of 40%. CONCLUSIONS: Resection of tumors involving the aorta and major arterial structures provides a reasonable option for treatment, but with significant perioperative morbidity. In selected patients, this aggressive intervention should be considered.

Contemporary management of aberrant right subclavian arteries.

BACKGROUND: Aberrant origin of right subclavian arteries represents the most common of the aortic arch anomalies. This variant has few published series to guide management. Our goal was to review treatment options and results for these potentially complex reconstructions. METHODS: A retrospective review was performed on all patients with a diagnosis of aberrant right subclavian artery at our institution between January 2003 and July 2009. RESULTS: A total of 24 patients, which comprises one of the largest series reported, including 10 males and 14 females (mean age: 46.6 years, range: 7-77), were diagnosed with an aberrant right subclavian artery. Sixteen (66%) were diagnosed incidentally, but eight (33%) had symptoms of either dysphagia, upper extremity ischemia, or both. Computed tomography was most commonly used to establish the diagnosis (19 patients, 79%). Magnetic resonance imaging established the diagnosis in three patients (12%), upper gastrointestinal barium study in one (4%), and standard angiography in one (4%). A Kommerell's diverticulum (KD) was the most common associated anomaly (seven patients, 29%). All seven patients (100%) with a KD required intervention for either symptoms or aneurysmal degeneration. Intervention was performed in 10 patients (42%), including carotid subclavian bypass in five (50%), carotid subclavian transposition in three (30%), and ascending aorta to subclavian bypass in two (20%). Four patients (40%) had additional intervention for management of aneurysmal disease of the aorta or KD, with open aortic replacement in two (20%) and aortic endografting in two (20%). There was one perioperative death (10%) in a patient undergoing aortic arch debranching with placement of an aortic endograft. In all, 18 patients survived without symptoms after a mean follow-up of 38 months. CONCLUSIONS: Aberrant right subclavian arteries are most commonly found incidentally with computed tomography. The presence of a KD seemed to correlate with the need for intervention. Patients with no symptoms with the absence of a KD can safely be followed.

Carotid endarterectomy surgeon volumes in contemporary practice: A comparison to randomized trial inclusion criteria.

BACKGROUND: Clinical decisions regarding the utility of carotid revascularization are informed by randomized controlled trial (RCT) results. However, RCTs generally require participating surgeons to meet strict inclusion criteria with respect to procedure volume. The purpose of this study was to compare annual surgeon volume for carotid endarterectomy (CEA) in contemporary practice to RCT inclusion thresholds. METHODS: Surgeon volume thresholds were identified in 17 RCTs evaluating the efficacy of CEA (1986-present, n = 17). Contemporary annual surgeon volumes (2012-2017) were identified by aggregating data from the Medicare Provider Utilization Database and Healthcare Cost and Utilization Project Network (HCUP), and compared to RCT inclusion thresholds. Further comparisons were performed over time, and across specialties (i.e., vascular surgeon vs. other, based on board certification associated with provider NPI). RESULTS: Minimal surgeon volume in 17 RCTs ranged from 10 to 25 CEA annually when specific case volumes were required. From 2012 to 2017, CEA incidence in Medicare beneficiaries declined from 68,608 to 56,004 and became increasingly consolidated in fewer providers (7,331 vs. 6,626). However, in 2016 only 26.2% of surgeons performing CEA in Medicare beneficiaries would have met the least stringent volume requirement (10 CEA/year). Only 6.5% of surgeons performing CEA met the most stringent RCT volume threshold (25 cases/year) during the same time period. In 2017, 819 vascular surgeons (25.5% of those certified in the specialty) performed >10 CEA in Medicare beneficiaries. CONCLUSIONS: The majority of surgeons performing CEA do not meet the annual volume thresholds required for participation in the RCTs that have evaluated the efficacy of carotid revascularization. Given the established volume-outcome relationship in CEA, the disparity between surgeon experience in the context of RCTs versus contemporary practice is concerning. These findings have potential implications for informed decision-making, hospital privileging, and regionalization of care.

Endarterectomy for Iliac Occlusive Disease during Kidney Transplantation: A Multicenter Experience.

Little is known about the surgical challenges and outcomes of kidney transplantation (KT) in the face of severe iliac occlusive disease (IOD). We aim to examine our institution's experience and outcomes compared with all KT patients. Retrospective review of our multi-institutional transplant database identified patients with IOD requiring vascular surgery involvement for iliac artery endarterectomy at time of KT from 2000 to 2018. Clinical data, imaging studies, and surgical outcomes of 22 consecutive patients were reviewed. Our primary end-point was allograft survival. Secondary end-points included mortality and perioperative complications. A total of 6,757 KT were performed at our three sites (Florida, Arizona, and Minnesota); there were 22 (0.32%) patients receiving a KT with concomitant IOD requiring iliac artery endarterectomy. Mean patient age was 61.45 ± 7 years. There were 13 (59.1%) male patients. The most common etiology of renal failure was diabetic nephropathy in 10 patients (45.5%) followed by a combination of hypertensive/diabetic nephropathy in five patients (22.7%), and hypertensive nephrosclerosis in three patients (13.6%). The majority ( n = 16, 72.7%) of patients received renal allografts from deceased donors and six (27.3%) were recipients from living donors. Mean time from dialysis to transplantation was 2.9 ± 2.9 years. Mean follow-up was 3.5 ± 2.5 years. Mean length of hospital stay was 6.3 ± 4.3 days (range: 3-18 days). Graft loss within 90 days occurred in two (9.1%) patients, one due to renal vein thrombosis and another due to acute tubular necrosis. Overall allograft survival was 90.1% at 1-year and 86.4% at 3-year follow-up. Overall mortality occurred in 6 (27.3%) patients. Perioperative complications (Clavien-Dindo Grade 2-4) occurred in 13 (59.1%) patients, including 10 (45.5%) with acute blood loss anemia requiring transfusion, 2 (9.1%) reoperations for hematoma evacuation, 1 (4.5%) ischemic colitis requiring total abdominal colectomy, and 1 (4.5%) renal vein thrombosis requiring nephrectomy. IOD patients selected for KT are not common and although challenging, they have similar outcomes to our standard KT patients. The 1- and 3-year allograft survivals were 90.1 and 86.4% versus 96.0 and 90.3% in the general KT patient population. With these excellent outcomes, we recommend expanding the criteria for KT to include patients with IOD with prior vascular surgery consultation to prevent progression of IOD or prevention of wait list removal in select patients who are otherwise good candidates for KT.