Vascular Surgery Education and Training in the American Continent: Current Status and Future Directions.

OBJECTIVE: Despite the increasing burden of cardiovascular diseases, there is a shortage of vascular surgeons worldwide, with a higher scarcity in low and middle-income countries. The objective of the present study was to report the current status of vascular surgery education and training on the American continent. MATERIALS AND METHODS: Official government, postgraduate medical schools, and medical associations' websites were searched for data regarding vascular surgery training positions, programs, and pathways available in the 35 countries of the American continent. RESULTS: There are 707 annual positions for training in vascular surgery offered by 367 training programs. Of the 35 countries in America, only 17 (48.5%) offer vascular surgery training as an independent specialty. In one (2.8%) country, Peru, vascular surgery is mixed with cardiothoracic surgery. There is no vascular surgery training in the remaining 17 (48.5%) countries. Brazil has the highest number of training positions, offering 292 (41.3%) positions per year, followed by the United States, with 214 (30.2%) positions per year, and Mexico, with 69 (9.7%) positions per year. The country with more positions per 1,000,000 inhabitants is Cuba (3.93), followed by Brazil (1.34) and Uruguay (0.87). Brazil, Canada, Mexico, and the United States are the only four countries that have vascular surgery board exams. CONCLUSION: This is the first report presenting a large-scale picture of vascular surgery education and training in the American continent. Brazil is the country that offers more vascular surgery training opportunities, followed by the United States and Mexico. Disseminating vascular surgery training in America is of utmost importance to help fight the cardiovascular diseases pandemic the world faces.

An analysis from the CAPACITY database of outcomes of preoperative embolization before carotid body tumor surgery compared with resection alone.

OBJECTIVE: There is no definitive consensus on the impact of preoperative embolization on carotid body tumor (CBT) treatment. The objective of this study was to compare surgical outcomes of patients who underwent preoperative embolization before CBT resection vs patients who underwent resection alone. METHODS: The CAPACITY registry included 1432 patients with CBT from 11 medical centers in four different countries. The group of patients undergoing CBT resection with preoperative embolization was matched in a 1:6 ratio from a pool of patients from the CAPACITY database, using a generated propensity score with patients who did not underwent preoperative embolization. RESULTS: A total of 553 patients were included for analysis. Mean patient age was 56.23 ± 12.22 years. Patients were mostly female (n = 469; 84.8%). Bilateral CBT was registered in 60 patients (10.8%). Seventy-nine patients (14.3%) underwent preoperative embolization. Embolized patients had larger CBT sizes than non-embolized patients (33.8 mm vs 18.4 mm; P = .0001). Operative blood loss was lower in the embolized group compared with the non-embolized group (200 mL vs 250 mL; P = .031). Hematomas were more frequent in the non-embolized group (0% vs 2.7%; P = .044). Operative time, rates of stroke, cranial nerve injuries, and death were not statistically significant between groups. CONCLUSIONS: Embolization before CBT resection was associated with significantly lower blood loss and lower neck hematomas than patients who underwent resection alone. Operative time, stroke, cranial nerve injuries, and death were similar between groups.

Risk Factors for Stroke After Carotid Paraganglioma Surgery.

BACKGROUND: The Carotid Paraganglioma Cooperative International Registry (CAPACITY) is an international registry composed of 1,432 patients with carotid body tumors (CBT) from 11 centers from 4 countries. The aim of this study was to identify risk factors for patients who presented stroke after carotid paraganglioma resection. METHODS: Clinical characteristics and demographics of patients who presented transoperatively and postoperatively stroke from the CAPACITY database were retrospectively gathered. Regression analysis was performed using single logistic regression with Omnibus' test for possible factors that might contribute to present stroke. RESULTS: Out of 1,432 patients, 8 (0.5%) female patients presented stroke. Median age was 53 years (range: 41-70 years). Six strokes occurred transoperatively, diagnosed clinically in the immediate postoperative period. Of them, none of the patients received any further treatment. Three of them died on postoperative day 2, 3, and 4. Two patients developed stroke during the first 24 postoperative hours, patients showed dysarthria, and aphasia. One of them was reintervened with thrombectomy due to thrombosis of the common carotid artery the other patient was treated conservatively. Median follow-up was 16 months (range: 2-72 months). Single logistic regression analysis revealed a history of diabetes mellitus (odds ratio (OR) 7.62), carotid artery disease (OR 17.51), and vascular lesion (OR 2.37) to have significantly increased odds of stroke during CBT surgery. CONCLUSIONS: In the present study history of diabetes mellitus, carotid artery disease, and vascular lesion had increased odds of stroke during CBT surgery. Findings are limited by low event rate and even larger cohorts are needed to fully define preventive preoperative strategies for preventing stroke.

Clinical Characteristics and Surgical Outcomes of Carotid Body Tumors: Data from the Carotid Paraganglioma Cooperative International Registry (CAPACITY) Group.

BACKGROUND: This study's objective was to conduct a multinational registry of patients with carotid body tumors (CBTs) and to analyze patients' clinical characteristics, treatments, and outcomes. METHODS: Retrospective study from the Carotid Paraganglioma Cooperative International Registry involving eleven medical centers in Bolivia, Ecuador, Mexico, and Spain, of all patients with a CBT who underwent resection between 2009 and 2019. RESULTS: A total of 1432 patients with a CBT surgically treated were included. Median patient age was 54 years (range: 45-63 years), and 82.9% (1184) of the study cohort were female. While at low altitude, the proportion of female-to-male cases was 2:1, at high altitude, this proportion increased to 8:1, with statistically significant differences (p = .022). Median operative time was 139 min (range: 110-180 min), while median operative blood loss was 250 ml (range: 100-500 ml), with statistically significant difference in increased blood loss (p = .001) and operative time (p = .001) with a higher Shamblin classification. Eight (0.6%) patients suffered stroke. Univariate analysis analyzing for possible factors associated with increased odds of stroke revealed intraoperative vascular lesion to present an OR of 2.37 [CI 95%; 1.19-4.75] (p = 0.001). In 245 (17.1%), a cranial nerve injury was reported. Seven (0.5%) deaths were recorded. CONCLUSION: The most common CBT type on this cohort was hyperplasic, which might be partially explained by the high altitudes where these patients lived. Increased blood loss and operative time were associated with a higher Shamblin classification, and the risk of stroke was associated with patients presenting transoperative vascular lesions.

High Altitude Carotid Body Tumors Growth During active Surveillance.

BACKGROUND: The gold standard for patients with carotid body tumors (CBT) is surgical resection; nevertheless, some patients are unfit for surgery or, for other reasons, could not be operated on. Active surveillance has been known to be a reasonable strategy for these cases. This study aimed to evaluate tumor growth in unoperated patients with CBTs. METHODS: A retrospective review of all unoperated patients with CBT from a single academic hospital diagnosed between 2014 and 2021 was performed. Results of nonparametric testing were presented using the median and ranges for Mann-Whitney-U or Kruskal-Wallis. Significance was defined as a 2-tailed P < .05. RESULTS: The cohort included a total of 31 patients, with a median age of 60 years (range: 37-80 years), of which 27 (87.1%) were females. The patients live at a median altitude of 2800 meters (range: 2756-2980 meters) above sea level. Twenty (64.5%) patients had Shamblin I tumors, eight (25.8%) patients had Shamblin II tumors, and three (9.7%) patients had Shamblin III tumors. Median CBT volume at diagnosis was 14.1 cm3 (range: .9 - 213.3 cm3). Median volume at diagnosis of symptomatic tumors was substantially larger than asymptomatic tumors, 49.2 cm3 vs 7.9 cm3, respectively (P = .03). Median growth of the tumors during a median 15-month follow-up (range: 3-43 months) was 3.3 cm3 (range: 0-199.9 cm3). Overall, 77% (n = 24) of the CBTs grew at least 1 cm3. CONCLUSION: Most patients in the present study had tumor growth by at least 1 cm3, with a median tumor growth of 3.3 cm.3 In the present study tumor growth was shown to be greater than other low altitude CBT active surveillance studies; therefore, surgical resection should be recommended in patients with CBT living at high altitudes.