Impact of COVID-19 on patients undergoing scheduled procedures for chronic venous disease.

OBJECTIVE: The COVID-19 pandemic has drastically altered the medical landscape. Various strategies have been employed to preserve hospital beds, personal protective equipment, and other resources to accommodate the surges of COVID-19 positive patients, hospital overcapacities, and staffing shortages. This has had a dramatic effect on vascular surgical practice. The objective of this study is to analyze the impact of the COVID-19 pandemic on surgical delays and adverse outcomes for patients with chronic venous disease scheduled to undergo elective operations. METHODS: The Vascular Surgery COVID-19 Collaborative (VASCC) was founded in March 2020 to evaluate the outcomes of patients with vascular disease whose operations were delayed. Modules were developed by vascular surgeon working groups and tested before implementation. A data analysis of outcomes of patients with chronic venous disease whose surgeries were postponed during the COVID-19 pandemic from March 2020 through February 2021 was performed for this study. RESULTS: A total of 150 patients from 12 institutions in the United States were included in the study. Indications for venous intervention were: 85.3% varicose veins, 10.7% varicose veins with venous ulceration, and 4.0% lipodermatosclerosis. One hundred two surgeries had successfully been completed at the time of data entry. The average length of the delay was 91 days, with a median of 78 days. Delays for venous ulceration procedures ranged from 38 to 208 days. No patients required an emergent intervention due to their venous disease, and no patients experienced major adverse events following their delayed surgeries. CONCLUSIONS: Interventions may be safely delayed for patients with venous disease requiring elective surgical intervention during the COVID-19 pandemic. This finding supports the American College of Surgeons' recommendations for the management of elective vascular surgical procedures. Office-based labs may be safe locations for continued treatment when resources are limited. Although the interventions can be safely postponed, the negative impact on quality of life warrants further investigation.

Exposing the chameleon-like nature of racism: a multidisciplinary look at critical race theory in higher education.

In higher education institutions, critical race theory (CRT) is known to be associated with fields that study racial disparities or systemic oppression such as law, education, and ethnic studies. The impression that CRT is unrelated to fields like business or computer science may have led scholars and practitioners from these disciplines to put their focus on elsewhere than on racial inequality and its implication in their research and practice, despite apparent need. To counter such fallacy, this review article-focusing primarily on the US context-discusses CRT literature in fields where its presence is less known which are nevertheless among the major domains of higher education institutions: health sciences, computer science and information technology, sports, business, and religion. By discussing example research of how scholars have utilized CRT in different fields to challenge the race-neutral thinking that often obscures structural racism, this paper exposes racism's ability to alter manifestations and to appear through various shapes and forms within the higher education context. Initial recommendations on how educators may engage in further discussions or actions will also be considered. This paper concludes that racist ideologies are often hidden behind discipline-specific vocabulary or technical language, and it is by tackling the ideologies at work underneath the technicalities can we address the chameleon-like nature of racism more effectively.

Society for Vascular Surgery appropriate use criteria for management of intermittent claudication.

The Society for Vascular Surgery appropriate use criteria (AUC) for the management of intermittent claudication were created using the RAND appropriateness method, a validated and standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process. These criteria serve as a framework on which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition of treatments rated as inappropriate (risk outweighs benefit). Clinical situations will occur in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC requires a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with the best available evidence should determine the treatment strategy. These scenarios require mechanisms to track the treatment decisions and outcomes. AUC should be revisited periodically to ensure that they remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral, and femoropopliteal segments in the round 2 rating. Of these, only nine (0.4%) showed a disagreement using the interpercentile range adjusted for symmetry formula, indicating an exceptionally high degree of consensus among the panelists. Post hoc, the term "inappropriate" was replaced with the phrase "risk outweighs benefit." The term "appropriate" was also replaced with "benefit outweighs risk." The key principles for the management of IC reflected within these AUC are as follows. First, exercise therapy is the preferred initial management strategy for all patients with IC. Second, for patients who have not completed exercise therapy, invasive therapy might provide net a benefit for selected patients with IC who are nonsmokers, are taking optimal medical therapy, are considered to have a low physiologic and technical risk, and who are experiencing severe lifestyle limitations and/or a short walking distance. Third, considering the long-term durability of the currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance. Fourth, in the common femoral segment, open common femoral endarterectomy will provide greater net benefit than endovascular intervention for the treatment of IC. Finally, in the infrapopliteal segment, invasive intervention for the treatment of IC is of unclear benefit and could be harmful.

Equal pay for equal work: Disparities in compensation in vascular surgery.

Physician compensation varies by specialty, gender, race, years in practice, type of practice, location, and individual productivity. We reviewed the disparities in compensation regarding the variation between medical and surgical specialties, between academic and private practice, between gender, race, and rank, and by practice location. The physician personal debt perspective was also considered to quantify the effect of disparities in compensation. Strategies toward eliminating the pay gap include salary transparency, pay equity audit, paid parental leave, mentoring, sponsorship, leadership, and promotion pathways. Pay parity is important because paying women less than men contributes to the gender pay gap, lowers pension contributions, and results in higher relative poverty in retirement. Pay parity will also affect motivation and relationships at work, ultimately contributing to a diverse workforce and business success. Rewarding all employees fairly is the right thing to do. As surgeons and leaders in medicine, establishing pay equity is a matter of ethical principle and integrity to further elevate our profession.

Telemedicine platforms and their use in the coronavirus disease-19 era to deliver comprehensive vascular care.

Implementation of telemedicine for patient encounters optimizes personal safety and allows for continuity of patient care. Embracing telehealth reduces the use of personal protective equipment and other resources consumed during in-person visits. The use of telehealth has increased to historic levels in response to the coronavirus disease 2019 (COVID-19) pandemic. Telehealth may be a key modality to fight against COVID-19, allowing us to take care of patients, conserve personal protective equipment, and protect health care workers all while minimizing the risk of viral spread. We must not neglect vascular health issues while the coronavirus pandemic continues to flood many hospitals and keep people confined to their homes. Patients are not immune to diseases and illnesses such as stroke, critical limb ischemia, and deep vein thrombosis while being confined to their homes and afraid to visit hospitals. Emerging from the COVID-19 crisis, incorporating telemedicine into routine medical care is transformative. By leveraging digital technology, the authors discuss their experience with the implementation, workflow, coding, and reimbursement issues of telehealth during the COVID-19 era.

Outcome benefit of arterial duplex stent imaging after superficial femoral artery stent implantation.

OBJECTIVE: In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion or symptom recurrence. Arterial duplex stent imaging (ADSI) can be used in the surveillance for recurrent stenosis; however, its uniform application is controversial. In this study, we aimed to determine, in patients undergoing SFA stent implantation, whether surveillance with ADSI yielded a better outcome than in those with only ankle-brachial index (ABI) follow-up. METHODS: We performed a retrospective analysis of all patients undergoing SFA stent implantation for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with ADSI and those with ABI follow-up only. Life-table analysis comparing stent patency, major adverse limb events (MALEs), limb salvage, and mortality between groups was performed. RESULTS: There were 248 patients with SFA stent implantation included, 160 in the ADSI group and 88 in the ABI group. Groups were homogeneous in clinical indications of claudication and critical limb-threatening ischemia (for ADSI, 39% and 61%; for ABI, 38% and 62%; P = .982) and TransAtlantic Inter-Society Consensus class A, B, C, and D lesions (for ADSI, 17%, 45%, 16%, and 22%; for ABI, 21%, 43%, 16%, and 20%; P = .874). Primary patency was similar between groups at 12, 36, and 56 months (ADSI, 65%, 43%, and 32%; ABI, 69%, 34%, and 34%; P = .770), whereas ADSI patients showed an improved assisted primary patency (84%, 68%, and 54%) vs ABI patients (76%, 38%, and 38%; P = .008) and secondary patency. There was greater freedom from MALEs in the ADSI group (91%, 76%, and 64%) vs the ABI group (79%, 46%, and 46%; P < .001) at 12, 36, and 56 months of follow-up. ADSI patients were more likely to undergo an endovascular procedure as their initial post-SFA stent implantation intervention (P = .001), whereas ABI patients were more likely to undergo an amputation (P < .001). CONCLUSIONS: In SFA stent implantation, patients with ADSI follow-up demonstrate an advantage in assisted primary patency and secondary patency and are more likely to undergo an endovascular reintervention. These factors are likely to have effected a decrease in MALEs, indicating the benefit of a more universal adoption of post-SFA stent implantation follow-up ADSI.

The initial experience and response of vascular surgeons in Michigan during the COVID-19 pandemic.

BACKGROUND/OBJECTIVE: The unprecedented pandemic spread of the novel coronavirus has severely impacted the delivery of healthcare services in the United States and around the world, and has exposed a variety of inefficiencies in healthcare infrastructure. Some states have been disproportionately affected such as New York and Michigan. In fact, Detroit and its surrounding areas have been named as the initial Midwest epicenter where over 106,000 cases have been confirmed in April 2020. METHOD, RESULTS AND CONCLUSIONS: Facilities in Southeast Michigan have served as the frontline of the pandemic in the Midwest and in order to cope with the surge, rapid, and in some cases, complete restructuring of care was mandatory to effect change and attempt to deal with the emerging crisis. We describe the initial experience and response of 4 large vascular surgery health systems in Michigan to COVID-19.

Analysis of Outpatient Telemedicine Reimbursement in an Integrated Healthcare System.

BACKGROUND: Current reimbursement policy surrounding telemedicine has been cited as a barrier for the adaptation of this care model. The objective of this study is to analyze the reimbursement figures for outpatient telemedicine consultation in vascular surgery. METHODS: Patients first underwent synchronous telemedicine visits after receiving point-of-care ultrasound at one of 3 satellite locations of Henry Ford Health System in Michigan. Visit types included new, return, and postoperative patients. Reimbursement information related to payor, adjustment, denial, paid and outstanding balances were recorded for each telemedicine visit. Then, using an enterprise data warehouse, a retrospective analysis was performed for the aforementioned telemedicine visits. The data were analyzed to determine the outcome of total billed charges, number of denied claims, reimbursement per payor, reimbursement per patient, and out-of-pocket costs to the patients. RESULTS: Among 184 virtual clinical encounters, the payors included Aetna US Healthcare, Blue Advantage, Blue Cross Blue Shield, Cofinity Plan, Health Alliance Plan, HAP Medicare Advantage, Humana Medicare Advantage, Medicaid, Medicare, Molina Medicaid HMO, United Healthcare, Blue Care Network, Aetna Better Health of Michigan, Priority Health, and self-pay. Among the 15 payors, reimbursement ranged from 0% to 67% of the total charges billed. Among the 184 virtual visits, a grand total of $22,145 was collected or an average of $120.35 per virtual encounter. The breakdown of charges billed was 40% adjusted, 41% paid by insurance, 10% paid by patient, and 13% denied. There were 27 total denials (15%). Denial of payment included telehealth and nontelehealth reasons, citing noncovered charges, payment included for other prior services, new patient quality not met, and not covered by payor. The average out-of-pocket cost to patients was $12.59 per visit. CONCLUSIONS: These reimbursement data validate the economic potential within this new platform of healthcare delivery. As our experience with the business model grows, we expect to see an increase in reimbursement from private payors and acceptance from patients. Within a tertiary care system, telemedicine for chronic vascular disease has proven to be a viable means to reach a broader population base, and without significant cost to the patients.

Outpatient Telemedicine Program in Vascular Surgery Reduces Patient Travel Time, Cost, and Environmental Pollutant Emissions.

BACKGROUND: We analyze the impact of outpatient telemedicine services on the travel burden of vascular surgery patients with regard to distance, time, and cost, as well as the emission of environmental pollutants. METHODS: Retrospective analysis was used to compare the patient travel expenditure and environmental impact associated with telemedicine encounters versus hypothetical in-person traditional consultations for all outpatient virtual care encounters with vascular surgery patients from October 2015 to October 2017. The primary outcomes measured were travel distance saved, travel time saved, travel costs saved, reduction in fuel consumption, and reduction in environmental pollutant emission. RESULTS: Over a two-year period, 146 outpatient telemedicine encounters were conducted among 87 unique patients (61 females, 26 males; mean age, 60 ± 13 years). The average one-way distance saved by the utilization of telemedicine services was 15.6 ± 6.3 miles, with an average roundtrip savings of 31.2 miles. The average one-way travel time saved was 19.5 ± 9.2 minutes, with an average roundtrip savings of 39 minutes. By using telemedicine services, these vascular surgery patients saved an average of $4.26 in gas and parking costs at each telemedicine encounter. The total reduction in passenger vehicle emission of environmental pollutants, including carbon dioxide, carbon monoxide, nitric oxides, and volatile organic compounds was 1632 kg, 42,867 g, 3160 g, and 4715 g, respectively, with a total of 194 gallons of gas saved from driving. CONCLUSIONS: Utilization of telemedicine services reduces the travel distance, time, and costs for vascular surgery patients. Outpatient telemedicine programs may also provide environmental benefit through the reduction of greenhouse gas and pollutant emissions.

Implementation of a virtual vascular clinic with point-of-care ultrasound in an integrated health care system.

OBJECTIVE: Using secured videoconferencing technologies, telemedicine may replace traditional clinic visits, save patients' time and travel, and improve use of limited surgeon and facility resources. We report our initial experience of the remote clinical encounter (RCE) by evaluating vascular surgery patients. METHODS: In this proof-of-concept pilot study, we conducted telemedicine evaluations of vascular patients at a tertiary care institution from October 2015 to August 2016. Patients were offered synchronous virtual visits from a surgical provider in lieu of an in-person visit. We used Skype for Business (Microsoft, Redmond, Wash) over secured networks for patient-provider interaction, clinical data entry in the Epic electronic medical record (Epic Systems Corporation, Verona, Wisc) for documentation, and established satellite facilities with existing vascular laboratories for imaging and laboratory testing. We evaluated feasibility, demographics, encounter type, and satisfaction of the patient through web-based questionnaires. RESULTS: During a 10-month period, 41 women and 14 men with an average age of 57 years (range, 29-79 years) underwent 82 RCEs. There were 43 white (78.1%), 9 black (16.3%), 1 Asian (1.8%), and 2 Middle Eastern (3.6%) patients. Diagnoses included both arterial (aneurysm, carotid, and occlusive disease) and venous (deep venous thrombosis and varicose vein) disease. Among the 82 RCEs, visit types included 15 new patients, 30 postoperative visits, and 37 follow-up visits. Ultrasound imaging was performed in conjunction with the RCE in 74 patients (90.2%). Most patients (57%) had multiple RCEs during the study period. All 55 patients responded to the satisfaction questionnaire; 91% stated that they would highly recommend a virtual physician encounter to a friend or colleague, and all of the respondents found their encounter more convenient than having a traditional office visit. All patients thought that they were able to communicate clearly with the provider, and overall quality responses were overwhelmingly positive. CONCLUSIONS: Secured virtual visits can be conducted using commercially available hardware and software solutions. Synchronous telemedicine with point-of-care ultrasound is effective in evaluating common vascular conditions. Virtual care may be used for management of patients with chronic vascular disease.

Clinical utility of carotid duplex ultrasound prior to cardiac surgery.

OBJECTIVE: Clinical utility and cost-effectiveness of carotid duplex examination prior to cardiac surgery have been questioned by the multidisciplinary committee creating the 2012 Appropriate Use Criteria for Peripheral Vascular Laboratory Testing. We report the clinical outcomes and postoperative neurologic symptoms in patients who underwent carotid duplex ultrasound prior to open heart surgery at a tertiary institution. METHODS: Using the combined databases from our clinical vascular laboratory and the Society of Thoracic Surgery, a retrospective analysis of all patients who underwent carotid duplex ultrasound within 13 months prior to open heart surgery from March 2005 to March 2013 was performed. The outcomes between those who underwent carotid duplex scanning (group A) and those who did not (group B) were compared. RESULTS: Among 3233 patients in the cohort who underwent cardiac surgery, 515 (15.9%) patients underwent a carotid duplex ultrasound preoperatively, and 2718 patients did not (84.1%). Among the patients who underwent carotid screening vs no screening, there was no statistically significant difference in the risk factors of cerebrovascular disease (10.9% vs 12.7%; P = .26), prior stroke (8.2% vs 7.2%; P = .41), and prior transient ischemic attack (2.9% vs 3.3%; P = .24). For those undergoing isolated coronary artery bypass grafting (CABG), 306 (17.8%) of 1723 patients underwent preoperative carotid duplex ultrasound. Among patients who had carotid screening prior to CABG, the incidence of carotid disease was low: 249 (81.4%) had minimal or mild stenosis (<50%); 25 (8.2%) had unilateral moderate stenosis (50%-69%); 10 (3.3%) had bilateral moderate stenosis; 9 (2.9%) had unilateral severe stenosis (70%-99%); 5 (1.6%) had contralateral moderate stenosis; 2 (0.7%) had bilateral severe stenosis; 4 (1.3%) had unilateral occluded with contralateral less than 50% stenosis, 1 (0.3%) had unilateral occluded with contralateral (70%-99%) stenosis; and 1 had bilateral occluded carotid arteries. Primary outcomes of patients who underwent isolated CABG showed no difference in the perioperative mortality (2.9% vs 4.3%; P = .27) and stroke (2.9% vs 2.6%; P = .70) between patients undergoing preoperative duplex scanning and those who did not. Primary outcomes of patients who underwent open heart surgery also showed no difference in the perioperative mortality (5.1% vs 6.9%; P = .14) and stroke (2.6% vs 2.4%; P = .85) between patients undergoing preoperative duplex scanning and those who did not. Operative intervention of severe carotid stenosis prior to isolated CABG occurred in 2 of the 17 patients (11.8%) identified who underwent carotid endarterectomy with CABG. CONCLUSIONS: In this study, the correlation between preoperative duplex-documented high-grade carotid stenosis and postoperative stroke was low. Prudent use of preoperative carotid duplex ultrasound should be based on the presence of cerebrovascular symptoms and the type of open heart surgery.

Survival after repair of pararenal and paravisceral abdominal aortic aneurysms.

OBJECTIVE: The objective of this study was to review our 27-year clinical experience with open proximal abdominal aortic aneurysm repairs, with a focus on long-term survival. METHODS: A retrospective cohort study was undertaken of all patients who underwent proximal abdominal aortic aneurysm repair between 1986 and 2013 at a tertiary care referral center. Demographics, operative variables, complications, and 30-day mortality were analyzed. Postoperative acute kidney injury was analyzed by the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease)/Acute Kidney Injury Network criteria. Long-term survival was assessed through review of electronic medical records and the Social Security Death Index. Associations between demographics and complications were investigated to determine predictors of long-term survival. RESULTS: The study identified 245 patients. Mean age was 71 years (range, 38-92 years); 69% were men, and 88% were white. Aneurysm type was juxtarenal in 127 patients (52%), suprarenal in 68 patients (28%), and type IV thoracoabdominal in 50 patients (20%). In-hospital mortality was 3.3% (eight patients), and 30-day mortality was 2.9% (seven patients). At least one major complication occurred in 64% of the patients, which included the following: acute kidney injury, 60% (persistent acute kidney injury at discharge, however, was 28%, and hemodialysis at discharge was 1.6%); major pulmonary complications, 22%; myocardial infarction, 4%; visceral ischemia, 2%; and paraplegia, 0.5%. Median follow-up was 54 months. Kaplan-Meier survival estimates were 70% at 5 years and 43% at 10 years. Variables associated with poorer survival included congestive heart failure (hazard ratio [HR], 3.5; P < .001), chronic obstructive pulmonary disease (HR, 1.8; P < .002), and increased aneurysm size at presentation (HR, 1.1; P < .013). Persistent stage 3 acute kidney injury was associated with poor long-term survival. CONCLUSIONS: Open surgical repair of proximal abdominal aortic aneurysms can be performed with low mortality. Acute kidney injury is the most frequent complication, but the need for hemodialysis at discharge is low. Long-term survival is favorable. These data should assist in establishing benchmarks for endovascular repair of complex proximal abdominal aortic aneurysms.

Oral History in Evaluation: A New Partnership to Expand and Enhance Both Fields.

Evaluators utilize a variety of qualitative and quantitative methods to assess outcomes and make recommendations; however, we were unable to find any reference in the literature regarding the incorporation of oral histories for evaluation purposes. Based on our use of oral histories to evaluate a Critical Race Theory (CRT)-based undergraduate research and mentoring program, we learned how oral histories can be used effectively-and meaningfully-for evaluations seeking a deeper understanding of the program participants' lived experiences. By sharing our (and our narrators') experiences as we delved into this new methodology, as well as lessons learned about the benefits, limitations, and considerations when incorporating oral histories into evaluations, we show how both can be adapted to honor oral history while also meeting our evaluation needs.

The role of robotic surgical system in the management of vascular disease.

BACKGROUND: The evolution of minimally invasive treatment for aneurysms and occlusive disease has led to the development of endovascular, laparoscopic, and robot-assisted techniques. This article reviews the current literature on the clinical use of robotic surgical systems in the treatment of patients with aneurysms and occlusive disease. METHODS: A MEDLINE search was performed using the keywords "robotic, vascular, AND surgery." All pertinent articles concerning the use of the robotic surgical system on aneurysms and occlusive disease were reviewed. The author's personal experience consisted of a retrospective review of a prospectively maintained confidential database on all procedures performed with the da Vinci(®) surgical system. RESULTS: Several robot-assisted laparoscopic series on the treatment of aortic disease were identified, including review articles of potential clinical applications in hybrid, laparoscopic vascular, and endovascular treatments for vascular patients using robotic technology. The use of computer-enhanced or robotic technology as a sole modality for bypass of occlusive disease and repair of abdominal aortic, splenic, and renal aneurysms was described in case series with satisfactory patient outcomes. Current robotic endovascular technology was also described. CONCLUSIONS: Minimally invasive techniques using endovascular, laparoscopic, or robot-assisted technology have revolutionized the treatment of aortoiliac, splanchnic, and renal aneurysms and occlusive disease. However, robot-assisted techniques for aortic disease may involve a learning curve and increased operating times. Although endovascular therapy is preferred because of faster recovery, this preference for improved short-term outcomes will be balanced with the superiority and durability of robot-assisted endoscopic methods as comparable to open surgery.

A Comparison between the Use of Patient-worn Virtual Reality in Wound Care and Hand Surgery: How Does Virtual Reality Work?

As virtual reality (VR) technology becomes smaller and more affordable, it is gaining in popularity as a tool to address the patient experience of pain and anxiety during invasive procedures. In this study, we explore the effect of VR on the patient experience in two clinical environments of different anxiety levels to propose a possible mechanism of VR on pain and anxiety reduction. Method: Twenty-five wound care patients were randomly assigned to either a VR group or non-virtual reality (NVR) group, singly blinded. Pre-debridement, peri-debridement, and immediately postdebridement anxiety, fun, and pain scores were collected using a Likert scale (0 = least; 10 = most) from each group of patients. These measurements were compared among the VR versus NVR group in the setting of routine wound debridement procedures. The results are compared with our previously published data on patients who underwent wide awake local anesthesia no tourniquet (WALANT) hand surgery. Results: The WALANT surgery patients using VR experienced significant reduction in anxiety and increase in fun compared with the NVR group. In the wound debridement group with VR, there was improved fun, but no statistically significant reduction in pain or anxiety when compared with the NVR group. The mean score for anxiety was higher for awake hand surgery than for wound debridement cases (3.3 versus 1.7, P = 0.004). Conclusions: VR seems to be more effective in higher anxiety settings, could VR work via a neurological mechanism akin to the Melzack and Wall gate control theory of pain? VR may act primarily on the anxiety axis, providing negative feedback via cortical pathways to the amygdala.

Robotic-assisted aortic surgery with and without minilaparotomy for complicated occlusive disease and aneurysm.

OBJECTIVE: Published reports of robotic-assisted aortic surgery involve a combination of laparoscopy for aortic dissection and a robotic system for vascular reconstruction. The objective of this study is to determine the feasibility and advantage of a total robotic-assisted aortic dissection and vascular reconstruction vs robotic-assisted aortic procedures for aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). METHODS: From February 2006 to August 2010, 21 patients were selected for robotic-assisted aortic procedures: aortobifemoral bypass in 12, AAA repair in 6, iliac aneurysm repair in 1, and ligation of type II endoleak after endovascular aneurysm repair in 2. Inclusion criteria included AAA >5 cm, iliac aneurysm >3 cm, and AIOD TransAtlantic InterSociety Classification (TASC) C or D lesions. The da Vinci S Surgical System (Intuitive Surgical Inc, Sunnyvale, Calif) was used for the abdominal aortic dissection in all cases and for the aortic anastomosis in three cases. RESULTS: The 21 patients (6 women, 15 men) were an average age of 65.7 years (range, 44-86 years), had a body mass index (BMI) of 27.23 kg/m(2), and 90.4% were American Society of Anesthesiologists (ASA) class 3 or 4. Robotic dissection of the abdominal aorta was successful in 20 patients (95.2%). One patient required full conversion to open AAA repair due to trocar injury. Of the remaining 20 patients, the average robotic dissection time of the infrarenal aorta was 113.1 minutes, and the average aortic clamp time was 86 minutes. The procedure in 15 patients was performed with a minilaparotomy using an average abdominal incision of 13 cm to implant the Dacron or polytetrafluoroethylene graft. Five patients underwent a total robotic-assisted procedure with robotic aortic reconstruction or ligation of a type II endoleak. The 30-day survival rate was 100%. Median length of stay was 7.5 days. All grafts were patent at a median follow-up of 32.0 months. CONCLUSIONS: For aortic procedures completed total robotically without an abdominal incision, the estimated blood loss was significantly less than in robotic-assisted procedures with a minilaparotomy. In these selected patients, robotic-assisted technology may be part of the armamentarium for the vascular surgeon as another less invasive method for the treatment of complicated occlusive disease or aneurysm.

A systematic literature review of breastfeeding interventions among Black populations using the RE-AIM framework.

BACKGROUND: Lactation support resources are less likely to be located in close proximity to where Black families live and there is a systemic racist health care belief that Black women prefer bottle feeding (with infant formula) over breastfeeding. Together, these lead to lower reported breastfeeding rates of Black babies compared to other racial / ethnic groups. It is imperative to have a deeper understanding of the cultural aspects as well as the underlying limitations that prevent Black women / persons from being supported to breastfeed. There is a need to know how effective breastfeeding interventions are in reaching the intended population; how well they work in promoting breastfeeding initiation and continuation; and how successful they are when implemented at the setting and staff level. The purpose of this investigation was to establish the level of internal and external validity that was reported by breastfeeding intervention studies among Black communities. METHODS: Studies on breastfeeding interventions on Black people that were published between the years 1990 and 2019 were carefully examined through PubMed, EBSCOhost, Web of Science, and OneSearch. A total of 31 studies fulfilled the requirements to be included for this evaluation. In order to extract the information from the articles, the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework extraction tool was utilized. RESULTS: On average, the proportion of studies that reported across reach, effectiveness, adoption, implementation, and maintenance indicators was 54, 35, 19, 48, and 9%, respectively. Across core RE-AIM indicators only sample size (100%) and breastfeeding outcomes (90%) were reported consistently. External validity indicators related to representativeness of participants (16%) and sites (3%) were rarely reported. Similarly, adherence to intervention protocol, and indicator of internal validity, was reported in a small proportion of articles (19%). CONCLUSION: This body of literature under-reported on aspects associated to both internal and external validity across all RE-AIM domains. The reporting of the individual level of representativeness; the setting level of representativeness; the intervention's adherence to the protocol; the expenses; and the factors of sustainability would benefit from improvement in future research.

Virtual Reality Improves Patient Experience and Anxiety During In-office Carpal Tunnel Release.

Background: This study examined how wide- awake local anesthesia no tourniquet (WALANT) surgery in the office versus the standard operating room (OR) impacts patient experience, and the effect wide awake virtual reality (WAVR) has in conjunction with WALANT on patient experience. Methods: This is a patient-reported outcome study of patients undergoing carpal tunnel release by a single surgeon between August 2017 and March 2021. Patients were classified by location; traditional OR versus WALANT in-office. In-office patients were further classified by whether they chose to use WAVR or not. Patients rated overall experience, enjoyability, and anxiety using a Likert scale (1-7). Results: The online survey had a 44.8% response rate. OR patients were twice as likely to report a neutral or negative experience (23% versus 11%, P = 0.03), significantly lower enjoyment scores (44% versus 20%, P = 0.0007)' and higher anxiety (42% versus 26%, P = 0.04) compared with office-based WALANT patients. With the addition of WAVR, office patients reported higher enjoyment than those who did not use WAVR (85% versus 73%, P = 0.05). Patients reporting an anxiety disorder were more likely to choose WAVR when compared with patients without anxiety disorder (73.8% versus 56.4%). When they chose WAVR, they had greater anxiolysis (79% versus 47%, P = 0.01)' and increased enjoyment (90% versus 59%, P = 0.005). Conclusions: This study demonstrates improved patient experience in the office setting, further amplified by WAVR. Preexisting anxiety disorder is a positive predictive variable toward the patients' choice to use WAVR.

Celiac artery dissection from heavy weight lifting.

In this case report, we present a 45-year-old man who experienced abdominal pain while bench-pressing heavy weights. A computed tomography angiogram showed a dissection of the celiac artery extending into the hepatic and splenic arteries, with thrombus in the false lumen into the common hepatic artery. With resolution of his symptoms, he was discharged after several days of warfarin and metoprolol therapy. To our knowledge, this is the first reported case of a dissection of the celiac artery and its branches caused by weight lifting.