Short-Term Complications and Mortality Following Open Abdominal Aortic Aneurysm Repair by a Single High-Volume Surgeon.

INTRODUCTION: Although endovascular repair is now considered the first-line surgical treatment for abdominal aortic aneurysms (AAAs), some surgeons maintain a high volume of open aortic repairs (OARs) with very good outcomes. This study examines postoperative 30-d and 12-mo mortality and in-hospital complications from a single surgeon who performed 316 elective OARs for unruptured AAAs over a 10-y period. METHODS: A retrospective cohort study was performed for all patients who underwent elective OAR for unruptured AAAs between April 1st, 2007, and March 31st, 2017, at a single community center in Quebec, Canada. The primary outcome was the incidence of all-cause 30-d and 12-mo mortality in patients undergoing OAR. Binomial logistic and linear regressions were performed to examine whether operative time correlated with postoperative outcomes. RESULTS: There were 316 patients included: most of whom were male (74.4%), with a mean age of 70 y, and a mean AAA diameter of 59.8 mm. Most patients had a low-to-intermediate predicted risk of postoperative major cardiovascular complications, myocardial infarction, or in-hospital mortality. At the time of OAR, 95.6% of patients were asymptomatic, 70.9% had a tube graft repair, and very few required suprarenal aortic clamping (1.6%). The mean operative time was 101 min, and the median length of hospital stay was six days. One patient died in hospital or within 30 d of surgery (0.3%), and 7 patients had died 12 mo after surgery (2.2%). All-cause mortality was 27.5% (87 patients) over a median follow-up of 5.5 y. Twenty-five percent of patients suffered any in-hospital complication postoperatively, and 18 (5.7%) patients suffered a major cardiac complication. The operative time was significantly associated with increased risk of any in-hospital complication (OR 1.02, 95% CI [1.01, 1.03], P = 0.001), reintervention (OR 1.04, 95% CI [1.02, 1.06], P = 0.001), and length of stay in hospital (ß = 0.063, 95% CI [0.01, 0.11], P = 0.044) or intensive care unit (ß = 0.043, 95% CI [0.01, 0.08], P = 0.021). There was no association between operative time and mortality at any time point. CONCLUSIONS: Favorable postoperative outcomes can be achieved with OAR as the first-line surgical management of unruptured asymptomatic AAAs when performed by an experienced high-volume surgeon in appropriately selected patients with favorable perioperative risk factors.

Exploring Prognostic Implications of Race and Ethnicity in Patients With Peripheral Arterial Disease.

INTRODUCTION: Significant health inequalities in major adverse limb events exist. Ethnically minoritized groups are more prone to have a major adverse event following peripheral vascular interventions. This systematic review and meta-analysis aimed to describe the postoperative implications of racial and ethnic status on clinical outcomes following vascular interventions for claudication and chronic limb-threatening ischemia. METHODS: Searches were conducted across seven databases from inception to June 2021 and were updated in October 2022 to identify studies reporting claudication or chronic limb-threatening ischemia in patients who underwent open, endovascular, or hybrid procedures. Studies with documented racial and ethnic status and associated clinical outcomes were selected. Extracted data included demographic and clinical characteristics, vascular interventions, and measured outcomes associated with race or ethnicity. Meta-analyses were performed using random-effect models to report pooled odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Seventeen studies evaluating the impact of Black versus White patients undergoing amputation as a primary intervention were combined in a meta-analysis, revealing that Black patients had a higher incidence of amputations as a primary intervention than White patients (OR: 1.91, 95% CI: 1.61-2.27). Another meta-analysis demonstrated that Black patients had significantly higher rates of amputation after revascularization (OR: 1.56, 95% CI: 1.28-1.89). Furthermore, multiple trends were demonstrated in the secondary outcomes evaluated. CONCLUSIONS: Our findings suggest that Black patients undergo primary major amputation at a significantly higher rate than White patients, with similar trends seen among Hispanic and First Nations patients. Black patients are also significantly more likely to be subjected to amputation following attempts at revascularization when compared to White patients.

Postoperative complications and their association with post-traumatic stress disorder in academic vascular surgeons.

OBJECTIVES: Postoperative complications are an inherent component of surgical practice. This study seeks to address their association with emotional responses of academic vascular surgeons. METHODS: An anonymous electronic survey was sent to all vascular surgery program directors in North America with a request to disseminate to their faculty. The survey captured data on demographics and practice type and used imbedded validated measures to determine emotional responses to postoperative complications and to assess coping mechanisms. Univariate analysis was performed to determine differences between those who reported at least partial symptoms of post-traumatic stress disorder (PTSD) following their worse major complication over the previous year and those who did not. Multivariable logistic regression analysis was performed for all covariates found significant on univariate analysis, and those deemed clinically relevant. RESULTS: The survey was distributed to 267 faculty at 128 institutions in the United States and 10 institutions in Canada and completed by 65 participants (response rate, 32%). Twenty of 65 (31%) identified as female, and the total group had a mean age of 47 ± 10.2 years. Most respondents (43/65; 66%) reported a major complication within 3 months of the survey, with the majority of respondents (45/65; 69%) reporting the outcome of patient mortality. Of respondents, 20 of 65 (31%) demonstrated at least partial symptoms of PTSD in response to the worst complication from the previous year, with 12 of 65 (19%) meeting the clinical diagnosis of PTSD. Respondents in the PTSD group were more likely to criticize/blame themselves following the complication (P = .0028); less likely to identify the complication as "expected" (P = .048) or to believe causes of their complications were due to others/external factors; and more likely to identify as a female (55% vs 20%; P = .008). Regarding support following major complications, most respondents (57/65; 88%) desired the ability to discuss details of the case with a respected peer. The most common external pressure influencing their emotional responses to complications was maintaining reputation and a sense of honor (66%). Gender differences persisted on multivariate analysis (P = .016). CONCLUSIONS: Emotional responses following major postoperative complications in vascular surgery are common and may pose a risk for PTSD. This may occur more commonly following complications that are unexpected or in cases in which the cause of the complication was due to a perceived or actual surgical mistake. The ubiquitous nature and severity of the emotional toll of major complications for vascular surgeons is poorly described and under-recognized. Gender-related differences may exist, and most surgeons desire a support network of respected peers with whom to discuss complications.

Females are less likely to receive best medical therapy for stroke prevention before and after carotid revascularization than males.

BACKGROUND: Current professional guidelines recommend best medical therapy (BMT) with statin agents and antiplatelet therapy for primary and secondary stroke prevention in patients with carotid artery stenosis. We aimed to assess the association of patient sex with preoperative BMT in patients undergoing carotid revascularization. METHODS: We performed a retrospective review of Vascular Quality Initiative patients who underwent carotid endarterectomy or carotid artery stenting between January 2003 and February 2022. Multivariable logistic regression models were used to assess the association of patient sex with preoperative BMT after adjusting for sociodemographic, comorbidity, and disease severity characteristics. In-hospital outcomes were assessed by sex and preoperative BMT status. RESULTS: Of 214,008 patients who underwent carotid revascularization, 38.7% (n = 82,855) were female and 61.3% (n = 131,153) were male. Overall, 77.2% (n = 63,922) of females were on preoperative BMT, compared with 80.4% (n = 105,375) of males (P < .001). After adjusting for baseline differences, females had 11% lower odds of being on BMT compared with males (adjusted odds ratio, 0.89; 95% confidence interval, 0.86-0.91). Postoperatively, females had 18% lower odds of being prescribed BMT than males (adjusted odds ratio, 0.82; 95% confidence interval, 0.79-0.84). In-hospital stroke (1.20% vs 1.51%), death (0.37% vs 0.66%), and stroke/death (1.46% vs 1.98%) were all significantly lower for patients on BMT (all P < .001). CONCLUSIONS: There is a significant discrepancy in the proportion of females versus males receiving preoperative BMT for stroke prevention before carotid artery revascularization. In-hospital outcomes are worse in patients without BMT, highlighting the importance of raising awareness and implementing targeted interventions to improve preoperative adherence to stroke prevention guidelines.

Socioeconomic status fails to account for worse outcomes in non-Hispanic black patients undergoing carotid revascularization.

OBJECTIVE: Previous studies have reported an association of Black race with worse carotid revascularization outcomes, but rarely include socioeconomic status as a confounding covariate. We aimed to assess the association of race and ethnicity with in-hospital and long-term outcomes following carotid revascularization before and after accounting for socioeconomic status. METHODS: We identified non-Hispanic Black and non-Hispanic white patients who underwent carotid endarterectomy, transfemoral carotid stenting, or transcarotid artery revascularization between 2003 and 2022 in the Vascular Quality Initiative. Primary outcomes were in-hospital stroke/death and long-term stroke/death. Multivariable logistic regression and Cox proportional hazards models were used to assess the association of race with perioperative and long-term outcomes after adjusting for baseline characteristics using a sequential model approach without and with consideration of Area Deprivation Index (ADI), a validated composite marker of socioeconomic status. RESULTS: Of 201,395 patients, 5.1% (n = 10,195) were non-Hispanic Black, and 94.9% (n = 191,200) were non-Hispanic white. Mean follow-up time was 3.4±0.01 years. A disproportionately high percentage of Black patients were living in more socioeconomically deprived neighborhoods relative to their white counterparts (67.5% vs 54.2%; P < .001). After adjusting for demographic, comorbidity, and disease characteristics, Black race was associated with greater odds of in-hospital (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.10-1.40) and long-term stroke/death (adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.23). These associations did not substantially change after additionally adjusting for ADI; Black race was persistently associated with greater odds of in-hospital (aOR, 1.23; 95% CI, 1.09-1.39) and long-term stroke/death (aHR, 1.12; 95% CI, 1.03-1.21). Patients living in the most deprived neighborhoods were at greater risk of long-term stroke/death compared with patients living in the least deprived neighborhoods (aHR, 1.19; 95% CI, 1.05-1.35). CONCLUSIONS: Non-Hispanic Black race is associated with worse in-hospital and long-term outcomes following carotid revascularization despite accounting for neighborhood socioeconomic deprivation. There appears to be unrecognized gaps in care that prevent Black patients from experiencing equitable outcomes following carotid artery revascularization.

Barriers to Implementing the Kidney Disease Outcomes Quality Initiative End-Stage Kidney Disease Life Plan Guideline.

OBJECTIVE: The updated 2019 National Kidney Foundation Kidney Disease Outcomes Quality Initiative vascular access guidelines recommend patient-centered, multi-disciplinary construction and regular update of an individualized end-stage kidney disease (ESKD) Life-Plan (LP) for each patient, a dramatic shift from previous recommendations and policy. The objective of this study was to examine barriers and facilitators to implementing the LP among key stakeholders. METHODS: Semi-structured individual interviews were analyzed using inductive and deductive coding. Codes were mapped to relevant domains in the Consolidated Framework for Implementation Research (CFIR). RESULTS: We interviewed 34 participants: 11 patients with end-stage kidney disease, 2 care partners, and 21 clinicians who care for patients with end-stage kidney disease. In both the clinician and the patient/care partner categories, saturation (where no new themes were identified) was reached at 8 participants. We identified significant barriers and facilitators to implementation of the ESKD LP across three CFIR domains: Innovation, Outer setting, and Inner setting. Regarding the Innovation domain, patients and care partners valued the concept of shared decision-making with their care team (CFIR construct: innovation design). However, both clinicians and patients had significant concerns about the complexity of decision-making around kidney substitutes and the ability of patients to digest the overwhelming amount of information needed to effectively participate in creating the LP (innovation complexity). Clinicians expressed concerns regarding the lack of existing evidence base which limits their ability to effectively counsel patients (innovation evidence base) and the implementation costs (innovation cost). Within the Outer Setting, both clinicians and patients were concerned about performance measurement pressure under the existing "Fistula First" policies and had concerns about reimbursement (financing). In the Inner Setting, clinicians and patients stressed the lack of available resources and access to knowledge and information. CONCLUSION: Given the complexity of decision-making around kidney substitutes and vascular access, our findings point to the need for implementation strategies, infrastructure development, and policy change to facilitate ESKD LP development.

Treating a Large Thoracoabdominal Aneurysm With Aberrant Right Subclavian Artery With a Physician-Modified Graft.

CLINICAL IMPACT: Large thoracoabdominal aortic aneurysms due to chronic aortic dissection in patients with connective tissue disorders such as Loeys-Dietz syndrome present a challenging scenario, particularly in cases of variant anatomy and when patients are not candidates for conventional open repair. We demonstrate how by combining and modifying off-the-shelf devices during a hybrid procedure, one can create an endovascular solution tailored to the patient's complex anatomy, making use of an aberrant right subclavian artery, and allow for good clinical outcomes.

Depression in Patients with Peripheral Artery Disease: An Underdiagnosis with Increased Mortality.

BACKGROUND: Among patients with peripheral artery disease (PAD), depression is diagnosed in 17-25% and negatively impacts wound healing, quality of life, and survival. We hypothesized that depression is underdiagnosed in patients with PAD. Additionally, given the associations between depression and mortality in PAD patients, there is an increased need to investigate the strength of this relationship. The present analysis includes 2 studies to address the following aims: (1) Investigation of the prevalence of concomitant PAD and depression in a cohort from the Southeastern United States, and (2) Examination of the association between depression and all-cause mortality in a cohort of Canadian patients with PAD. METHODS: STUDY 1: From June-August 2022, the Patient Health Questionnaire Module 9 (PHQ-9) was administered to all patients seeking PAD-related care including medical, wound/podiatric, or vascular interventional/surgical treatment, in the University of North Carolina-Chapel Hill Vascular, Wound, and Podiatry clinics. The PHQ-9 assesses symptoms over 2 weeks and is scored 0-27, with higher scores indicating increasingly severe depression. Demographics, primary diagnosis, depression history, and antidepressant prescription were determined through chart review. We compared the proportion of positive depression screenings (PHQ-9 ≥ 5) to known depression. Among those treated for depression, the PHQ-9 score severity was evaluated. T-tests and χ2 tests were used to compare means and proportions. STUDY 2: From July 2015 to October 2016, the Geriatric Depression Scale Short Form was administered to adult patients with PAD undergoing revascularization. The Geriatric Depression Scale Short Form is a self-report measure of depression with a score >5 consistent with depression. The prevalence of depression was determined; primary outcome was all-cause mortality at 6 months. RESULTS: STUDY 1: In 104 PAD patients (mean age 66.6 ± 11.3 years, 37% female), 37% of respondents scored ≥5 on the PHQ-9 survey, indicating at least mild depression. Only 18% of PAD patients had a history of depression, demonstrating a significant difference between the PHQ-9 findings and documented medical history. While depression was underdiagnosed in both men and women, men were more likely to have unrecognized depression (chi-squared statistic = 35.117, df = 1, P < 0.001). Among those with a history of depression, 74% had a current prescription for antidepressant medication, but 57% still had an elevated PHQ-9 score indicating possible undertreatment. STUDY 2: In 148 patients (mean age 70.3 ± 11.0 years, 39% female) the prevalence of screened depression was 28.4%, but only 3.3% had a documented history of depression suggesting significant underdiagnosis. Patients with depression were significantly more likely to die within 6 months of revascularization (9.5% vs. 0.9%; odds ratio 1.48, 95% confidence interval: 1.08 to 2.29). There was no association between depression and risk of length of stay, reintervention, or readmission. CONCLUSIONS: Depression is underdiagnosed and undertreated among patients with PAD, which has grave consequences as it is associated with 1.5 times the odds of mortality within 6 months of revascularization. There is a critical need for more robust screenings and comprehensive mental health treatment for patients with concomitant depression and PAD.

A Systematic Review and Meta-Analysis on Sex-Based Disparities in Patients with Chronic Limb Threatening Ischemia Undergoing Revascularization.

BACKGROUND: This systematic review and meta-analysis sought to describe the prognostic implications of sex on the clinical outcomes of patients undergoing interventions for chronic limb threatening ischemia (CLTI). METHODS: Studies were systematically searched across 7 databases from inception to August 25, 2021 and rerun on October 11, 2022. Studies focusing on patients with CLTI undergoing open surgery, endovascular treatment (EVT), or hybrid procedures were included if sex-based differences were associated with a clinical outcome. Two independent reviewers screened studies for inclusion, extracted data, and assessed risk of bias using the Newcastle-Ottawa scale. Primary outcomes included inpatient mortality, major adverse limb events (MALE), and amputation-free survival (AFS). Meta-analyses were performed using random effects models and reported pooled odds ratio (pOR) and 95% confidence interval (CI). RESULTS: A total of 57 studies were included in the analysis. A meta-analysis of 6 studies demonstrated that female sex was associated with statistically higher inpatient mortality compared to male sex undergoing open surgery or EVT (pOR, 1.17; 95% CI: 1.11-1.23). Female sex also demonstrated a trend toward increased limb loss in those undergoing EVT (pOR, 1.15; 95% CI: 0.91-1.45) and open surgery (pOR 1.46; 95% CI: 0.84-2.55). Female sex also had a trend toward higher MALE (pOR, 1.06; 95% CI, 0.92-1.21) in 6 studies. Finally, female sex had a trend toward worse AFS (pOR, 0.85; 95% CI, 0.70-1.03) in 8 studies. CONCLUSIONS: Female sex was significantly associated with higher inpatient mortality and a trend toward higher MALE following revascularization. Female sex trended toward worse AFS. The reasons for these disparities are likely multifaceted on patient, provider, and systemic levels and should be explored to identify solutions for decreasing these health inequities across this vulnerable patient population.

A scoping review of malnutrition in patients undergoing interventions for peripheral arterial disease.

BACKGROUND: Peripheral arterial disease (PAD) is associated with comorbid conditions and frailty. The role of preoperative nutrition in patients with PAD has not been well characterized. In the present scoping review, we sought to describe the prevalence and prognostic implications of preoperative malnutrition in patients undergoing vascular interventions for claudication or chronic limb-threatening ischemia (CLTI). METHODS: We systematically searched for studies across six databases from inception to August 2021. Studies that had focused on patients with claudication or CLTI who had undergone open or endovascular procedures were included if preoperative nutrition had been measured and correlated with a clinical outcome. RESULTS: Of 4186 records identified, 24 studies had addressed the prevalence or prognostic effects of malnutrition in patients who had undergone interventions for PAD. The proportion of women included in these studies ranged from 6% to 58%. The prevalence of preoperative malnutrition ranged from 14.6% to 72%. Seven different malnutrition assessments had been used in these studies. Across all the scales, preoperative malnutrition was associated with at least one of the following outcomes: mortality, postoperative complications, length of stay, readmission rates, and delayed wound healing. CONCLUSIONS: A variety of tools were used to measure malnutrition in patients undergoing interventions for PAD. Our findings suggest that preoperative malnutrition is associated with adverse clinical outcomes for patients undergoing open and endovascular procedures for claudication or CLTI and that consensus is lacking regarding which tool to use. Clinicians and surgeons should be sensitized to the importance of assessing for malnutrition preoperatively in adults undergoing interventions for PAD.

A gender-based analysis of predictors and sequelae of burnout among practicing American vascular surgeons.

OBJECTIVE: Surgeons report higher burnout and suicidal ideation (SI) rates than the general population. This study sought to identify the prevalence and gender-specific risk factors for burnout and SI among men and women vascular surgeons to guide future interventions. METHODS: In 2018, active Society for Vascular Surgery members were surveyed confidentially using the Maslach Burnout Index embedded in a questionnaire that captured demographic and practice-related characteristics. Results were stratified by gender. Univariate and multivariate logistic regression models were developed to identify predictors for the end points of burnout and SI. RESULTS: Overall survey response rate was 34.3% (N = 878) of practicing vascular surgeons. A higher percentage of women responded (19%) than compose membership in the Society for Vascular Surgery (13.7%). Women respondents were significantly younger, with fewer years in practice, and were less likely to be in private practice than the men who responded. Women were also less likely to be married/partnered, or to have children. The prevalence of burnout was similar for women and men (42.3% and 40.9%; P = nonsignificant); however, the prevalence of SI was significantly higher in women (12.9% vs 6.6%; P < .007). Whereas there was no difference in mean hours worked or call taken, women were more likely to have had a recent conflict between work and home responsibilities and to have resolved this conflict in favor of work. Although men and women had the same incidence of reported recent medical errors, women were less likely to self-report a recent malpractice suit or to think that a fair resolution was reached. There was no gender difference in reported work-related pain. Multivariable analysis revealed that not enough family time and work-related pain were predictors for burnout in both men and women. Additional factors were associated with burnout in men, such as malpractice and electronic medical record dissatisfaction. Multivariable analysis revealed that work-related pain was an independent predictor for SI for the entire cohort. CONCLUSIONS: The prevalence of burnout among vascular surgeons is high. Women vascular surgeons have double the rates of SI compared with male vascular surgeons. Taken together, this study demonstrated that many of the same factors are associated with burnout in women and men, which include not enough family time, conflict between work and personal life, and work-related pain. Additional factors in men included conflict between work and family, work-related pain, and electronic medical record dissatisfaction.

Professionalism in (vascular) surgery: What does it mean?

A publication in the August 2020 issue of the Journal of Vascular Surgery, "Prevalence of unprofessional social media content among young vascular surgeons," brought the concept of professionalism in the vascular surgery community to the forefront. In response to the methodology used in the article, and the definitions of professionalism, a global backlash from health care providers and lay people ensued. The article has since been retracted; however, its publication highlighted the need to reexamine current definitions and philosophies surrounding professionalism in medicine and surgery that may be discriminatory and exclusive. The term professionalism has no standard definition as evidenced by varying definitions among different societies and organizations. The lack of a structured, universally accepted definition of professionalism in the medical and surgical communities has resulted in no standard by which to measure the actions of physicians and surgeons. The definition of professionalism need not be complex and should not vary among specialties and societies. In its most simplistic form, the core definition of "professionalism" embedded in the volumes of publications, guidelines, and charters that exist on the subject of professionalism in medicine is respect. We propose a tiered approach to define professionalism in medicine that builds on fundamental principles of respect and inclusivity, and includes actionable steps at three levels: (1) individual, (2) organizational, and (3) societal. Through this approach, any physician, regardless of specialty, practice type or location, can apply these concepts to ensure they consistently embody what it means to be "professional."

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.

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.

Frailty assessment in older adults undergoing interventions for peripheral arterial disease.

OBJECTIVE: Frailty is a multidimensional syndrome that influences postoperative morbidity and mortality after vascular procedures; however, its integration in clinical practice has been limited, given the lack of consensus on how to measure it. This study sought to compare the incremental predictive value of six different nonphysical performance frailty scales to predict poor outcomes after interventions for peripheral arterial disease (PAD). METHODS: This preplanned analysis of the FRailty Assessment In Lower Extremity arterial Disease (FRAILED) prospective cohort included two centers recruiting patients between July 1, 2015, and October 1, 2016. Individuals who underwent vascular interventions for Rutherford class 3 or higher PAD were enrolled. The following scales were compared: Edmonton Frail Scale, Groningen Frailty Indicator (GFI), modified Essential Frailty Toolset (mEFT), modified Frailty Index, Multidimensional Prognostic Index, and the Risk Analysis Index-C. The primary end point was a composite of all-cause mortality and major disability at 12 months after the procedure. The secondary end point was length of stay. Logistic regression was used to determine the association of frailty with the primary end point after adjusting for confounders. To compare the incremental predictive value of each frailty scale, model performance statistics were calculated. RESULTS: The cohort was composed of 148 patients with a mean age of 70 years. Depending on the scale used, the prevalence of frailty ranged from 16% to 70%. Frailty as measured by the GFI (adjusted odds ratio, 1.76; 95% confidence interval, 1.14-2.72) and mEFT (adjusted odds ratio, 2.71; 95% confidence interval, 1.29-5.73) predicted mortality and worsening disability at 12 months after interventions for PAD. Furthermore, there was statistically significant C-statistic, Bayesian information criterion, and integrated discrimination improvement when the GFI and mEFT were added to the baseline model. Frailty was not associated with length of stay. CONCLUSIONS: Frailty is associated with mortality and worsening disability after interventions for PAD. The GFI and mEFT performed well and identified vulnerable older adults who are at risk of poor outcomes after interventions for PAD and recommended for use in this setting.

Scoping review of frailty in vascular surgery.

OBJECTIVE: This review sought to describe the current state of knowledge of the impact of frailty on perioperative clinical outcomes in patients undergoing vascular interventions. METHODS: A scoping review of the literature from both PubMed and Ovid Embase databases was conducted to identify relevant English- and French-language articles published from inception to May 31, 2018. Patients undergoing vascular surgery interventions were included. RESULTS: Twenty-three studies have addressed the prevalence or prognostic impact of frailty in patients undergoing vascular surgery procedures. The prevalence of frailty ranged from 20% to 60%, and notably 14 different frailty assessments were used in these studies. Frailty was associated with increased comorbid status, prolonged length of stay, discharge to assisted living facility, loss of independence, postoperative morbidity, and all-cause mortality. CONCLUSIONS: There are a variety of heterogeneous tools to measure frailty in patients undergoing vascular surgery interventions. The prevalence of frailty varies by the scale used to measure it, as does its predictive value. Clinicians and surgeons should be sensitized to the importance of assessing frailty preoperatively in older adults undergoing vascular surgery and using it to assist in the decision-making process and allocation of surgical resources.

Preoperative Exercise Rehabilitation in Cardiac and Vascular Interventions.

BACKGROUND: Exercise-based interventions have become part of the standard of care in rehabilitation programs for cardiovascular risk reduction and the promotion of a healthy lifestyle. The systematic review describes the current state of knowledge of the effects of preoperative exercise training (prehabilitation) on perioperative clinical outcomes in patients undergoing cardiac and vascular interventions. METHODS: Studies were systematically searched within 14 databases from inception to October 2016. Only studies that assessed a preoperative exercise program in adult patients undergoing cardiac or vascular interventions with clinical or patient-centered endpoints were included in the review. Two independent reviewers selected studies for inclusion, extracted data, and assessed quality using Cochrane Collaboration's tool for RCTs11111111111111111 and ROBINS-I tool for nonrandomized studies. RESULTS: Nine studies met our inclusion criteria and were stratified for qualitative analyses by cardiac (n = 7) and vascular (n = 2) procedures. Prehabilitation was associated with decreased length of stay, reduced postoperative complications, improved objective physical functioning, and improved subjective quality of life (SF-36 physical and mental health domains) measures in patients undergoing cardiac and vascular procedures. Given the amount of heterogeneity that was present in the designs, populations, and comparators among the included studies, we were unable to statistically pool data across trials. CONCLUSIONS: Our qualitative findings suggest that prehabilitation may improve clinical outcomes, physical performance, and health-related quality-of-life measures in patients undergoing cardiac and vascular surgery procedures.

Review of biologic and behavioral risk factors linking depression and peripheral artery disease.

The incidence of depression has been rising rapidly, and depression has been recognized as one of the world's leading causes of disability. More recently, depression has been associated with an increased risk of symptomatic atherosclerotic disease as well as worse perioperative outcomes in patients with cardiovascular disease. Additionally, recent studies have demonstrated an association between depression and peripheral artery disease (PAD), which has been estimated to affect more than 200 million people worldwide. These studies have identified that depression is associated with poor functional and surgical outcomes in patients with PAD. Although the directionality and specific mechanisms underlying this association have yet to be clearly defined, several biologic and behavioral risk factors have been identified to play a role in this relationship. These factors include tobacco use, physical inactivity, medical non-adherence, endothelial and coagulation dysfunction, and dysregulation of the hypothalamic-pituitary-adrenal axis, autonomic system, and immune system. In this article, we review these potential mechanisms and the current evidence linking depression and PAD, as well as future directions for research and interventional strategies. Understanding and elucidating this relationship may assist in preventing the development of PAD and may improve the care that patients with PAD and comorbid depression receive.