Letter of Recommendation Characteristics Associated with Interview Offer to a Vascular Surgery Residency Program.

BACKGROUND: Letters of recommendation (LOR) are considered by program directors (PDs) to be an integral part of the residency application. With the conversion of United States Medical Licensing Examination (USMLE) Step 1 to a binary pass/fail outcome, LORs will likely have higher important in the application process moving forward. However, their utility in securing an interview for a particular applicant remains undetermined. This study aims to identify the applicant and LOR characteristics associated with an interview invitation. METHODS: Letter writer (n = 977) characteristics were abstracted from applications (n = 264) to an individual integrated vascular surgery residency program over 2 application cycles. A validated text analysis program, Linguistic Inquiry and Word Count, was used to characterize LOR content. Applicant, letter writer, and LOR characteristics associated with an interview invitation were determined using multivariable analysis. RESULTS: Letter writers were 70.9% vascular surgeons (VS), 23.7% PDs, and 45.4% professors. Applicants offered an interview were more likely to come from a top 50 medical school (35.2% vs 25.8%, P = 0.013) and an institution with a home vascular program (45.5% vs 34.1%, P = 0.006). Alpha Omega Alpha membership was significantly associated with interview offer (28.4%, P < 0.001). A greater proportion of letters from VS was associated with an interview offer (P < 0.001) compared with letter writers of other specialties. One or more PD letters were significantly associated with an interview offer (79.55% vs 20.45%, P = 0.008), whereas number of letters from APDs was not significantly associated with interview offer. Letters written by away institution faculty were significantly associated with interview offer (75%, P < 0.001), whereas nonclinical letters were not. Presence of one or more letters from a chair (57.95% vs 42.05%, P = 0.015) or chief (67.05% vs 32.95%, P = 0.028) was significantly associated with interview offer. Letters for applicants offered an interview had more references to research and teaching, which were more common in letters written by versus Letters written by PDs were more likely to use assertive, advertising language in favor of applicants. There were no significant applicant, letter writer, or LOR characteristics associated with a top 20 rank. CONCLUSIONS: Successful applicants were more likely to have LORs written by VS, PDs, and those of higher academic rank with references to research and teaching.

Benefits of early vascular provider involvement in wound care center management of patients with underlying arterial disease.

OBJECTIVES: Peripheral arterial disease (PAD) can reduce wound healing rates by ≤30%. Current literature suggests wound outcomes are improved when management is driven by vascular providers. However, whether this benefit is derived solely from early vascular provider involvement remains unclear. METHODS: A retrospective analysis was performed of 80 limbs with chronic wounds and underlying PAD seen at our institution's wound center between July 2022 and July 2023. Arterial disease was defined by the following criteria: (1) prior PAD diagnosis, (2) ankle-brachial-index of <0.9 or toe pressure of <70 mm Hg, or (3) absent peripheral pulses. Patients were divided into early (<6 week) vascular provider exposure (EVE; n = 45) or late/no vascular exposure (LNVE; n = 35). Providers included vascular surgeons and affiliated advanced practitioners. The primary outcome studied was overall time to wound healing. Statistical analysis included χ2 tests, t test, Pearson correlation, Kaplan-Meier analysis, and Cox regression modeling (variables included in a multivariate model if univariate effect on healing was associated at P < .1). RESULTS: Baseline demographic profiles were similar between groups with exception of lower baseline albumin (P = .037), more heart failure (P = .013), and more prior peripheral endovascular interventions (P = .013) in the EVE group. Although the initial wound locations and sizes were similar, EVE wounds had significantly higher WIfI wound scores (1.9 ± 0.1 vs 1.6 ± 0.1; P = .039). Although more LNVE patients developed radiographic osteomyelitis (31.8% vs 55.6%; P = .033), fewer underwent operative debridement or amputation (100% vs 63.2%; P = .008). On univariate analysis, healing time tended to be shorter in EVE, but not significantly (P = .089). When controlled for comorbidities, however, healing rates were nearly two-fold higher in EVE (hazard ratio, 2.42; 95% confidence interval, 1.21-4.84). LNVE wounds also took significantly longer to reach checkpoints including time to >75% granulation (P = .05), 15% weekly size decrease (P = .044), and epithelialization (P = .026). LNVE patients required more wound center visits (P = .024) and procedures (P = .005) with a longer time to intervention (P = .041). All EVE patients obtained ankle-brachial indices, with 90.9% of them available at their first wound care visit (P < .001). Although a slightly greater proportion of patients underwent a major amputation in EVE (15.6% vs 11.4%; P = .595), this difference did not attain significance; additionally, 100% of EVE patients had documented discussion of nonsalvageable limbs before amputation. CONCLUSIONS: Early exposure to vascular practitioners improves wound healing time, timeliness to intervention, and wound center and hospital resource use in patients with PAD. Further investigation into benefits of vascular involvement within community wound center models could significantly improve awareness and accessibility of arterial wound care in smaller/remote communities.

Definition and Perception of Autonomy in Vascular Surgery Training.

BACKGROUND: There is a lack of data evaluating operative autonomy within vascular surgery. This study aims to determine where discrepancies exist in the definition of autonomy between trainees and attending faculty. METHODS: An Institutional Review Board-approved, anonymous survey was e-mailed to vascular trainees and attending faculty at all Accreditation Council for Graduate Medical Education-approved vascular surgery training programs in the United States. Data were compared using chi-square statistical analysis. RESULTS: One-hundred forty-nine responses from vascular surgery trainees (n = 89) and faculty (n = 60) were obtained. The most highly ranked preoperative skill by trainees was Case Planning, at all post-graduate year-levels. Although a majority of trainees believe this skill is expected of them, only 36.1% of attendings responded that they expect all trainee levels to perform this task. Draping/positioning was ranked as the second most important intraoperative task for all post-graduate year-levels by attendings; however, only 32.8% of attendings expect trainees to perform this. Exposure of Critical Structures was ranked as the most important intraoperative task by both trainees and attendings at the Chief and Fellow level. However, responses by both trainees and attendings showed that this is expected <70% of the time. When asked about double-scrubbing independently of other tasks, most trainees assessed double-scrubbing as inherently important to autonomy at all levels of training and within all regions. Only 44.3% of attendings responded that they expect all trainees to double-scrub. Additionally, most trainees in all regions responded that they spend <25% of cases double-scrubbed. CONCLUSIONS: These responses show a discrepancy between the skills that both trainees and attendings deem important to autonomy versus what is being expected of trainees in reality.

Surgical Specialty Impacts Quality of Operative Training in Carotid Endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is currently performed by multiple surgical specialties. The impact of surgical specialty and operative volume on post-CEA outcomes has been well described. However, it is unclear whether trainees of different surgical specialties have similar quality of operative training. METHODS: Data from Accreditation Council for Graduate Medical Education annual reports were collected and compared between graduating vascular surgery (VS) residents, VS fellows, and neurological surgery (NS) residents. Only cases reported as chief/senior/lead resident, surgeon junior, or surgeon fellow were included in analysis. Linear regression analysis was utilized to evaluate trends in case-mix and volume. RESULTS: From 2013 to 2022, total CEA case volume was higher among VS residents and fellows, compared to NS residents (52.8 ± 0.8 vs. 44.3 ± 1.4 vs. 12.9 ± 0.6, P < 0.0001). Additionally, VS residents and fellows performed other carotid operations including transfemoral or transcarotid artery stenting (11.1 ± 0.9 vs. 11.2 ± 0.8 vs. 0), carotid body tumor resection (0.7 ± 0.1 vs. 0.7 ± 0.0 vs. 0), and extracranial cervical bypass (6.7 ± 0.3 vs. 6.3 ± 0.3 vs. 0) that were not reported by the NS resident cohort (P < 0.0001 each). On linear regression analysis, total CEA procedures did not change for VS residents (R2 = 0.03, P = 0.62), decreased for VS fellows (-1.29 cases/yr, R2 = 0.75, P < 0.0001), and decreased among NS residents (-0.41 cases/yr, R2 = 0.44, P = 0.01) over the study period. CONCLUSIONS: Although residents of multiple surgical specialties are trained in CEA, vascular training offers significantly greater numbers and diversity of extracranial carotid cases. It also appears that CEA volume is decreasing among neurosurgical trainees. In light of recent reports on the volume-outcome effect in carotid surgery, these data may have implications for future practice patterns in the domain of extracranial carotid artery disease.

Symptomatic peripheral artery disease increases risk of perioperative mortality following open abdominal aortic aneurysm repair.

OBJECTIVE: Peripheral artery disease (PAD) is associated with worse survival following abdominal aortic aneurysm (AAA) repair. However, little is known about the impact of PAD and sex on outcomes following open infrarenal AAA repair (OAR). METHODS: All elective open infrarenal AAA cases were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2003 to 2022. PAD was defined as history of non-cardiac arterial bypass, non-coronary percutaneous vascular intervention (PVI), or non-traumatic major amputation. Cohorts were stratified by sex and history of PAD. Multivariable logistic regression and Cox proportional hazards models were constructed to assess the primary endpoints: 30-day and 5-year mortality, respectively. RESULTS: Of 4910 patients who underwent elective OAR, 3421 (69.7%) were men without PAD, 298 (6.1%) were men with PAD, 1098 (22.4%) were women without PAD, and 93 (1.9%) were women with PAD. Men with PAD had prior bypass (45%), PVI (62%), and amputation (6.7%). Women with PAD had prior bypass (32%), PVI (76%), and amputation (5.4%). Thirty-day mortality was significantly higher in men with PAD compared with men without PAD (4.4% vs 1.7%; P = .001) and in women with PAD compared with women without PAD (7.5% vs 2.4%; P = .01). After risk adjustment, when compared with men without PAD, women with PAD had nearly four times the odds of 30-day mortality (odds ratio, 3.86; 95% confidence interval [CI], 1.55-9.64; P = .004) and men with PAD had almost three times the odds of 30-day mortality (odds ratio, 2.77; 95% CI, 1.42-5.40; P = .003). Five-year survival was 87.8% in men without PAD, 77.8% in men with PAD, 85% in women without PAD, and 76.2% in women with PAD (P < .001). After risk adjustment, only men with PAD had an increased hazard of death at 5 years (hazard ratio, 1.52; 95% CI, 1.07-2.17; P = .019) compared with men without PAD. CONCLUSIONS: PAD is a potent risk factor for increased perioperative mortality in both men and women following OAR. In women, this equates to nearly four times the odds of perioperative mortality compared with men without PAD. Future study evaluating risk/benefit is needed to determine if women with PAD reflect a high-risk cohort that may benefit from a more conservative OAR threshold for treatment.

Celiac Artery Coverage During TEVAR for Dissection and Acute Aortic Injury is Not Associated with Worse Outcomes.

BACKGROUND: Studies have previously identified increased morbidity and mortality with celiac artery coverage during thoracic endovascular aortic repair (TEVAR) for aneurysmal disease. This study aimed to delineate the risks associated with celiac artery coverage in all patients undergoing TEVAR for dissection, trauma, or aneurysmal disease. METHODS: Using the Vascular Quality Initiative database, we identified all patients undergoing TEVAR from 2012 to 2020 and categorized them based on the underlying pathology (aneurysm, dissection, or acute/trauma). Patients were excluded if their endograft was deployed distal to aortic zone 6 or if they had any preoperative/operative celiac revascularization procedure. Univariate, regression, and Kaplan-Meier analysis were performed for all 3 groups, focusing on postoperative complications and survival. RESULTS: There were 8,265 patients who underwent TEVAR over the 8-year study period with 142 (1.7%) having celiac artery coverage during their index procedure. Of those patients, the celiac artery was covered during TEVAR in 1.2% of patients with dissection, 1.3% with aneurysm, and 0.7% with trauma. On unadjusted analysis, celiac artery coverage in TEVAR for aneurysmal disease was associated with increased in-hospital mortality (16% vs. 5%, P < 0.001), 30-day mortality (33% vs. 23%, P = 0.029), any postoperative complication (excluding death) (42% vs. 25%, P < 0.001), and postoperative bowel complication (3% vs. 0.7%, P = 0.003). There were no differences in outcomes for patients treated with celiac coverage versus those without celiac coverage during TEVAR for dissection or trauma on univariate analysis. After risk adjustment, celiac artery coverage remained predictive of worse postoperative outcomes in patients with aneurysmal disease: in-hospital mortality (odds ratio [OR] = 3.6, confidence interval [CI] 1.8-6.9), 30-day death (OR = 1.6, CI 1.0-2.4), any postoperative complication (OR 2.2, CI 1.4-3.5), and bowel-specific postoperative complication (3.3, CI 1.0-10.8). There were no differences in patient outcomes for those treated with celiac coverage versus those without celiac coverage during TEVAR for dissection or trauma on multivariate analysis. Kaplan-Meier curves show a significant difference in overall survival based on pathology, specifically lower survival rates for patients with celiac coverage treated for aneurysmal disease. Cox regression analysis showed that celiac artery coverage for aneurysmal disease was associated with significantly increased hazard ratio affecting overall survival (hazard ratio = 2.6, P < 0.001), but there was no impact on survival in patients who underwent TEVAR with celiac coverage for dissection or trauma. CONCLUSIONS: Celiac artery coverage for patients with aneurysmal disease was correlated with a significant increase in postoperative morbidity, mortality, and lowers overall survival. However, for patients with dissection or acute/traumatic aortic pathology, celiac artery coverage does not portend worse outcomes.

Virtual Simulation of Intra-operative Decision-Making for Open Abdominal Aortic Aneurysm Repair: A Mixed Methods Analysis.

OBJECTIVE: To create and pilot test a novel open abdominal aortic aneurysm (AAA) repair virtual simulation focused on intraoperative decision-making. To identify if the simulation replicated real-time intra-operative decision-making and discover how learners' respond to this type of simulation. DESIGN: An explanatory sequential mixed methods study. We developed a step-by-step outline of major intra-operative decision points within a standard open AAA repair. Perioperative and intraoperative decision-making trees were developed and coded into an online virtual simulation. The simulation was piloted. Quantitative data was collected from the simulation platform. We then performed a qualitative thematic analysis on feedback from interviewed participants. SETTING: Four academic general and vascular surgical training programs across the US. PARTICIPANTS: Seventeen vascular and general surgery trainees and 6 vascular surgery faculty. RESULTS: Participants spent on average 27 minutes (range: 8-45 minutes) interacting with the interface. 93% of participants reported feeling they were making real intraoperative decisions. 85% said it added to their knowledge base. 96% requested additional simulations. 22 interviews were completed: 241 primary codes were collapsed into 21 parent codes, and 6 emerging themes identified. Themes included the benefit of how (1) "Virtual Learning Could Standardize the Training Experience"; how (2) "Dealing with the Unexpected" as a trainee is an important part of surgical education growth, and that this (3) "Choose Your Own Adventure" virtual format simulates this intraoperative growth experience. Participants requested a (4) "Looping Feature Feedback Diagram" for future simulation iterations and highlighted that (5) "Fancier is Not Necessarily More Educational." Finally, many trainees wondered about (6) "The Attending Impact" from the simulation: if faculty would notice a difference between trainees who did vs did not utilize the simulation for case preparation. CONCLUSIONS: Operative simulation training should focus on both technical skills and intra-operative decision-making, particularly "dealing with the unexpected." The learners' responses indicate that a low-fidelity, scalable, virtual platform can effectively deliver knowledge and allow for intra-operative decision-making practice in a remote learning environment.

The Weekend Effect in Carotid Endarterectomy for Symptomatic Carotid Stenosis.

BackgroundRecent studies report a limited window in which carotid endarterectomy (CEA) provides the greatest benefit for symptomatic carotid stenosis. Given the time-sensitive nature of CEA for symptomatic stenosis, it is important to understand whether patient outcomes are adversely affected by undergoing CEA over the weekend. Currently, it is unclear whether CEA is impacted by the "weekend effect" phenomenon. Methods A multi-institutional database was queried for all patients undergoing CEA for symptomatic carotid artery stenosis from 2015 to 2020 via ICD-9 codes. A total of 288 patients were identified during the study period. Univariate and multivariate analysis were used to compare outcomes based on weekend vs weekday surgery. Results A total of 261 patients (90.6%) underwent weekday CEA, as compared to 27 (9.4%) on the weekend. There were no differences in age, race, gender, or medical comorbidities between groups. Primary surgeon specialty was predominantly vascular surgery (77.0% weekday and 74.1% weekend) followed by neurosurgery (19.9% weekday and 25.9% weekend). Operative time was similar between groups (3.1 (weekday) vs 2.9 hr (weekend), P = .33) as well as estimated blood loss (100 vs 100 mL, P = .54). Hospital length of stay did not differ between groups (P = .69). Combined stroke and 30-day mortality rate was 2.0% on weekdays, compared to 3.7% on weekends (P = .75). On multivariate analysis, weekend surgery was not predictive of postoperative stroke or 30-day mortality (odds ratio .11 [95% CI: -1.57 to 1.85], P = .90). Conclusion In our multi-institutional experience, we did not identify a "weekend effect" in patients undergoing CEA for symptomatic carotid artery stenosis. Surgical revascularization should not be withheld on account of a weekend procedure in similar academic medical centers.

Pregnancy conditions and complications associated with the development of varicose veins.

BACKGROUND: Pregnancy is a known risk factor for developing varicose veins (VV). However, pregnancy is often considered a homogeneous entity and few studies have examined if specific characteristics and complications of pregnancy may influence VV formation. This study sought to identify which pregnancy-specific factors are associated with the development of VV. METHODS: All women who gave birth (live or still) between 1998 and 2020 within a multicenter health care system were identified retrospectively and followed through all hospital encounters (inpatient and outpatient). The primary outcome was VV, defined as any encounter with a primary diagnosis code for VV or a procedure for VV. The study period for each woman was the time from the first to last encounter. Extended Cox regression modeling evaluated the association between VV and pregnancy-related factors as a time-varying covariates while controlling for patient comorbidities. RESULTS: There were 156,622 women with a median follow-up of 8.3 years (interquartile range, 2.7-16.6 years) included. During this time, 225,758 deliveries occurred. The 10- and 20-year freedom from VV was 97.0% (95% CI, 96.8%-97.1%) and 92.7% (95% CI, 92.4%-93.0%), respectively, from the estimated start of first pregnancy. Overall, 4028 patients (2.57%) developed VV during the follow-up period and 1594 (1.02%) underwent a procedure for VV. After risk adjustment, increasing parity was significantly associated with VV, with each subsequent pregnancy increasing hazard of developing VV (parity = 1: hazard ratio [HR], 1.78; 95% CI, 1.55-1.99; P < .001; parity ≥6: HR, 4.83; 95% CI, 2.15-1.99-10.9; P < .001), Other significant pregnancy factors included excessive weight gain in pregnancy (HR, 1.44; 95% CI, 1.09-1.91; P = .011), post-term pregnancy (HR, 1.12; 95% CI, 1.02-1.21; P = .021), pre-eclampsia (HR, 0.79; 95% CI, 0.70-0.90; P < .001), and postpartum transfusion of platelets, plasma, or cryoprecipitate (HR, 2.05; 95% CI, 1.19-3.53; P = .001). CONCLUSIONS: Increasing parity, excessive weight gain in pregnancy, post-term pregnancy, and pre-eclampsia affect the development of VV after pregnancy. Although VV after pregnancy are likely underreported and true incidence is unknown, women should be counseled about the impact of these factors on VV development after pregnancy.

The current status of the diversity pipeline in surgical training.

OBJECTIVE: Recent initiatives have emphasized the importance of diversity, equity, and inclusion in academic surgery. Racial/ethnic disparities remain prevalent throughout surgical training, and the "diversity pipeline" in resident recruitment and retention remains poorly defined. METHODS: Data was retrospectively collected using two separate datasets. The Association of American Medical Colleges database was used to obtain demographic data on US medical school graduates. The US Graduate Medical Education annual report was used to obtain demographic data on surgical residents. Wilcoxon signed-rank test was used to compare racial/ethnic distribution within surgical residency programs with graduating medical students. Linear regression analysis was performed to analyze population trends over time. RESULTS: The study population included 184,690 surgical residents from 2011 to 2020. Nine resident cohorts were created according to surgical specialty - general surgery, neurosurgery, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, cardiothoracic surgery, urology, and vascular surgery. Among surgical programs, White residents were overrepresented in 8 of 9 specialties compared to the concurrent graduating medical student class for all years (p < 0.01 each, no difference in ophthalmology). Black residents were underrepresented in 8 of 9 specialties (p < 0.01 each, no difference in general surgery). Asian representation was mixed among specialties (4 overrepresented, 1 equal, 4 underrepresented), as was Hispanic representation (5 overrepresented, 4 equal) (p < 0.01 each). CONCLUSIONS: These data suggest that racial/ethnic disparities are inherent to the process of recruitment and retention of surgical residents. Efforts to improve the "diversity pipeline" should focus on mentorship and development of minority medical students and creating an equitable learning environment.

Trends in Female Authorship in High Impact Surgical Journals Between 2008 and 2018.

OBJECTIVE: This study evaluates the distribution of authorship by sex over the last 10 years among the top 25 surgical journals. SUMMARY OF BACKGROUND DATA: Despite an increase in women entering surgical residency, there remains a sex disparity in surgical leadership. Scholarly activity is the foundation for academic promotion. However, few studies have evaluated productivity by sex in surgical literature. METHODS: Original research in the 25 highest-impact general surgery/subspecialty journals were included (1/2008-5/2018). Journals with <70% identified author sex were excluded. Articles were categorized by sex of first, last, and overall authorship. We examined changes in proportions of female first, last, and overall authorship over time, and analyzed the correlation between these measurements and journal impact factor. RESULTS: There were 71,867 articles from 19 journals included. Sex was successfully predicted for 87.3% of authors (79.1%-92.5%). There were significant increases in the overall percentage of female authors (ß = 0.55, P < 0.001), female first authors (ß = 0.97, P < 0.001), and female last authors (ß = 0.53, P < 0.001) over the study period. Notably, all cardiothoracic subspecialty journals did not significantly increase the proportion of female last authors over the study period. There were no correlations between journal impact factor and percentage of overall female authors (rs = 0.39, P = 0.09), female first authors (rs = 0.29, P = 0.22), or female last author (rs = 0.35, P = 0.13). CONCLUSIONS: This study identifies continued but slow improvement in female authorship of high-impact surgical journals during the contemporary era. However, the improvement was more apparent in the first compared to senior author positions.

The Changing Demographics of Surgical Trainees in General and Vascular Surgery: National Trends over the Past Decade.

OBJECTIVE: Recent initiatives have targeted the issue of gender and ethnic/racial disparities in general surgery and vascular surgery. However, the prevalence of these disparities in general and vascular surgical training programs is unknown. DESIGN: A retrospective analysis was conducted using data from three separate sources, including the US Graduate Medical Education annual report, Electronic Residency Application Service database, and National Resident Matching Program annual report. Demographic information regarding gender distribution and ethnic/racial identity was collected from 328 general surgery residency programs, 59 vascular surgery residency programs, and 100 vascular surgery fellowship programs across the US. The primary outcomes of this study were to evaluate national trends in gender and ethnic diversity in general surgery and vascular surgery training programs, including both traditional fellowship and integrated residency paradigms. RESULTS: From 2011-2020, general surgery residency programs showed a positive trend towards both female applicants (from 31.9%-41.5%) and trainees (from 36.2%-43.1%) (p < 0.0001 each). The proportion of minority trainees decreased, primarily among Black (from 7.2%-5.4%) and Asian trainees (from 21.5%-19.2%) (p < 0.0001 each). Concurrently, the number of vascular integrated residency programs grew from 27 to 59, resulting in a fivefold increase in trainees (from 64-335). Despite this growth, there was no change in the proportion of women applicants or trainees for both vascular integrated residency (24.9% applicants; 36.2% trainees) and fellowship programs (27.4% applicants; 25.9% trainees) over the study period (p = 0.11, 0.89, 0.43, and 0.13 respectively). Moreover, there was no significant change in proportion of minority trainees in both vascular integrated residency and fellowship programs. CONCLUSION: While general surgery programs have expanded in proportion of both female applicants and trainees, racial diversity has decreased. Gender and racial diversity in vascular training has not changed. Future initiatives in general and vascular surgery should focus on recruitment and promotion of proficient women and minority trainees.

Addition of common carotid intervention increases the risk of stroke and death after carotid artery stenting for asymptomatic patients.

BACKGROUND: A recent review of Vascular Study Group of New England data suggested that simultaneous endovascular treatment of tandem carotid lesions (TCAL: common carotid artery + internal carotid artery) is associated with a fourfold increase in perioperative neurologic events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous TCAL stenting in cohorts stratified by symptom status. METHODS: Vascular Quality Initiative data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, internal carotid artery lesions with stenosis <50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative stroke and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with TCAL forced into the models. RESULTS: There were 18,886 carotid arteries stented (18,441 patients): 18,077 (96%) with isolated carotid artery lesions and 809 (4%) with TCAL. Mean age was 70.0 ± 9.7. Symptomatic lesions were present in 58.9% of cases (isolated carotid artery lesions: 59.1% vs TCAL: 52.5%; P < .001). More TCAL arteries had a prior carotid endarterectomy (38.3% vs 23.8%; P < .001). TCAL had a higher perioperative stroke/death (3.4% vs 1.8%; P = .026) for asymptomatic lesions, but not symptomatic lesions (4.5% vs 3.7%; P = .41). TCAL were independently associated with stroke/death in asymptomatic patients (odds ratio, 1.85; 95% confidence interval, 1.03-3.33; P = .039) but not symptomatic patients (odds ratio, 1.22; 95% confidence interval, 0.76-1.97; P = .42). CONCLUSIONS: The addition of endovascular treatment of common carotid artery lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of TCAL is not associated with an increased risk of stroke/death for symptomatic lesions.

Hybrid and Total Endovascular Approaches to Tandem Carotid Artery Lesions Have Similar Short- and Long-Term Outcomes.

BACKGROUND: Addition of ipsilateral proximal endovascular intervention (PEI, common carotid/innominate) increases the risk of perioperative stroke/death for both carotid endarterectomy (CEA) and carotid stenting (CAS). However, these approaches have not been directly compared and is the subject of this study. METHODS: VQI (2005-2020) was queried for CEA and CAS with PEI, excluding emergent, bilateral, and repeat procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis<50%, and transcarotid ICA stents. Primary outcome were the composite of perioperative stroke/death and long-term stroke/reintervention/death. Operative approach was evaluated with logistic regression, adjusted propensity scores, symptomatic status, and stenosis>70%. Long-term outcomes were compared with Kaplan-Meier Analysis. RESULTS: There were 1,433 patients (795 endovascular;638 hybrid); mean age 69.8±9.4 years. Patients undergoing hybrid procedures were more likely to be female (49.4% vs. 37.5%; P < 0.001), less likely to have diabetes (29.5% vs. 38.2%; P P< 0.001), less likely to have a prior ipsilateral CEA (3.8% vs. 32.2%; P< 0.001), less likely to be symptomatic (34.6% vs. 52.8%; P < 0.001), and less likely to have >70% stenosis (77.3% vs. 95.6%%; P < 0.001). Perioperative stroke/death was 3.6% for hybrid and 3.9% for endovascular approaches (P = 0.77). In the multivariable model, hybrid operative approach (compared to the total endovascular approach) was not significantly associated with stroke/death (OR 1.29; 95%CI: 0.55-3.07; P = 0.56). For the 981 patients with long-term follow-up (556 endovascular; 425 hybrid), 1-year freedom from stroke/reintervention/death was 94.0% (95%CI: 90.9%-96.0%) for hybrid approach vs. 92.3% (95%CI: 89.5%-94.4%) for endovascular approach (P = 0.27). CONCLUSION: Although simultaneous repair of tandem carotid lesions portends worse outcomes when compared to CEA or CAS alone, there was no difference in short or long-term stroke and death rates with a hybrid or totally endovascular approach.  Therefore, it is reasonable to use either approach in the select patients who require simultaneous repair of both lesions.

Simultaneous treatment of common carotid lesions increases the risk of stroke and death after carotid artery stenting.

BACKGROUND: Tandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. Some studies have shown that the addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy (CEA) increases the risk of stroke and death. However, the stroke and death risks associated with a totally endovascular approach to tandem lesions is unknown and is the subject of this study. METHODS: Vascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis of less than 50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of stroke and death. Predictors of stroke or death were determined with multivariable logistic regression. RESULTS: There were 2016 carotid arteries stented in 1950 patients-1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. The mean patient age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P < .001) and in patients with a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Other covariates were similar between the groups. Symptomatic lesions accounted for 42.3% of cases (isolated, 42.2% vs tandem, 43.0%; P = .86). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). ICA neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), more perioperative neurologic events (stroke or transient ischemic attack) (8.1% vs 2.0%; P < .001), and a higher incidence of stroke or death (5.9% vs 1.9%; P = .002). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.39-6.89; P = .006), symptomatic lesions (OR, 2.24; 95% CI, 1.21-4.17; P = .010), chronic obstructive pulmonary disease (OR, 2.14; 95% CI, 1.17-3.92; P = .014), general anesthesia (OR, 3.34; 95% CI, 1.35-8.26; P = .009), and advancing age (OR, 1.05 per year; 95% CI, 1.01-1.09; P = .006). CONCLUSIONS: The addition of endovascular treatment of tandem CCA lesions with CAS is associated with a three-fold increase in perioperative stroke and death and should be avoided if possible.

Single Center Outcomes of Carotid Artery Stenting in Veterans with Prior Head and Neck Cancer.

BACKGROUND: Patients meeting criteria for intervention of carotid stenosis with a history of prior cervical radiation or neck dissection are considered "high risk" for carotid endarterectomy. This is a well-established indication for carotid artery stenting (CAS). The long-term outcomes of CAS in this population are less frequently published in the literature but are poor. The purpose of this study was to review long-term results of CAS in veteran patients with a prior history of treatment for head and/or neck cancer. METHODS: This is a retrospective review of a veteran patient population from 1998 to 2016. All patients at our institution with a prior history of treatment for head and/or neck cancer who underwent CAS were included in the analysis. During this time period, 44 patients met inclusion criteria and were treated with 57 carotid stenting interventions. The Kaplan-Meier analysis was used to determine survival and primary patency. The secondary aims were to analyze early outcomes and to identify predictive risk factors for mortality and reintervention. RESULTS: The mean follow-up was 42.9 ± 36.6 months. The cumulative survival at 1, 5, and 10 years was 91%, 67%, and 48%, respectively. The primary patency at 1, 5, and 10 years was 95%, 86%, and 86%, respectively. The reintervention rate was 11% (n = 6) with an assisted primary patency rate of 100%. No neurologic events occurred within 30 days. There were 3 strokes in late follow-up and no stroke-related deaths. Eighteen patients (41%) died during the follow-up period, 15 of whom died during the first 5 years of follow-up. Ten (66%) of those patients died of recurrent or active index cancer. On univariate analysis, tumor, node, metastasis stage IV was significantly associated with death (P = 0.02). Multivariate models were not statistically significant for predicting mortality or reintervention CONCLUSIONS: On the basis of the results in this series, CAS can be performed in these patients with low long-term rates of neurologic events and need for reintervention. However, the survival of patients with head and neck cancer undergoing CAS in this cohort is poor, which is consistent with other published series of patients undergoing CAS for head/neck cancer with at least 5-year follow-up. In this specific patient population, a more critical analysis of the patient's overall prognosis, especially as related to cancer, should be undertaken before offering CAS.

Early vascular surgery response to the COVID-19 pandemic: Results of a nationwide survey.

OBJECTIVE: The COVID-19 pandemic has had major implications for the United States health care system. This survey study sought to identify practice changes, to understand current personal protective equipment (PPE) use, and to determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers vs in states with low case numbers. METHODS: A 14-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons' current practice was sent to 365 vascular surgeons across the country through REDCap from April 14 to April 21, 2020, with responses closed on April 23, 2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania, and California) differed from those with lower case numbers (all other states). RESULTS: A total of 121 vascular surgeons responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE. The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between states with high and low COVID-19 case volumes (P = .285). States with high case volume were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs 77.5%; P = .046), but otherwise case types did not differ. Most attending vascular surgeons worked with residents (90.8%) and limited their exposure to procedures on suspected or confirmed COVID-19 cases (56.0%). Thirty-eight percent of attending vascular surgeons have been redeployed within the hospital to a vascular access service or other service outside of vascular surgery. This was more frequent in states with high case volume compared with low case volume (P = .039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons think that they do not have adequate PPE to perform their clinical duties. CONCLUSIONS: The initial response to the COVID-19 pandemic has resulted in reduced elective cases, with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty; however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey.

Sex-related outcomes after open type IV thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Although outcomes after infrarenal abdominal aortic aneurysm surgery are worse in women, sex-specific differences in outcomes after open type IV thoracoabdominal aortic aneurysm (TAAA) surgery are undefined. The goal of this study was to define sex-based disparities in short- and long-term outcomes after open type IV TAAA surgery. METHODS: All open type IV TAAA repairs performed during 27 years were evaluated using a single institutional database. Charts were retrospectively evaluated for major adverse events (in-hospital death, other major in-hospital complication) and long-term complications (graft- and aortic-related events and death). Univariate analyses were performed using the Fisher's exact test for categorical variables and Wilcoxon rank-sum testing for continuous variables. Logistic multivariable regression was used for the in-hospital end points death and major complication, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. RESULTS: During the 27-year study period, 234 patients had an open type IV TAAA repair; 85 were female and 149 were male. There were 26 (17.5%) men and 16 (18.8%) women who suffered a major in-hospital complication/death. There were eight (3.4%) in-hospital deaths, all occurring in men. Unadjusted survival at 5 years was 67.9% for women and 58.4% for men. Multivariable analyses revealed no sex-based difference in combined major in-hospital events and death (female: odds ratio [OR], 1.8; confidence interval [CI], 0.83-4.0; P = .13) or any complication (OR, 1.0; CI, 0.55-1.8; P = .99). However, women were less likely than men to be discharged to home (OR, 0.28; CI, 0.13-0.60; P = .001) and had decreased survival compared with men after discharge (hazard ratio, 2.1; CI, 1.2-3.5; P = .008). CONCLUSIONS: No sex-based differences were found for the in-hospital outcomes of death or major complication after open type IV TAAA repair. However, women are less likely than men to be discharged home. Among those who survive the index operation, female sex portends decreased survival following discharge after repair.

Thoracic aortic remodeling with endografting after a decade of thoracic endovascular aortic repair experience.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention. METHODS: This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates. RESULTS: During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, -1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P < .001), preoperative carotid-subclavian bypass (OR, 8; P = .003), and graft oversizing <20% (OR, 15; P = .046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P = .049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P = .0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of <.001 (P = .032). This was counterbalanced by the fact that patients with graft oversizing >30% had an increased odds of mortality with HR >10 (P = .049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P = .033), diabetes (HR, 4.1; P = .048), age (every 1-year increase in age; HR, 1.2; P = .002), year of surgery (every year subsequent to 2004; HR, 1.3; P = .012), and peripheral artery disease (HR, 5.2; P = .041). CONCLUSIONS: The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention.

Arteriovenous Access superficialization: A New Technique and Review of Options.

BACKGROUND: Up to 30% of autogenous cephalic vein arteriovenous fistulas (AVFs) are too deep for reliable cannulation. Techniques to superficialize these AVFs have been described previously. This study describes a new surgical technique for AVF superficialization and provides a review of the alternative techniques. METHODS: The path of the fistula is marked using ultrasound, and transverse incisions are made along this path. The underlying tissue is separated from the dermis over this area to expose the fistula outflow vein. The mobilized vein is then elevated and "trapped" directly under the dermis by closing the superficial fascia and adipose tissue beneath it. RESULTS: Between March 2016 and February 2019, 23 patients underwent superficialization using this technique at two centers. The mean time between AVF creation and superficialization was 6.3 months, and the time to first use for hemodialysis after superficialization was 38.8 ± 27.9 days. The average presuperficialization depth was 7.1 ± 2.4 mm and average postsuperficialization depth was 3.7 ± 2.7 mm (P = 0.002). Sixteen fistulas were successfully accessed for a cannulation rate of 89%. 94.7% of fistulas remained patent at last visit, with only one thrombosed 8-10 weeks after superficialization. CONCLUSIONS: This technique appears to be both safe and effective, and results in a vein that is immediately subdermal without major contour deformity. Early outcomes are comparable to those alternative methods described in the literature.