Exercise versus vasodilator stress limb perfusion imaging for the assessment of peripheral artery disease.

PURPOSE: Our aim was to determine whether pharmacologic vasodilation is an alternative to exercise stress during limb perfusion imaging for peripheral artery disease (PAD). METHODS: Quantitative contrast-enhanced ultrasound (CEU) perfusion imaging of the bilateral anterior thigh and calf was performed in nine control subjects and nine patients with moderate to severe PAD at rest and during vasodilator stress with dipyridamole. For those who were able, CEU of the calf was then performed during modest plantar flexion exercise (20 watts). CEU time-intensity data were analyzed to quantify microvascular blood flow (MBF) and its parametric components of microvascular blood volume and flux rate. RESULTS: Thigh and calf skeletal muscle MBF at rest was similar between control and PAD patients. During dipyridamole, MBF increased minimally (

Quality-of-life assessment as an outcomes measure in critical limb ischemia.

Critical limb ischemia (CLI) is a diagnosis plagued by significant comorbidity and high mortality rates. Overall survival remains poor in this population regardless of the procedure-related success as demonstrated by freedom from amputation, intervention, and patency. The literature has traditionally focused on physician-centered and lesion-centered outcomes with regards to limb salvage procedures, but there remains a relative paucity of studies of CLI patients describing patient-centered outcomes such as quality of life (QoL), independent living, and ambulation status. Review of the available literature indicates patients do not always experience significant gains in their QoL after limb salvage interventions, despite reasonable graft patency, amputation-free survival, and limb salvage rates. Further research is required using QoL tools in a measurable and clinically relevant fashion to guide optimal quality care that maximizes patient-centered outcomes.

Incidence and outcomes of intraoperative vascular surgery consultations.

OBJECTIVE: Vascular surgeons may aid in primarily nonvascular procedures. Such activity has not been quantified, and hospital administrators may be unaware of the importance of vascular surgeons to support other hospital-based surgical programs. This study reviewed intraoperative consultations by vascular surgeons to support other surgical services. METHODS: Intraoperative vascular consultations were reviewed from January 2006 to January 2014 for consulting service, indication, and whether consultation occurred with advanced notice. Patient demographics, operative times, estimated blood loss, length of stay, and relative value units (RVUs) assigned for each consultation were also assessed. Consultations for trauma and iatrogenic injuries occurring outside the operating theater were excluded. RESULTS: Vascular surgeons performed 225 intraoperative consultations in support of procedures by nonvascular surgeons. Requesting services were surgical oncology (46%), orthopedics (17%), urology (11%), otolaryngology (7%), and others (19%). Reasons for consultation overlapped and included vascular reconstruction (53%), control of hemorrhage (39%), and assistance with difficult dissections (43%). Seventy-four percent were for intra-abdominal procedures, and venous (53%) and arterial (50%) problems were encountered equally with some overlap. Most patients were male (59%), overweight (56%; body mass index ≥25 kg/m(2)), had previous surgery (72%) and were undergoing elective procedures (89%). Mean total procedural anesthesia time was 9.4 hours, mean procedural operating time was 7.9 hours, and mean total and vascular-related estimated blood loss was 1702 mL and 327 mL, respectively. Mean length of stay was 14.7 days, mean intensive care unit stay was 2.9 days, and 30-day mortality was 6.2%. Mean nonvascular RVUs per operation were 46.0, and mean vascular RVUs per operation were 30.9. CONCLUSIONS: Unexpected intraoperative need for vascular surgical expertise occurs often enough that vascular surgeons should be regarded as an essential operating room resource to the general operating room, nonvascular surgeons, and their patients. Intraoperative vascular surgical consultation in support of other surgeons requires a high level of open technical operative skills and is time and labor intensive.

A systematic review of assessment of skill acquisition and operative competency in vascular surgical training.

OBJECTIVE: The aim of this systematic review is to describe the literature and assessment tools evaluating vascular surgical operative performance that could potentially be used for the assessment of educational outcomes applicable to the Milestone Project and the Next Accreditation System. METHODS: A systematic review of PubMed/MEDLINE, EMBASE, PsycINFO, and key journals from 1985 to 2013 was performed to identify English-language articles describing assessment of vascular surgical skills and competence. Qualifying studies were abstracted for data concerning study aims, study and assessment setting, skills measured, and metrics used to determine competency. Strengths, weaknesses, and psychometric robustness of the assessment tools were determined. RESULTS: The literature search identified 617 citations. After title and abstract review, 65 articles were retrieved for full-text assessment and 48 articles were included in the final review. Twenty-nine articles assessed open vascular skills; 19, endovascular skills; six, nontechnical skills; and one, teamwork skills. The majority (84%) of studies were performed in a simulated environment, four (8%) were performed in the operating room, and the remaining three were performed in both a simulated environment and an operating room. Strengths and weaknesses of assessment tools were study and assessor dependent, with none applicable to all study scenarios or procedures. CONCLUSIONS: The literature describing assessment tools pertinent to vascular surgery is diverse. Existing assessment tools may be relevant to individual technical skill acquisition assessment; however, an operative assessment tool relevant to vascular/endovascular surgery and generalizable to the wide spectrum of technical and nontechnical skills pertinent to vascular surgery needs to be developed, validated, and implemented to allow the practical assessment of resident readiness to operate in an unsupervised setting.

Compliance with long-term surveillance recommendations following endovascular aneurysm repair or type B aortic dissection.

OBJECTIVE: Lifelong surveillance is recommended for both endovascular aneurysm repair and acute, uncomplicated type B thoracic aortic dissection, though compliance remains a significant challenge. We sought to determine factors associated with failure to obtain recommended surveillance. METHODS: Patients surviving to discharge who had endovascular repair of thoracic (thoracic endovascular aortic aneurysm repair [TEVAR]) or abdominal aortic aneurysms (endovascular aortic aneurysm repair [EVAR]) or medical management for type B dissections from 2004-2011 were reviewed. Primary end points were compliance with follow-up and need for reintervention. Comorbidities examined included coronary artery disease, congestive heart failure, hypertension, chronic obstructive pulmonary disease, diabetes, and chronic kidney disease. Socioeconomic factors examined were age, sex, distance from hospital, discharge destination (ie, home or skilled nursing facility), and insurance type. Endoleak and sac expansion were recorded, as were complications, including endograft migration, infection or thrombosis, and aneurysm degeneration. RESULTS: Two hundred four patients, median age 71.9 years, were identified; 171 had EVAR and 33 had type B dissection. EVAR patients included 45 thoracic, 100 abdominal, and 12 thoracoabdominal endografts, as well as 7 iliac artery aneurysm repairs and 7 proximal/distal graft extensions. Median follow-up was 28 ± 10.5 months. Overall, 56% were lost to follow-up, whereas 11% never returned for surveillance after initial hospitalization. Follow-up was compared for each of the comorbidities and socioeconomic factors; none were found to significantly affect follow-up. The known complication rate was 9.3% (n = 19), with reintervention performed in 14% of EVAR/TEVAR patients. Thirty-eight percent of medically managed patients with type B dissections eventually required surgical intervention. All-cause 5-year mortality was 27% as determined by the Social Security Death Index. CONCLUSIONS: Despite a significant rate of reintervention following EVAR, TEVAR, and type B dissection, long-term compliance with surveillance is limited. In addition, predicting who is at risk of being lost to follow-up remains difficult. If current recommendations for lifelong surveillance are to be followed, coordinated protocols are required to capture EVAR, TEVAR, and type B dissection patients to ensure optimal follow-up for these patients. However, the lack of survival benefit in those with complete follow-up suggests that further study is needed with regard to ideal duration of long-term follow-up.

Factors affecting career choice among the next generation of academic vascular surgeons.

OBJECTIVE: Few studies have examined factors that influence an individual's decision to enter an academic medical career after residency training. We sought to evaluate whether sex, ethnicity, child care issues, and debt burden influenced residents' choice for a career in academic vascular surgery. METHODS: A 39-item Web survey, designed to elucidate which factors motivated residents to seek a career in academic vascular surgery, was sent to 295 vascular surgery residents currently enrolled in Accreditation Council on Graduate Medical Education-accredited training programs. RESULTS: A total of 128 responses (43%) were received. Of these, 53% of respondents were white and 47% were nonwhite and 34 (27%) were women and 94 (73%) were men. Fifty-seven percent of minorities anticipate a career in academic vascular surgery. There were no statistical differences between sex and ethnicity for factors influencing career choice, including training paradigm, presence of a life partner or dependents, mentorship role, participation in research, service, and teaching, anticipated salary, and debt burden (P > .05). Seventy-seven percent of respondents carry significant debt; of those with debt, 81% owe >$100,000 and 40% owe >$200,000. Seventy-three percent of 0+5 trainees anticipated choosing an academic practice compared with 42% of 5+2 trainees (P < .01). Respondents planning an academic career cited procedural variation, breadth and depth of practice/tertiary referral experience, and research opportunities as the most important drivers of career choice. Income potential, strength of the job market, and child care needs were deemed less important. CONCLUSIONS: This study shows that academic vascular surgery is a popular career option for current vascular surgery trainees, especially those in 0+5 programs. Choosing a career in academic vascular surgery appears not to be influenced by sex, ethnicity, child care concerns, salary expectations, or debt burden, even though most trainees carry enormous debt. The data imply future academic vascular surgeons will likely have greater gender and ethnic variability than is currently seen.

Does lower-extremity bypass improve quality of life? Is it cost effective?

Limb salvage, operative mortality and short and long term graft patency have long been important variables for assessment of infrainguinal arterial reconstructions. More recently it is now appreciated that patient and society oriented measures of outcomes in determining the effectiveness of any surgical procedure are also important. In particular, the impact of an intervention on a patient's overall quality of life (QOL) and whether it is cost effective in achieving improvement of QOL are questions of increasing importance from the patient's perspective and from the perspective of those who must make difficult health policy decisions. This chapter reviews the cost effectiveness and impact of infrainguinal bypass on patient perceived quality of life in patients with intermittent claudication and patients with critical limb ischemia. The data are not robust but suggest favorable impact of infrainguinal bypass in terms of both QOL and cost effectiveness in both patients with intermittent claudication and critical limb ischemia.

The effect of dehydration on wrestling minimum weight assessment.

UNLABELLED: Given that some wrestlers arrive for minimum weight (MW) testing in a dehydrated condition, it is important to understand the effects of dehydration on MW assessment methods. PURPOSE: To determine the effect of dehydration on the assessment of MW by three-site skinfolds with the Lohman formula (SF), leg-to-leg bioelectrical impedance analysis (BIA), and multifrequency bioelectrical impedance spectroscopy (BIS) compared with a four-component (4C) criterion. METHODS: Twenty-two male collegiate wrestlers (mean +/- SD, age: 19.9 +/- 1.4 yr, height: 174.0 +/- 6.8 cm, body mass: 77.4 +/- 9.1 kg) had their body composition assessed by the 4C criterion, hydrostatic weighing (HW), SF, BIA, and BIS in euhydration (EUH) and dehydration (DEH). Subjects dehydrated 2-5% of body weight through fluid restriction and exercise in a hot environment. RESULTS: In EUH, the total error (TE) for HW (1.75 kg) and SF (2.15 kg) were not significantly different, but the TE for HW and SF methods were significantly lower than the TE for both BIS (3.68 kg) and BIA (3.77 kg). In DEH, SF, BIA, and BIS methods had a TE approaching or exceeding 4 kg (8.8 lb). Dehydration increased the TE for SF and BIA through an artificial lowering of body weight and for BIS by an increased error in intracellular water prediction. CONCLUSION: Acute thermal dehydration violates assumptions necessary for the accurate and precise prediction of MW by SF, leg-to-leg BIA, and multifrequency BIS.