Identifying potentially avoidable femoral to popliteal expanded polytetrafluoroethylene bypass for claudication using cross-site blinded peer review.

OBJECTIVE: The surgical treatment of claudication can be associated with significant morbidity and costs. There are growing concerns that some patients proceed to interventions without first attempting evidence-based nonoperative management. We used a direct, cross-site, blinded expert review to evaluate the appropriateness of the surgical treatment of claudication. METHODS: We enlisted practicing vascular surgeons to perform retrospective clinical assessments of lower extremity bypass procedures in a statewide clinical registry. Cases were limited to elective, open, infrainguinal bypasses performed for claudication using prosthetic grafts. Reviewing surgeons were randomly assigned 10 cases from a sample of 139 anonymized bypass operations and instructed to evaluate procedural appropriateness based on their expert opinion and evidence-based guidelines for preoperative treatment, namely, antiplatelet, statin, cilostazol, exercise, and smoking cessation therapy as documented in the medical record. Ninety-day episode payments were estimated from a distinct but similar cohort of patients undergoing lower extremity bypass for claudication. RESULTS: Of 325 total reviews, surgeons stated they would not have recommended bypass in 134 reviews (41%) and deemed bypass inappropriate in 122 reviews (38%). The most common reason for inappropriateness was lack of preoperative medical and lifestyle therapy, which was present in 63% of reviews where bypass was deemed appropriate and 39% of reviews where bypass was deemed inappropriate (P < .001). Surgeons stated they would have recommended additional preoperative therapy in 65% of reviews where bypass was deemed inappropriate and 35% of reviews where bypass was deemed appropriate (P < .001). The mean total episode payments in a similar cohort of 1458 patients undergoing elective open lower extremity bypass for claudication were $31,301 ± $21,219. Extrapolating to the 325 reviews, the 134 reviews in which surgeons would not have recommended bypass were associated with potentially avoidable estimated total payments of $4,194,334, and the 122 reviews in which bypass was deemed inappropriate were associated with potentially avoidable estimated total payments of $3,818,722. CONCLUSIONS: In this cross-site expert peer review study, 40% of lower extremity bypasses were deemed premature and, therefore, potentially avoidable, primarily owing to a lack of medical and lifestyle management before surgery. Reviews deemed inappropriate were associated with approximately $4 million in potentially avoidable costs. This approach could inform performance feedback among surgeons to help align clinical practice with evidence-based recommendations for the treatment of claudication.

Is There a Role for Neoadjuvant Systemic Therapy for cT4bM0 Colon Cancer? A Propensity Score-Matched Analysis of the National Cancer Database.

BACKGROUND: Nonmetastatic T4b colon cancer has been traditionally treated with upfront surgery, often requiring technically challenging multiorgan resection. Neoadjuvant chemotherapy can potentially downsize these tumors and improve their resectability. OBJECTIVE: This study aimed to explore trends and outcomes of neoadjuvant chemotherapy use compared to upfront surgery in patients with nonmetastatic T4b colon cancer. This study also sought to determine factors associated with increased neoadjuvant chemotherapy use and with overall survival. DESIGN: Retrospective cohort study. SETTINGS: Conducted using the National Cancer Database. PATIENTS: Patients with nonmetastatic T4b colon cancer who underwent colectomy (2006-2016) were included in the study. Patients receiving neoadjuvant chemotherapy were propensity-matched (1:2) to those who underwent upfront surgery in either clinically node-negative or node-positive disease. MAIN OUTCOME MEASURES: Postoperative outcomes (length of stay, 30-d readmission, 30/90-d mortality), oncologic resection adequacy (R0 rate, number of resected/positive nodes), and overall survival were the main outcome measures. RESULTS: Neoadjuvant chemotherapy was used in 7.7% of the patients. Neoadjuvant chemotherapy use increased over the study period from 4% to 16% in the entire cohort, from 3% to 21% in patients with clinically node-positive disease, and from 6% to 12% in patients with clinically node-negative disease. Factors associated with increased use of neoadjuvant chemotherapy included younger age (OR 0.97; 95% CI, 0.96-0.98; p < 0.001), male sex (OR 1.35; 95% CI, 1.11-1.64; p = 0.002), recent diagnosis year (OR 1.16; 95% CI, 1.12-1.20; p < 0.001), academic centers (OR 2.65; 95% CI, 2.19-3.22; p < 0.001), clinically node-positive (OR 1.23; 95% CI, 1.01-1.49; p = 0.037), and tumor located in the sigmoid colon (OR 2.44; 95% CI, 1.97-3.02; p < 0.001). Patients who received neoadjuvant chemotherapy had significantly higher R0 resection compared with upfront surgery (87% vs 77%; p < 0.001). On multivariable analysis, neoadjuvant chemotherapy was associated with higher overall survival (HR 0.76; 95% CI, 0.64-0.91; p = 0.002). On propensity-matched analyses, neoadjuvant chemotherapy was associated with a higher 5-year overall survival compared to upfront surgery in patients with clinically node-positive disease (57% vs 43%; p = 0.003) but not in patients with clinically node-negative disease (61% vs 56%; p = 0.090). LIMITATIONS: Retrospective design. CONCLUSION: Neoadjuvant chemotherapy use for nonmetastatic T4b has increased significantly on the national level, more so in patients with clinically node-positive disease. Patients with node-positive disease treated with neoadjuvant chemotherapy had higher overall survival compared to those who underwent upfront surgery. See Video Abstract at http://links.lww.com/DCR/C228 . EXISTE LUGAR PARA LA TERAPIA SISTMICA NEOADYUVANTE PARA EL CNCER DE COLON CTBM UN ANLISIS EMPAREJADO DE PUNTAJE DE PROPENSIN DE LA BASE DE DATOS NACIONAL DEL CNCER: ANTECEDENTES:El cáncer de colon T4b no metastásico se ha tratado tradicionalmente con cirugía inicial, que frecuentemente requiere de una resección multiorgánica técnicamente desafiante. La quimioterapia neoadyuvante puede potencialmente reducir el tamaño y mejorar la resecabilidad de esos tumores.OBJETIVO:Explorar las tendencias y los resultados del uso de quimioterapia neoadyuvante en pacientes con cáncer de colon T4b no metastásico, en comparación con la cirugía inicial. Determinar los factores asociados con el aumento del uso de quimioterapia neoadyuvante y con la supervivencia general.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Utilizando de la Base de Datos Nacional del Cáncer.PACIENTES:Pacientes con cáncer de colon T4b no metastásico sometidos a colectomía (2006-2016). Los pacientes que recibieron quimioterapia neoadyuvante fueron emparejados por propensión (1:2) con aquellos sometidos a cirugía inicial, ya sea en enfermedad clínica con ganglios negativos o ganglios positivos.PRINCIPALES MEDIDAS DE RESULTADO:Resultados posoperatorios (duración de la hospitalización, reingreso a los 30 días, mortalidad a los 30/90 días), adecuación de la resección oncológica (tasa R0, número de ganglios resecados/positivos) y supervivencia general.RESULTADOS:La quimioterapia neoadyuvante se utilizó en el 7,7% de los pacientes. El uso de quimioterapia neoadyuvante aumentó durante el período de estudio del 4% al 16% en toda la cohorte; del 3% al 21% en pacientes con enfermedad clínica y ganglios positivos; y del 6% al 12% en pacientes con enfermedad clínica y ganglios negativos. Los factores asociados con un mayor uso de quimioterapia neoadyuvante incluyeron, edad más joven (OR 0,97, IC del 95 %: 0,96-0,98, p < 0,001), sexo masculino (OR 1,35, IC del 95 %: 1,11-1,64, p = 0,002), año de diagnóstico mas reciente (OR 1,16, 95% IC: 1,12-1,20, p < 0,001), centros académicos (OR 2,65, 95% IC: 2,19-3,22, p < 0,001), enfermedad clínica con ganglios positivos (OR 1,23, 95% IC: 1,01-1,49, p = 0,037), y tumor localizado en colon sigmoide (OR 2,44, 95% IC: 1,97-3,02, p < 0,001). Los pacientes que recibieron quimioterapia neoadyuvante tuvieron una resección R0 significativamente mayor en comparación con la cirugía inicial (87 % frente a 77 %, p < 0,001). En análisis multivariable, la quimioterapia neoadyuvante se asoció con una mayor supervivencia global (HR 0,76, IC del 95%: 0,64-0,91, p = 0,002). En los análisis de propensión pareada, la quimioterapia neoadyuvante se asoció con una mayor supervivencia general a los 5 años en comparación con la cirugía inicial en pacientes con enfermedad clínica con ganglios positivos (57% frente a 43%, p = 0,003), pero no en pacientes con enfermedad clínica y ganglios negativos (61% vs 56%, p = 0,090).LIMITACIONES:Diseño retrospectivo.CONCLUSIÓN:El uso de quimioterapia neoadyuvante para T4b no metastásico ha aumentado significativamente a nivel nacional, más aún en pacientes con enfermedad clínica y ganglios positivos. Los pacientes con enfermedad y ganglios positivos tratados con quimioterapia neoadyuvante tuvieron una mayor supervivencia general en comparación con la cirugía inicial. Consulte Video Resumen en http://links.lww.com/DCR/C228 . (Traducción-Dr. Fidel Ruiz Healy ).

Endovascular experience at an academic office-based procedure center.

OBJECTIVE: The number of office-based procedure centers with the capability of performing a wide range of endovascular procedures has substantially increased over the past decade. This shift in practice settings has occurred faster in the private sector as compared to the academic environment. The purpose of our study was to evaluate the clinical outcomes of endovascular procedures performed at a dedicated academic outpatient procedural center. METHODS: We reviewed the clinical data of 400 patients who underwent 499 endovascular procedures in a university-based, academic outpatient procedure center between November 2013 and December 2016. Outcomes analyzed included procedure-related complications, limb loss, mortality, and emergency department visits or hospital admissions that occurred within 30 days following the procedure. RESULTS: The 400 patients had a mean age of 65 ± 13 years with slightly more females (51%; n = 203) as compared to males (49%; n = 197). Most patients (71%; 284) were Caucasian while 80 (20%) were African-Americans. Associated comorbidities included hypertension (86%), diabetes mellitus (51%), chronic kidney disease (42%), and obesity (mean body mass index of 29 ± 6). Based on anesthetic risk, most were ASA class 3 (81%), while ASA 1 and 2 comprised 17% and ASA 4 only 2%. Medicare beneficiaries accounted for 254 (64%) of our patients. Pre-operative studies included mainly duplex ultrasound (62%) and other noninvasive arterial studies (57%).The mean procedural time was 58 min (range, 7 to 200) with an overall technical success rate of 97%. There were no deaths. Complications developed in 10 patients following the 483 procedures (2.1%) being hospitalized with four of them transferred directly to the emergency room. The reasons for these hospitalizations included acute limb ischemia, arterial pseudoaneurysm, deep vein thrombosis, congestive heart failure, myocardial infarction, and lower extremity pain not vascular in origin. Financial reimbursement at the office-based center was higher than that seen with hospital-based procedures. CONCLUSIONS: Endovascular procedures performed in an academic office-based procedure center are safe and associated with good clinical outcomes. A small minority of patients have subsequent ER visits or hospital admissions. Academic institutions should consider adding an office-based procedure center based on today's competitive healthcare market.

Robotic Approach is Associated With a Lower Conversion Rate Compared to Laparoscopic Approach for Patients Undergoing Colectomy for T4b Colon Cancer. An Analysis of the National Cancer Database.

INTRODUCTION: We examined the perioperative outcomes of patients undergoing open, laparoscopic, or robotic colectomy for T4b colon cancer, as well as the clinical factors associated with conversion to an open approach and its consequences on perioperative and oncologic outcomes. METHODS: The National Cancer Database was queried for patients undergoing colectomy for cT4b colon cancer (2010-2016). Patients undergoing laparoscopic or robotic colectomy were matched using Propensity-Score analysis. Factors associated with conversion to an open approach were assessed using Logistic-regression multivariable-analysis (MVA). RESULTS: Colectomy for cT4b colon cancer was performed in 9030 patients (open: n = 6,543, robotic: n = 157, laparoscopic: n = 2330). In the propensity-matched groups, robotic approach had lower rate of conversion (12% vs 37%, P < .001), shorter hospital stays (5 vs 7-days, P = .02), and similar overall-survival (5-yr: 49% vs 39%, P = .16), compared to laparoscopic approach. Conversion to an open approach was noted in 801(32%) of the patients undergoing minimally invasive surgical colectomy (robotic n = 23(15%), laparoscopic n = 778(33%). Factors associated with lower rate of conversion on multivariable-analysis included recent year of surgery (95% CI: 0.88-.97), robotic approach (95% CI: 0.22-.56), and surgeries performed in Academic hospitals (95% CI: 0.65-.96). Conversion to an open approach was associated with higher rate of positive parenchymal margin (31% vs 25%, P = .001), higher rate of 30-day readmission (12% vs 9.5%, P = .04), and similar overall survival (5-yr: 32% vs 35%, P = .19), compared to those who had no conversion. CONCLUSION: At the National level, patients undergoing colectomy for T4b colon cancer via a robotic approach had more favorable perioperative outcomes compared to laparoscopic approach. Conversion to an open approach did not compromise long term survival, despite being associated with higher rate of positive margins and readmissions rate.

National Trends and Perioperative Outcomes of Robotic-assisted Hepatectomy in the USA: A Propensity-score Matched Analysis from the National Cancer Database.

BACKGROUND: A paucity of data exists on the national use of robotic hepatectomy. We assessed national trends and perioperative outcomes of robotic hepatectomy in the USA. In addition, factors associated with use of the robotic approach were analyzed. METHODS: The National Cancer Database (NCDB) was queried for patients undergoing hepatectomy from 2010 to 2016. Patients undergoing total hepatectomy for transplant were excluded. Factors associated with the use of the robotic approach were assessed using logistic regression multivariable analysis. Propensity-score analysis was performed (robotic vs. laparoscopic and robotic vs. open approaches), and perioperative outcomes were compared between the matched groups. RESULTS: The robotic approach was used in 287 patients (110 hospitals). Utilization of the robotic approach increased significantly on the national level from 0.8% in 2010 to 4.1% in 2016 (P<0.001). The number of hospitals performing a minimum of one robotic hepatectomy per year increased from 8 in 2010 to 35 in 2016. The median hospital length of stay was 4 days (IQR 3-6), 30-day readmission rate was 5%, and 30-day/90-day mortality rates were 3%/4%. Factors associated with using robotic approach were African-American race (95% CI 1.02-2.11), recent year of surgery (95% CI 1.11-1.32), HCC histology (95% CI 1.01-52.03), tumor size (95% CI 0.87-0.96), and early-stage tumor (Stage I-II, 95% CI 1.27-3.99). On propensity-matched analysis, there were no differences between robotic and open approaches (n=184 each group) in 30-day readmission (5% vs. 7%, P=0.651), 30-day mortality (2% vs. 4%, P=0.106), 90-day mortality (3% vs. 7%, P=0.080), or 5-year overall survival (58% vs. 43%, P=0.211). However, the robotic approach was associated with a significantly shorter hospital stay (median: 4 vs. 6 days, P<0.001). There were no differences between matched groups of patients undergoing robotic and laparoscopic approaches (n=182 in each group) in perioperative outcomes or length of hospital stay. CONCLUSION: National use of robotic-assisted hepatectomy has increased by fivefold over the seven-year study period. It was associated with a shorter hospital length of stay compared to the open approach without compromising perioperative outcomes or survival.

The educational value of an audience response system use in an Iraqi medical school.

BACKGROUND: Medical education is continually evolving particularly through the modern implementation of educational technology. Enhancing interactive learning in the classroom or lecture settings is one of the growing uses of educational technology. The role and potential benefits of such technology may not be as evident in developing educational systems like the one in Iraq. The purpose of this study was to examine the effect and perception of the use of an audience response system (ARS) on interactive medical education in Iraq. A mixed quantitative and qualitative research methodology approach was used to study the effects and users' perceptions (both student and tutor) of the ARS. METHOD: The study was conducted in an Iraqi medical school in the Head and Neck course during the spring semester for third-year medical students. The course involved fifteen one-hour lectures over fifteen weeks. Users' perceptions were evaluated by survey and focus group discussions (FGD). Descriptive statistics were used for quantitative measures and thematic analysis for the qualitative data. An ARS system was installed and integrated into the course lectures throughout the course period of three months to enhance interactive learning. Three to five interactive questions were used in each lecture. Anonymous participation and answers were maintained. The appropriate discussion was initiated when pertinent depending on students' answers. RESULT: Most students (77% of survey, 85% of FGD) perceived the use of ARS as impactful on their learning. They found the ARS engaging (70%), motivating (76%), promoting interactions (73%), and augment learning through better understanding and remembering (81%). Through the FGD, students expressed improved focus, enhanced thinking and reflection, and joyful learning. The educator perceived the ARS use as practical, interactive, thinking-stimulator, and reflective of student's understanding. The required technology skills were reasonable; however, it demanded extra non-insignificant time to learn the use. CONCLUSION: The perception of the ARS in this study was overall positive, providing encouragement for wide application of this technology in medical education in the developing world. Further studies are needed to validate and prioritize ARS usage in medical education in Iraq.

Factors influencing resilience and burnout among resident physicians - a National Survey.

BACKGROUND: Residency training exposes young physicians to a challenging and high-stress environment, making them vulnerable to burnout. Burnout syndrome not only compromises the health and wellness of resident physicians but has also been linked to prescription errors, reduction in the quality of medical care, and decreased professionalism. This study explored burnout and factors influencing resilience among U.S. resident physicians. METHODS: A cross-sectional study was conducted through an online survey, which was distributed to all accredited residency programs by Accreditation Council of Graduate Medical Education (ACGME). The survey included the Connor-Davidson Resilience Scale (CD-RISC 25), Abbreviated Maslach Burnout Inventory, and socio-demographic characteristics questions. The association between burnout, resilience, and socio-demographic characteristics were examined. RESULTS: The 682 respondents had a mean CD-RISC score of 72.41 (Standard Deviation = 12.1), which was equivalent to the bottom 25th percentile of the general population. Males and upper-level trainees were more resilient than females and junior residents. No significant differences in resilience were found associated with age, race, marital status, or training program type. Resilience positively correlated with personal achievement, family, and institutional support (p <  0.001) and negatively associated with emotional exhaustion and depersonalization (p <  0.001). CONCLUSIONS: High resilience, family, and institutional support were associated with a lower risk of burnout, supporting the need for developing a resilience training program to promote a lifetime of mental wellness for future physicians.

Preliminary Results of the Outpatient Endovascular and Interventional Society National Registry.

PURPOSE: To present a new outcomes-based registry to collect data on outpatient endovascular interventions, a relatively new site of service without adequate historical data to assess best clinical practices. Quality data collection with subsequent outcomes analysis, benchmarking, and direct feedback is necessary to achieve optimal care. MATERIALS AND METHODS: The Outpatient Endovascular and Interventional Society (OEIS) established the OEIS National Registry in 2017 to collect data on safety, efficacy, and quality of care for outpatient endovascular interventions. Since then, it has grown to include a peripheral artery disease (PAD) module with plans to expand to include cardiac, venous, dialysis access, and other procedures in future modules. As a Qualified Clinical Data Registry approved by the Centers for Medicare and Medicaid Services, this application also supports new quality measure development under the Quality Payment Program. All physicians operating in an office-based laboratory or ambulatory surgery center can use the Registry to analyze de-identified data and benchmark performance against national averages. Major adverse events were defined as death, stroke, myocardial infarction, acute onset of limb ischemia, index bypass graft or treated segment thrombosis, and/or need for urgent/emergent vascular surgery. RESULTS: Since Registry inception in 2017, 251 participating physicians from 64 centers located in 18 states have participated. The current database includes 18,134 peripheral endovascular interventions performed in 12,403 PAD patients (mean age 72.3±10.2 years; 60.1% men) between January 2017 and January 2020. Cases were performed primarily in an office-based laboratory (85.1%) or ambulatory surgery center setting (10.4%). Most frequently observed procedure indications from 16,086 preprocedure form submissions included claudication (59%), minor tissue loss (16%), rest pain (9%), acute limb ischemia (5%), and maintenance of patency (3%). Planned diagnostic procedures made up 12.2% of cases entered, with the remainder indicated as interventional procedures (87.6%). The hospital transfer rate was 0.62%, with 88 urgent/emergent transfers and 24 elective transfers. The overall complication rate for the Registry was 1.87% (n=338), and the rate of major adverse events was 0.51% (n=92). Thirty-day mortality was 0.03% (n=6). CONCLUSION: This report describes the current structure, methodology, and preliminary results of OEIS National Registry, an outcomes-based registry designed to collect quality performance data with subsequent outcome analysis, benchmarking, and direct feedback to aid clinicians in providing optimal care.

Mastication Steal Syndrome.

A 56-year-old woman presented with episodic vertigo, dizziness, and diplopia during meals and prolonged verbal presentations at work. Subsequent work-up included an eventual catheter-based angiogram revealing an ostial left external carotid artery (ECA) occlusion with reconstituted retrograde flow via a variant collateral branch from the dominant left vertebral artery. The findings demonstrate that repetitive activities involving craniofacial muscular systems supplied by the ECA result in a symptomatic arterial steal syndrome via the enhanced diverted flow from the collateral vertebral-basilar arterial system. A left ECA endarterectomy with reimplantation of the vessel was performed, and the patient has been episode free thereafter.

Laser Atherectomy for the Treatment of Peripheral Arterial Disease.

BACKGROUND: The aim of the study was to investigate the clinical results of laser atherectomy in the treatment of peripheral arterial disease. METHODS: Retrospective analysis of consecutive patients underwent laser atherectomy at a single institution during a 7-year period by vascular surgeons and interventional cardiologists in a tertiary university-affiliated hospital. Clinical data were retrieved from patient charts and hospital electronic medical records along with the associated arteriograms. RESULTS: A total of 461 lesions in 343 limbs were treated in 300 patients with a mean age of 70 years. The indication was critical limb ischemia (CLI) with rest pain or tissue loss in 227 (66%) of interventions and claudication in 116 (34%). All procedures included an associated balloon angioplasty, while stenting was performed in 33%. Technical success was achieved in 99% with only 2 (<1%) cases with an acute procedure-related complication requiring surgical intervention. At a mean follow-up of 28 months (range, 1-87 months; median 24 months), 156 patients (45%) became asymptomatic or achieved significant clinical improvement (resolution of tissue loss or rest pain), 60 (17%) remained with CLI, 30 (9%) had a major proximal amputation, and 18 (5%) had a minor amputation. Freedom from major amputation was 90% at 5 years by life-table analysis. Univariate statistical analysis demonstrated the risk of a major amputation to be associated with diabetes, hemodialysis, and tissue loss (P < 0.05 to P < 0.005), while multivariate logistic regression analysis indicated diabetes to be overwhelmingly important (RR: 4.84; 95% confidence interval [CI]: 1.1-21.3; P < 0.05). In a similar manner, multivariate analysis indicated dialysis (RR: 2.46; 95% CI: 1.01-5.98; P < 0.05) and CLI (RR: 2.27; 95% CI: 1.42-3.65; P < 0.01) were associated with higher likelihood for lack of clinical improvement. There was no difference in major amputation rates between surgeons and interventional cardiologists (RR: 1.5; 95% CI: 0.7-2.1; P < 0.1) although it was 3 times more likely for the patients treated by surgeons to suffer from CLI (odds ratio: 3.2; 95% CI: 1.9-5.4; P < 0.0001). CONCLUSIONS: Laser atherectomy is a safe and useful adjunct in limb salvage. Diabetics have much higher probability of requiring a proximal amputation, while those on dialysis and with CLI are least likely to gain clinical benefit.

Perception of Chemical Venous Thromboprophylaxis for Oncologic Lung Resections among Thoracic Surgeons.

BACKGROUND: Controversies on chemical venous thromboembolic (VTE) prophylaxis in patients undergoing lung resection for malignancy exist. The available guidelines on VTE do not specifically address its prophylaxis in patients undergoing oncologic lung resections. The goal of this survey was to evaluate the perception of VTE prophylaxis among thoracic surgeons performing these operations. METHODS: A self-reported online survey was distributed to 267 active members of the General Thoracic Surgical Club between July and September 2015. The survey consisted of 22 questions related to the use of chemical venous thromboprophylaxis in patients undergoing oncologic lung resection and their impact on outcomes. RESULTS: Fifty-six thoracic surgeons replied to the survey. The majority of these surgeons (57%) perform both open and thoracoscopic surgery for lung cancer. All respondents stated that treatment modality and extent of surgical resection have no influence on their decision to use chemical VTE prophylaxis. Twenty-two (39%) respondents do not use chemical VTE prophylaxis prior to their oncologic lung resections, while the remaining 34 (61%) reported use of anticoagulants prior to them. None of the respondents prescribe extended 30-day VTE prophylaxis to these patients. Forty-nine (87%) respondents believe that chemical VTE prophylaxis is not related to major postoperative bleeding episodes. Forty-five (81%) respondents reported that none of their reoperations for bleeding were secondary to VTE prophylaxis or if it was, that isolated event could be successfully managed nonoperatively. CONCLUSIONS: The majority of thoracic surgeons surveyed believe that chemical VTE prophylaxis is safe and should be used regardless of the magnitude of oncologic lung resections whenever possible. Extended 30-day VTE prophylaxis is not yet used by the survey respondents.

The efficacy and durability of the Venous Window Needle Guide implanted on uncannulatable arteriovenous fistulas.

BACKGROUND: The Venous Window Needle Guide (VWING; Vital Access Corp, Salt Lake City, Utah) is a surgically implanted titanium device designed to facilitate cannulation of uncannulatable dialysis access arteriovenous fistulas (AVFs) because of excessive depth, aneurysm formation, or tortuosity but that exhibit sufficient flow volume to support hemodialysis. We report the 18-month fistula patency, functionality, and complications of the use of the VWING device. METHODS: This retrospective study examined AVF patency, VWING functionality, interventions, and device infections at 18 months after VWING implantation. The study population comprised the eligible patients enrolled in the VWING Salvage of AV Fistula (SAVE) trial. RESULTS: Fifty-four patients were originally enrolled in the SAVE trial, and 35 were enrolled in the follow-up study. At 18 months, when considering surgical or percutaneous interventions at the VWING site(s) only, the primary AVF patency rate was 78%. Interventions elsewhere on the AVF, outside the boundaries of the VWING, resulted in a primary patency rate of 38%. The VWING accounted for 13% loss of AVF primary patency compared with 53% loss from the remaining AVFs. The overall AVF assisted primary patency rate was 91%, and the primary patency rate was 21%. VWING secondary functionality, the continued ability to access the fistula through the VWING using a constant site cannulation technique, was 65%. During the 12 months after the SAVE Study 80% of patients did not require the use of a central venous catheter. Eleven VWING devices were removed from eight patients, all but one for cannulation difficulties. One device was removed during the SAVE trial because of infection. No device or systemic infection was identified in the ensuing 12 months, for an overall systemic infection rate of 0.014 per device-year. An intervention rate of 0.32 per device-year was required to maintain device functionality during the 18-month follow-up period. CONCLUSIONS: Implantation of the VWING device is a safe and effective means of establishing hemodialysis access in an otherwise functional but uncannulatable AVF. The device infection rate is acceptably low.

Axillary Artery Deployment of Endovascular Aortic Repair Iliac Limb for Preservation of Internal Iliac Artery Blood Flow.

The axillary artery approach has been used for access for complex endovascular aortic procedures such as thoracic endovascular aortic repair with poor anatomy for traditional deployment as well as for fenestrated and branched abdominal aortic endografts. We report the first case of an iliac graft limb deployment through the axillary artery during an endovascular aortic repair for maintenance of anterograde internal iliac flow in a patient with a symptomatic abdominal aortic aneurysm and chronic occlusion of both the external iliac and common femoral arteries.

Subclavian Vein Stent Fracture and Venous Motion.

Primary subclavian vein stents are not recommended for venous thoracic outlet syndrome before surgical decompression by first rib resection due to a high risk of fracture because they are compressed between the clavicle and first rib. After rib removal, however, stent insertion has been advocated for venous restenosis, and it is felt that stent fracture is unlikely to occur. We present a case suggesting that repetitive differential vein movement during respiration may be one of the causative factors for stent fractures occurring in this anatomic region.

Mechanochemical ablation: disappointing long-term anatomic results and worsening symptoms.

An updated report on the five-year results in the treatment of great saphenous vein incompetence with mechanochemical ablation (MOCA) provides additional evidence for higher rates of anatomic recanalization compared to other treatment modalities and progressive worsening of symptoms with time.

Quantitative measurement of pitting edema with a novel edema ruler.

Lower extremity edema is a symptom of chronic venous disease and venous insufficiency. However, clinical evaluations rely on the qualitative evaluation of the pitting depth, which is neither well-defined nor quantitative. We created a novel three-dimensionally printed edema ruler as a quantitative method to measure pitting depth. Twenty-five patients (50 legs) with chronic venous disease were evaluated for ankle edema using the edema ruler. The results demonstrate excellent intraclass correlation for both single (0.944, P < .001) and average (0.971, P < .001) measurements. The edema ruler is a noninvasive, useful, and objective tool for the clinical measurement of lower extremity edema.

Detection and quantitation of venous leg edema with the edema ruler and ultrasound.

Objective: Lower extremity edema is characteristic of C3 chronic venous disease. We developed a new clinical and duplex ultrasound (DUS) methodology for the detection and quantification of leg edema and prospectively evaluated its usefulness. Methods: Forty-seven venous patients (94 legs) were evaluated for ankle edema using an Edema RulerTM and DUS using a modified Suehiro grading scale. Results: Interobserver reliability for the use of the Edema RulerTM was 0.985 (p < .001) and 0.883 (p < .001) for the Modified Suehiro Grade. The Edema RulerTM had stronger significant correlations with Edema rVCSS (0.842; p < .001) compared to DUS: (0.474;p < .001) with Edema rVCSS. There were significant differences between the edema pitting depth in CEAP classification of C1 and C2 compared to C3, C4a, and C4c. DUS analysis only had significant differences between CEAP classification C2 and C4a. Conclusions: The Edema RulerTM provides a quantitative measurement of lower extremity edema with high reliability which can be easily integrated into clinical practice. While both methods had good inter-observer reliability, the Edema RulerTM had stronger correlations to Edema rVCSS and showed significant differences in pitting depths between lower CEAP scores (C1-2) compared to higher CEAP scores (C3-4c).