Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy.

OBJECTIVE: Left vertebral artery revascularization is indicated in surgery involving zone 2 of the aortic arch and is typically accomplished indirectly via subclavian artery revascularization. For aberrant left vertebral anatomy, direct revascularization is indicated. Our objective was to compare the outcomes of direct vertebral artery revascularization with indirect subclavian artery revascularization for treating aortic arch pathology and to identify predictors of mortality. METHODS: A retrospective cohort study was conducted at a single tertiary hospital, including patients who underwent open or endovascular vertebral artery revascularization from 2005 to 2022. Those who underwent direct vertebral revascularization were compared with those who were indirectly revascularized via subclavian artery revascularization. The outcomes of interest were a composite outcome (any of death, stroke, nerve injury, and thrombosis) and mortality. Univariate logistic regression models were fitted to quantify the strength of differences between the direct and indirect revascularization cohorts. Cox regression was used to identify mortality predictors. RESULTS: Of 143 patients who underwent vertebral artery revascularization, 21 (14.7%) had a vertebral artery originating from the aortic arch. The median length of stay was 10 days (interquartile range, 6-20 days), and demographics were similar between cohorts. The incidence of composite outcome, bypass thrombosis, and hoarseness was significantly higher in the direct group (42.9% vs 18.0%, P = .019; 33.3% vs 0.8%, P < .0001; 57.1% vs 18.0%, P < .001, respectively). The direct group was approximately three times more likely to experience the composite outcome (odds ratio, 3.41; 95% confidence interval, 1.28, 9.08); similarly, this group was approximately six times more likely to have hoarseness (odds ratio, 5.88; 95% confidence interval, 2.21, 15.62). There was no significant difference in mortality rates at 30 days, 1, 3, 5, and 10 years of follow-up. Age, length of hospital stay, and congestive heart failure were identified as predictors of higher mortality. After adjusting for these covariates, the group itself was not an independent predictor of mortality. CONCLUSIONS: Direct vertebral revascularization was associated with higher rates of composite outcome (death, stroke, nerve injury, and thrombosis), bypass thrombosis and hoarseness. Patients with aberrant vertebral anatomy are at higher risks of these complications compared with patients with standard arch anatomy. However, after adjusting for other factors, mortality rates were not significantly different between the groups.

Evaluation of factors associated with limb thrombus formation after endovascular aortic aneurysm repair.

BACKGROUND: Limb thrombus formation is a complication that can occur after endovascular aortic repair (EVAR), and its clinical significance has continued to be debated. Our objective was to report the incidence of limb thrombus after EVAR and determine the association of specific demographic, anatomic, and/or graft variables. METHODS: A retrospective analysis of EVAR patients at a single tertiary center between January 2010 and December 2018 was performed to determine the limb thrombus rate. Demographic, graft, and anatomic variables were analyzed for an association with limb thrombus. RESULTS: A total of 301 patients were included. The average follow-up was 27.6 ± 4.9 months. The mean age was 76.5 ± 0.5 years, and 85% were men. Limb thrombus occurred in 22 patients (7.3%). Of these 22 patients, 11 (50.0%) had had occlusive limb thrombus, 14 (63.6%) were symptomatic, and 17 (77.3%) had required intervention. The patients with limb thrombus were younger (69.8 ± 1.3 years vs 77.1 ± 0.5 years; P < .0001) and more likely to be smokers (10.2% vs 5.2%; P = .10). The incidence of limb thrombus with the Alpha graft (10.7%; Cook Medical Inc, Bloomington, IN) was compared with that with non-Cook grafts (4.0%; P = .07). The average common iliac artery diameter for patients with and without limb thrombus was 14.1 mm and 16.1 mm, respectively (P < .01). Right-sided limb thrombus was more likely in smaller right iliac arteries (14.7 ± 0.9 cm vs 17.0 ± 0.6 cm; P < .05), with a similar finding on the left (13.6 ± 0.9 cm vs 15.2 ± 0.4 cm; P = .13). Unilateral limb thrombus was almost twice as likely on the main body side than on the contralateral side (11 vs 6). Limb thrombus was not associated with aortoiliac disease (odds ratio [OR], 1.31; 95% confidence interval [CI], 0.37-4.62), limb extension (OR, 0.47; 95% CI, 0.06-3.62), or nonmatching limb heights (OR, 1.36; 95% CI, 0.54-3.43). Limb thrombus was also not associated with increased 30-day mortality (P > .05). CONCLUSIONS: Limb thrombus formation is a complication that can occur after EVAR (7.3%). In our study, limb thrombus was seen more frequently in younger patients and those who smoked. Cook Alpha grafts had a thrombus formation rate of 10.7%, which was not significantly higher than that with other brands. Limb thrombus was more likely in smaller iliac arteries and on the main body side.

A comparison of outcomes between open and endovascular arteriovenous access creation for hemodialysis.

OBJECTIVE: Preliminary outcomes for percutaneous endovascular autogenous access (endoAVF) have shown promising results; however, comparisons with surgical cohorts in dialysis populations are lacking. This study compares autogenous arteriovenous access created with the EverlinQ endoAVF system with accesses created by conventional surgical technique with respect to functional and patency related outcomes. METHODS: This is a multicenter, retrospective review of autogenous arteriovenous accesses entered into a prospective database. Patients receiving radiocephalic, brachiocephalic, or endoAVF arteriovenous accesses between 2014 and 2019 were included. Autogenous access maturation, primary patency, secondary patency, steal syndrome, and reinterventions were collected and analyzed using standard statistical and survival analyses. RESULTS: A total of 369 accesses were created during the study period, including 61 endovascular accesses, 171 radiocephalic accesses, and 137 brachiocephalic accesses (median follow-up, 17 months; range, 1-71 months). Maturation failure at the end of follow-up was 27% ± 6%, 27% ± 5%, and 18% ± 4% for endovascular, radiocephalic, and brachiocephalic accesses, respectively (P = .049 for brachiocephalic vs endovascular accesses). Primary patencies at 12 and 24 months were 42% ± 5% and 32% ± 7% for endovascular accesses, 43% ± 4% and 24% ± 4% for radiocephalic accesses, and 42% ± 4% and 29% ± 4% for brachiocephalic accesses (P = .906). Secondary patencies at 12 and 24 months were 68% ± 6% and 60% ± 7% for endovascular accesses, 75% ± 3% and 67% ± 4% for radiocephalic accesses, and 91% ± 3% and 81% ± 4% for brachiocephalic accesses (P = .006 for brachiocephalic vs endovascular accesses). There were no statistically significant differences in ischemic steal syndrome (3.3%, 4.1%, and 8.0%; P = .229) or total reinterventions/year (1.0 ± 3.1, 0.9 ± 1.8, and 1.2 ± 1.8; P = .289) for endovascular, radiocephalic, or brachiocephalic arteriovenous accesses, respectively. CONCLUSIONS: EndoAVF compare favorably with respect to maturation and patency compared with surgically created accesses in a real-world cohort. Outcomes and reintervention rates are similar to conventional radiocephalic arteriovenous accesses, but are inferior with respect to patency and maturation to brachiocephalic accesses.

Survey of Canadian vascular surgeons and trainees finds work-related musculoskeletal pain and discomfort is common.

BACKGROUND: Occupational injuries and disability are a source of surgeon morbidity. The purpose of this study was to assess the physical toll of working in operating rooms by Canadian vascular surgeons. OBJECTIVE: To assess workplace musculoskeletal (MSK) complaints and challenges faced by Canadian vascular surgeons and trainees and their implications on surgical practice and occupational longevity. METHODS: An online survey was distributed to resident and surgeon members of the Canadian Society of Vascular Surgery. The survey collected data on demographics, operative volume, and work-related MSK symptoms. RESULTS: The survey was distributed to 188 surgeons and trainees. After three e-mailings, 109 surveys were returned (58% response rate). Of the responders, 87% were male, 51% were 45 years or older, and 56% had been in practice for 10 or more years. Workplace MSK symptoms were reported by 83% of the responders. The most common locations were the low back (78%), neck (74%), and shoulder (30%). Most responders (83%) believed that these symptoms were related to their operative environment. Almost half (48%) sought medical care. As a result of these MSK symptoms, 25% experience chronic pain with 8% reporting time off work as a consequence. Another 11% reported an impact on their operative performance with 14% considering early retirement. A lack of operating room system changes to prevent workplace injury and disability was noted by 85% of the responders although only 3% reported their disability to their department. CONCLUSIONS: Occupational MSK symptoms and disability are common among Canadian vascular surgeons. Further research is needed to create programs to improve surgeon morbidity.

Exploring the Utility of Brain Natriuretic Peptide Measurement in Vascular Surgery.

BACKGROUND: The Canadian Cardiovascular Society 2016 guidelines recommend pre-operative measurement of brain natriuretic peptide (BNP) to risk-stratify patients for a 30-day composite outcome of death, myocardial infarction, or asymptomatic myocardial injury after noncardiac surgery (MINS). Whether this practice affects outcomes is unclear. The aim of this study was to examine the clinical utility of brain natriuretic peptide and myocardial injury after noncardiac surgery. METHODS: Analysis of a prospectively maintained database identified all elective open vascular surgery cases at an academic teaching hospital from January 2015 to December 2018. Pre-operative BNP values were available from June 2018 onward after becoming institutionally mandated. Co-morbidities were also collected to stratify patients using the Revised Cardiac Risk Index. The composite outcome of 30-day mortality, myocardial infarction, or MINS was determined. RESULTS: Prior to BNP becoming an institutionally required test, data was available from 1176 open cases. The 30-day mortality was 1.3% (15/1176) and post-operative myocardial infarction rate was 2.3% (27/1176). BNP measurements were collected in 91 consecutive patients. Ten patients (11%) experienced the composite outcome of mortality, myocardial infarction, or MINS. Elevated BNP was associated with increased odds of the composite outcome (P = 0.04), but not with mortality or myocardial infarction. Revised Cardiac Risk Index score was not predictive of outcomes. The majority of patients who qualified for the composite outcome experienced only an asymptomatic troponin rise (80%). Two patients met the universal definition of myocardial infarction, one of whom died. No other deaths occurred within 30 days. Detection of MINS did not result in any significant changes to patient management. CONCLUSIONS: Elevated BNP correlates with increased MINS. An asymptomatic troponin rise is the most commonly observed event, with unclear clinical implications. BNP may over-estimate surgical risk. Further studies on the long-term outcomes of patients with elevated BNP and MINS are required before widely adopting this strategy in vascular surgery patients.

Influence of artery and vein diameters on autogenous arteriovenous access patency.

OBJECTIVE: Previous investigations have suggested that a minimum venous outflow diameter (MVOD) and perianastomotic arterial diameter are associated with successful autogenous arteriovenous maturation and patency. The goal of this study was to determine anatomic and clinical variables that may influence access patency to guide optimal autogenous access configuration selection. METHODS: Accesses created from 2010 to 2016 were analyzed from data entered into a prospective database. Preprocedure duplex ultrasound mapping data of artery and tourniquet-derived vein diameters and demographic and clinical variables were collected. Survival-based cut point analysis was used to determine anatomic parameters most predictive of access failure. Kaplan-Meier and Cox proportional hazards analyses were used to assess patencies and maturation and to identify independent predictors of access failure. RESULTS: A total of 356 first-time autogenous accesses were created (median follow-up, 20 months; range, 0-73 months). Of these, 202 (56.7%) were radiocephalic and 154 (43.3%) were brachiocephalic. Maturation failure at end of follow-up for arteriovenous accesses was 26% ± 3% for radiocephalic accesses and 15% ± 3% for brachiocephalic accesses (P < .001). For radiocephalic accesses, MVOD <3.0 mm and radial artery diameter <2.1 mm independently predicted access maturation failure (MVOD <3.0 mm: hazard ratio [HR], 2.62 [95% confidence interval (CI), 1.27-5.39; P = .009]; radial artery diameter <2.1 mm: HR, 2.20 [95% CI, 1.20-4.05; P = .011]) and secondary patency loss (MVOD <3.0 mm: HR, 2.21 [95% CI, 1.24-3.96; P = .007]; radial artery diameter <2.1 mm: HR, 2.11 [95% CI, 1.26-3.63; P = .004]). A combination of radial artery diameter <2.1 mm and MVOD <3.0 mm most strongly predicted maturation failure (HR, 4.24; 95% CI, 1.71-10.49; P = .002) and loss of secondary patency (HR, 4.03; 95% CI, 1.88-8.64; P < .001). Only diabetes mellitus (HR, 2.24; P = .012) predicted secondary patency loss. For brachiocephalic accesses, MVOD <3.4 mm (HR, 2.12; 95% CI, 1.02-4.46; P = .043) was found to independently predict secondary patency loss in addition to previous ipsilateral (HR, 2.37; P = .038) and bilateral (HR, 4.00; P = .015) tunneled hemodialysis catheters. Brachial artery diameter was not associated with either access maturation or patency. CONCLUSIONS: Artery and tourniquet-derived vein diameters independently predict radiocephalic access patency and functional outcomes. A combination of a radial artery diameter <2.1 mm and MVOD <3.0 mm best predicts maturation failure and patency loss for radiocephalic access. MVOD <3.4 mm was associated with increased loss of brachiocephalic access secondary patency, but MVOD was not associated with maturation.

Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair.

BACKGROUND: Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR. METHODS: Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI. RESULTS: Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52 hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9 days, P = 0.012), operative room time (262 vs. 209, P = 0.040), and perioperative mortality (28.6% vs. 4.1%, P = 0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P = 0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis. CONCLUSIONS: Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.

An age-based comparison of fistula location, patency, and maturation for elderly renal failure patients.

OBJECTIVE: Current Kidney Disease Outcomes Quality Initiative guidelines do not incorporate age in determining autogenous arteriovenous hemodialysis access placement, and the optimal initial configuration in elderly patients remains controversial. We compared patency, maturation, survival, and complications between several age cohorts (<65 years, 65-79 years, >80 years) to determine whether protocols should be modified to account for advanced age. METHODS: All patients at two teaching hospitals undergoing a first autogenous arteriovenous access creation in either arm between 2007 and 2013 were retrospectively analyzed from a prospectively maintained database. Kaplan-Meier survival and Cox hazards models were used to compare access patency and risk factors for failure. RESULTS: There were 941 autogenous arteriovenous accesses (median follow-up, 23 months; range, 0-89 months) eligible for inclusion; 152 (15.3%) accesses were created in those >80 years, 397 (42.2%) in those 65 to 79 years, and 392 (41.8%) in those <65 years. Primary patencies in patients >80 years, 65 to 79 years, and <65 years were 40% ± 4%, 38% ± 3%, and 51% ± 3% at 12 months and 12% ± 5%, 13% ± 3%, and 27% ± 3% at 36 months (P < .001). Primary assisted patencies were 72% ± 4%, 70% ± 2%, and 78% ± 2% at 12 months and 52% ± 5%, 52% ± 3%, and 67% ± 3% at 36 months (P < .001). Secondary patencies were 72% ± 4%, 71% ± 2%, and 79% ± 2% at 12 months and 54% ± 5%, 55% ± 3%, and 72% ± 3% at 36 months (P < .001). Radiocephalic patencies were lowest among older cohorts; in those >80 years, 65 to 79 years, and <65 years, they were 65% ± 7%, 67% ± 4%, and 77% ± 3% at 12 months and 41% ± 8%, 51% ± 5%, and 68% ± 4% at 36 months (P = .019). Secondary brachiocephalic access patencies in these cohorts were 78% ± 5%, 80% ± 3%, and 82% ± 3% at 12 months and 68% ± 7%, 66% ± 5%, and 77% ± 4% at 36 months (P = .206). Both the age groups 65 to 79 years and >80 years demonstrated superior brachiocephalic vs radiocephalic secondary patencies (P = .048 and P = .015, respectively); however, no differences between configuration and secondary patency were observed within the cohort <65 years. Radiocephalic access maturation failure at 12 and 24 months was 25% ± 3% and 29% ± 4% in those <65 years, 32% ± 3% and 39% ± 4% in those 65 to 79 years, and 40% ± 7% and 48% ± 8% in those >80 years (P = .006). Brachiocephalic access maturation failures were 17% ± 3% and 20% ± 3% at 12 and 24 months in those <65 years, 21% ± 3% and 25% ± 4% in those 65 to 79 years, and 18% ± 5% and 21% ± 5% in those >80 years (P = .740). On multivariate analysis, coronary disease, female sex, previous ipsilateral or bilateral catheters, radiocephalic configuration, and age >65 years were associated with secondary patency loss. CONCLUSIONS: Patients aged 65 to 79 years and >80 years had inferior primary, primary assisted, and secondary patency and maturation compared with those <65 years. When stratified by configuration, radiocephalic accesses demonstrated lower patency and maturation compared with brachiocephalic accesses for patients aged 65 to 79 years and >80 years and were an independent predictor of secondary patency loss.

A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia.

OBJECTIVE: Access-related hand ischemia (ARHI) is a potentially limb-threatening complication of arteriovenous access for dialysis. The distal revascularization-interval ligation (DRIL) and revision using distal inflow (RUDI) procedures both allow treatment of ischemic symptoms while maintaining fistula patency. Although outcomes with the DRIL are well established, experience with the RUDI for ARHI remains preliminary. We compared outcomes in these procedures with respect to cumulative patency, resolution of symptoms, and patient survival. METHODS: A large, prospectively maintained database was used to identify all patients after autogenous arteriovenous fistula construction at two hospitals between 2005 and 2015. Patients with severe Society for Vascular Surgery grade 3 ARHI were included for analysis. RESULTS: A total of 2035 autogenous accesses were created during the study period, and 58 (3%) developed grade 3 ARHI. Of this cohort, RUDI was performed in 20 and DRIL in 21. The indication for intervention was tissue loss (61%) or ischemic rest pain (39%). Mean age was 57.5 years, and 54% of patients were female. Most patients had diabetes (86%) and symptomatic peripheral arterial disease (63%). The mean preoperative digital-brachial index was 0.25 ± 0.12. There were no preoperative differences in patient comorbidities between the RUDI and DRIL cohorts. Primary patency between the RUDI and DRIL cohorts at 12 months (58% ± 11% vs 55% ± 12%) and 36 months (51% ± 12% vs 41% ± 12%) were similar (P = .841). Cumulative secondary patency at 12 months (84% ± 8% vs 94% ± 6%) and 36 months (78% ± 9% vs 86% ± 9%) showed no significant difference (P = .398). Resolution of ischemic symptoms, including resolution or improvement in pain or healing of ischemic ulcers or amputations, occurred in 90% with RUDI and in 81% with DRIL (P = .131). Survival for patients who underwent RUDI or DRIL procedures at 1 and 3 years was 85% vs 86% (P = .948) and 55% vs 49% (P = .278). CONCLUSIONS: In this preliminary study, the RUDI demonstrated similar patency, symptom resolution, and survival compared with the DRIL for patients with severe ARHI. All-cause mortality after any procedure for severe steal syndrome is high, and the particular intervention for management of steal must account for anatomic-, patient-, and disease-related considerations.

Geographic disparities in the burden of ruptured and unruptured abdominal aortic aneurysms.

BACKGROUND: The province of Saskatchewan presents unique challenges for the care of ruptured abdominal aortic aneurysms (AAAs), including variable access to health care resources and long transportation distances to tertiary vascular care. This study assessed the rates of ruptured and total AAA to determine regional variations within Saskatchewan and ascertain whether there are areas of high AAA prevalence that would possibly benefit from the implementation of a targeted screening program. METHODS: All diagnoses of AAA from 2001 to 2012 in the province of Saskatchewan were reviewed, with patients grouped by health region of residence. Diagnoses of ruptured and unruptured AAAs were obtained from the Saskatchewan Discharge Abstracts Database, Medical Services Billings Claims data, and Vital Statistics data. RESULTS: During the study period, 6163 AAAs were diagnosed. The provincial age-adjusted rate of AAA was 53.0/100,000 person-years (95% confidence interval, 48.8-57.6). The highest age-adjusted rate of AAA was found in the Five Hills Health Region (FHHR), at 63.1/100,000 person-years (95% confidence interval, 57.6-69.0), which was significantly higher than the provincial average (P < .05). The rate of ruptured AAA in FHHR was nearly twofold higher than the provincial average (6.0 vs 2.9/100,000 person-years, respectively). CONCLUSIONS: There are significant geographic variations in the prevalence of AAA in the province of Saskatchewan, with the highest rate of AAA found in the FHHR.

Using a Chimney to Make a Sandwich: Salvage of a Multibranched Thoracoabdominal Aortic Endograft with a Type IIIb Endoleak.

BACKGROUND: The advent of branched and fenestrated aortic endografts has facilitated the treatment of increasingly complex aortic pathology. The management of complications and endoleaks involving the branches and fenestrations of these grafts represents an increasingly significant clinical and technical challenge. METHODS: A 79-year-old woman developed a rare type IIIb endoleak from a tear in the graft fabric immediately posterior to the celiac axis branch 3 years after the placement of an off-the-shelf branched endograft for a type II thoracoabdominal aortic aneurysm. The patient presented urgently with abdominal pain and a maximal aneurysm diameter of 15.3 cm. RESULTS: The operative plan was to create a chimney graft completely within the original branched endograft to cover the defect and maintain celiac branch flow. The celiac trunk was accessed from a left axillary approach and access for the main endograft body was achieved via the left femoral artery. Two balloon-expandable covered stents were deployed from the celiac branch extending into the main endograft as a chimney and molded to 2 aortic extension cuffs to cover the fabric defect. The resultant configuration was a modified-sandwich graft within the original stent graft and resulted in successful exclusion of the endoleak. Postoperative imaging at 1, 6, and 12 months has demonstrated continued patency of the celiac trunk, no further endoleak, and a 16-mm reduction in aneurysm size. CONCLUSIONS: The chimney technique was successfully applied as an endovascular option to salvage a multibranched endograft with a significant and anatomically unfavorable defect. Careful follow-up and additional clinical study are required to clarify the role of off-the-shelf solutions in complex endoleak management.

The Emotional Impact and Coping Mechanisms Following Adverse Patient Events Among Canadian Vascular Surgeons and Trainees.

BACKGROUND: This study's objective is to evaluate the emotional experiences, coping mechanisms, and support resources for Canadian vascular surgeons and trainees following an adverse patient event or near miss. METHODS: This is a cross-sectional survey study of all Canadian Society for Vascular Surgery (CSVS) members from October to November 2021. We collected data on participant experiences with adverse events, their emotional responses, the coping mechanisms used, and their perceptions on available support resources. RESULTS: The survey was sent to 233 CSVS members yielding 66 responses. The majority (77%) of respondents had experiences with adverse event causing serious patient harm. The most common negative experience following an adverse event included feelings of negativity towards oneself, general distress, and anxiety about potential for future errors. The most common coping mechanism was seeking advice from a mentor or close colleague. Peers (82%) and senior colleagues (59%) were the most preferred sources of support. Most of the respondents would reach out to a mentor if they had 1, but 30% reported no mentor or close colleague for support. CONCLUSION: Adverse patient events and near misses have serious negative impact on the lives of Canadian vascular surgeons and trainees. Peers and senior colleagues are the most desired source for support, but this is not universally available. Organized efforts are needed to bring awareness in our vascular surgery community on the ubiquitous nature and detrimental effects of adverse events.

Surgical management of intravenous leiomyomatosis with intracardiac extension.

Intravenous leiomyomatosis is a rare smooth muscle tumor that is associated with uterine leiomyomas. Intravenous leiomyomatosis often presents with nonspecific abdominal and cardiac symptoms, making the diagnosis difficult. We present a comprehensive review of a case of a 52-year-old woman with intravenous leiomyomatosis with intracardiac extension, who was successfully treated with complete surgical resection.

The arteriovenous fistula and the history of a forgotten pioneer.

Objective: The radiocephalic arteriovenous fistula (AVF), first introduced by Dr Kenneth Charles Appell, allowed for the provision of hemodialysis for patients with chronic kidney disease (CKD) and remains a reliable method for vascular access today. The purpose of this study is to review the contributions that led to the development of the AVF. We describe the work of Dr Appell, whose procedure bypassed the need for repeated cannulation in achieving vascular access, transforming the management of patients with dialysis-dependent CKD. Methods: A literature search was conducted by searching "arteriovenous fistula," "history of surgery," "hemodialysis," "vascular access," "chronic kidney disease," "repeated cannulation," and "Kenneth Charles Appell" on PubMed, Embase, and Web of Science. Only articles written in English were considered. Results: Before the arteriovenous fistula, glass cannulae were used for vascular access, beginning with Abel's "vividiffusion" apparatus in animals and Haas's experimental dialysis on humans. The use of glass cannulae was continued by Kolff, who transitioned from venipuncture needles to glass cannulae. However, these attempts were complicated by thrombosis, excessive bleeding related to heparin use, and damage to vascular access sites from repeated cannulation. Arteriovenous shunts, using polytetrafluoroethylene tubing, were an improvement from previous attempts at vascular access, but were prone to local bleeding, shunt occlusion, phlebitis, cellulitis, and rarely lasted more than a few months. To address these challenges, Dr Appell created an upper extremity AVF, allowing for the provision of maintenance dialysis without externalized devices, repeated cannulation, and extensive anticoagulant administration. Despite Dr Appell's vision and pioneering contributions to vascular surgery, he has received little credit for his work. Conclusions: The enormous contribution by Dr Appell in the development of the AVF that transformed the modern management of patients with CKD is recognized in this review of the history of vascular access surgery for hemodialysis.