Natural history of grade I-II blunt traumatic aortic injury.

BACKGROUND: Endovascular aortic repair has revolutionized the management of traumatic blunt aortic injury (BAI). However, debate continues about the extent of injury requiring endovascular repair, particularly with regard to minimal aortic injury. Therefore, we conducted a retrospective observational analysis of our experience with these patients. METHODS: We retrospectively reviewed all BAI presenting to an academic level I trauma center over a 10-year period (2000-2010). Images were reviewed by a radiologist and graded according to Society for Vascular Surgery guidelines (grade I-IV). Demographics, injury severity, and outcomes were recorded. RESULTS: We identified 204 patients with BAI of the thoracic or abdominal aorta. Of these, 155 were deemed operative injuries at presentation, had grade III-IV injuries or aortic dissection, and were excluded from this analysis. The remaining 49 patients had 50 grade I-II injuries. We managed 46 grade I injuries (intimal tear or flap, 95%), and four grade II injuries (intramural hematoma, 5%) nonoperatively. Of these, 41 patients had follow-up imaging at a mean of 86 days postinjury and constitute our study cohort. Mean age was 41 years, and mean length of stay was 14 days. The majority (48 of 50, 96%) were thoracic aortic injuries and the remaining two (4%) were abdominal. On follow-up imaging, 23 of 43 (55%) had complete resolution of injury, 17 (40%) had no change in aortic injury, and two (5%) had progression of injury. Of the two patients with progression, one progressed from grade I to grade II and the other progressed from grade I to grade III (pseudoaneurysm). Mean time to progression was 16 days. Neither of the patients with injury progression required operative intervention or died during follow-up. CONCLUSIONS: Injury progression in grade I-II BAI is rare (~5%) and did not cause death in our study cohort. Given that progression to grade III injury is possible, follow-up with repeat aortic imaging is reasonable.

Teaching in the operating room: results of a national survey.

BACKGROUND: With the institution of the work-hour restrictions in 2003, less time may be available for surgical residents to learn operative technique and judgment. While numerous studies have evaluated the use of surgical simulation training to enhance operative skills, little is known about the quality of teaching that takes place in the operating room (OR). The purpose of this study was to assess residents' perception of faculty teaching in the OR in order to target ways to improve operative education. METHODS: A request for resident participation in an online survey was sent to the Program Coordinator at all 255 ACGME-accredited general surgery residency programs. RESULTS: A total of 148 programs (59%) participated in the survey, and anonymous responses were submitted by 998 of 4926 residents (20%). Most residents reported that attending surgeons verbalize their operative approach (55%), include residents in intraoperative decisions (61%), and offer technical advice (84%). However, few residents reported that faculty help to identify the resident's personal educational operative goals preoperatively (18%) or discuss areas of improvement with residents (37%). Of all cases scrubbed in the past year, most residents feel as though they only actually performed the procedure between 26% and 50% (29%) or between 51% and 75% (32%) of the time. However, more than half of all residents (51%) log these procedures for ACGME as primary surgeon 76%-100% of the time. CONCLUSIONS: This study demonstrates that from the residents' perspective, a number of opportunities exist to improve teaching in the OR, such as guiding residents with preoperative preparation and providing them with constructive feedback. These findings also suggest that residents may be logging cases without feeling as though they actually perform the operations.

Patient education level affects functionality and long term mortality after major lower extremity amputation.

BACKGROUND: The aim of this study was to examine the relationship between patient education level and 5-year mortality after major lower extremity amputation. METHODS: The records of all patients who underwent above-knee or below-knee amputation at the Nashville Veterans Affairs Medical Center by the vascular surgery service between January 2000 and August 2006 were retrospectively reviewed. Formal levels of education of the study patients were recorded. Outcomes were compared between those patients who had completed high school and those who had not. Bivariate analysis using χ(2) and Student's t tests and multivariate logistic regression were performed. RESULTS: Five-year mortality for patients who had completed high school was lower than for those who had not completed high school (62.6% vs 84.3%, P = .001), even after adjusting for important clinical factors (odds ratio for death, .377; 95% confidence interval, .164-.868; P = .022). CONCLUSION: Patients with less education have increased long-term mortality after lower extremity amputation.

The use of a multidisciplinary morbidity and mortality conference to incorporate ACGME general competencies.

BACKGROUND: The Surgical Morbidity and Mortality conference has long been used as an opportunity for both process improvement and resident education. With recent heightened focus on creating environments of safety and on meeting the Accreditation Council for Graduate Medical Education (ACGME) General Competencies, novel approaches are required. With the understanding that the provision of medical care is an inherently multidisciplinary enterprise, we advocate the creation and use of a Multidisciplinary Morbidity and Mortality conference (MM&M) as a means to establish this culture of safety while teaching the ACGME General Competencies to surgery residents. METHODS: A quarterly MM&M conference was implemented to foster communication between disciplines, provide a forum for quality improvement, and enhance patient care. All stakeholders in the perioperative enterprise attend, including the departments of surgery, anesthesia, radiology, pharmacy, nursing, environmental services, risk management, and patient services. Cases that expose system issues with potential to harm patients are discussed in an open, nonconfrontational forum. Solutions are presented and initiatives developed to improve patient outcomes. We retrospectively reviewed the topics presented since the conference's inception, grouping them into 1 of 7 categories. We then evaluated the completion of the improvement initiatives developed after discussion at the conference. RESULTS: Over a 21-month period, 11 cases were discussed with 23 "actionable" initiatives for quality improvement. Cases were grouped by category; procedures (36.5%), process (36.5%), patient-related (9%), communication (9%), medication (9%), device (0%), and ethics (0%). All cases discussed addressed at least 4 of the 6 ACGME General Competencies. CONCLUSIONS: Like the practice of medicine, the occurrence of adverse outcomes is frequently multidisciplinary. An MM&M conference is useful in its potential to meet ACGME General Competencies, engender a culture of patient safety, and rapidly achieve quality improvement and systems health care delivery initiatives in a large academic medical center.

Guidelines for maintaining a professional compass in the era of social networking.

OBJECTIVES: The use of social networking (SN) sites, such as Facebook and Twitter, has skyrocketed during the past 5 years, with more than 400 million current users. What was once isolated to high schools or college campuses has become increasingly ubiquitous in everyday life and across a multitude of industries. Medical centers and residency programs are not immune to this invasion. These sites present opportunities for the rapid dissemination of information from status updates, to tweets, to medical support groups, and even clinical communication between patients and providers. Although powerful, this technology also opens the door for misuse and policies for use will be necessary. We strive to begin a discourse in the surgical community in regard to maintaining professionalism while using SN sites. RESULTS: The use of SN sites among surgical house staff and faculty has not been addressed previously. To that end, we sought to ascertain the use of the SN site Facebook at our residency program. Of 88 residents and 127 faculty, 56 (64%) and 28 (22%), respectively, have pages on Facebook. Of these, 50% are publicly accessible. Thirty-one percent of the publicly accessible pages had work-related comments posted, and of these comments, 14% referenced specific patient situations or were related to patient care. CONCLUSIONS: Given the widespread use of SN websites in our surgical community and in society as a whole, every effort should be made to guard against professional truancy. We offer a set of guidelines consistent with the Accreditation Council for Graduate Medical Education and the American College of Surgeons professionalism mandates in regard to usage of these websites. By acknowledging this need and by following these guidelines, surgeons will continue to define and uphold ethical boundaries and thus demonstrate a commitment to patient privacy and the highest levels of professionalism.

Retroperitoneal repair of abdominal aortic aneurysms offers postoperative benefits to male patients in the Veterans Affairs Health System.

BACKGROUND: Transperitoneal (TP) and retroperitoneal (RP) approaches have equal efficacy in elective open abdominal aortic aneurysm (AAA) repair. The effect of open operative approach on patient-specific outcomes after AAA repair was tested. METHODS: Consecutive patients undergoing open AAA repair at the Veterans Affairs Tennessee Valley Healthcare System between January 2000 and August 2008 were retrospectively reviewed. Analysis was performed to examine the effects of demographic and clinical covariates on postoperative outcomes. RESULTS: A total of 106 patients were identified: 54 with TP approach and 52 with RP approach. Demographics and preoperative comorbidities were equivalent (p > or = 0.10), with the exception of chronic obstructive pulmonary disease which was more prevalent in the TP group (61 vs. 40%). Operative times were longer in the TP group (4.6 vs. 3.5 hours; p < 0.01); however, significantly more TP patients had reconstruction with a bifurcated graft (72 vs. 2%; p < 0.01). Postoperative nasogastric tube decompression times were shorter in the RP group (1 vs. 3 days; p < 0.01), and RP approach led to a quicker return to preoperative diet (4 vs. 6 days; p = 0.05). Patients undergoing RP repair developed fewer incisional hernias (2 vs. 15%; p = 0.03). CONCLUSION: RP approach to AAA repair offers patients faster return of bowel function and is associated with fewer incisional hernias.

Vacuum-pack temporary abdominal wound management with delayed-closure for the management of ruptured abdominal aortic aneurysm and other abdominal vascular catastrophes: absence of graft infection in long-term survivors.

Patients who undergo open repair of ruptured abdominal aortic aneurysms (rAAA) may require delayed abdominal wound closure to prevent the adverse consequences of intra-abdominal hypertension and abdominal compartment syndrome. However, surgeons may be reticent to use delayed abdominal closure techniques due to concern that such management may increase the risk of graft infection. We retrospectively reviewed our patient experience with rAAA and other vascular catastrophes in which vacuum-pack abdominal wound management with delayed closure was used between 2000 and 2007. Eighteen of 23 patients treated with delayed closure survived (78%). In five early deaths, graft infection was not clinically suspected. Sixteen of 20 rAAA patients survived, with abdominal wound closure achieved at a mean of 4 days. Mean follow up was 53 months, the longest among comparable series. Graft infection has not been encountered in this group. Our results suggest that the potential risk of graft infection should not outweigh the benefits of vacuum-pack temporary abdominal wound management with delayed closure in critically ill patients at high risk for intra-abdominal hypertension and abdominal compartment syndrome after major abdominal vascular procedures.

Factors in fellowship selection: effect of services and fellows.

PURPOSE: General Surgery residents are increasingly pursuing fellowships. We examine whether perceived subspecialty content, dedicated services, and fellows impact fellowship choices. METHODS: Specialty content was assessed through a survey linking 228 operations to 9 content areas. The presence of dedicated services and fellows and the post-residency activities of graduates 1997-2006 were collected from 2 program directors. RESULTS: A total of 75% of residents (26 University of Mississippi, UM; 22 Vanderbilt University, VU) completed surveys. Five dedicated services and 2 fellowships at UM and VU were identical; VU had an additional 4 services and 3 fellowships. UM and VU residents similarly associated 184 operations (81%) with General Surgery. Agreement was not linked to services or fellows. A total of 44% of UM graduates and 68% of VU graduates pursued fellowships. The top choice at UM was Plastic/Hand (14%, versus 6% VU) and Oncology/Endocrine at VU (19%, versus 2% UM). Differences in specialties selected could not be linked consistently to dedicated services or fellows. CONCLUSION: Dedicated services and fellows appear to have little impact on fellowship specialty selection by chief residents. There may be a generic effect of dedicated services favoring fellowship versus no fellowship. Differential faculty mentoring skills may influence specific fellowship choices.

Risk factors and angiographic technical considerations to guide carotid intervention.

Carotid angioplasty and stenting (CAS) with embolic protection is currently accepted as treatment for patients considered to be at high risk for carotid endarterectomy (CEA). The purpose of this study was (1) to determine what proportion of patients treated with CEA would be categorized as "high" risk by currently accepted criteria, (2) to characterize preoperative angiographic findings in patients with carotid stenosis, and (3) to determine the potential technical challenges of CAS in these patients. Consecutive patients who underwent CEA from January 1999 through August 2004 prior to introduction of CAS at our institution were identified. Demographics, indications, perioperative complications, and deaths were reviewed. Published guidelines defining high risk for CEA were applied, and preoperative angiograms were examined for technical limitations to CAS. Two hundred and seventy-nine CEAs were performed in 259 patients for asymptomatic carotid occlusive disease (57%), transient ischemic attacks (35%), or stroke (8%) during the study period. Of these, 35.5% (n = 99) would have met one or more high-risk criteria. Overall risks of perioperative stroke, myocardial infarction, and death were 1.1%, 2.2%, and 0.4% (n = 279), respectively, with a combined major complication rate of 3.3%. No difference in major complication rates was observed between standard-risk and high-risk patients. Preoperative angiograms were available for review in 83.5% of CEAs (n = 233). The distribution of aortic arch configurations included types I (3.5%), IIa (39.5%), IIb (54.5%), and III (1.3%). Aortic arch anomalies were observed in 15.5% (n = 35) of angiograms. There were 77.7% (n = 181) with one or more angiographic findings that would have increased the technical difficulty of CAS, but only 17.6% had relative angiographic contraindications to CAS. A significant proportion of patients with carotid stenosis previously managed with CEA would be categorized as high risk and considered potential candidates for CAS by currently accepted criteria. Based on preoperative angiography, technically challenging factors, some of which limit the ability to perform CAS, are common and should be anticipated when planning CAS.

Ischemic complications of percutaneous femoral artery catheterization.

Ischemic injuries following percutaneous femoral artery catheterization are uncommon but have been associated with vascular closure devices (VCDs). The purpose of this study was to retrospectively compare ischemic and hemorrhagic complications of femoral artery catheterization and to identify factors associated with ischemic injuries. The operative registries of the attending vascular surgeons at one academic and two community hospitals were retrospectively reviewed to identify all complications of femoral artery catheterization requiring operative intervention. Demographic, clinical, procedural, operative, and outcome data were compared between patients who sustained ischemic and hemorrhagic complications. From January 2001 to December 2006, 95 patients required operative management of complications related to femoral artery catheterization including 40 patients who experienced ischemic (group 1) and 55 patients who experienced hemorrhagic (group 2) complications. Compared to those sustaining hemorrhagic complications, ischemic complications were more frequently associated with younger age, smoking, VCD deployment, and, when controlling for VCD use, female gender. Time to presentation was also significantly longer in patients experiencing ischemic complications. Ischemic complications are increasingly recognized following femoral artery catheterization. Vascular surgeons should anticipate a new pattern of injury following femoral artery catheterization, one that often requires complex arterial reconstruction.

Should simulator-based endovascular training be integrated into general surgery residency programs?

BACKGROUND: The impact of high-fidelity simulators as an adjunct for endovascular training of general surgery residents has not yet been defined. The purpose of this study was to evaluate general surgery resident perspectives on the value of a simulator-based endovascular training program by using various measurement tools. METHODS: General surgery residents in postgraduate years 1 to 5 (n = 50) participated in a focused endovascular training course covering aortoiliac, renal, and carotid artery disease. The components of the course included didactic lecture, self-learning course material and computer training modules, hands-on exposure to endovascular instruments, and endovascular procedure simulation using a mobile SimSuite unit (Medical Simulation Corporation, Denver, CO). Course participants completed pre- and postcourse questionnaires, knowledge-based testing, and endovascular simulator metric testing. RESULTS: Of the 50 general surgery residents who completed the precourse questionnaire and knowledge-based testing, 41 completed the entire program including the postcourse questionnaire and knowledge-based testing, and 33 completed endovascular simulation metric testing. Subjective responses from pre- and postcourse surveys highlighting the residents' perceptions of the potential role of endovascular simulation as part of general surgery residency training showed favorable responses. On completion of the course, mean knowledge-based test scores had statistically significant improvement (pretest, n = 50, 59.5% +/- 12.1% correct and posttest, n = 41, 69.1% +/- 15.4% correct [P = .003]). For metric testing of a simulated endovascular procedure (n = 33), 93.9% completed all of the defined tasks within the allotted time period (mean time, 12.2 +/- 4.36 minutes; range, 4.1-26.6 minutes; 95% confidence interval for mean 10.8-13.6 minutes). CONCLUSIONS: Based on subjective and objective measures, general surgery residents found valuable and benefited in knowledge base from a focused simulator-based endovascular training program. Integrating endovascular simulation into general surgery resident training and its influence on resident interest in vascular specialization as a career choice holds future potential.

Combined endovenous ablation and transilluminated powered phlebectomy: is less invasive better?

This study was undertaken to evaluate the evolution of operative vein approaches from combined "open" saphenous stripping-stab avulsion phlebectomy to combined "minimally invasive" endovenous ablation-transilluminated powered phlebectomy with a focus on comparing clinical outcomes. All patients undergoing a combined operative approach for concomitant saphenous vein insufficiency and associated varicose tributary veins between January 1, 1998 and December 31, 2005 were identified. Patients were stratified by operative approach into 3 groups: combined saphenous vein stripping-stab avulsion phlebectomy (STRIP-PHLEB); combined saphenous vein stripping-transilluminated phlebectomy (STRIP-TPP); and combined endovenous ablation-transilluminated phlebectomy (EVAB-TPP). Clinical volume, indications, technical details, and complications were retrospectively reviewed. Over the 8-year period, there were 72 limbs in 59 patients treated with STRIP-PHLEB, 92 limbs in 81 patients with STRIP-TPP, and 99 limbs in 76 patients with EVAB-TPP, with a time-dependent transition in operative techniques noted. There was no difference in distribution of CEAP clinical classification between groups, overall with most limbs in the C2-C4 categories (93.1%) and fewer in the C5-C6 categories (6.9%). There was no difference in overall complication rates between STRIP-PHLEB and EVAB-TPP, although the distribution of complications did shift with a trend toward more wound problems noted in procedures involving saphenous stripping (STRIP-PHLEB 5.6%, STRIP-TPP 6.5%, EVAB-TPP 2.0%; P = NS), and more hematomas in procedures involving transilluminated powered phlebectomy (STRIP-PHLEB 5.6%, STRIP-TPP 16.3%, EVAB-TPP 6.9%; P < .05; see Table 2). Complications associated with the endovenous ablation portion were low including technical inability to cannulate 1.6%, saphenous re-cannulation 2.4%, hematoma 2.4%, severe phlebitis 3.1%, venous thromboembolism 0.8%, and no wound or thermal injury problems. With the shift of combined operative vein approaches for concomitant saphenous vein insufficiency and varicose tributary veins towards "minimally invasive" techniques the overall complication rate has remained unchanged. While combined endovenous ablation-transilluminated phlebectomy offers some advantage of "less" invasiveness, this perceived benefit should be balanced against unchanged overall risk over traditional operative approaches.

Carotid body tumor resection: does the need for vascular reconstruction worsen outcome?

We evaluated outcomes after carotid body tumor resection (CBR) requiring vascular reconstruction. Patients undergoing CBR at an academic medical center between 1990 and 2005 were identified. Medical records were retrospectively reviewed for clinical data, operative details, Shamblin's classification, tumor pathology, complications, and mortality. Comparisons were performed between those undergoing CBR alone and CBR requiring vascular reconstruction (CBR-VASC). Of the 71 CBRs performed in 62 patients, 16 required vascular reconstruction (23%). Although there was no difference in mean tumor size (CBR 29.1 +/- 11.9 mm, CBR-VASC 32.5 +/- 9.9 mm; p = 0.133), carotid body tumors were more commonly Shamblin's I when CBR was performed alone (CBR 53% vs. CBR-VASC 25%, p = 0.045) and Shamblin's II/III when vascular reconstruction was required (CBR 47% vs. CBR-VASC 75%, p = 0.045). There was also a significant difference in malignant tumor pathology when vascular reconstruction was required (CBR 4.4% vs. CBR-VASC 25%, p = 0.034). Cranial nerve dysfunction was higher in patients requiring vascular repair (CBR 27% vs. CBR-VASC 63%, p = 0.012), but there was no difference in baroreflex failure (CBR 7.27% vs. CBR-VASC 0%, p = 0.351), Horner's syndrome (CBR 5.5% vs. CBR-VASC 6.25%, p = 0.783), or first bite syndrome (CBR 7.27% vs. CBR-VASC 12.5%, p = 0.877). There were no perioperative strokes in either group, and one death was unrelated to operation. When required, carotid artery reconstruction at the time of CBR can be performed safely. Although cranial nerve dysfunction is more common when vascular repair is required, this is more likely related to locally advanced disease and tumor pathology rather than operative techniques.

Bedside placement of inferior vena cava filters by using transabdominal duplex ultrasonography and intravascular ultrasound imaging.

Bedside placement of inferior vena cava filters by using either transabdominal duplex ultrasonography or intravascular ultrasonography (IVUS) has been shown to be safe and effective. We review techniques for bedside filter placement with transabdominal duplex ultrasonography, IVUS with dual venous access, and IVUS with single venous access. Transabdominal duplex ultrasonography and IVUS remain our preferred techniques for filter placement when feasible, especially in critically ill and immobilized patients.

Neoaortic reconstruction for aortic graft infection: need for endovascular adjunctive therapies?

Neoaortic reconstruction using an autogenous conduit is an increasingly accepted option for the management of aortic graft infections. However, this approach is not without technical challenges and potential graft-related problems, some of which can be solved with endovascular techniques. All patients who underwent neoaortic reconstruction with femoral-popliteal vein for aortic graft infection over a 6-year period were identified from the operative registry. Those patients requiring endovascular adjunctive therapies form the basis of this report. Of 17 cases of neoaortic reconstruction for aortic graft infection, five (29%) required endovascular adjunctive procedures. These included stent placement for graft stenosis (n = 3), stent graft placement for proximal anastomotic stenosis (n = 1), and stent graft placement for anastomotic disruption (n = 1). While two of these procedures occurred within 30 days of the original neoaortic reconstruction, three were required during late follow-up. Although there were no direct complications related to the endovascular procedures, the patient with anastomotic disruption died within 30 days of causes unrelated to the endovascular procedure. Primary patency of neoaortic reconstruction was 87% at 30 days and 61% at 3 years, with assisted primary patency increasing to 100% at 3 years after endovascular adjunctive intervention. While neoaortic reconstruction using an autogenous conduit for aortic graft infection has proven durability, it is not without potential early and late graft complications. When graft problems occur, endovascular options are an attractive alternative to reoperative open aortic procedures, especially in the setting of a vastly altered surgical field.

Comparison of bedside transabdominal duplex ultrasound versus contrast venography for inferior vena cava filter placement: what is the best imaging modality?

While contrast venography is considered the gold standard for imaging prior to inferior vena cava (IVC) filter insertion, bedside placement via transabdominal duplex ultrasound (DUS) has been recognized as a safe and effective alternative. To date, there has been no direct comparison of the efficacy of both imaging modalities for IVC filter placement. A concurrent cohort of patients who underwent IVC filter placement at a single institution over a 7-year period with either contrast venography or transabdominal DUS performed at bedside was retrospectively reviewed. Patient demographics, venous thromboembolism risk factors, indications, technical success, and procedural complications were compared. Of 439 patients initially imaged with transabdominal DUS, IVC filter placement was determined to be technically feasible in 382 patients (87%). The procedural technical success rate for IVC filter placement using transabdominal DUS when IVC visualization was adequate was 97.4% (n = 382 patients), compared to 99.7% (n = 318 patients) for contrast venography (p = 0.018). Patients undergoing IVC filter placement with transabdominal DUS more commonly required IVC filter for venous thromboembolism prophylaxis (81.1% vs. 27.8%, p < 0.001), had increased incidence of multiple traumatic injuries (28% vs. 10%, p < 0.001), and had increased risk from immobilization (91.3% vs. 34.1%, p < 0.001). Overall complication rates were 0.6% for venography and 1.8% for transabdominal DUS (p = NS). When IVC visualization was adequate, contrast venography and transabdominal duplex ultrasound both had high rates of success and a low incidence of complications. A technical success advantage was observed for contrast venography; this difference in technical success must be weighed against the bedside insertion advantage offered by DUS, which may be especially important in the immobilized or critically ill patient. Transabdominal DUS remains our preferred technique when feasible, especially when bedside placement is desired.