A Multi-Institutional Study from the US ROPE Consortium Examining Factors Influencing Vascular Surgery Specialization among General Surgery Residents.

BACKGROUND: There remains a progressive projected deficit in the vascular surgery (VS) workforce for decades yet to come. Despite the rise of an expanding integrated VS residency pathway, the fellowship training model remains critical in supporting our future workforce. Therefore, it is imperative to understand the resident and program-specific factors that influence VS specialization among general surgery (GS) residents. METHODS: Data from the US Resident OPerative Experience (ROPE) Consortium, comprising 20 Accreditation Council for Graduate Medical Education (ACGME)-accredited GS residency programs across the United States, were queried for resident demographics and residency program-related details. Logistic regression analysis was used to identify factors associated with VS specialization. RESULTS: From 2010 to 2020, a total of 1343 graduating GS residents were included in the study. Of these, 135 (10.1%) pursued VS fellowship training. Residents pursuing VS were more frequently male (80.7% vs 62.8%, p<0.0001) and younger (median 32 vs 33 yr, p=0.03) compared with other GS residents. Racial and ethnic group, underrepresented in medicine (URiM) status, and international medical graduate (IMG) status were similar between VS and non-VS groups. Residency program-level details were also similar between groups, including program type (university vs community-based), region, size, resident volume, dedicated research experience, and National Institutes of Health funding. Dedicated vascular rotations were common among all GS programs (95.4%), and total months spent on a VS rotation (median 4 vs 4.5 mo, p=0.11) did not differ among residents pursuing VS and all other residents. The presence of a collocated traditional (5+2) VS fellowship (91.1% vs 90.4%, p=0.79) or integrated (0+5) VS residency (56.3% vs 55.0%, p=0.77) were also similar between groups. On multivariate analysis, only male sex (odds ratio 2.34, 95% confidence interval, 1.50-3.81, p<0.001) was associated with pursuing VS fellowship. Factors that did not impact VS specialization included resident age, URiM status, IMG status, program volume, dedicated research experience, or total months spent on a VS rotation. CONCLUSIONS: In this multi-institutional study, we did not find any program-specific factors that influence VS specialization among GS residents. Notably, the presence of a collocated 0+5 residency or 5+2 fellowship program did not appear to deter GS residents from pursuing VS fellowship. These data suggest that individual factors, such as mentorship, may be more impactful in recruiting GS residents to the VS specialty.

The Geographic Distribution of Vascular Surgeons and Trainees by State in 2023.

OBJECTIVE: Approximately 1.4 vascular surgeons/100,000 persons are estimated to fulfill current patient needs in the United States (US), but an ongoing shortage exists. The aims of this study are to provide an updated nationwide state-by-state workforce analysis and compare the distribution of practicing vascular surgeons and training opportunities. METHODS: Vascular surgeons in the US were identified using the National Provider Identifier registry in 2023. Only board-certified and actively licensed vascular surgeons were included. To estimate the number of vascular surgery graduates per year in each state, integrated residency and fellowship-matched positions (trainees) were ascertained from the National Resident Matching Program website. Surgeons and trainees were totaled by state, and densities were calculated using the 2020 US Census Bureau state populations. These two cohorts were also examined together using simple linear regression and geographic mapping. RESULTS: This study included 3399 board-certified vascular surgeons and 228 newly matched trainees. The average densities of vascular surgeons and trainees in the US are 1/100,000 persons and 0.06/100,000 persons, respectively. The five states with the lowest densities of vascular surgeons are AR, ND, NV, OK, and WY, averaging 0.4/100,000 persons. Eight states (AK, ID, KS, ND, NM, NV, RI, WY) had zero training programs offering positions in 2023 and ranked in the lowest quartile for the number of practicing vascular surgeons (Figure 1). Simple linear regression demonstrated a statistically significant correlation between state rates of vascular surgeons and trainees (p < 0.001). CONCLUSION: States with zero training positions also have the fewest vascular surgeons per capita. Statewide attention to expanding vascular surgery training opportunities targeted in these areas could positively impact the current maldistribution and shortage of vascular surgeons.

Positive experiences with the use of an eHealth smartphone application during the treatment of an abdominal aortic aneurysm.

OBJECTIVE: To evaluate the patient perceived satisfaction and feasibility of a personalized eHealth application (app) for abdominal aortic aneurysm (AAA) patients undergoing surgery. METHODS: Patients were offered to download the app prior to undergoing AAA surgery, in a prospective single centre cohort study, using a mixed methods sequential explanatory design. It offers information via the timely delivery of push notifications with text, images, and videos. The information includes chapters regarding the AAA, surgical techniques (endovascular aneurysm repair and open surgical repair), and perioperative lifestyle advice such as; physical exercise programmes, healthy and protein rich diet, geriatric care, and to stop smoking or drinking alcohol. RESULTS: The app was installed by 59/65 patients (91%). After installation, six patients deactivated the app (10%). The mean age was 74 years (SD = 7) and 85% of patients were male. The app was opened a median of 67 times (interquartile range [IQR] 33-127) and with a median time interval of 50 hours (IQR 28-74). Overall, 90% (53/59) completed a satisfaction questionnaire. On a numeric rating scale from 0 to 10, the median scored satisfaction for guidance was 8 (IQR 6-8), provided information was 8 (IQR 6-8), usefulness was 7 (IQR 6-8.5), and for recommending it to others 8 (IQR 6-9). Using purposeful sampling, seven patients underwent a semi-structured interview on user-experience of the app. They described experiencing positive changes to lifestyle habits, and appreciating the ability to share it with loved ones or informal caregivers. Several areas of improvement were reported. CONCLUSION: The personalized eHealth app is feasible in older AAA patients and valued as a useful supplement to the standard of care. We argue that the app aids in managing a prehabilitation programme, aids in the digital transformation of healthcare, and thereby decreases the workload of hospital staff.

Recovery of the hibernating cavernosum by penile revascularization.

Objective: Chronic ischemia-related cavernous dysfunction is considered irreversible. However, in certain patients, cavernous function appears to recover with penile revascularization. In this study, we investigated a potential cavernous dysfunction reversibility from a clinical perspective. Patients and Methods: We involved 93 young patients in the study with arterial erectile dysfunction (ED) (median age: 30 years). Erectile function tests were performed according to the standard operating procedures of the International Society of Sexual Medicine. Among the participants, 63 and 30 displayed pure arteriogenic and mixed vasculogenic (due to both arterial insufficiency and cavernous dysfunction) ED, respectively. Penile revascularization was performed by anastomosing the inferior epigastric artery to the dorsal artery. The ED treatment success was considered from a score of at least 24 on the International Index of Erectile Function-6. Results: Our results proved that penile revascularization cured 92.1% and 73.8% of the patients with pure arteriogenic and mixed vasculogenic ED, respectively (Kaplan-Meier method, log-rank test: no significant difference). The required time for curing 50% of the patients was 10.5 and 10.0 months for pure arteriogenic and mixed vasculogenic ED, respectively, indicating no recovery delay in patients with mixed vascular ED. Furthermore, the cavernous dysfunction degree did not influence cavernous function recovery. Conclusion: Penile revascularization cured ED in 73.8% of the patients with mixed vasculogenic ED. Cavernous dysfunction appears to be reversible in certain cases. Furthermore, we observed no delay in functional recovery compared to participants with healthy cavernous function. These two discoveries suggest that cavernous function recovery after penile revascularization is similar to the concept of hibernating myocardium in ischemic myocardium. Although cavernous dysfunction is considered irreversible, it could be reversed in multiple cases with blood flow restoration to the cavernous tissue.

Abdominal aortic aneurysm repair in Sweden vs. Finland: benefits of population-wide screening.

BACKGROUND AND AIMS: In 2006, screening of 65-year-old men for abdominal aortic aneurysm (AAA) was started in Sweden. Decline in aneurysm-related mortality has been reported since, but aneurysm incidence has been diminishing globally. Neighbouring Finland with similar population structure and health care system has no AAA screening programme. The aim of this study was to compare incidence and results of AAA repair in Sweden and Finland to differentiate the effect of screening from other changes in the epidemiology and treatment of AAA. METHODS: All repairs for intact AAA (iAAA) or ruptured AAA (rAAA) from 1998 to 2017 were identified from national registers, and mortality data for these patients were collected. RESULTS: A total of 15 927 operations for iAAA were performed in Sweden and 6933 in Finland. In Sweden, the yearly operation volume increased after introduction of screening. Both countries showed a decrease in number of rAAA operations, but the decrease was more pronounced in Sweden. Sweden had a higher proportion of all AAA repairs because of rupture in the start of the study but by the end, the proportions were similar in both countries. Long-term survival improved for 65-79-old men in Sweden after start of screening. CONCLUSIONS: This study reveals improvements in results of AAA repair in Sweden. A decrease in rAAA repair and increase in iAAA repair were evident after AAA screening was started in 2006 and resulted in better outcomes. These changes are likely the result of AAA screening as they cannot be seen in neighbouring Finland that is lacking an AAA screening programme.

Rupture of an Aneurysmal Pulmonary Sequestration Artery.

Pulmonary sequestration (PS) is a rare lung malformation seldomly accompanied by aneurysmal deformation of its arterial vasculature. This is a first report of aneurysmal PS presenting with acute aneurysmal rupture. The ruptured aneurysm was treated uneventfully by emergency endovascular coiling, and thoracoscopic hemothorax drainage.

Gender Parity Among Vascular Surgeons: Progress and Attrition.

INTRODUCTION: Improving representation of women in medicine and surgery has been tempered by higher rates of attrition from residencies and from academic medicine among women compared to men. The attrition of women from the practicing vascular surgery workforce has not been studied. METHODS: We utilized the Center for Medicare and Medicaid Services' Doctors and Clinicians database to study vascular surgery employment patterns from 2015 to 2022. We examined gender balance within the workforce and attrition rates among male and female vascular surgeons. We utilized a logistic regression to calculate the odds of attrition by gender. RESULTS: The percentage of female vascular surgeons grew from 11% to 16% between 2015 and 2022, with each graduating class since 2005 having between 20% and 38% women. Yet, female surgeons were 2.05 (95% confidence interval: 1.36-3.08) times more likely to leave practice than their male counterparts when controlling for graduation year and practice in academic medicine. CONCLUSIONS: The proportion of women in vascular surgery is increasing as more women graduate into the specialty. Despite increasing representation, women are more likely than men to leave the workforce.

Outcomes Following Vascular and Endovascular Procedures Performed During the First COVID-19 Pandemic Wave.

Objective: The first COVID-19 pandemic wave was a period of reduced surgical activity and redistribution of resources to only those with late stage or critical presentations. This Vascular and Endovascular Research Network COVID-19 Vascular Service (COVER) study aimed to describe the six-month outcomes of patients who underwent open surgery and or endovascular interventions for major vascular conditions during this period. Methods: In this international, multicentre, prospective, observational study, centres recruited consecutive patients undergoing vascular procedures over a 12-week period. The study opened in March 2020 and closed to recruitment in August 2020. Patient demographics, procedure details, and post-operative outcomes were collected on a secure online database. The reported outcomes at 30 days and six months were post-operative complications, re-interventions, and all cause in-hospital mortality rate. Multivariable logistic regression was used to assess factors associated with six-month mortality rate. Results: Data were collected on 3 150 vascular procedures, including 1 380 lower limb revascularisations, 609 amputations, 403 aortic, 289 carotid, and 469 other vascular interventions. The median age was 68 years (interquartile range 59, 76), 73.5% were men, and 1.7% had confirmed COVID-19 disease. The cumulative all cause in-hospital, 30-day, and six-month mortality rates were 9.1%, 10.4%, and 12.8%, respectively. The six-month mortality rate was 32.1% (95% CI 24.2-40.8%) in patients with confirmed COVID-19 compared with 12.0% (95% CI 10.8-13.2%) in those without. After adjustment, confirmed COVID-19 was associated with a three times higher odds of six-month death (adjusted OR 3.25, 95% CI 2.18-4.83). Increasing ASA grade (3-5 vs. 1-2), frailty scores 4-9, diabetes mellitus, and urgent and or immediate procedures were also independently associated with increased odds of death by six months, while statin use had a protective effect. Conclusion: During the first wave of the pandemic, the six-month mortality rate after vascular and endovascular procedures was higher compared with historic pre-pandemic studies and associated with COVID-19 disease.

Persistent Left-Sided Superior Vena Cava: A Case Report.

A persistent left-sided superior vena cava (PLSVC) is the most common thoracic venous anomaly. However, it is still quite rare in the general population. PLSVC occurs during the embryological stages and is seen mostly in patients with congenital heart disease. Normally during development, the left anterior cardinal vein will regress and obliterate to form the ligament of Marshall. In cases of PLSVC, the left anterior cardinal vein persists and can become a persistent left superior vena cava (SVC). There are different anatomical variants of a left-sided SVC, most commonly presenting with both a right and a left SVC. In some PLSVC cases, there is an isolated left SVC. Though rare, this anomaly is not without clinical significance. This case report describes a 48-year-old male with incidental findings of isolated PLSVC seen on chest X-ray after the placement of a temporary dialysis catheter. This report will also describe the incidence/prevalence, embryological origin including anatomical variants, and clinical implications of PLSVC.

Prevalence of Varicose Veins Among Surgeons: A Cross-Sectional Study.

Background Extended periods of standing, obesity, female sex, and older age are risk factors associated with a higher probability of developing varicose veins (VV). This study aimed to determine the prevalence of VV among surgeons in public hospitals in Makkah, Saudi Arabia, and to identify the risk factors associated with this condition.  Methodology This is a descriptive cross-sectional study based on a validated online questionnaire distributed via hospital WhatsApp (Meta Platforms Inc., Menlo Park, CA) groups conducted between January and June 2024. The inclusion criteria of this study were surgeons of both sexes and any age group working in the selected hospitals in Makkah City, who agreed to participate in the study. The exclusion criteria were any other healthcare workers from outside the surgical field. We included 192 participants, and Epi Info software (Centers for Disease Control and Prevention, Atlanta, GA) was used to calculate the sample size. The data were collected, reviewed, and then fed into IBM SPSS Statistics software for Windows version 21 (IBM Corp., Armonk, NY). Every participant filled out a consent form. The university ethics committee of Umm Al-Qura University, Makkah, granted ethical permission. Result This study comprised 192 surgeons in Makkah hospitals. Twenty-eight surgeons were either diagnosed with VV or had signs of VV. Varicose veins were detected among 50% of thoracic surgeons, 42.9% of pediatric surgeons, and 26.3% of orthopedic surgeons. The most reported risk factors were a family history of VV (17%), hypertension (16%), and diabetes mellitus (14%). Surgeons aged 40 years or older had a higher prevalence of VV than younger ones. Also, 55.6% of obese surgeons had VV compared to 7.8% of others with average weight. Conclusion We found that VV is a common problem, particularly among individuals with predisposing factors, such as long standing hours, smoking, pregnancy, and obesity. We found that surgeons specializing in thoracic and pediatric specialties and female surgeons were more likely to be affected by VV. Preventive measures, such as avoiding prolonged standing, wearing compression stockings, and maintaining a healthy lifestyle, are recommended.

Designing a Perioperative Mind-Body Intervention for Peripheral Vascular Interventions.

Background: Peripheral vascular interventions (PVIs) performed under procedural sedation and analgesia (PSA) can be associated with anxiety and poor compliance with patient instructions during surgery. Mind-body interventions (MBIs) such as meditation have demonstrated the potential to decrease perioperative anxiety, though this area is understudied, and no tailored interventions have been developed for the vascular surgical patient population. Objectives: We aimed to design a perioperative MBI that specifically targeted vascular surgical patients undergoing PVIs under PSA. We sought to perform this in a scientifically rigorous, multi-disciplinary collaborative manner. Methods: Following the Obesity-Related Behavioral Intervention Trials (ORBIT) model, we designed (Phase 1a) and then refined (Phase 1b) a MBI for patients undergoing PVIs under PSA to decrease perioperative anxiety and sedation and facilitate patient intraoperative compliance. Phase 1a involved a literature review, informal information gathering and synthesis, and drafting a preliminary protocol for a perioperative MBI. Phase 1b involved assembling a multi-disciplinary expert panel of perioperative and mind-body clinicians and researchers to improve the MBI using an iterative, modified Delphi approach. Results: The modified Delphi process was completed, and a consensus was reached after three iterations. The resulting MBI consisted of two seven-minute preoperative guided meditations on the day of surgery, including diaphragmatic breathing, body scans, and guided imagery emphasizing awareness of the ipsilateral leg where the vascular surgery was performed. A document delineating the integration of the MBI into the operating room workflow was produced, including details regarding the intervention's timing, duration, and modality. Conclusion: Using a multi-specialty expert panel, we designed a novel MBI in the form of a guided meditation with elements of mindfulness and guided imagery to decrease anxiety and increase intraoperative compliance for patients undergoing PVIs under PSA. A prospective pilot study is being planned to test the program's feasibility.

The application and uses of telemedicine in vascular surgery: A narrative review.

Technological advances over the past century have accelerated the pace and breadth of medical and surgical care. From the initial delivery of "telemedicine" over the radio in the 1920s, the delivery of medicine and surgery in the 21st century is no longer limited by connectivity. The COVID-19 pandemic hastened the uptake of telemedicine to ensure that health care can be maintained despite limited face-to-face contact. Like other areas of medicine, vascular surgery has adopted telemedicine, although its role is not well described in the literature. This narrative review explores how telemedicine has been delivered in vascular surgery. Specific themes of telemedicine are outlined with real-world examples, including consultation, triaging, collaboration, mentoring, monitoring and surveillance, mobile health, and education. This review also explores possible future advances in telemedicine and issues around equity of care. Finally, important ethical considerations and limitations related to the applications of telemedicine are outlined.

Large language models and artificial intelligence chatbots in vascular surgery.

Natural language processing is a subfield of artificial intelligence that aims to analyze human oral or written language. The development of large language models has brought innovative perspectives in medicine, including the potential use of chatbots and virtual assistants. Nevertheless, the benefits and pitfalls of such technology need to be carefully evaluated before their use in health care. The aim of this narrative review was to provide an overview of potential applications of large language models and artificial intelligence chatbots in the field of vascular surgery, including clinical practice, research, and education. In light of the results, we discuss current limits and future directions.

Extended and augmented reality in vascular surgery: Opportunities and challenges.

Extended reality has brought new opportunities for medical imaging visualization and analysis. It regroups various subfields, including virtual reality, augmented reality, and mixed reality. Various applications have been proposed for surgical practice, as well as education and training. The aim of this review was to summarize current applications of extended reality and augmented reality in vascular surgery, highlighting potential benefits, pitfalls, limitations, and perspectives on improvement.

Comprehensive review of virtual assistants in vascular surgery.

Virtual assistants, broadly defined as digital services designed to simulate human conversation and provide personalized responses based on user input, have the potential to improve health care by supporting clinicians and patients in terms of diagnosing and managing disease, performing administrative tasks, and supporting medical research and education. These tasks are particularly helpful in vascular surgery, where the clinical and administrative burden is high due to the rising incidence of vascular disease, the medical complexity of the patients, and the potential for innovation and care advancement. The rapid development of artificial intelligence, machine learning, and natural language processing techniques have facilitated the training of large language models, such as GPT-4 (OpenAI), which can support the development of increasingly powerful virtual assistants. These tools may support holistic, multidisciplinary, and high-quality vascular care delivery throughout the pre-, intra-, and postoperative stages. Importantly, it is critical to consider the design, safety, and challenges related to virtual assistants, including data security, ethical, and equity concerns. By combining the perspectives of patients, clinicians, data scientists, and other stakeholders when developing, implementing, and monitoring virtual assistants, there is potential to harness the power of this technology to care for vascular surgery patients more effectively. In this comprehensive review article, we introduce the concept of virtual assistants, describe potential applications of virtual assistants in vascular surgery for clinicians and patients, highlight the benefits and drawbacks of large language models, such as GPT-4, and discuss considerations around the design, safety, and challenges associated with virtual assistants in vascular surgery.

e-Health and environmental sustainability in vascular surgery.

e-Health technology holds great promise for improving the management of patients with vascular diseases and offers a unique opportunity to mitigate the environmental impact of vascular care, which remains an under-investigated field. The innovative potential of e-Health operates in a complex environment with finite resources. As the expansion of digital health will increase demand for devices, contributing to the environmental burden of electronics and energy use, the sustainability of e-Health technology is of crucial importance, especially in the context of increasing prevalence of cardiovascular diseases. This review discusses the environmental impact of care related to vascular surgery and e-Health innovation, the potential of e-Health technology to mitigate greenhouse gas emissions generated by the health care sector, and to provide leads to research promoting e-Heath technology sustainability. A multifaceted approach, including ethical design, validated eco-audits methodology and reporting standards, technological refinement, electronic and medical devices reuse and recycling, and effective policies is required to provide a sustainable and optimal level of care to vascular patients.

A surgical approach to complex regional pain syndrome with neurogenic thoracic outlet syndrome in a reoperation patient.

Thoracic outlet syndrome (TOS) and complex regional pain syndrome (CRPS) are two etiologies of chronic pain. TOS is a group of conditions that occur due to compression of the neurovascular structures of the upper extremity while CRPS is a disorder characterized by chronic and unremitting pain. This case highlights the experience of a 22-year-old female who presented following a traumatic injury to her left arm and was initially diagnosed with neurogenic TOS and later CRPS. Over a 10-year-period, she underwent a total of four operations to try and address her debilitating pain. In our third-time reoperation, symptoms of both pathologies nearly completely resolved with extensive neurolysis of the left brachial plexus and application of a scar tissue barrier.

A case report of a patient with severe & debilitating arm pain: Neurogenic thoracic outlet syndrome and complex regional pain syndrome are two disorders with the potential to cause severe and debilitating long-term pain, typically in an arm or leg. These two disorders are hard to diagnose, and patients can have variable responses to treatment. This case discussed a young woman who has severe pain of her left arm which eventually progress to the point that she had lost all meaningful use of the arm. After 8 years of treatments and four surgeries, she improved and began to regain her arm function.

Comparison of Duplex Ultrasound and Digital Subtraction Angiography for Assessing Tibial Vessel Disease.

Background Duplex ultrasonography (DUS) is readily available and often used as the first diagnostic test for patients with peripheral artery diseases (PADs). PAD is a disease that affects the general population but more commonly affects diabetics. To date, the role of DUS in the assessment of tibial vessel disease is inconclusive at best. The goal of our study is to assess the validity of DUS in characterizing the presence and severity of tibial diseases via comparison with digital subtraction angiography (DSA) findings. Methods This is a single-center retrospective cohort study analyzing three arterial segments (anterior tibial, posterior tibial, and fibular arteries) in patients who received a duplex study followed by DSA within a 30-day period. All arterial segments were graded from normal (Grade 0) to occluded (Grade 4), based on duplex interpretation and directly compared to direct visualization findings from DSA. Using statistical methods, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of DUS were determined. Results A total of 171 tibial vessel segments from 57 enrolled subjects with critical limb ischemia symptoms were analyzed in this study. The agreement between both modalities was poor (Kappa=0.19, p < 0.05), with DUS demonstrating a significant underestimation of vessel pathologies. This is also reflected by the overall sub-optimal sensitivity (23%), specificity (84%), PPV (69%), and NPV (41%) in DUS when compared to DSA results as the gold standard. Conclusion Significant disagreements were noted in this study between DUS and DSA findings, primarily significant underestimation of tibial vessel disease by the DUS when compared with the DSA. Caution is advised in the clinical application of DUS in patients with chronic limb-threatening ischemia (CLTI) symptoms and multi-segment tibial vessels due to its demonstrated limitations in this study.

Clinical Outcomes of 5000 IU Heparin Versus Activated Clotting Time-Guided Heparinization During Noncardiac Arterial Procedures: A Propensity Score Matched Analysis.

PURPOSE: Previous studies have shown that activated clotting time (ACT)-guided heparinization leads to better anticoagulation levels during noncardiac arterial procedures (NCAP) than a standardized bolus of 5000 IU. Better anticoagulation should potentially result in lower incidence of thrombo-embolic complications (TEC). Comparative investigations on clinical outcomes of these heparinization strategies are scarce. This study investigated clinical outcomes of ACT-guided heparinization with a starting dose of 100 IU/kg in comparison with a single standardized bolus of 5000 IU heparin during NCAP. MATERIALS AND METHODS: Analysis from a prospectively collected database of patients undergoing NCAP in 2 vascular centers was performed. Patients receiving ACT-guided heparinization were matched 1:1 with patients receiving 5000 IU heparin using propensity score matching (PSM). Primary outcomes were TEC, bleeding complications, and mortality within 30 days of procedure or during the same admission. RESULTS: A total of 759 patients (5000 IU heparin: 213 patients, ACT-guided heparinization: 546 patients) were included. Propensity score matching resulted in 209 patients in each treatment group. After PSM, the groups were comparable, with the exception of a higher prevalence of peripheral arterial disease in the ACT-guided heparinization group (103 patients, 49% vs 82 patients, 39%, p=0.039). The target ACT (>200 seconds) was reached in 198 patients (95%) of the ACT-guided group versus 71 patients (34%) of the 5000 IU group (p<0.001), indicating successful execution of the ACT-guided protocol. Incidence of TEC (13 patients, 6.2% vs 10 patients, 4.8%, p=0.52), mortality (3 patients, 1.4% vs 0 patients, p=0.25), and bleeding complications (32 patients, 15% vs 25 patients, 12%, p=0.32) did not differ between patients receiving ACT-guided heparinization and 5000 IU heparin. Protamine was administered in 118 patients (57%) in the ACT group versus 11 patients (5.3%) in the 5000 IU group (p<0.001), but did not influence incidence of TEC (17 patients, 5.9% vs 6 patients, 4.7%, p=0.61) or bleeding complications (34 patients, 12% vs 22 patients, 17%, p=0.14). CONCLUSION: No difference in TEC, bleeding complications, or mortality was found between ACT-guided heparinization and a single bolus of 5000 IU heparin during NCAP. CLINICAL IMPACT: Previous studies have shown that activated clotting time (ACT)-guided heparinization leads to better anticoagulation levels during non-cardiac arterial procedures (NCAP) then a standardized bolus of 5000 IU. Comparative investigations on clinical outcomes are scarce. This study focussed on clinical outcomes of both protocols in NCAP in a propensity score matched cohort. Thrombo-embolic complications (TEC), bleeding complications and mortality within 30 days after NCAP or during the same admission were comparable between groups. Future studies should focus on optimizing ACT-guided protocols, specifically in patients with a high risk of TEC and bleeding complications.

The difficulties and solutions in operationalising a hybrid operating room.

As the population ages and grows, health services must evolve in ways to offer versatile patient care, whilst improving patient outcomes and maintaining long-term economic viability. A facility assisting in the provision of such healthcare is the hybrid operating room (HOR): a specialised suite allowing simultaneous radiological and surgical diagnostics and therapeutics in a single episode of care. Versatile and customizable, the HOR is utilised by a broad range of subspecialties in elective and emergency settings, including (but not limited to) vascular surgery, trauma surgery and interventional radiology. Though the benefits of hybrid techniques to patient care are well known, the actual steps in operationalising the HOR can be challenging if not considered and coordinated appropriately. The intention of this narrative review is to highlight issues and suggest solutions in the design and commissioning of an HOR. Key areas in need of specific attention include stakeholder involvement, economic feasibility, suite location, workflow planning, hybrid equipment choice, and team organisation.