Lower-Extremity Vascular Ulcers: Assessment and Approaches to Management.

Healing of skin wounds of the lower extremities can be complicated by concomitant vascular disease. Dysfunction of the arterial, venous, and/or lymphatic systems can compromise the healing of skin ulcers of the legs, creating a burden for patients from painful, draining wounds and placing patients at risk for infection, amputation, and even death. Insights into vascular pathophysiology and an understanding of the processes of wound healing permit an evidence-based approach to patients with vascular leg ulcers. Clinical trials have demonstrated opportunities to improve the care of patients with vascular leg ulcers, thereby reducing morbidity and mortality and easing patients' burdens.

Relative value unit-based compensation incentivization in an academic vascular practice improves productivity with no early adverse impact on quality.

OBJECTIVE: Given the increased pressure from governmental programs to restructure reimbursements to reflect quality metrics achieved by physicians, review of current reimbursement schemes is necessary to ensure sustainability of the physician's performance while maintaining and ultimately improving patient outcomes. This study reviewed the impact of reimbursement incentives on evidence-based care outcomes within a vascular surgical program at an academic tertiary care center. METHODS: Data for patients with a confirmed 30-day follow-up for the vascular surgery subset of our institution's National Surgical Quality Improvement Program submission for the years 2013 and 2014 were reviewed. The outcomes reviewed included 30-day mortality, readmission, unplanned returns to the operating room, and all major morbidities. A comparison of both total charges and work relative value units (RVUs) generated was performed before and after changes were made from a salary-based to a productivity-based compensation model. P value analysis was used to determine if there were any statistically significant differences in patient outcomes between the two study years. RESULTS: No statistically significant difference in outcomes of the core measures studied was identified between the two periods. There was a trend toward a lower incidence of respiratory complications, largely driven by a lower incidence in pneumonia between 2013 and 2014. The vascular division had a net increase of 8.2% in total charges and 5.7% in work RVUs after the RVU-based incentivization program was instituted. CONCLUSIONS: Revenue-improving measures can improve sustainability of a vascular program without negatively affecting patient care as evidenced by the lack of difference in evidence-based core outcome measures in our study period. Further studies are needed to elucidate the long-term effects of incentivization programs on both patient care and program viability.

Open abdominal aortic aneurysm repair is still necessary in an era of advanced endovascular repair.

OBJECTIVE: Recent advances in endovascular aneurysm repair have overcome substantial anatomic barriers associated with short and challenging necks. With greater range to treat more difficult anatomy from an endovascular approach, one would assume the need of open surgical repair (OSR) would be diminished. The purpose of our study was to determine the need for OSR for abdominal aortic aneurysms, in a tertiary academic setting, with a moderate volume (10-15 cases/year) of fenestrated endografting being performed. METHODS: An Institutional Review Board approved retrospective review was performed of all patients who underwent elective aortic aneurysm repair between January 2010 and July 2014. Computed tomography scans for patients who underwent OSR were reviewed and anatomic characteristics obtained. Instructions for use of (IFU) a commercially available fenestrated device (Cook Medical, Bloomington, Ind) were used to determine if open repair patients had anatomy amenable to advanced endovascular repair. RESULTS: During the study interval, 415 patients underwent abdominal aortic aneurysm repair. Of those patients who underwent elective aneurysm repair, 105 patients had OSR. The study subsequently excluded 11 patients because they underwent secondary interventions after a failed endovascular repair and thus were not further evaluated. Also excluded were 18 patients who had OSR for an emergency intervention. The remaining 76 patients (35 female, 41 male; average age, 72 ± 8 years) had OSR and were outside the IFU of the fenestrated endovascular aneurysm repair (FEVAR) device. The average diameter of the abdominal aorta was 5.9 cm. Indications for OSR were an aneurysm neck <4 mm (71%), inclusion of at least 1 visceral vessel (69.7%), unilateral iliac artery aneurysms (15.5%), bilateral iliac artery aneurysms (14.3%), iliac artery tortuosity >40° of angulation (37.6%), extensive aortic thrombus (23.2%), and aortic neck angulation >45° (11.8%). Rejected patients had an average of 1.7 ± 0.8 anatomic constraints (range 1-4) that prevented use of the FEVAR device. CONCLUSIONS: With evidence to support the strict adherence to IFU protocols of the FEVAR device in patients, our institution's practice has been to continue to perform open abdominal aortic aneurysm repair for patients with anatomy outside device protocols. Although it was thought that the decreased requirement of aortic neck required to deploy an endograft would lead to an increased patient population amenable to endovascular repair, there is still a clinically significant need for open aortic surgery.

Modified eversion carotid endarterectomy.

BACKGROUND: Eversion carotid endarterectomy is a well-described technique for carotid endarterectomy (CEA). The advantage of this technique is a completely autogenous repair. We describe a modification of eversion endarterectomy (MEE) that expeditiously extracts the plaque through a linear incision over the common carotid artery and the proximal bulbous internal carotid artery (ICA) only, allowing primary closure. Selective shunting can also be performed without difficulty. METHODS: A retrospective review of CEAs using MEE at two institutions by three vascular surgeons during a 5-year period was performed. Data were collected from the medical records, with institutional review board approval. Information regarding neurologic symptoms, degree of ICA stenosis, CEA technique, ICA clamp time, shunting, electroencephalographic monitoring, and postoperative complications was tabulated. Rate of significant restenosis (stenosis >50% by duplex criteria) was also calculated during the follow-up period. RESULTS: Between 2005 and 2009, a total of 221 patients underwent MEE for carotid artery stenosis (CAS): 69 patients (31%) underwent MEE for symptomatic and 152 (68.8%) underwent MEE for asymptomatic CAS. Neuromonitoring in the form of electroencephalography was used in 85 (39%) patients, and an intraluminal shunt was used in 29 patients (13%) who had either severe contralateral disease or a previous ipsilateral cerebral infarction. Postoperative complications included transient ischemic attack (four, 2%), cerebral infarction (three, 1%), myocardial infarction (three, 1%), and hematoma (six, 3%). Four patients (2%) required a return to the operating room (OR). within 24 hours for hematoma (one, 1%) or postoperative neurologic deficit (three, %). The 30-day mortality was 1%. One patient (1%) required patch angioplasty because of the extent of disease and inability to obtain a good end point. Average cross-clamp time for MEE was 12.8 minutes. Two patients (1%) were reported to have hemodynamically significant restenosis within 2 years, with one patient requiring intervention. CONCLUSIONS: MEE is a safe and effective way of treating CAS, with acceptable morbidity, mortality, and low rate of recurrent stenosis despite the absence of a patch. Given the brief clamp time required, routine shunting and/or neuromonitoring for this technique may have questionable clinical value and expense.

Violations of behavioral practices revealed in closed claims reviews.

OBJECTIVE: Closed claims against general surgeons were reviewed, seeking insights into the effects of surgeons' deficient behavioral practices on outcomes. Research and educational strategies based on findings may reduce errors and improve care. SUMMARY BACKGROUND DATA: Adverse events occur in 2.9% to 3.7% of hospital admissions in the United States. Of these adverse events, 27.4% to 32.6% are the result of errors. Failures at the point-of-service can undermine the other elements of systems of care designed to reduce preventable adverse outcomes. In this regard, the relative importance of surgeons' behavior is poorly defined. METHODS: Fellows of the American College of Surgeons (ACS) reviewed 460 malpractice claims against general surgeons. The relationship between detrimental behavioral practice patterns--deficiencies in care that reflected a lack of diligence, vigilance, and/or commitment of time more than a lack of knowledge and/or skill--and the preventability of adverse events was assessed. RESULTS: Failures in practice patterns of behavior occurred in 78% of cases and were frequently associated with preventable injuries. When both behavioral practice violations and technical misadventures occurred, the complications were more likely to be preventable than if only a technical misadventure had occurred. Among several deficient behavioral practices, the failure to communicate was most pervasive, accounting for 22% of complications in the study. CONCLUSIONS: Stakeholders in health care policy should focus on the issue of physician behavior in crafting shifts in institutional cultures and in targeting new CME toward evidenced-based behavioral practices.

The American College of Surgeons' closed claims study: new insights for improving care.

BACKGROUND: All physicians must be vigilant in the pursuit of safe care for patients. While problems in care are identified, education that provides an understanding of these problems and guidelines for improvement can enhance patient safety. Our objective was to determine problematic aspects of surgical care, including care provided by surgeons before, during, after, and instead of surgery, that negatively affect patient safety. STUDY DESIGN: Four hundred sixty malpractice claims against general surgeons were reviewed by surgeons (FACS). All claims were closed in 2003 or 2004. The data collection was completed at five medical liability companies representing a nationwide distribution of surgeons. Surgeons also dictated or wrote narratives for each case. The quantitative data and narratives were later analyzed to determine events responsible for unsafe care. RESULTS: Surgeon-reviewers identified deficiencies in care that fell below accepted standards more often before and after operations than during them. These deficiencies were often the result of a failure to recognize surgical injuries, and many of these deficiencies were preventable. The quality of surgical care was satisfactorily met in 36% of cases. The most common procedures involving patient safety concerns were those involving the biliary tract, intestines, hernias, vascular system, esophagus, and stomach. The most frequent events leading to claims included delayed diagnosis, failure to diagnose, failure to order diagnostic tests, technical misadventure, delayed treatment, and failure to treat. Complications occurring most frequently were organ injuries, adult respiratory distress syndrome, and infection. CONCLUSIONS: Closed claims reviews provide valuable data that may enhance provider performance through heightened awareness of common unsafe practices. Specifically, opportunities exist to improve surgical care provided during the preoperative and postoperative phases of treatment through continuing medical education to improve patient safety.

Care of critically ill surgical patients using the 80-hour Accreditation Council of Graduate Medical Education work-week guidelines: a survey of current strategies.

As a result of the recently mandated work-hour restrictions, it has become more difficult to provide 24-hour intensive care unit (ICU) in-house coverage by the general surgical residents. To assess the current state of providing appropriate continuous care to surgical critical care patients during the era of resident work-hour constraints, a national survey was conducted by the Association of Program Directors of Surgery. The results revealed that 37 per cent of programs surveyed have residents other than general surgery housestaff providing cross-coverage and writing orders for surgical ICU patients. Residents in emergency medicine, anesthesia, family medicine, otorhinolaryngology, obstetrics/gynecology, internal medicine, urology, and orthopedic surgery have provided this cross-coverage. Some found it necessary to use physician extenders (i.e., nurse practitioners or physician assistants), thereby decreasing the burden of surgical housestaff coverage. The results indicated that 30 per cent use physician extenders to help cover the ICU during daytime hours and 11 per cent used them during nighttime hours. In addition, 24 per cent used a "night-float" system in an attempt to maintain continuous care, yet still adhere to the mandated guidelines. In conclusion, our survey found multiple strategies, including the use of physician extenders, a "night-float" system, and the use of nongeneral surgical residents in an attempt to provide continuous coverage for surgical ICU patients. The overall outcome of these new strategies still needs to be assessed before any beneficial results can be demonstrated.

Blunt handlebar injury of the common femoral artery: a case report.

Bicycle handlebar-related blunt trauma to the femoral vessels with resulting arterial injury has been described previously. However, significant injury to the ileofemoral tree with underlying arterial occlusive disease in the face of handlebar-related trauma has not been reported. We present the case of an all-terrain vehicle accident with isolated injury to the common femoral artery in a patient with underlying atherosclerotic disease.

Nicotine induces mononuclear leukocyte adhesion and expression of adhesion molecules, VCAM and ICAM, in endothelial cells in vitro.

The pathology of atherosclerotic cardiovascular disease (ASCVD) has been characterized as an inflammatory response to vessel injury. The initial steps of this response involve mononuclear leukocyte (MNL) attachment and infiltration into the vessel wall. Leukocyte adhesion is potentiated by expression of cellular adhesion molecules. Vascular cell adhesion molecule-1 (VCAM) and intracellular adhesion molecule-1 (ICAM) are markers of cellular activation and have the ability to attach leukocytes to the endothelium, which is an initial event in the inflammatory response in the vessel wall. Human umbilical vein endothelial cells (HUVEC) were plated in endothelial growth medium (EGM) on plastic coverslips and grown until cells were 75% confluent. Free base nicotine (FBN) was diluted in EGM to a concentration of 10(-8) M and added to experimental cells. At 3 hr, coverslips were removed and fixed. Immunohistochemical staining (IHCS) was performed using a monoclonal antibody to human ICAM and VCAM. Digital image analysis (DIA) was performed to quantify the expression of ICAM and VCAM. An intensity stain index (ISI) measuring area and intensity of stain/total cellular area was determined. Additional HUVEC grown in a similar manner were either exposed to 10(-8) M FBN in EGM or EGM control for 4 hr, then were exposed to MNL suspension for 10 min. Coverslips were removed, rinsed, and fixed. Hematoxylin and eosin staining was performed and cells examined under light microscopy. Leukocyte number per high power field (HPF) was counted and compared to controls. Data were analyzed using analysis of variants (ANOVA) and Student's t-test. Differences were considered significant if p < 0.05. ICAM and VCAM expression was absent in control cells. Nicotine exposure at 3 hr induced expression of VCAM (ISI = 30.85+/-0.77) and to a lesser extent ICAM (ISI = 16.6+/-1.39) (p < 0.001). MNL adhesion was markedly increased in cells exposed to nicotine (79.4+/-16.9/HPF) when compared to control cells (1.8+/-0.91/HPF) exposed to MNL (p < 0.01). These data show nicotine's ability to activate HUVEC as evidenced by induction of ICAM and VCAM expression in vitro. The biological effects of these adhesion molecules are demonstrated by a marked increase in MNL adhesion to HUVEC as demonstrated by leukocyte adhesion assay (LAA). MNL adhesion and subsequent migration into the intima, if occurring in vivo, may be a vital step in the pathogenesis of ASCVD associated with nicotine exposure.

A case of warfarin skin necrosis despite enoxaparin anticoagulation in a patient with protein S deficiency.

Warfarin-induced skin necrosis is a rare complication associated with the use of oral anticoagulants. Most patients develop this at the initiation of therapy, often while still receiving intravenous unfractionated heparin (UFH). Recently, low-molecular-weight heparins (LMWHs) have gained wider use, providing an option for outpatient treatment of deep-vein thrombosis. The treatment protocols are similar to UFH, including the early initiation of oral anticoagulation with warfarin. A Medline search failed to reveal any cases of warfarin-induced skin necrosis while using a LMWH. We present a patient with protein S deficiency who developed warfarin skin necrosis despite appropriate anticoagulation with enoxaparin, and review the chemical and clinical difference between UFH and LMWH.