Aortic valve-sparing operations: my perspectives.

Valve-sparing procedures have been established as a durable option for treatment of patients with aortic root pathology. Complex cases where aortic valve-sparing root replacement (VSRR) is applied require specific surgical techniques to ensure good outcomes. Herein, we review main concepts of VSRR and aortic valve repair. In addition, we provide three complex clinical scenarios: treatment of neo-aortic dilation after a Ross procedure, acute aortic insufficiency in a type A dissection, and chronic aortic insufficiency with a bicuspid aortic valve. Technical suggestions to achieve a safe and durable result are set forth. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01587-4.

Valve-sparing root replacement-reimplantation technique.

The first valve sparing root replacement (VSRR) was first described over thirty years ago. Reimplantation is favored at our institution to provide maximum annular support in the setting of annuloaortic ectasia. Multiple iterations for this operation have been reported. Surgical intervention varies in terms of graft sizing, the number and method of inflow suture placement, strategy for annular plication and stabilization, and finally choice of graft type. Our specific technique has evolved over the last eighteen years and the current approach is to use a larger straight graft loosely based on the original Feindel-David formula, six inflow sutures to anchor the graft, and some degree of annular plication with annular stabilization. The long-term results for both trileaflet and bicuspid valves are associated with a low reintervention rate. Herein we provide a clear outline for our specific approach to the reimplantation technique.

Too big to fail?-An aggressive strategy for a dire problem.

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aortotracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery, the authors propose a surgical treatment that is reproducible for the correct anatomic configuration-an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage. While this intervention is a large undertaking for a small defect, it is a safe and durable repair.

A Statewide Multi-Institutional Study of Asymptomatic Pretreatment Testing of Radiation Therapy Patients for SARS-CoV-2 in a High-Incidence Region of the United States.

PURPOSE: Our purpose was to establish the prevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in asymptomatic patients scheduled to receive radiation therapy and its effect on management decisions. METHODS AND MATERIALS: Between April 2020 and July 2020, patients without influenza-like illness symptoms at four radiation oncology departments (two academic university hospitals and two community hospitals) underwent polymerase chain reaction testing for SARS-CoV-2 before the initiation of treatment. Patients were tested either before radiation therapy simulation or after simulation but before treatment initiation. Patients tested for indications of influenza-like illness symptoms were excluded from this analysis. Management of SARS-CoV-2-positive patients was individualized based on disease site and acuity. RESULTS: Over a 3-month period, a total of 385 tests were performed in 336 asymptomatic patients either before simulation (n = 75), post-simulation, before treatment (n = 230), or on-treatment (n = 49). A total of five patients tested positive for SARS-CoV-2, for a pretreatment prevalence of 1.3% (2.6% in north/central New Jersey and 0.4% in southern New Jersey/southeast Pennsylvania). The median age of positive patients was 58 years (range, 38-78 years). All positive patients were white and were relatively equally distributed with regard to sex (2 male, 3 female) and ethnicity (2 Hispanic and 3 non-Hispanic). The median Charlson comorbidity score among positive patients was five. All five patients were treated for different primary tumor sites, the large majority had advanced disease (80%), and all were treated for curative intent. The majority of positive patients were being treated with either sequential or concurrent immunosuppressive systemic therapy (80%). Initiation of treatment was delayed for 14 days with the addition of retesting for four patients, and one patient was treated without delay but with additional infectious-disease precautions. CONCLUSIONS: Broad-based pretreatment asymptomatic testing of radiation oncology patients for SARS-CoV-2 is of limited value, even in a high-incidence region. Future strategies may include focused risk-stratified asymptomatic testing.

Patient information sources when facing repair of abdominal aortic aneurysm.

OBJECTIVE: Shared medical decision making is most important when there are competing options for repair such as in treatment of abdominal aortic aneurysm (AAA). We sought to understand the sources of patients' pre-existing knowledge about AAA to better inform treating physicians about patients' needs for preoperative counseling. METHODS: We performed a multicenter survey of patients facing AAA repair at 20 Veterans Affairs hospitals across the United States as part of the Preferences for Open Versus Endovascular Repair of AAA study. A validated survey instrument was administered to examine the sources of information available and commonly used by patients to learn about their repair options. The survey was administered by study personnel before the patient had any interaction with the vascular surgeon because survey data were collected before the vascular clinic visit. RESULTS: Preliminary analysis of data from 99 patients showed that our cohort was primarily male (99%) and elderly (mean age 73 years). Patients commonly had a history of hypertension (86%), prior myocardial infarction (32%), diabetes (32%), and were overweight (58%). Patients arrived at their surgeon's office appointment with limited information. A majority of patients (52%) reported that they had not talked to their primary care physician at all about their options for AAA repair, and one-half (50%) reported that their view of the different surgical options had not been influenced by anyone. Slightly less than one-half of patients reported that they did not receive any information about open surgical aneurysm repair and endovascular aortic aneurysm repair (41% and 37%, respectively). Few patients indicated using the internet as their main source of information about open surgical aneurysm repair and endovascular aortic aneurysm repair (10% and 11%, respectively). CONCLUSIONS: Patients are commonly referred for AAA repair having little to no information regarding AAA pathology or repair options. Fewer than one in five patients searched the internet or had accessed other sources of information on their own. Most vascular surgeons should assume that patients will present to their first vascular surgery appointment with minimal understanding of the treatment options available to them.

Variation in timing and type of groin wound complications highlights the need for uniform reporting standards.

BACKGROUND: Groin wound infections represent a substantial source of patients' morbidity and resource utilization. Definitions and reporting times of groin infections are poorly standardized, which limits our understanding of the true scope of the problem and potentially leads to event under-reporting. Our objective was to investigate the timing and variation of groin wound complications after vascular surgery. METHODS: We reviewed all patients who underwent vascular surgery with a groin incision at our institution during 2013 (N = 256; 32% female; mean age, 68.8 years). We analyzed patient- and procedure-level variables. Our primary outcome was any groin complication within 180 days. We classified groin-related events as major (hospital readmission or reoperation for groin wound) or minor (wound opened in clinic, initiation of antibiotics specifically for a groin wound, or new groin hematoma or wound drainage). RESULTS: The Kaplan-Meier estimated rate of groin complications at 180 days was 23% (n = 53/256); 29 (54%) were major and 24 (46%) were minor. The Kaplan-Meier 30-day event rate was 13% for any complication and only 3% for major complications, indicating that most events occurring within the first 30 days did not require readmission or reoperation. By 180 days, the overall complication rate rose to 23% and the major event rate to 14%, indicating that nearly all complications occurring after 30 days required readmission or reoperation. Those with a groin complication more commonly had tissue loss (23% vs 12%; P = .05), underwent infrainguinal bypass (42% vs 22%; P=.004), had a redo incision (32% vs 18%; P = .03), and had a longer operation (77% vs 65% surgery >200 minutes; P = .07). There were no significant differences in patients' comorbidities, skin closure, dressing type, prosthetic implants, hemostatic agents, or discharge status. CONCLUSIONS: Whereas >20% of patients suffered a groin complication, nearly half of these events occurred after 30 days. Standardized reporting measures limited to 30-day events or infection definitions that are limited to the need for antibiotic use may misrepresent the true infection rate and thus highlight the need for uniform reporting standards.

Disparity in Medicaid physician payments for vascular surgery.

OBJECTIVE: Medicare reimbursements are standardized nationwide on the basis of resource-dependent inputs of physicians' time, intensity, practice costs, and malpractice costs, whereas Medicaid payments vary and are determined by individual states. Our objectives were to determine Medicaid reimbursement to physicians for common vascular procedures for the seven states in the Northeast that compose the New England Society for Vascular Surgery and to compare Medicaid payments with Medicare. METHODS: Using publicly available data, we obtained Medicaid physician payments in Connecticut, Massachusetts, Maine, New Hampshire, New York, Rhode Island, and Vermont for 10 commonly performed vascular surgery procedures. For comparison, Medicare physician payments for these procedures were adjusted for regional differences using Medicare geographic payment cost indices. Descriptive statistics were calculated by state; Wilcoxon signed rank test was used to compare fees, and one-way analysis of variance was used to compare variance. RESULTS: Medicaid payments varied widely by state. Within individual states (except Vermont), there was no relationship between Medicaid and Medicare payments. Medicaid reimbursement for common vascular procedures ranged from 25% to 91% of Medicare rates and had up to a threefold variation in payment among states for a single procedure. The mean Medicaid payment was 60% of Medicare payment. The greatest state-to-state variance in payment was for open abdominal aortic repair (standard deviation, $227.31); the least was for femoral artery exposure (standard deviation, $31.86). For a Medicaid-based, frequency-weighted analysis of services, New Hampshire exhibited the lowest payments (43% Medicare) and Vermont the highest (80% Medicare). CONCLUSIONS: Among the seven Northeast states considered, with the exception of Vermont, there is no logical relationship between Medicaid and Medicare payments. Because Medicare payments are determined by the Centers for Medicare and Medicaid Services with consideration of resource-based inputs, we conclude that in six of the seven states, Medicaid payments bear no relationship to resource utilization. With Medicaid expansion, access to vascular procedures may be limited by payments insufficient to meet resource needs.

Factors affecting operative time and outcome of carotid endarterectomy in the Vascular Quality Initiative.

OBJECTIVE: Prior studies have suggested a relationship between operative (Op) time and outcome after major vascular procedures. This study analyzed factors associated with Op time and outcome after carotid endarterectomy (CEA) in the Vascular Quality Initiative (VQI) registry. METHODS: Elective, primary CEAs without high anatomic risk or concomitant procedures from 2012 to 2015 in the VQI were analyzed (N = 26,327, performed by 1188 surgeons from 249 centers). Multivariable analysis was used to identify patient, procedure, and surgeon factors associated with Op time and major adverse events (MAEs), categorized as either technical (ipsilateral stroke, cranial nerve injury, reoperation) or cardiac (myocardial infarction, congestive heart failure, dysrhythmia requiring treatment, surgical site infection, and death). RESULTS: The mean CEA Op time in the VQI was 114 minutes, with the mean Op time for individual surgeons ranging from 37 to 305 minutes. Procedural factors and the surgeon's volume were responsible for much of the variation in overall Op time (patient factors that reflected demographics and comorbidities each added 5.9 to 6.8 minutes; procedural factors, such as patch angioplasty and completion duplex ultrasound, each added 5.5 to 16.4 minutes; the lowest quartile of the surgeon's annual case volume added 24 minutes). Chi-pie analysis demonstrated that patient factors accounted for 17% of variability in Op time; procedural factors, 44%; and the surgeon's annual volume, 39%. Increasing Op time was highly associated with increased rates of MAEs (P < .001 for cardiac, technical, and death rates). Based on hierarchical multiple logistic regression, cardiac complications were independently associated with increased Op time (comparing surgeons in highest quartile of Op time with those in the lowest: odds ratio, 2.16 for cardiac MAE; 95% confidence interval, 1.59-2.95; P < .001) but not with the surgeon's annual volume. Technical complications were independently associated with a surgeon's low volume (comparing surgeons with the highest annual case volume by quartile against the lowest: odds ratio, 1.25 for technical MAE; 95% confidence interval, 1.06-1.48; P < .001) but not with Op time. CONCLUSIONS: Op time for elective, primary CEAs varies substantially across surgeons in the VQI. Increased Op time is associated with a surgeon's lower annual CEA volume in addition to patient variables and techniques employed. Cardiac complications after CEA are associated with longer Op time, whereas technical complications are associated with a surgeon's low annual volume.

Reimbursement in hospital-based vascular surgery: Physician and practice perspective.

OBJECTIVE: The purpose of this study was to determine change in value of a vascular surgery division to the health care system during 6 years at a hospital-based academic practice and to compare physician vs hospital revenue earned during this period. METHODS: Total revenue generated by the vascular surgery service line at an academic medical center from 2010 through 2015 was evaluated. Total revenue was measured as the sum of physician (professional) and hospital (technical) net revenue for all vascular-related patient care. Adjustments were made for work performed, case complexity, and inflation. To reflect the effect of these variables, net revenue was indexed to work relative value units (wRVUs), case mix index, and consumer price index, which adjusted for work, case complexity, and inflation, respectively. Differences in physician and hospital net revenue were compared over time. RESULTS: Physician work, measured in RVUs per year, increased by 4%; case complexity, assessed with case mix index, increased by 10% for the 6-year measurement period. Despite stability in payer mix at 64% to 69% Medicare, both physician and hospital vascular-related revenue/wRVU decreased during this period. Unadjusted professional revenue/wRVU declined by 14.1% (P = .09); when considering case complexity, physician revenue/wRVU declined by 20.6% (P = .09). Taking into account both case complexity and inflation, physician revenue declined by 27.0% (P = .04). Comparatively, hospital revenue for vascular surgery services decreased by 13.8% (P = .07) when adjusting for unit work, complexity, and inflation. CONCLUSIONS: At medical centers where vascular surgeons are hospital based, vascular care reimbursement decreased substantially from 2010 to 2015 when case complexity and inflation were considered. Physician reimbursement (professional fees) decreased at a significantly greater rate than hospital reimbursement for vascular care. This trend has significant implications for salaried vascular surgeons in hospital-based settings, where the majority of revenue generated by vascular surgery care is the technical component received by the facility. Appropriate care for patients with vascular disease is increasingly resource intensive, and as a corollary, reimbursement levels must reflect this situation if high-quality care is to be maintained.

Rotator cuff repair augmentation with local autogenous bone marrow via humeral cannulation in a rat model.

BACKGROUND: Growth factors have been shown to improve healing after rotator cuff repair. Bone marrow is a potential vehicle for growth factor augmentation, yet methods of delivering marrow to cuff repair sites are still under-researched. We hypothesized that a cannulated humeral implant would deliver local bone marrow and thereby improve healing in a rat model. METHODS: Twenty-eight rats underwent bilateral rotator cuff injury and repair. Each rat acted as its own control, randomized to a cannulated humeral implant in one shoulder and a solid implant in the other. Rats were euthanized at 4 and 8 weeks to create 4 time-treatment cohorts. Tendon healing was evaluated by dimensional measurements, biomechanical testing, and histology. RESULTS: Tendon thickness, all biomechanical measures, and semi-quantitative histologic scores improved over time (P < .05) but not with treatment. The most common site of biomechanical tendon failure was midsubstance in the 8-week cannulated cohort and at the tendon footprint in the other 3 cohorts. Intraluminal bone growth was evident in all cannulated implants. CONCLUSIONS: Humeral cannulation did not quantifiably improve tendon-to-bone healing in a rat model. The diminutive size of implants in rats, however, may have prevented sufficient delivery of local autogenous bone marrow; hence, further study in a larger animal is recommended.