A Tiered Mentorship Program to Integrate Medical Students Into Clinical Research Projects.

OBJECTIVE: Herein we describe the development, implementation, and growth of our Vascular Research Training Program (VRTP), emphasizing the intentional involvement of medical students in clinical research. METHODS: We developed a VRTP focusing on medical student engagement to encompass 4 pillars: ownership, mentorship, experience, and independence within the research process. The program is organized by clinical projects with an attending surgeon, surgical trainee (fellow or resident), and medical student comprising each research project team. The VRTP program sought to facilitate a culture of learning, accountability, and mentorship to engage and encourage medical student involvement in clinical research. RESULTS: We reviewed the productivity of our current vascular surgery faculty by reviewing divisional records of faculty publications and conducting a literature search for the period of 2012 to 2019. The pre-VRTP model produced 13 included manuscripts in 2012-2015 (3.25 per year), while the implemented VRTP model yielded 43 articles (10.75 per year) from 2016-2019. There was no significant change in the impact factor (pre-VRTP mean ± SD was 1.8 ± 1.0 vs 2.2 ± 1.1, P = .17). Medical student productivity rose from 1.3 to 2.7 publications, with a similar rise in the number of students participating in more than one manuscript from 2 to 14. CONCLUSIONS: Deliberate involvement of medical trainees as a member of the clinical research team has the potential to generate subsequent increases in research productivity and effective mentorships. Academic surgical divisions should consider organized and intentional involvement of medical students as an essential component of clinical research.

Characteristics and Outcomes of Patients Transferred for Treatment of Acute Limb Ischemia.

BACKGROUND: Patients requiring emergent vascular surgery often undergo transfer from one facility to another for definitive surgical care. In this study, we analyzed morbidity and mortality in patients presenting for emergent lower extremity thrombectomy and embolectomy in the transferred and nontransferred populations. METHODS: A retrospective analysis of prospectively collected data was performed utilizing the National Surgical Quality Improvement Program (NSQIP) database for all nonelective, emergent lower extremity embolectomy or thrombectomy (Current Procedural Terminology [CPT] 34,201 and 34,203) performed between 2011 and 2014. Demographics, comorbidities, and 30-day complications, and outcomes were compared among patients presenting from home versus those presenting from another hospital, emergency department, or nursing home. Multivariate analysis was performed to determine the association between mode of presentation, major complications, and death. RESULTS: We identified 1,954 patients who underwent emergent lower extremity embolectomy or thrombectomy. 40.7% (795 patients) were identified as transfer patients. Odds of transfer were significantly increased if a patient was functionally dependent (odds ratio OR 1.95, P < 0.001) or had a history of chronic obstructive pulmonary disease (COPD) (OR 1.348, P = 0.05). Odds of transfer were decreased if a patient was of a nonWhite race (OR 0.511, P < 0.001). 11.7% (229) patients in the described cohort died within 30 days of surgery. Those who died were more likely to present to the treating hospital as a transfer (56.3% vs. 38.6%, P < 0.001). In multivariate analysis, transfer status was significantly associated with 30-day mortality (OR 1.9: 95% confidence interval CI 1.40-2.64; P < 0.001). CONCLUSIONS: Patients transferred from an outside hospital or nursing home who present for emergent vascular procedures demonstrated increased mortality compared to those who present from home direct to the emergency department despite similar comorbid conditions. In addition, race was identified as an independent factor for transfer. Further studies are needed to understand the complex interactions between inter-hospital transfer patterns, emergency vascular surgery presentations, and racial biases to improve outcomes for this population.

Ruptured Iliac Arteriovenous Fistula Presenting With Thigh Pain and Swelling: Case Report.

The presentation of abdominal arteriovenous fistulas is classically described as a triad of a pulsatile abdominal mass with a bruit, high-output heart failure, and regional venous hypertension with primarily open operative therapy. In the following case, we present the treatment of a patient who arrived with acute right heart failure and renal failure due to an arteriovenous fistula and who was successfully treated with endovascular repair.

Distal Superior Mesenteric Artery Endarterectomy Remains an Excellent Option for Mesenteric Revascularization in the Endovascular Era.

BACKGROUND: Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be used. Herein, we present 2 cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. METHODS/RESULTS: Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status after placement of a proximal SMA stent and was transferred to our institution because of concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up, and radiographic imaging at 2 months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with postprandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with a stent was not successful because of flush occlusion of the SMA approximately 1 centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The postoperative course was uneventful, and at 1-month follow-up, she reported continued improvement in pain and appetite. CONCLUSIONS: SMA endarterectomy can be successfully performed on mid to distal lesions of the SMA. This operation should remain a viable option in the management of CMI.

Preventing Retained Surgical Items During Endovascular Procedures: Bridging the Gap Between Guidelines and Practice.

A retained surgical item (RSI) can be a devastating and costly procedural complication. Although the current incidence of RSIs is unknown, perioperative personnel routinely perform surgical counts according to their facility's policies and procedures to prevent this sentinel event. The American College of Surgeons, The Joint Commission, and AORN emphasize the importance of communication and standardized protocols for the counting of surgical items. However, there is a lack of current evidence to support specific recommendations for the counting of items during endovascular procedures. After the occurrence of RSIs during endovascular procedures at our facility, we convened an interdisciplinary workgroup, conducted an analysis of root causes, reviewed the available literature, and revised the existing policy. This article reviews the available literature on RSIs, describes root causes, discusses recommendations from national organizations, and describes the process that we used to create the policy changes at our facility.

Intraoperative Fragmentation and Retention of Endovascular Devices: Clinical Consequences and Preventative Strategies.

BACKGROUND: Expanded applications and increasing volumes of complex endovascular procedures have increased the risk of unintended intraoperative fragmentation and retention of catheters and sheaths. We describe a series of retained or fragmented endovascular devices, a quality improvement program to address this unmet need for improved detection of catheter fragmentation, and the results of this program. METHODS: Cases utilizing endovascular devices that resulted in a retained catheter fragment were identified and analyzed during divisional quality improvement review. One consistent area of concern was operating room (OR) staff unfamiliarity with verifying the integrity of an endovascular device. In response, a slide-based training protocol of focused, endovascular nursing education was implemented. Following perceived lack of improvement after this approach, we developed a handheld visual reference display of the tips of common catheters and sheaths. Staff was surveyed before and after intervention to assess the educational value of the display and the impact on staff device familiarity. RESULTS: All 4 described cases resulted in an unplanned return to the OR for retrieval of the fragmented catheter or sheath. No thromboembolic complications were observed, although associated intra-arterial thrombus was noted in 2 cases. Thirty-four OR nurses were polled to trial the visual reference display initiative, with 70% of those reporting primary surgical assignments outside of cardiovascular ORs. Introduction of the new visual reference display improved staff confidence in their ability to identify a broken device (2.4-3.7, P < .001). This improvement was most significant in OR staff with primary assignments in noncardiovascular services. CONCLUSION: Current OR standard operating procedures fail to address the potential for unintentionally retained catheters and wires during endovascular procedures. Our novel visual reference display of common endovascular items rather than conventional in-service training improved the ability of staff to identify device fragmentation at the time of the index procedure.

A modified activity protocol for claudication.

BACKGROUND: We propose the use of a monitored step tracking device, the FitBit® to supplant supervised exercise therapy (SET) programs to facilitate improvement in walking distance in veteran claudicators. METHODS: In this prospective study, we enrolled forty-nine patients with clinical evidence of lower extremity claudication in a six-month walking program. Each patient was given a FitBit® device to track daily number of steps. Patients were seen in clinic monthly to collect data and discuss walking goals. Surveys at the beginning and end of each study assessed patient perception of changes in walking distance as well as symptoms. The primary outcome was monthly distance walked. Changes over time in each outcome variables were examined using a random effects mixed model. RESULTS: In the first month, the adjusted mean number of steps per day was 3492 (95% CI: 2661-4322). By month 5, this had increased to 4502 (3636-5367) (P=0.0007). Twenty-eight patients used the tracker at least for 1 month, while 21 (43%) did not. Being bothered by symptoms was the only patient variable that was significantly associated with use of the FitBit®. Those who used the tracker tended to be younger, heavier, more active, and were more likely to have diabetes. CONCLUSIONS: In the veteran population, the use of a monitored step tracking device such as the FitBit® is a potentially effective strategy to improve walking distance in claudicators particularly in those with mild symptoms. Additional investigation is needed to determine which patients will benefit most from this walking protocol.

Use of Structured Presentation Formatting and NSQIP Guidelines Improves Quality of Surgical Morbidity and Mortality Conference.

BACKGROUND: Surgical Morbidity and Mortality (M&M) conference lacks a standardized structure across institutions. We compared implementation of structure and National Surgical Quality Improvement Program's (NSQIP) definitions to organize our M&M and identify cases for discussion versus the usually used method at many centers of case identification by an attending surgeon or resident. METHODS AND MATERIALS: A prospective study was performed, over a 10-wk period, to compare the identification of adverse events and the educational value of our M&M conference before and after implementation of structured NSQIP-defined presentations. Chart review was performed by a trained surgical clinical reviewer and trained NSQIP resident of all cases over the study period to identify NSQIP-defined occurrences. All presented M&Ms were evaluated for adequate reporting of adverse events and areas for improvement on a three-point scale. Surveys were administered before and after intervention to assess educational value to resident and faculty on a five-point Likert scale. Survey and presentation data were compared using Student's t-tests. P-values <0.05 were considered significant. RESULTS: Before intervention, 15% of NSQIP-defined occurrences were identified compared with 81% after intervention (P < 0.01). Thirty-three percent of deaths (1 of 3) before intervention were identified versus 100% (4 of 4) identified after intervention. Surveys obtained from faculty, residents, and students of individual presentations found improved clarity and educational content in cases presented (2.6-2.8) and improved identification of etiology (2.5-2.8), learning points (2.1-2.7), and opportunities for prevention of future adverse events (2.1-2.6) (all P < 0.01). Residents and faculty overall found that the postintervention model better identified adverse events (3.0-3.7, P = 0.02), opportunities for prevention (2.8-3.3, P = . 04), and promoted improved transparency (2.9-3.8, P < 0.01). Eighty-five percent of participants supported the changes in M&M conference. CONCLUSIONS: Incorporation of a clearly defined structure using NSQIP definitions for morbidity and identification of every mortality in our M&M conference standardized identification of adverse events thus improving conference quality. Consideration of the use of this structure should be given to other surgical departmental M&Ms.

IV Versus Subcutaneous Enoxaparin in Critically Ill Infants and Children: Comparison of Dosing, Anticoagulation Quality, Efficacy, and Safety Outcomes.

OBJECTIVE: Subcutaneous enoxaparin is the mainstay anticoagulant in critically ill pediatric patients although it poses several challenges in this patient population. Enoxaparin infused IV over 30 minutes represents an attractive alternative, but there is limited experience with this route of administration in children. In this study, we assess dosing, anticoagulation quality, safety, and clinical efficacy of IV enoxaparin compared to subcutaneous enoxaparin in critically ill infants and children. DESIGN: Retrospective single-center study comparing dosing, anticoagulation quality, safety, and clinical efficacy of two different routes of enoxaparin administration (IV vs subcutaneous) in critically ill infants and children. Key outcome measures included dose needed to achieve target antifactor Xa levels, time required to achieve target antifactor Xa levels, proportion of patients achieving target anticoagulation levels on initial dosing, number of dose adjustments, duration spent in the target antifactor Xa range, anticoagulation-related bleeding complications, anticoagulation failure, and radiologic response to anticoagulation. SETTING: Tertiary care pediatric hospital. PATIENTS: All children admitted to the cardiac ICU, PICU, or neonatal ICU who were prescribed enoxaparin between January 2014 and March 2016 were studied. INTERVENTIONS: One hundred ten patients were identified who had received IV or subcutaneous enoxaparin and had at least one postadministration peak antifactor Xa level documented. MEASUREMENTS AND MAIN RESULTS: Of the 139 courses of enoxaparin administered, 96 were therapeutic dose courses (40 IV and 56 subcutaneous) and 43 were prophylactic dose courses (20 IV and 23 subcutaneous). Dosing, anticoagulation quality measurements, safety, and clinical efficacy were not significantly different between the two groups. CONCLUSIONS: Our study suggests that anticoagulation with IV enoxaparin infused over 30 minutes is a safe and an equally effective alternative to subcutaneous enoxaparin in critically ill infants and children.

Risk of tumor transmission after thoracic allograft transplantation from adult donors with central nervous system neoplasm-A UNOS database study.

BACKGROUND: We analyzed the UNOS database to better define the risk of transmission of central nervous system (CNS) tumors from donors to adult recipients of thoracic organs. METHODS: Data were procured from the Standard Transplant Analysis and Research dataset files. Donors with CNS tumors were identified, and recipients from these donors comprised the study group (Group I). The remaining recipients of organs from donors who did not have CNS tumors formed the control group (Group II). Incidence of recipient CNS tumors, donor-related malignancies, and overall survival were calculated and compared in addition to multivariable logistic regression. RESULTS: A cohort of 58 314 adult thoracic organ recipients were included, of which 337 received organs from donors who had documented CNS tumors (Group I). None of these recipients developed CNS tumors at a median follow-up of 72 months (IR: 30-130 months). Although overall mortality in terms of the percentage was higher in Group I than Group II (163/320=51% vs 22 123/52 691=42%), Kaplan-Meier curves indicate no significant difference in the time to death between the two groups (P=.92). CONCLUSIONS: There is little risk of transmission of the common nonaggressive CNS tumors to recipients of thoracic organs.

Reoperation rates after open and endovascular abdominal aortic aneurysm repairs.

OBJECTIVE: This study compared reoperation rates associated with open abdominal aortic aneurysm (AAA) repair (OR) outcomes vs endovascular AAA repair (EVAR). METHODS: A retrospective review of the Veterans Affairs Surgical Quality Improvement Project data was performed with inclusion criteria defined as all patients who underwent AAA repair from October 1, 2007, to October 1, 2013. The primary outcome was the incidence of reoperations. Reoperations included subsequent OR or EVAR procedures performed on the abdominal aorta or iliac arteries, surgical treatment of temporally related bowel obstruction, as well as treatment of abdominal or groin wound complications ≤6 months and treatment of bowel or lower limb ischemia ≤10 days. RESULTS: Of 6677 patients who underwent AAA repair, 476 (7.1%) required reoperations. OR was associated with a higher rate of reoperations overall (10.0% vs 6.3%; P < .01), with most being intra-abdominal and wound complications. OR also had higher rates of bowel ischemia requiring operation (0.7% vs 0.3%; P = .01) and lower extremity ischemia (0.5% and 0.06%; P < .01). Significantly more endovascular stents were placed during EVAR (2.8% vs 0.5%; P < .01). Logistic regression showed EVAR is a negative predictor for reoperation after controlling for comorbidities (P < .001). CONCLUSIONS: The long-term burden of reoperations after OR may actually be more significant than current understanding when including all possible abdominal complications in an extended analysis. Future prospective trials should include all potential reoperations extended >30 days with associated cost analysis. As surgical innovation in EVAR technology advances, complication comparisons with OR should undergo frequent re-evaluation given that endovascular indications and outcomes continue to expand and improve.

Functional status as a predictor of outcomes in open and endovascular abdominal aortic aneurysm repair.

BACKGROUND: Functional status is a simple and rapidly assessable metric that may be used as a predictor for surgical outcomes. This study examined the association of functional status with short-term mortality after abdominal aortic aneurysm (AAA) repair in octogenarians to characterize the utility of functional status as a means of preoperative risk assessment. METHODS: All patients who underwent endovascular and open AAA repair from 2002 to 2010 within the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database were identified. Functional status, defined as an ordinal scale from 1 to 3 (1, independent; 2, partially dependent; 3, totally dependent), was examined using multivariate regression models with 30-day mortality as the primary outcome. For the purpose of analysis, this 3-point scale was converted into a binomial scale of function, with "normal" including 1 (completely independent) and "abnormal" including 2 or 3 (partially to totally dependent). RESULTS: We identified 9030 patients who underwent AAA repair (46.6% open and 53.4% endovascular). Mortality at 30 days was 2.8% for the entire cohort (4.2% open, 1.7% endovascular; P < .001). There were 1340 patients aged ≥80 years, of which 67.3% underwent endovascular AAA repair. Among all age groups, functional status was a significant predictor of 30-day mortality (<80 years, P < .001; ≥80 years, P < .001). The ≥80 cohort with abnormal function status also demonstrated increased operative mortality (P = .002), length of stay (P = .001), and incidence of pulmonary complications (P = .025) compared with the cohort with normal functional status. Multivariate logistic regression demonstrated that within the ≥80-year-old cohort, only functional status remained a significant predictor of mortality (P < .001). In addition, the strength of the association between functional status and mortality was greater in the older cohort than in the younger one (Cox regression hazard ratio: 3.13 vs 2.18). CONCLUSIONS: Functional status is a simple and rapidly applicable predictor of mortality within AAA patients and may be a useful tool to help preoperatively risk-stratify elderly patients presenting with AAA in need of repair. Further studies are needed to understand how best to apply these data to the clinical setting to guide preoperative decision making.

Acquired von Willebrand Syndrome: An Under-Recognized Cause of Major Bleeding in the Cardiac Intensive Care Unit.

BACKGROUND: Acquired von Willebrand syndrome (AvWS) in the setting of congenital heart disease is an under-recognized cause of bleeding in the pediatric cardiac critical care unit. METHODS: Fourteen patients diagnosed with AvWS admitted to the cardiac intensive care unit at the Children's National Health System between December 2009 and September 2015 were identified with subsequent chart review and case analysis. RESULTS: Of the 14 patients included in this study, 4 patients were on ventricular-assist devices, 6 patients were on extracorporeal membrane oxygenation, and 4 were patients with congenital heart disease not receiving any mechanical circulatory support. All patients identified manifested persistent severe bleeding, despite appropriate management of anticoagulation and blood product administration based on the established protocols. Detailed hemostatic testing including quantitative von Willebrand factor (vWF) multimer analysis revealed decreased high-molecular-weight multimers (HMWMs) and absent ultra-HMWM, consistent with AvWS in all patients. Eight patients received treatment with vWF concentrate, one patient with desmopressin, and five recovered without specific treatment. Bleeding ceased in all but one patient. CONCLUSIONS: Acquired von Willebrand syndrome is an uncommon but important cause of bleeding in pediatric patients with cardiac disease. A high index of clinical suspicion with knowledge of the characteristic clinical scenario in addition to low levels of vWF multimers is required to manage and diagnose AvWS. Although the optimal management of AvWS in this patient population is unclear, vWF concentrates are available and appear to be efficacious for controlling life-threatening bleeding.

Rapid Response Extracorporeal Membrane Oxygenation Deployment-Surgical Technique.

The availability of extracorporeal membrane oxygenation (ECMO) is the standard of care at most high-acuity congenital heart surgery programs. Extracorporeal membrane oxygenation is also an integral part of managing children with in-hospital cardiac arrest refractory to conventional cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation). In this article, we aim to provide a practical guide to initiate rapid ECMO in a nonoperating room setting.

B-type Natriuretic Peptide Predicts Morbidity and Long-Term Mortality in Coronary Artery Bypass Grafting and Valve Surgery.

OBJECTIVE: To assess whether B-type natriuretic peptide (BNP) levels are a useful predictor of morbidity and mortality as well as long-term survival in patients after coronary artery bypass grafting (CABG) and valve surgery. METHODS: A retrospective review of CABG and/or valve surgery patients from 2012 to 2015 at a single center was conducted. A total of 432 patients were identified (CABG, 295 patients; valve, 82 patients; and CABG + valve, 55 patients). B-type natriuretic peptide levels were divided into quartiles (Q1-Q4). Mortality data were available for up to 3.4 years after surgery. RESULTS: B-type natriuretic peptide quartile was independently associated with any complication on multivariate analysis. Patients in Q4 were at highest risk (adjusted odds ratio, 3.81; P = 0.047 vs Q1). There was a significant association between BNP quartile and time to death (log-rank χ, 8.30; P = 0.04) with greatest association 9 months postoperatively. B-type natriuretic peptide quartile was significantly associated with time to death in Cox regression in Q2 (hazard ratio [HR], 3.73 (1.04-13.44); P = 0.044) and Q4 (HR, 4.33 (1.14-16.44); P = 0.031). Q3 also had a higher risk of death (HR, 3.5 vs Q1); however, this was only significant at a trend level (P = 0.06). Using a risk model generated from logistic regression, we determined that the highest risk group had relative risk of complications 30 times higher than the lowest risk group. CONCLUSIONS: B-type natriuretic peptide levels are an independent predictor of morbidity after CABG and/or valve surgery regardless of type of procedure or on/off bypass usage. B-type natriuretic peptide levels also correlate with time to death, highlighting the need for sustained follow-up and heart failure management to improve survival in patients with elevated BNP levels presenting for all cardiac surgery.

Intracardiac tumor causing left-ventricular outflow-tract obstruction in a newborn.

The following report describes the case of newborn girl with an asymptomatic systolic murmur, which on imaging revealed a nearly obstructive mass in the left-ventricular outflow tract. The mass was resected and found to be consistent with a rhabdomyoma. Here, we describe the pathologic and clinical characteristics of this tumor.

Perceptions of Bedside Cardiac Critical Care Registered Nurses on 24 Hour Attending Intensivist Coverage.

OBJECTIVE: To elicit the perceptions of bedside critical care nurses toward continual in-house attending coverage and its effect on patient safety, communication, and nursing education. DESIGN: A 5-point Likert-type questionnaire was designed to evaluate the perception of bedside nurses in the pediatric cardiac intensive care unit (PCICU) toward the presence of a 24 hour in-house attending physician. SETTING: Single tertiary referral PCICU in Washington, DC SUBJECTS: The 46 PCICU nurses who participated in the study were separated into two groups based on exposure to the recent implementation of continual in-house attending coverage at our institution. Group one consisted of 14 nurses with only exposure to the new 24/7 in-house coverage while group two encompassed 32 nurses who had experienced both the new and old system (off-site on-demand attending physician). MEASUREMENTS AND MAIN RESULTS: Surveys demonstrated that both groups found that the new system has a positive impact on nursing education (median score of 5) as well as a positive impact on the communication between multidisciplinary teams and between care team and families (median score of 5). Nurses who experienced only the new system scored one point lower (median score of 4) regarding the effect of this staffing model on patient outcomes than nurses who had experienced both systems (median score of 5, P = .016). Between 83% and 98% of all 46 nurses who participated indicated they agree or strongly agree with each of the questions regarding the benefit of 24 hour in-house attending coverage. CONCLUSION: Our study suggests that regardless of differences in experience, pediatric cardiac nurses believe the presence of an on-site intensivist to be beneficial to both nursing and patients.