Jejunal ischaemia following inferior mesenteric artery angioembolisation for type 2 endoleak.

We present a rare case of short-segment jejunal infarction following inferior mesenteric artery embolisation for type 2 endoleak in a patient who previously underwent endovascular repair of abdominal aortic aneurysm. Potential causes for the event might include thromboembolism or traumatic thrombosis of a jejunal branch of the superior mesenteric artery (SMA) caused by a buddy guide wire used to maintain the position of the long vascular sheath in the SMA hiatus. The condition was recognised on CT and treated with resection of the infarcted segment of the small bowel followed by primary anastomosis.

Residual Popliteal Aneurysm Perfusion Leading to Embolic Complications: A Case Report.

Introduction: Surgical management of popliteal artery aneurysms has been described for half a century. Long term development of the excluded aneurysm sac in the popliteal segment however remains widely unknown, with only a few small series describing outcomes. Residual aneurysm perfusion has the potential to lead to serious complications. Report: A 63 year old man presents with skin and soft tissue necrosis of the right calf two years after proximal and distal aneurysm ligation and great saphenous vein bypass for a popliteal artery aneurysm. Computed tomography and magnetic resonance angiography show perfusion of the excluded aneurysm as well as extensive necrosis of the gastrocnemius muscle. Direct angiography of the aneurysm demonstrated retrograde aneurysm perfusion due to insufficient distal ligation with recurrent micro-embolisation to the calf via geniculate arteries. Coiling of the geniculate arteries was performed, plugging the connection to the tibiofibular trunk and embolisation of the aneurysm sac. After the intervention, no flow was seen in the aneurysm sac and the patient made full recovery. Discussion: Residual aneurysm sac perfusion can lead to complications long after successful aneurysm exclusion. Follow-up after surgery of popliteal aneurysms should include observation of the excluded aneurysm sac with control of residual blood flow. For persistent sac perfusion, aneurysm enlargement or symptoms, further treatment should be considered. Surgical aspects such as complete transection of the artery after aneurysm ligation or end to end anastomosis of the bypass may be considered, to prevent such complications.

Medicare billing and utilization trends in vascular surgery.

OBJECTIVE: Within the past decade, Medicare Part B reimbursements for various surgical procedures have been declining, whereas health care expenses continue to increase. As a result, hospitals may increase service charges to offset losses in revenue, which may disproportionately affect underinsured patients. Our analysis aimed to characterize Medicare billing and utilization trends across common vascular surgical procedures. METHODS: The 2017 to 2021 Medicare Physician and Other Practitioners by Provider and Service dataset was queried for Current Procedural Terminology (CPT) codes for common vascular surgery procedures. The average charges, reimbursements, charge-to-reimbursement ratios, and service counts were calculated for the most common interventions performed by vascular surgeons. Data was stratified by care setting, facility (inpatient and outpatient hospital) vs non-facility locations. All monetary values were adjusted to the 2021 United States dollars to account for inflation. RESULTS: For facility settings, the mean charge billed to Medicare Part B increased from $3708 to $3952 (6.6%) from 2017 to 2021, with the average charge-to-reimbursement ratio increasing from 7.2 to 8.6. There were 17 of the 19 facility procedures that had a decline in reimbursements, decreasing from an average of $558 to $499 (-10.4%). Stab phlebectomy had the largest individual decrease in facility reimbursement (-53.5%), followed by above-knee amputation (-11.3%) and below-knee amputation (-11.0%). Both non-facility charges (-10.8%) and reimbursements (-12.2%) declined over the study period. Procedural utilization remained stable from 2017 to 2019. Tibial and femoral-popliteal atherectomy had increases of 45.9% and 33.7%, respectively, in overall procedural utilization when performed in non-facility settings from 2017 to 2019. CONCLUSIONS: Our analysis of vascular surgery procedures billed to Medicare Part B from 2017 to 2021 demonstrates an increase in charges, a decline in reimbursements, and a resultant increase in charge-to-reimbursement ratios for facility care settings. In contrast, non-facility charges have decreased in the face of declining reimbursements. These markups in submitted charges in facility locations may serve as an additional barrier to accessing care for patients who are underinsured.

Carotid Artery Reconstruction with an Autologous Bifurcated Saphenous Vein Graft.

We present a new technique for carotid artery reconstruction using a modified bifurcated saphenous vein graft in a patient with a malignant neck tumor. This technique can optimize the size match between the SVG and common carotid artery, as well as the internal and external carotid arteries. Post operative computed tomography performed a year after the operation demonstrated excellent graft alignment and patent carotid arteries.

The evolution and impact of the Society for Vascular Surgery Resident and Student Program.

OBJECTIVE: There is an ongoing national shortage in the vascular surgery (VS) workforce. To increase interest in the specialty, the Society for Vascular Surgery (SVS) Resident and Student Outreach Committee (RSOC) developed a dedicated general surgery (GS) resident and medical student (MS) program at the Vascular Annual Meeting (VAM) and invested in a scholarship program to help reduce attendee expenses. This study assesses the program's effectiveness, correlating recipient feedback with the likelihood of matching into a VS training program. METHODS: Records related to the SVS VAM GS resident and MS program from 2013 to 2023 were reviewed, focusing on attendee evaluations of the program. The program included a simulation session from 2013 to 2019. VS training program match rates among scholarship recipients were determined. The annual average match rate in VS was used to divide the survey responses into two groups: below average (BA) and above average (AA) match rate groups. Survey responses were based on a 5-point Likert scale and allowed for comments. Responses were divided into high value, strongly favoring the activity (scores 4-5), and low value (scores 1-3) categories. The survey responses from the group of years with AA match rates were compared with the group of years with BA rates. RESULTS: The SVS awarded 1040 GS resident and MS travel scholarships over the 10 years assessed. Overall, applicants had a 43% success rate in receiving a scholarship. During the study period, the annual number of applicants increased, whereas the number of scholarships and match success rates significantly decreased. The average match rate into VS among scholarship recipients was 50.2%. The survey response rate was 33%. During AA match rate years, evaluations for simulation allotted time and lectures were significantly more likely to be high value compared with BA years. Simulation content and the residency fair consistently had the most favorable evaluations (>90% high value), and overall, the program had a consistently positive impact on recipients' interest in VS (>90% high value). Trainees in the AA group were significantly more likely to provide positive comments (73% vs 55%; P < .001). Numerous recipients commented on the need for a dedicated space to interact with faculty and mentors and highlighted simulation as the standout aspect of the program. CONCLUSIONS: The SVS VAM RSOC program is positively correlated with attendee interest in VS, with approximately 50% of scholarship recipients matching into the field. The quality of the program and the number of scholarships correlate with VS match rates. Additional investments in similar programs could help close the workforce gap.

Factors Associated With Tobacco Cessation Advice Recall and Quit Rates in Vascular Surgery Patients. A Single Center Study.

OBJECTIVES: Smoking is an important modifiable risk factor in all vascular diseases and verbal advice from providers has been shown to increase rates of tobacco cessation. We sought to identify factors that will improve tobacco cessation and recall of receiving verbal cessation advice in vascular surgery patients at a single institution. METHODS: The study is a retrospective cohort study. Patients seen in outpatient vascular surgery clinic who triggered a tobacco Best Practice Advisory (BPA) during their office visits over a 10-month period were contacted post-clinic and administered surveys detailing smoking status, cessation advice recall, and validated scales for nicotine dependence and willingness to quit smoking. This BPA is a "hard stop" that requires providers to document actions taken. Charts were reviewed for tobacco cessation documentation. Nine-digit zip-codes identified the area deprivation index, a measure of socioeconomic status. Univariate analysis was used to identify factors associated with cessation and advice recall. RESULTS: One hundred out of 318 (31.4%) patients responded to the survey. Epic Slicer Dicer found 97 BPA responses. To dismiss the BPA, 89 providers (91.8%) selected "advised tobacco cessation" and "Unable to Advise" otherwise. Of the 318 patients, 115 (36.1%) had cessation intervention documented in their provider notes and 151 (47.5%) received written tobacco cessation advice. Of survey respondents, 70 recalled receiving verbal advice, 27 recalled receiving written advice, 28 reported receiving offers of medication/therapy for cessation. 55 patients reported having tobacco cessation plans, and among those 17 reported having quit tobacco. Recall of receiving written advice (P < .001) and recall of receiving medication/therapy (P = .008) were associated with recall of receiving verbal cessation advice. CONCLUSIONS: Providing patients with tobacco cessation medication/therapy and written tobacco cessation education during office visits is associated with increased patients' recall of tobacco cessation advice. Vascular surgeons should continue to provide directed tobacco cessation advice.

Post-operative infections after cardiothoracic surgery and vascular procedures: a bibliometric and visual analysis of the 100 most-cited articles in the past 2 decades.

Aim: To recognize and analyze the 100 most-cited articles on post-operative infections following cardiothoracic surgery and vascular procedures in the past 20 years. Methods: Articles published on post-operative infections following cardiothoracic surgery and vascular procedures from inception 1986 till 2020 were reviewed and selected by two authors, based on their number of citations using the Scopus database. Their characteristics were recorded, i.e., title, authors, publication date, total no. of citations, citations per year (CPY), country of research, institutional affiliation, journal, research subject, and article type. Results: The top 100 most influential articles were published between 1968 and 2017, with the peak in 2002. The mean number of total citations was 236.79 (range: 108-1,157). Areas with a medical focus were predominant in the studied research articles on the researched topic. The top-most journals in which these articles were published include Annals of Thoracic Surgery (14), followed by Circulation (8), and the New England Journal of Medicine (8). The number of publications affiliated with an institution were highest in the United States, with the Cleveland Clinic Foundation (6) having the most. Conclusion: These findings highlight that there is a great potential to conduct research and publish the prevalence, causes, risk factors, pathogenesis and molecular biology of post-cardiac and -vascular surgery infections to prevent their adverse effects. The results can be taken into consideration for policy making to improve post-cardiac-surgery outcomes.

Observational Study on the Risk of Surgical Site Infection in Patients Undergoing Common Femoral Endarterectomy in Conjunction With an Endovascular Procedure Compared With Common Femoral Endarterectomy Alone.

Objective: A hybrid approach is being employed increasingly in the management of peripheral arterial disease. This study aimed to assess the surgical site infection (SSI) incidence of hybrid revascularisation (HR) compared with common femoral endarterectomy (CFEA) alone. Methods: This was a retrospective review of consecutive patients who underwent CFEA or HR alongside CFEA between 2017 and 2021 including one year of follow up. The primary outcome was SSI incidence. Secondary outcomes included length of surgery, duration of admission, further revascularisation surgery, limb salvage, and death. Differences in outcomes were assessed with the Student's unpaired t test, chi square test, and Fisher's exact test. Results: A total of 157 groin incisions from 155 patients were included: 78 had CFEA procedures and 79 had HR procedures. No statistical difference was found between groups for age, sex, and indication for surgery. Surgical site infection occurred in five of the CFEA patients (6%) compared with seven of the HR patients (9%) (p = 0.77). The HR procedures took significantly longer, with an average of 299 minutes compared with 220 minutes for CFEA (p < 0.001). No statistically significant difference was identified for length of admission: median stay five days for CFEA vs. four days for HR (p = 0.44). Major amputation was performed within one year in five of the CFEA procedures (6%) and five of the HR procedures (6%) (p = 1.0). Further revascularisation surgery was attempted in two patients in the HR group and six patients in the CFEA group (p =. 17). No statistically significant difference was found in the one year mortality rate: eight CFEA (10%) and seven HR (9%) (p = 0.77). Conclusion: Patients who underwent HR alongside CFEA did not have a statistically significantly increased incidence of SSI, despite increased surgical time. Using HR techniques enabled patients to have multilevel disease treated in one stage without an increased incidence of SSI.

Advances and challenges in regenerative therapies for abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is a significant source of mortality worldwide and carries a mortality of greater than 80% after rupture. Despite extensive efforts to develop pharmacological treatments, there is currently no effective agent to prevent aneurysm growth and rupture. Current treatment paradigms only rely on the identification and surveillance of small aneurysms, prior to ultimate open surgical or endovascular repair. Recently, regenerative therapies have emerged as promising avenues to address the degenerative changes observed in AAA. This review briefly outlines current clinical management principles, characteristics, and pharmaceutical targets of AAA. Subsequently, a thorough discussion of regenerative approaches is provided. These include cellular approaches (vascular smooth muscle cells, endothelial cells, and mesenchymal stem cells) as well as the delivery of therapeutic molecules, gene therapies, and regenerative biomaterials. Lastly, additional barriers and considerations for clinical translation are provided. In conclusion, regenerative approaches hold significant promise for in situ reversal of tissue damages in AAA, necessitating sustained research and innovation to achieve successful and translatable therapies in a new era in AAA management.

Out-Patient versus In-Patient Arteriovenous Fistula Creation for Dialysis: Assessing Cost-Effectiveness Alongside Clinical Implications.

(1) Background: The surgical procedure to create an arteriovenous fistula (AVF) can be performed in either an ambulatory or in-patient hospital setting, depending on the case's complexity, the anesthesia type used, and the patient's comorbidities. The main scope of this study is to assess the cost-effectiveness and clinical implications of surgically creating an AVF in both ambulatory and in-hospital settings. (2) Methods: We conducted a retrospective observational study, in which we initially enrolled all patients with end-stage kidney disease (ESKD) admitted to the Vascular Surgery Department, Emergency County Hospital of Targu Mures, Romania, to surgically create an AVF for dialysis, between January 2020 and December 2022. The primary endpoint of this study is to assess the cost-effectiveness of surgically creating an AVF in an ambulatory vs. in-hospital setting by comparing the costs required for the two types of admissions. Further, the 116 patients enrolled in this study were divided into two groups based on their preference for hospitalization: out-patients and in-patients. (3) Results: Regarding in-patient comorbidities, there was a higher prevalence of peripheral artery disease (PAD) (p = 0.006), malignancy (p = 0.020), and previous myocardial infarction (p = 0.012). In addition, active smoking (p = 0.006) and obesity (p = 0.018) were more frequent among these patients. Regarding the laboratory data, the in-patients had lower levels of white blood cells (WBC) (p = 0.004), neutrophils count (p = 0.025), lymphocytes (p = 0.034), and monocytes (p = 0.032), but there were no differences between the two groups regarding the systemic inflammatory biomarkers or the AVF type. Additionally, we did not register any difference regarding the outcomes: local complications (p = 0.588), maturation failure (p = 0.267), and primary patency (p = 0.834). In our subsequent analysis, we discovered no significant difference between the hospitalization type chosen by patients regarding AVF primary patency failure (p = 0.195). We found no significant association between the hospitalization type and the recorded outcomes (all ps > 0.05) in both multivariate linear regression and Cox proportional hazard analysis. (4) Conclusions: In conclusion, there are no significant differences in the clinical implications, short-term and long-term complications of AVF for out-patient and in-patient admissions. Additionally, we found no variation in the costs associated with laboratory tests and surgical supplies for an AVF creation. Therefore, it is safe to perform ambulatory AVFs, which can reduce the risk of hospital-acquired infections and provide greater comfort to the patient.

Benefits of early vascular provider involvement in wound care center management of patients with underlying arterial disease.

OBJECTIVES: Peripheral arterial disease (PAD) can reduce wound healing rates by ≤30%. Current literature suggests wound outcomes are improved when management is driven by vascular providers. However, whether this benefit is derived solely from early vascular provider involvement remains unclear. METHODS: A retrospective analysis was performed of 80 limbs with chronic wounds and underlying PAD seen at our institution's wound center between July 2022 and July 2023. Arterial disease was defined by the following criteria: (1) prior PAD diagnosis, (2) ankle-brachial-index of <0.9 or toe pressure of <70 mm Hg, or (3) absent peripheral pulses. Patients were divided into early (<6 week) vascular provider exposure (EVE; n = 45) or late/no vascular exposure (LNVE; n = 35). Providers included vascular surgeons and affiliated advanced practitioners. The primary outcome studied was overall time to wound healing. Statistical analysis included χ2 tests, t test, Pearson correlation, Kaplan-Meier analysis, and Cox regression modeling (variables included in a multivariate model if univariate effect on healing was associated at P < .1). RESULTS: Baseline demographic profiles were similar between groups with exception of lower baseline albumin (P = .037), more heart failure (P = .013), and more prior peripheral endovascular interventions (P = .013) in the EVE group. Although the initial wound locations and sizes were similar, EVE wounds had significantly higher WIfI wound scores (1.9 ± 0.1 vs 1.6 ± 0.1; P = .039). Although more LNVE patients developed radiographic osteomyelitis (31.8% vs 55.6%; P = .033), fewer underwent operative debridement or amputation (100% vs 63.2%; P = .008). On univariate analysis, healing time tended to be shorter in EVE, but not significantly (P = .089). When controlled for comorbidities, however, healing rates were nearly two-fold higher in EVE (hazard ratio, 2.42; 95% confidence interval, 1.21-4.84). LNVE wounds also took significantly longer to reach checkpoints including time to >75% granulation (P = .05), 15% weekly size decrease (P = .044), and epithelialization (P = .026). LNVE patients required more wound center visits (P = .024) and procedures (P = .005) with a longer time to intervention (P = .041). All EVE patients obtained ankle-brachial indices, with 90.9% of them available at their first wound care visit (P < .001). Although a slightly greater proportion of patients underwent a major amputation in EVE (15.6% vs 11.4%; P = .595), this difference did not attain significance; additionally, 100% of EVE patients had documented discussion of nonsalvageable limbs before amputation. CONCLUSIONS: Early exposure to vascular practitioners improves wound healing time, timeliness to intervention, and wound center and hospital resource use in patients with PAD. Further investigation into benefits of vascular involvement within community wound center models could significantly improve awareness and accessibility of arterial wound care in smaller/remote communities.

Medicine's Glass Slipper: The PAVAEX Boot and 20th Century Negative Pressure Therapy.

Before the 20th century, peripheral artery disease (PAD) manifested as extreme pain, chronic wounds, and, eventually, gangrene requiring amputation. Despite this, it was rarely diagnosed. However, at the turn of the century, Western medicine shifted focus from infectious to chronic illnesses, and with this change, physicians' engagement with PAD transformed. Aiming to mitigate long-term injury, physicians now worked to identify and treat vessel disease to restore meaningful blood circulation. This article explores the development and deployment of a new device resulting from this refocus, the PAssive VAscular EXerciser (PAVAEX) Boot, and its role as a creative response to a previously intractable clinical problem. The PAVAEX Boot, designed in 1933 by vascular surgeons Louis G. Herrmann and Mont R. Reid, was one of the few interventions for PAD at the time. Based on the observation that continuous negative pressure results in vasoconstriction, while short bursts transiently increase blood flow, the PAVAEX Boot utilized intermittent negative pressure to enhance peripheral vascular perfusion. Well-marketed and praised throughout the 1930s, it vanished from public writing and academic literature just 20 years later. However, negative pressure wound therapy resurged in the late 20th century, and though its inventors failed to recognize the precedent of the PAVAEX Boot, many of these devices and therapies are rooted in identical theories. We examine why the PAVAEX Boot faded from use and argue that the device remains a crucial advancement in negative pressure therapy.

A Comprehensive Analysis of Leadership Attributes, Discrepancies, and Implications for Gender Equity in Vascular Surgery.

OBJECTIVE: Well-developed leadership skills have been associated with a better understanding of healthcare context, increased team performance, and improved patient outcomes. Surgeons, in particular, stand to benefit from leadership development. While studies have focused on investigating knowledge gaps and needs of surgeons in leadership roles, there is a noticeable gap in the literature concerning leadership in Vascular Surgery. The goal of this study was to characterize current leadership attributes of vascular surgeons and understand demographic influences on leadership patterns. METHODS: This retrospective cohort study was a descriptive analysis of vascular surgeons and their observers who took the leadership practice inventory (LPI) from 2020 to 2023. The LPI is a 30 question inventory that measures the frequency of specific leadership behaviors across five practices of leadership. RESULTS: A total of 110 vascular surgeons completed the LPI. The majority of participants were white (56%) and identified as male (60%). Vascular surgeons most frequently observed the "enabling others to act" leadership practice style (8.90 ± 0.74) by all evaluators. Vascular surgeons were most frequently above the 70th percentile in the "challenge the process" leadership practice style (49%) compared to the average of other leaders world-wide. Observers rated vascular surgeons as displaying significantly more frequent leadership behaviors than vascular surgeons rated themselves in every leadership practice style (P-value < 0.01). The only demographic variable associated with a significantly increased occurrence of achieving 70th percentile across all five leadership practice styles was the male gender: a multivariable model adjusting for objective experience showed men were at least 3.5 times more likely to be rated above the 70th percentile than women. CONCLUSIONS: Vascular surgeons under report the frequency at which they practice leadership skills across all five leadership practice styles and should recognize their strengths of enabling others to act and challenging the process. Men are recognized as exhibiting all five leadership practices more frequently than women, regardless of current position or experience level. This observation may reflect the limited leadership positions available for women, thereby restricting their opportunities to demonstrate leadership practices as frequently or recognizably as their male counterparts.

Staged bilateral release of the popliteus muscle using a posterior surgical approach to the popliteal fossa to treat type 4 popliteal artery entrapment.

Popliteal artery entrapment syndrome (PAES) is a rare cause of intermittent claudication in the young. Aberrant embryological development results in entrapment of the popliteal artery by myofascial structures of the popliteal fossa. Type 4 PAES is due to aberrant development of the popliteus muscle superficial to the popliteal artery. We present a case of bilateral type 4 PAES, along with intraoperative photography highlighting the anatomical cause for this pathology. Both limbs in this patient were treated successfully with surgical release of the entrapping popliteus muscle via a posterior surgical approach to the popliteal fossa. This report emphasises the importance of determining popliteal artery integrity and entrapment subtype to guide the management of this condition.

Pseudoaneurysm of the superolateral genicular artery following ACL outside-in reconstruction.

A female underwent arthroscopic anterior cruciate ligament reconstruction (ACLR) via an outside-in drilling technique. At 4 weeks after surgery, she presented with a pulsatile painful mass on the lateral femoral condyle. Imaging confirmed a superolateral genicular artery pseudoaneurysm. Thrombin injections were administered twice, resulting in reduced size and minimal pain. This case emphasises the rare occurrence of pseudoaneurysms post-ACLR and highlights the importance of early detection and intervention for vascular complications. Although debated, we suggest tourniquet deflation before closure to facilitate identification and management of vascular issues. This report contributes valuable insights into managing pseudoaneurysms following ACLR.