Implementation of a Vascular Acute Care Surgery Service Model is Associated with Decreased Surgeon Burnout.

Vascular surgeons have one of the highest rates of burnout among surgical specialties, often attributed to high patient acuity and clinical workload. Acute Care Surgery (ACS) models are a potential solution used among general and trauma surgeons. This is a retrospective analysis of prospectively collected Accreditation Council for Graduate Medical Education (ACGME) survey results from faculty and residents before and after implementation of a vascular ACS (VACS) model. The VACS model assigns a weekly rotation of an attending surgeon with no elective cases or clinic responsibilities and a monthly rotating resident team. Residents and attendings are in-house to cover all urgent and emergent vascular daytime consultations and procedures, while nights and weekend coverage remain a typical rotating schedule. Survey question results were binned into domains consistent with the Maslach Burnout Inventory (MBI). Both residents and faculty reported an increase in median scores in MBI domains of Emotional Exhaustion (Faculty:2.9 vs. 3.4, p<0.001; Residents:3.1 vs. 3.6, p<0.001) and faculty reported higher Personal Accomplishment scores (Faculty:3.3 vs. 3.8, p=0.005) after the VACS model implementation. A VACS model is a tangible practice change that can address a major problem for current vascular surgeons as it is associated with decreased burnout for faculty and residents through improvement in both emotional exhaustion and personal accomplishment. Improved longitudinal assessment of resident and faculty burnout is needed and future work should identify specific practice patterns related to decreased burnout.

Strategies to reduce rates of severe endothermal heat-induced thrombosis following radiofrequency ablation.

OBJECTIVE: Endothermal heat-induced thrombosis (EHIT) is a potential complication of radiofrequency ablation (RFA). Data on effective prophylaxis of EHIT are limited. In 2018, a high-volume, single institution implemented strategies to decrease the incidence of EHIT, including a single periprocedural prophylactic dose of low-molecular-weight heparin to patients with a great saphenous vein (GSV) diameter of ≥8 mm or saphenofemoral junction (SFJ) diameter of ≥10 mm and limiting treatment to one vein per procedure. The size threshold was derived from existing literature. The study objective was to evaluate the effects of these institutional changes on thrombotic complication rates after RFA. METHODS: A retrospective cohort control study was conducted using the Vascular Quality Initiative database. Data were collected for patients who underwent RFA with a GSV diameter of ≥8 mm or SFJ diameter of ≥10 mm from January 2015 to July 2022. The clinical end points were thrombotic complications (ie, thrombophlebitis, EHIT, deep vein thrombosis) and bleeding complications. Patient demographic and procedural variables were included in the analysis, and significant variables after univariable logistic regression were included in a multivariable logistic regression. RESULTS: After the policy change, the overall vein center EHIT rate decreased from 2.6% to 1.5%, with a trend toward significance (P = .096). The inclusion criterion of a GSV diameter of ≥8 mm or an SFJ diameter of ≥10 mm yielded 845 patients, of whom 298 were treated before the policy change and 547 after. There was a significant reduction in the rate of EHIT classified as class ≥III (2.34 vs 0.366; P = .020) after the institutional changes. Treatment of two or more veins and an increased vein diameter were associated with an increased risk of EHIT (P = .049 and P < .001, respectively). No significant association was found between periprocedural anticoagulation and all-cause thrombotic complications or EHIT (P = .563 and P = .885, respectively). CONCLUSIONS: The institutional policy changes have led to lower rates of EHIT, with a reduction in severe EHIT rates in patients with an ≥8-mm diameter GSV or a ≥10-mm diameter SFJ treated with RFA. Of the changes implemented, restricting treatment to one vein was associated with a reduction in severe EHIT. No association was found with periprocedural low-molecular-weight heparin, although a type 2 error might have occurred. Alternative strategies to prevent thrombotic complications should be explored, such as increasing the dosage and duration of periprocedural anticoagulation, antiplatelet use, and nonpharmacologic strategies.

Left Subclavian Artery Coverage is Not Associated with Neurological Deficits in Trauma Patients Undergoing Thoracic Endovascular Repair.

BACKGROUND: Endovascular repair of the thoracic aorta (TEVAR) outcomes have been studied with an interest in complications related to left subclavian artery (LSA) coverage in patients with atherosclerotic pathologies; however, specific data on the management of the LSA in a trauma population are lacking. The objective of this study is to evaluate outcomes following TEVAR for traumatic aortic injury based on LSA coverage. METHODS: The Vascular Quality Initiative thoracic endovascular aortic repair module (2010-2017) was analyzed. Patients were included if they had a traumatic aortic injury requiring TEVAR. Patients were placed in 2 groups based on coverage of the LSA. Patients were propensity score matched and the primary outcomes were cerebrovascular symptoms and spinal cord ischemia. Additional clinical and resource utilization outcomes were analyzed. RESULTS: Four hundred and fifty one patients were included in the analysis. There were 268 patients in the LSA not-covered group and 183 patients in the LSA covered group. The mean aortic injury grade was 2.88 ± 0.056 vs. 2.88 ± 0.049 in the covered versus not-covered group (P = 0.957). Glasgow coma scale and injury severity score were not different between the groups. There was no difference between groups for cerebrovascular symptoms or spinal cord ischemia, 1.4% vs. 2.8%, P = 0.684 and 0% vs. 2.1%, P = 0.247, after propensity score matching. Significant differences in access site complications and resource utilization were identified between groups. CONCLUSIONS: This is the largest series to evaluate complications based on LSA coverage following TEVAR in trauma patients. Our data demonstrate that coverage of the LSA during TEVAR following blunt trauma is associated with no difference in central nervous system outcomes. As such, LSA revascularization strategies, while possible, are not directly supported by these data and should be individualized based on each patient's specific clinical scenario.

Long-term anticoagulation is associated with type II endoleaks and failure of sac regression after endovascular aneurysm repair.

OBJECTIVE: Within the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm. METHODS: Retrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm. RESULTS: There were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants. CONCLUSIONS: These data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.

Evaluation of Opioid Prescription and Consumption Habits Following Endovascular Aortic Aneurysm Repair.

BACKGROUND: There has been a dramatic rise in opioid-related deaths over the past decade. Most of the reduction strategies have focused on outpatient use; however, recent studies have demonstrated an association between inpatient opioid use and consumption following discharge across a variety of surgical procedures. The objective of this study is to evaluate the association of inpatient use of opioids as well as the consumption of opioids after discharge following endovascular aortic aneurysm repair (EVAR). METHODS: A prospectively maintained database was reviewed for cases between 2015 and 2018. Patients were included in the study if they underwent an elective EVAR, had an intensive care unit stay less than 1 day and total length of stay less than 3 days. Patients were contacted to participate in a survey of opioid use if they received a prescription at discharge. The primary outcome was percent of prescribed opioids consumed following discharge. Multivariate analyses were performed to determine predictors of receiving an opioid prescription. RESULTS: One hundred seventy-one patients were included in the analysis; 95% patients were white and 85% male. 59% of patients responded to the survey. Seventy-one (42%) received an opioid prescription at discharge. Patients that received a discharge prescription tended to be younger (71 vs. 75 years, P = 0.005) and more likely to have received opioids while in the hospital (79% vs. 45%, P < 0.001). Additionally, patients who received opioids at discharge received a significantly greater amount of milligram oral morphine equivalents (OME) while in the hospital (27.76 ± 38.91 vs. 10.05 ±29.43, P < 0.001). Multivariate analysis demonstrated age, estimated blood loss (EBL), and OME per day to be significant inpatient predictors of requiring an outpatient opioid prescription. Open femoral access (27%) was not a predictor of opioid prescription at discharge. A total of 1185 pills were prescribed (29.6 ± 2.06 per patient), but only 208 pills consumed (5.2 ± 1.27 per patient). Around 82% of total pills prescribed were not consumed. CONCLUSIONS: This study evaluates inpatient opioid use and postdischarge consumption following EVAR. These data identify key factors associated with receiving an opioid prescription at discharge and demonstrate that patients consume far fewer opioids than prescribed. These findings provide insight as to which patients may not require an outpatient prescription following EVAR, leading to potential practice-changing opioid reduction strategies.

Regional Variation in Usage of Ultrasound-Guided Femoral Access in the Vascular Quality Initiative.

BACKGROUND: Access site complications are among the most common complications following peripheral vascular interventions. Previous studies have demonstrated a reduced rate of complications with ultrasound-guided vascular access (UGVA). The objective of this study is to evaluate the regional use of UGVA within the Vascular Quality Initiative (VQI). METHODS: The VQI peripheral intervention module between 2010 and 2018 was evaluated. Regional ID was used to compare distribution of ultrasound usage. Regions were grouped into terciles based on the rate of ultrasound use. Patients were categorized based on type of access. Primary outcome was use of ultrasound across regions. Secondary outcomes were access site complications. RESULTS: Over 43,000 cases across the 18 VQI regions were evaluated. The average rate of ultrasound usage was 71% across the regions with a wide variation (range 38-97%). There is a significant difference in utilization among the top third (87%), middle third (79%), and bottom third (58%) (P < 0.001). Average sheath size was similar across all 3 groups. A higher use of ultrasound-guided access was associated with significantly fewer access site complications (top third 1.96% vs. bottom third 3.04%, P < 0.001), the most significant of which was a decreased rate of access site hematoma (top third 1.37% vs. bottom third 2.35%, P < 0.001). CONCLUSIONS: This is the first study to evaluate ultrasound-guided access across VQI regions. Our results demonstrate that despite strong evidence supporting the utilization of UGVA, there remains a wide variation in ultrasound usage across VQI regions. This is also the first study to show that the prevalence of ultrasound use in peripheral vascular interventions (PVI) is inversely related to access site complications. Given all of the data supporting the usage of UGVA across numerous specialties, our findings encourage the consideration of an ultrasound-first approach for vascular access in PVI and the implementation of targeted strategies and evidence-based guidelines to enhance UGVA utilization in PVI.

Association Between the Atherosclerotic Disease Risk Score and Carotid Artery Stenosis.

BACKGROUND: Carotid artery stenosis (CAS) is the most frequently detected treatable cause of ischemic stroke. However, there are no recommendations to screen asymptomatic patients. The atherosclerotic cardiovascular disease (ASCVD) risk score estimates individuals' 10-year risk for developing cardiovascular disease. The objective of this study is to identify a relationship between the ASCVD risk score and moderate/severe CAS based on ultrasound findings. MATERIALS AND METHODS: We performed a single-institution retrospective review of patients who underwent a surveillance ultrasound for CAS between 2015 and 2018. We used Strandness velocity criteria to separate patients into two cohorts: none to mild CAS (<50%) and moderate/severe CAS (≥50%). We performed Student's t-test, multivariate analysis, and receiver operator characteristic (ROC) curve analysis to determine a relationship between the ASCVD risk score and degree of CAS. We evaluated a new risk score model based on stepwise logistic regression of significant variables on univariate analysis. RESULTS: Two thousand eight hundred and fifty-six patients with carotid ultrasounds (1623 with none to mild, 1161 with moderate, and 72 with severe disease) were included in the study. The ASCVD risk score significantly predicted moderate/severe CAS in an adjusted multivariate analysis. Each 10% increase in the ASCVD risk score corresponded to an additional 11% likelihood of moderate/severe stenosis (OR: 1.11 [1.04-1.20], P = 0.004). The ROC area under the curve for predicting moderate/severe CAS based on the ASCVD risk score was 0.59 (Youden index (J) = 0.14); the optimized ASCVD cutoff point was 28.4%. Our new atherosclerotic disease model demonstrated increased odds of moderate/severe CAS with scores greater than zero (ROC area under the curve = 0.57). CONCLUSIONS: This is the first study to demonstrate an association between atherosclerotic disease risk factors as measured by the ASCVD risk score and moderate/severe CAS. However, this tool is not sensitive or specific for using the ASCVD risk score as a screening mechanism for moderate/severe CAS.

Implementation of an E-Learning Academic Elective for Hands-On Basic Surgical Skills to Supplement Medical School Surgical Education.

OBJECTIVE: To examine the feasibility and utility of a completely online surgical skills elective for undergraduate medical students. DESIGN: The fully asynchronous, one-week, online learning elective addressed surgical instrument identification, knot tying, and suturing. Tools for knowledge acquisition and self-practice were outlined and individualized performance feedback on technical skills performance was incorporated from peers and experts through video conference. SETTING: University of Rochester School of Medicine & Dentistry, Rochester, NY. PARTICIPANTS: A total of 86 third- and fourth-year medical students enrolled and successfully completed the elective. RESULTS: At elective completion, nearly all students met their course objectives and significantly increased their confidence in surgical instrument identification, knot tying, and suturing. Objective measures of student knowledge and technical skills acquisition were overwhelmingly positive, and faculty and students were very satisfied with providing and receiving performance feedback. Students reported that expert feedback was more useful than peer feedback, and more students than faculty reported that the online modality was equivalent to an in-person session for performance review. CONCLUSIONS: This innovative online surgical skills elective improved undergraduate medical student confidence, knowledge, and skillset with surgical instrument identification, knot tying, and suturing while also facilitating effective expert feedback on individual performance.

Postdischarge Opioid Use after Lower Extremity Bypass Surgery.

BACKGROUND: Opioid overprescription for acute postoperative pain is an inadvertent contributor to the opioid epidemic via pill diversion and misuse. In response, the surgical community advocates for evidence-based postoperative opioid prescribing guidelines. The objective of this study is to evaluate patient-reported opioid consumption after lower extremity bypass surgery. METHODS: We conducted a retrospective review of a prospectively maintained database of infrainguinal bypass operations from 2016 to 2019. For patients receiving an opioid prescription at discharge, a telephone survey was administered questioning the percentage of pills used. Exclusion criteria included chronic opioid use and reoperations or amputations within 30 days. The primary outcome was the difference in opioids prescribed versus opioids consumed. RESULTS: Forty-nine patients met inclusion criteria. Forty-one (84%) were prescribed opioids at discharge, and 27 (65.9%) completed the survey. The average age was 65.8 ± 7.7 years; 29.6% were women. Oxycodone immediate-release was most commonly prescribed (78%). On average, patients received 318 ± 156 morphine milligram equivalent. A total of 940 opioid pills were prescribed (36.0 ± 11.3 per patient), but only 37% were consumed. This difference resulted in 568 unused pills. CONCLUSIONS: This is the first study to specifically evaluate opioid use in a strictly lower extremity bypass population. Over 60% of pills were unused, which poses significant societal risk for misuse. Our findings contribute to knowledge of operation-specific opioid use, which may shape practice recommendations and reduce opioid overprescription after vascular surgery.

COVID-19 Pandemic and the Lived Experience of Surgical Residents, Fellows, and Early-Career Surgeons in the American College of Surgeons.

BACKGROUND: To better understand how the COVID-19 pandemic has affected surgical trainees' and early-career surgeons' professional and personal experiences, a survey of the membership of the American College of Surgeons (ACS) Resident and Associate Society (RAS) and Young Fellows Association (YFA) was performed. STUDY DESIGN: An anonymous online survey was disseminated to members of RAS and YFA. Descriptive analyses were performed and factors associated with depression and burnout were examined with univariate and multivariable stepwise logistic regression. RESULTS: Of the RAS/YFA membership of 21,385, there were 1,160 respondents. The majority of respondents (96%) reported the COVID-19 pandemic having a negative impact on their clinical experience, with 84% of residents reporting a > 50% reduction in operative volume and inability to meet minimum case requirements. Respondents also reported negative impacts on personal wellness. Nearly one-third reported inadequate access to personal protective equipment, and depression and burnout were pervasive (≥21% of respondents reported yes to every screening symptom). On multivariable analysis, female sex (odds ratio [OR] 1.54 for depression, OR 1.47 for burnout) and lack of wellness resources (OR 1.55 for depression, OR 1.44 for burnout) predicted depression and burnout. Access to adequate personal protective equipment was protective against burnout (OR 0.52). CONCLUSIONS: These data demonstrate a significant impact of the COVID-19 pandemic on the lives of residents and early-career surgeons. Actionable items from these data include mitigation of burnout and depression through increasing personal protective equipment access and provision of wellness programs, with a particular focus on high-risk groups.

Opioid Consumption after Carotid Revascularization.

BACKGROUND: Opioid overdose is now the leading cause of injury-related death in the United States. Overprescription of opioids is one factor contributing to this epidemic. Previous studies demonstrated an overprescription of opioids compared with patient consumption after general surgery procedures. The objective of this study is to evaluate opioid consumption after carotid revascularization. METHODS: This is a retrospective review of the opioid-prescribing habits after discharge of carotid revascularization. Patients who were documented to receive an opioid prescription were included in the study. A phone survey was conducted to determine patient consumption of the prescribed pills. Surgical procedures include carotid endarterectomy (CEA) and transcarotid arterial revascularization (TCAR). The primary outcome is the difference between opioids prescribed and opioids consumed. RESULTS: There were 209 patients available for inclusion. The mean age was 68 years with white (98%) males (58%) making up most patients. CEA and TCAR accounted for 75% and 25% of cases, respectively. About 98 (47%) patients were prescribed opioids after discharge. Eight were excluded from analysis (3 for prior opioid use and 5 declined participation). About 71% of patients participated in the survey. A total of 1,623 pills were prescribed (25.4 ± 5.5 per patient), but only 336 pills were consumed (5.3 ± 1.1 per patient). About 1,287 (79% of total) pills were not consumed. CONCLUSIONS: These data are the first to compare opioid prescription with opioid consumption after carotid revascularization. We demonstrate that patients consume much less opioids than prescribed. These findings indicate that a reduction in opioid prescriptions may be possible after carotid revascularization.

Recurrent Superior Mesenteric Artery Stent Fracture.

Ostial stenosis of the superior mesenteric artery (SMA) is usually a benign finding due to the significant collateralization inherent with visceral vessels. There is a subset of patients, however, with significant atherosclerotic disease leading to in situ thrombosis and subsequent mesenteric ischemia requiring intervention. Over the last 20 years, management of mesenteric ischemia-acute or chronic-has transitioned from an open embolectomy or bypass to an endovascular-first approach involving angioplasty and stenting. We are reporting a unique case of recurrent SMA stent fracture with imaging demonstrating diaphragmatic compression of the SMA during the respiratory cycle, subsequent management, and recommendations for future intervention.

Aortic Anatomic Severity Grade Correlates with Midterm Mortality in Patients Undergoing Abdominal Aortic Aneurysm Repair.

BACKGROUND: Anatomic severity grade (ASG) can be used to assess abdominal aortic aneurysm (AAA) anatomic complexity. High ASG is associated with complications following endovascular repair of AAAs and we have demonstrated that ASG correlates with resource utilization. The hypothesis of this study is that ASG is directly related to midterm mortality in patients undergoing AAA repair. METHODS: Patients who underwent infrarenal AAA repairs between July 2007 and August 2014 were retrospectively reviewed and ASG scores were calculated using 3-dimensional computed tomography reconstructions. Perioperative mortalities (≤30 days) were excluded. The ASG value of 15 was chosen based on previous receiver-operator curve analysis, which showed that an ASG of 15 was predictive of postoperative complications and resource utilization. The 5-year survivors and mortalities were compared utilizing comorbidities, pharmacologic variables, and anatomic variables at or above the defined threshold. RESULTS: A total of 402 patients (80% male and 96% Caucasian) with complete anatomic and survival data were included in the analysis. Mean ASG and age at the time of repair were 16 ± 0.15 and 73 ± 0.43 years old, respectively. The 5-year mortality was significantly associated with ASG >15 (hazard ratio [HR]: 1.504, confidence interval [CI]: 1.077-2.100, P < .017), hyperlipidemia (HR: 1.987, CI: 1.341-2.946, P < .001), coronary artery disease (HR: 1.432, CI: 1.037-1.978, P < .029), and chronic obstructive pulmonary disease (HR: 1.412, CI: 1.027-1.943, P < .034). Kaplan-Meier analysis demonstrated improved survival in the low score ASG ≤15 group at 1, 3, and 5 years (96% vs 93%, 81% vs 69%, and 53% vs 41%; P = .0182; Figure 1). CONCLUSIONS: Increasing aortic anatomic complexity as characterized by ASG >15 is an independent predictor of midterm mortality following elective infrarenal AAA repair. Therefore, it may be a useful tool for appropriate patient selection and risk stratification prior to elective infrarenal AAA repair.

Aortoiliac calcification correlates with 5-year survival after abdominal aortic aneurysm repair.

BACKGROUND: An anatomic severity grade (ASG) score to categorize and to define anatomic factors for abdominal aortic aneurysm (AAA) repair was proposed. Other studies have previously reported that aortic anatomic complexity is a marker of survival and resource utilization after repair, although it remains unclear whether individual components of the ASG score independently contribute to survival. This study analyzed and validated an aortic and iliac artery calcium scoring system that can potentially predict survival after AAA repair. METHODS: Patients who underwent infrarenal AAA repairs from July 2007 to May 2012 were analyzed using complete 5-year records. Those who died ≤30 days of surgery were excluded. Calcium score (CS) was defined using the ASG scoring system for its basis by preoperative imaging <6 months before surgery. A CS for any patient was 0 to 5 points, the sum of the points assigned to aortic neck (2 points total) and iliac artery (3 points total) calcification. A receiver operating characteristic curve was used to determine a CS threshold for mortality. The 5-year survivors and deaths were compared in regard to comorbidities, pharmacology, and CS at or above the defined threshold. Each variable with a P value <.1 between the groups was then placed into a Cox proportional hazards model, with statistical significance of P < .05. RESULTS: There were 356 patients who underwent AAA repair with complete 5-year follow-up data; 26% died within 5 years of surgery. Of these, 13% had CS of 0 with 15% mortality, 28% had CS of 1 with 21% mortality, 24% had CS of 2 with 24% mortality, 23% had CS of 3 with 35% mortality, 10% had CS of 4 with 40% mortality, and 2% had CS of 5 with 17% mortality. The receiver operating characteristic curve demonstrated an appropriate threshold of CS 3. Of these patients, 65% had a CS <3, whereas 35% had a CS ≥3. Patients with a CS ≥3 had a lower 5-year survival probability (P = .003). Comparing 5-year survivors and deaths in a Cox proportional hazards analysis, CS ≥3 was associated with a hazard ratio of 1.579 (95% confidence interval, 1.038-2.402; P = .0328). CONCLUSIONS: A CS ≥3 is linked to a lower 5-year survival after AAA repair in our population. This system potentially can be another measure for risk stratification and serve as a means to predict midterm mortality in AAA repairs. Future study will be needed for further validation to predict midterm mortality and to better guide surgical decision-making.

Prediction of postoperative myocardial infarction after suprainguinal bypass using the Vascular Quality Initiative Cardiac Risk Index.

BACKGROUND: The Vascular Quality Initiative (VQI) Cardiac Risk Index (CRI) was developed to estimate the risk of postoperative myocardial infarction (POMI) for noncardiac vascular procedures. Whereas suprainguinal bypass carried the second highest odds of POMI, the performance of the all-procedure model declined when it was applied to the suprainguinal subset. We sought to improve the VQI CRI for application in this high-risk group undergoing open revascularization for aortoiliac occlusive disease. METHODS: The VQI Suprainguinal Bypass Registry was queried for elective procedures performed between January 2010 and March 2017. Logistic regression was used to create a model for estimating the risk of in-hospital POMI with preoperative variables including demographics, comorbidities, and planned inflow source. After adjustment for overfitting, internal validation was performed using both bootstrapping and 10-fold cross-validation methods. RESULTS: Among 8157 procedures, the incidence of POMI was 3.2% (n = 258). After bootstrapping variable selection, age, graft inflow, preoperative stress test, American Society of Anesthesiologists class, indication for procedure, and coronary artery disease were chosen for inclusion as predictors in the final risk model. The final model demonstrated good discrimination (area under the curve = 0.725). On internal validation, the model discriminated well (area under the curve = 0.713), with good calibration (plot intercept = 0.0006 and slope = 1.001). Using this model, POMI risk estimates ranged from 0.6% to 30.4%. CONCLUSIONS: Whereas the incidence of POMI among all suprainguinal bypasses was 3%, model-based estimates ranged 50-fold, from 0.6% to 30.4%. This underscores the heterogeneity of this cohort and the need for patient-specific risk estimation. Although some of the strongest predictors were nonmodifiable (eg, age), the model provided specific estimates according to graft inflow and stress testing. This supraspecific VQI CRI module risk predictor may enhance preoperative counseling by influencing the decision to pursue preoperative stress testing and ultimately the type of revascularization strategy chosen.

Incidental posterior mediastinal paraganglioma: The safe approach to management, case report.

INTRODUCTION: Paragangliomas are neuroendocrine tumors arising from chromaffin cells located in sympathetic paraganglia. Mediastinal paragangliomas are extremely rare and can be classified as functional or non-functional according to their ability for secreting catecholamines. Patients can be asymptomatic and the diagnosis is usually incidental. Complete surgical resection remains the standard of care for paragangliomas. PRESENTATION OF CASE: We present a 44-year-old woman with a functional mediastinal paraganglioma incidentally found during the perioperative imaging workup for a diagnosed breast carcinoma. Chest radiograph and computed tomography (CT) showed a well-defined lesion in the posterior mediastinum suspicious for an esophageal malignancy. Endoscopic and CT-guided biopsies were performed confirming the diagnosis of a neuroendocrine tumor. Laboratory studies showed elevated catecholamines and chromogranin A levels, consistent with a paraganglioma. Appropriate pre-operative management was done and successful surgical resection without catecholamine related complications was achieved. DISCUSSION: The workup and treatment of incidentally discovered adrenal and extra-adrenal lesions are controversial. Because of the absence of symptoms and the wider differential diagnosis of extra-adrenal lesions, an attempt for biopsying and surgically remove these lesions prior to biochemical testing is not an uncommon scenario, although this could be potentially harmful. Surgeons should have an index of suspicion for catecholamine-secreting tumors and hormonal levels should be assessed prior to biopsy or surgical resection. CONCLUSION: Surgeons should consider paragangliomas as a differential diagnosis for extra-adrenal lesions. Biochemical testing with catecholamines and chromogranin A levels should be performed prior to biopsy or surgical removal in order to avoid catastrophic complications.

Outcomes for critical limb ischemia are driven by lower extremity revascularization volume, not distance to hospital.

OBJECTIVE: The objective of this study was to identify relationships among geographic access to care, vascular procedure volume, limb preservation, and survival in patients diagnosed with critical limb ischemia (CLI). METHODS: Using New York State administrative data from 2000 to 2013, we identified a patient's first presentation with CLI defined by International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Distance from the patient's home to the index hospital was calculated using the centroids of the respective ZIP codes. A multivariable logistic regression model was employed to estimate the impact of distance, major lower extremity amputation (LEA) volume, and lower extremity revascularization (LER) volume on major amputation and 30-day mortality. Volumes and distances were analyzed in quintiles. The farthest distance quintile and the highest procedure volume quintiles were used as references for generating odds ratios (ORs). RESULTS: There were 49,576 patients identified with an initial presentation of CLI. The median age was 73 years, 35,829 (73.2%) had Medicare as a primary insurer, 11,395 (23.0%) had a major amputation, and 4249 (8.6%) died within 30 days of admission. Patients in the closest distance quintile were more likely to undergo amputation (OR, 1.53 [1.39-1.68]; P < .0001). Patients who visited hospitals in the lowest LER volume quintile with at least one procedure per year faced higher 30-day mortality rates (OR, 2.05 [1.67-2.50]; P < .0001) and greater odds of amputation (OR, 9.94 [8.5-11.63]; P < .0001). Patients who visited hospitals in the lowest LEA volume quintile had lower odds of 30-day mortality (OR, 0.66 [0.50-0.87]; P = .0033) and lower odds of amputation (OR, 0.180 [0.142-0.227]; P < .0001). CONCLUSIONS: Rates of major amputation are inversely associated with distance from the index hospital, whereas rates of both major amputation and mortality are inversely associated with LER volume. Rates of major amputation and mortality are directly associated with LEA volume. We believe that unless it is otherwise contraindicated, these data support consideration for selective referral of CLI patients to high-volume centers for LER regardless of distance. Within the context of value-based health care delivery, policy supporting regionalization of CLI care into centers of excellence may improve outcomes for these patients.

Bundling of Reimbursement for Inferior Vena Cava Filter Placement Resulted in Significantly Decreased Utilization between 2012 and 2014.

BACKGROUND: On January 1, 2012, reimbursement for inferior vena cava filters (IVCFs) became bundled by the Centers for Medicare and Medicaid Services. This resulted in ICVF placement (CPT code 37191) now yielding 4.71 relative value units (RVUs), a decrease from 15.6 RVUs for placement and associated procedures (CPT codes 37620, 36010, 75825-26, 75940-26). Our hypothesis was that IVCF utilization would decrease in response to this change as other procedures had done once they had become bundled. METHODS: Including data from 2010 to 2011 (before bundling) and 2012 to 2014 (after bundling), we utilized 5% inpatient, outpatient, and carrier files of Medicare limited data sets and analyzed IVCF utilization before and after bundling across specialty types, controlling for total diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE) (ICD-9 codes 453.xx and 415.xx, respectively) and placement location. RESULTS: In 2010 and 2011, the rates/10,000 DVT/PE diagnoses were 918 and 1,052, respectively (average 985). In 2012, 2013, and 2014, rates were 987, 877, and 605, respectively (average 823). Comparing each year individually, there is a significant difference (P < 0.0001) with 2012, 2013, and 2014 having lower rates of ICVF utilization. Comparing averages in the 2010-2011 and 2012-2014 groups, there is also a significant decrease in utilization after bundling (P < 0.0001). CONCLUSIONS: Following the bundling of reimbursement for IVCF placement, procedural utilization decreased significantly. More data from subsequent years will be needed to show if this decrease utilization continues to persist.

Aortic anatomic severity grade correlates with resource utilization.

BACKGROUND: Potential cost effectiveness of endovascular aneurysm repair (EVAR) compared with open aortic repair (OAR) is offset by the use of intraoperative adjuncts (components) or late reinterventions. Anatomic severity grade (ASG) can be used preoperatively to assess abdominal aortic aneurysms, and provide a quantitative measure of anatomic complexity. The hypothesis of this study is that ASG is directly related to the use of intraoperative adjuncts and cost of aortic repair. METHODS: Patients who undergo elective OAR and EVAR for abdominal aortic aneurysms were identified over a consecutive 3-year period. ASG scores were calculated manually using three-dimensional reconstruction software by two blinded reviewers. Statistical analysis of cost data was performed using a log transformation. Regression analyses, with a continuous or dichotomous outcome, used a generalized estimating equations approach with the sandwich estimator, being robust with respect to deviations from model assumptions. RESULTS: One hundred forty patients were identified for analysis, n = 33 OAR and n = 107 EVAR. The mean total cost (± standard deviation) for OAR was per thousand (k) $38.3 ± 49.3, length of stay (LOS) 13.5 ± 14.2 days, ASG score 18.13 ± 3.78; for EVAR, mean total cost was k $24.7 ± 13.0 (P = .016), LOS 3.0 ± 4.4 days (P = .012), ASG score 15.9 ± 4.13 (P = .010). In patients who underwent EVAR, 25.2% required intraoperative adjuncts, and analysis of this group revealed a mean total cost of k $31.5 ± 15.9, ASG score 18.48 ± 3.72, and LOS 3.9 ± 4.5, which were significantly greater compared with cases without adjunctive procedures. An ASG score of ≥15 correlated with an increased propensity for requirement of intraoperative adjuncts; odds ratio, 5.75 (95% confidence interval, 1.82-18.19). ASG >15 was also associated with chronic kidney disease, end stage renal disease, hypertension, female sex, increased cost, and use of adjunctive procedures. CONCLUSIONS: Complex aneurysm anatomy correlates with increased total cost and need for adjunctive procedures during EVAR. Preoperative assessment with ASG scores can delineate patients at greater risk for increased resource use. Patient comorbid factors are associated with anatomic complexity defined according to ASG. A critical examination of the relationship between anatomic complexity and finances is required within the context of aggressive endovascular treatment strategies and shifts toward value-based reimbursement.

Factors affecting Cook Gunther Tulip and Cook Celect inferior vena cava filter retrieval success.

OBJECTIVE: Success rates vary for the retrieval of inferior vena cava filters (IVCFs). The optimal retrieval time and factors influencing retrieval success remain unproven. This study aims to determine optimal time and evaluate factors related to successful IVCF retrieval. METHODS: An institutional prospectively maintained database was reviewed for all IVCF retrieval attempts from 2006 to 2012. Patient demographics, comorbidities, indications for procedure, placement technique, IVCF type, presence of angulation, and time to retrieval were evaluated with respect to success or failure of retrieval. Statistical analyses (t-test, χ(2), correlations, and Kaplan-Meier plots) were performed comparing successful and unsuccessful retrievals. RESULTS: Of 121 attempted IVCF retrievals, 92 (76%) were successful and 29 (24%) were unsuccessful. There were no significant differences between the successful and unsuccessful attempts in terms of patient demographics, comorbidities, indications for procedure, placement technique, or IVCF type, which included 93 Celect (77%) and 28 Gunther Tulip (23%). Time since IVCF placement was significantly different (P = .025) between the successful and unsuccessful retrieval groups (medians were 105 [7-368] and 162 [43-379] days, respectively). Time since IVCF placement greater than 117 days correlated significantly with unsuccessful IVCF retrieval (R = 0.218; P = .017; odds ratio, 2.88; P = .02). Angulation greater than 20 degrees on anteroposterior radiograph was noted in seven of 29 (24%) unsuccessful retrievals compared with seven of 92 (8%) successful retrievals and was significant (P = .012). CONCLUSIONS: Cook Gunther Tulip and Celect IVCF retrieval is most likely to be successful within 3 to 4 months of placement. Unsuccessful retrieval attempts are more likely to occur when IVCF position is angulated.