Long-Term Outcome of Lower Extremity Bypass Surgery in Patients with Chronic Kidney Disease and Critical Limb Ischemia in Germany.

The aim of this study is to present short- and long-term outcomes after lower extremity bypass (LEB) surgery in patients with chronic limb-threatening ischemia (CLTI) and chronic kidney disease (CKD), differentiated by peripheral artery disease (PAD) Fontaine stage III and IV. METHODS: Retrospective analysis of anonymized data from a nationwide German health insurance company (AOK). Data from 22,633 patients (14,523 men) who underwent LEB from 2010 to 2015, were analyzed, presenting 18,271 with CKD stage 1/2, 2,483 patients with CKD stage 3 and 1,879 with CKD stage 4/5. RESULTS: Perioperative mortality (60-day mortality) was 7.2% for CKD stage 1/2, 12.4% for CKD stage 3, and 18.0% for CKD stage 4/5. Patients with PAD stage IV had a significantly higher perioperative mortality (43.2%) than patients with PAD stage III (22.7%). The perioperative major amputation rate depended significantly on PAD stage IV (Odds Ratio (OR): 2.57 CI: 2.16 - 3.05, p < .001), the LEB level below the knee and crural/pedal (OR: 2.49 CI: 2.14 - 2.90, p < .001), CKD stage 4/5 (OR: 1.28, CI: 1.06 - 1.54, p = .009), and the presence of diabetes mellitus type 2 (OR: 1.19, CI: 1.05 - 1.36, p = .007). Kaplan-Meier estimated long-term survival of up to 9 years after surgery was 31.7% for patients with CKD stage 1 and 2, 14.3% for CKD stage 3, and only 10.1% for CKD stage 4 and 5 (p < .001). PAD Fontaine stage IV vs. III (Hazard Ratio (HR): 1.64, CI: 1.56 - 1.71, p < .001), but not bypass level had an independent adverse influence on long-term survival. CONCLUSION: CKD and PAD stage were equally significant independent predictors of patient survival and MACE with higher PAD and CKD stages associated with less favorable long-term outcomes.

Publication performance of university maxillofacial surgeons in Germany.

The aim of this bibliometric analysis was to benchmark the publication activities of German university departments of oral and maxillofacial surgery. The publication performance of staff surgeons (chief and consultants), documented by first or last authorship, from 37 German university departments was captured over a 10-year period (January 1, 2010, to December 31, 2019). All publications listed in PubMed were included. Additionally, the Impact Factor (IF) was determined. A total of 213 surgeons were identified, of whom 158 (74.2%) were publishing. The number of publications was 1,777, published in 311 journals. Publication activity ranged from an average of 23.3 publications per staff surgeon in the top-ranked department to 0 publications in the last-ranked. The same trend was observed for the total cumulative IFs (CIFs) per member (range from 56.2 to 0). The most common used journal was the Journal of Cranio-Maxillofacial Surgery (19.7%), with focus on "dentoalveolar surgery" (24%) and "operative techniques and procedures" (28.3%). Women constituted 19.2% of the staff, contributing to 8.5% of the publications. The publication performance of German university departments of oral and maxillofacial surgery exhibits a high variance, which did not correlate with the number of personnel and could only be explained by different research motivations.

[Inpatient rehabilitation for patients 65 years and older with abdominal aortic aneurysm repair: Indications and long-term outcome]. / Stationäre Frührehabilitation nach endovaskulärer und offener Versorgung eines Bauchaortenaneurysmas bei über 65-Jährigen: Indikation und langfristiges Outcome.

BACKGROUND: In Germany, there is no data available on the frequency of inpatient rehabilitation (IR) after elective endovascular (EVAR) and open (OAR) abdominal aortic aneurysm (AAA) repair. OBJECTIVE: To report for the first time on the outcome of patients 65 years and older and thus of retirement age with and without IR after AAA repair in a retrospective analysis of routine data from all eleven regional companies of the AOK health insurance fund (AOK-Gesundheit). METHODS: Anonymized data of 16,358 patients 65 years and older with intact abdominal aortic aneurysm treated with EVAR (n = 12,960) or OAR (n = 3,398) between 01/01/2010 and 12/31/2016 were analyzed. Patients with postoperative IR (n = 1,531) were compared to those without postoperative IR (n = 14,827) with respect to general patient characteristics, comorbidities, perioperative and postoperative outcomes, and survival. The average follow-up of patients with postoperative and without postoperative IR was 49.9 months and 51.8 months, respectively. RESULTS: 5.4% of EVAR patients, but 24.6% of OAR patients were referred to IR (p < 0.001). Patients with IR were sicker than those without IR. Parameters significantly influencing the use of IR included OAR vs EVAR (Odds Ratio [OR] 6.03), condition after cerebral infarction (OR 1.53), and women vs men (OR 1.49). Perioperative influencing parameters were cerebral infarction (OR 2.40), blood transfusions (OR 2.21) and complex critical care (OR 2.15). After nine years, the Kaplan-Meier estimated survival was 41.9% for patients with vs 43.4% for those without IR in the EVAR group (p = 0.178). For OAR, it was 50.2% for patients with IR vs 49.8% for patients without IR (p = 0.006). In multivariate regression analysis, postoperative IR had a significant effect on long-term survival in OAR but not in EVAR patients. CONCLUSION: There are no generally binding guidelines for the indication of IR after AAA repair. It should therefore be a requirement for the future that the fitness of each patient with elective AAA repair be determined with a score before and after the procedure in order to make indications for AHB more comparable. The score should be documented in the hospital discharge letter.

Long-term outcome and cancer incidence after lower extremity bypass surgery in patients with critical limb threatening ischemia.

PURPOSE: The influence of cancer development on long-term outcome after lower extremity bypass surgery in patients with critical limb threatening ischemia was investigated. METHODS: Patient survival and cancer incidence were recorded for 21,082 patients with peripheral artery disease (PAD) stage III (n = 5631; 26.7%) and stage IV (n = 15,451; 73.3%) registered with the AOK health insurance company in Germany who underwent infrainguinal bypass surgery. All patients were preoperative and in their history cancer-free. RESULTS: After a median follow-up of 44 months, 25.6% of all patients developed cancer (Kaplan-Meier estimated), with no significant differences between patients with PAD stage III and IV (cancer incidence stage III 25.7%, stage IV 25.5%; p = 0.421). In the Cox regression analysis, male gender (HR 1.885; 95% CI 1.714-2.073, p < 0.001) and age over 70 years (HR 1.399; 95% CI 1.285-1.522, p < 0.001) were significant risk factors for the development of cancer. Survival was significantly lower in stage IV (23.4%) compared to stage III (44.5%) (HR 1.720; 95% CI 1.645-1.799, p < 0.001). Cancer was a significant risk factor for overall survival in PAD stage III patients (HR: 1.326; 95% CI 1.195-1.471, p < 0.001) but not in PAD stage IV (HR 0.976; 95% CI 0.919-1.037, p = 0.434). CONCLUSION: Patients with PAD stage III have significantly better survival after infrainguinal bypass surgery compared to patients with stage IV. While cancer incidence was essential for survival in stage III, it was of no importance in stage IV.

The Treatment of Patients With an Unruptured Abdominal Aortic Aneurysm and a Concomitant Malignancy.

BACKGROUND: Having cancer adversely effects the outcome of treatment for an unruptured abdominal aortic aneurysm (AAA). METHODS: A retrospective secondary analysis was performed on the basis of anonymized data from AOK, a German nationwide statutory healthinsurance carrier. Data were evaluated from all of the 20 683 patients who underwent either endovascular (EVAR, 15 792) or open surgical (OAR, 4891) treatment for an unruptured AAA in the years 2010-2016. It was determined in each case whether the patient had a known cancer at the time of the procedure to treat AAA. The analysis concerned patient characteristics, periprocedural complications, and survival after the procedure up to 31 December 2018. RESULTS: 18 222 patients were free of cancer. In accordance with the known 6:1 sex ratio of AAA, 85.3% of the cancer-free patients and 92.8% of those with cancer were men. At the time of their AAA procedure, 1398 had cancer of the intestine (n = 318), lung (n = 301), prostate (n = 380), or bladder or ureter (n = 399). One-year survival after the AAA procedure was 91.5% in cancer-free patients and 84%, 74.4%, 85.8%, and 85.5% in the patients with the respective types of cancer just mentioned. Having cancer was a significant risk factor for periprocedural mortality (OR 1.326, p = 0.041) and for long-term survival (HR 1.515; p < 0.001). CONCLUSION: Having cancer is a risk factor for periprocedural mortality and long-term survival in patients undergoing treatment for an unruptured AAA. This implies that the indications for surgery should be considered with care, particularly in patients with lung cancer, whose 5-year survival rate is only 37.2%.

Long-Term Outcome of Intact Abdominal Aortic Aneurysm After Endovascular or Open Repair.

OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) has been established as a standard treatment option for intact abdominal aortic aneurysm (iAAA) and gained importance due to a lower perioperative mortality than open repair (OAR). However, whether this survival advantage can be maintained or if OAR is beneficial in terms of long-term complications and reinterventions remains questionable. DESIGN: In this retrospective cohort study data from patients undergoing elective EVAR or OAR for iAAAs in the years 2010-2016 was analyzed. The patients were followed through 2018. METHODS: In the propensity score matched cohorts the perioperative and long-term outcomes of the patients were assessed. We identified 20 683 patients undergoing elective iAAA repair (76.4% EVAR). The propensity matched cohorts included 4886 pairs of patients. RESULTS: The perioperative mortality was 1.9% for EVAR and 5.9% for OAR (P = <.001). The perioperative mortality was mainly influenced by patients age (Odds-Ratio (OR):1.073, confidence interval (CI):1.058-1.088, P ≤ .001) and OAR (OR:3.242, CI:2.552-4.119, P ≤ .001). The early survival benefit after endovascular repair persisted for approximately 3 years (estimated survival EVAR 82.3%, OAR 80.9%, P = .021). After that time the estimated survival curves were similar. After 9 years the estimated survival was 51.2% after EVAR as compared to 52.8% after OAR (P = .102). The operation method didn't influence long-term survival significantly (Hazard-Ratio (HR): 1.046, CI: .975-1.122, P = .211). The vascular reintervention rate was 17.4% in the EVAR cohort and 7.1% in the OAR cohort (P ≤ .001). CONCLUSION: EVAR has a significantly lower perioperative mortality than OAR, a survival benefit that lasts up to 3 years after intervention. Thereafter, no significant difference in survival was observed between EVAR and OAR. The decision between EVAR or OAR may depend on patient preference, surgeons' experience, and the institutions' ability to handle complications.

Outcomes of endovascular repair of infrarenal penetrating aortic ulcers.

Background: To report technical success as well as perioperative outcomes of patients who underwent endovascular aortic repair (EVAR) of penetrating abdominal aortic ulcers ≤35 mm in diameter (PAU). Patients and methods: The abdominal aortic aneurysm (AAA) quality registry of the German institute for vascular research (DIGG) was used to identify patients with standard EVAR for infrarenal PAU ≤35 mm between 1/1/2019 and 12/31/2021. Infectious, traumatic, inflammatory PAUs, PAUs associated with connective tissue disease, PAUs following aortic dissection as well as true aneurysms were excluded. Demographics, cardiovascular comorbidity, technical success as well as perioperative morbidity and mortality were determined. Results: Amongst 11 537 patients who underwent EVAR during the study period, 405 with PAU ≤35 mm were eligible from 95 participating hospitals across Germany (22% women, 20.5% octogenarians). The median aortic diameter was 30 mm (Interquartile range 27-33). Cardiovascular comorbidities were frequent with coronary artery disease (34.8%), chronic heart failure (30.9%), history of myocardial infarction (19.8%), hypertension (76.8%), diabetes (21.7%), smoking (20.8%), history of stroke (9.4%), symptomatic lower extremity peripheral arterial disease (20%), chronic kidney disease (10.4%) and chronic obstructive pulmonary disease (9.6%). Most patients were asymptomatic (89.9%). Among the symptomatic patients, 13 presented with distal embolization (3.2%) and 3 with contained ruptures (0.7%). Technical success of endovascular repair was 98.3%. Both, percutaneous (37.1%) or femoral cut-down access approaches (58.5%) were registered. Endoleaks of any type were present with type 1 (0.5%), type 2 (6.4%) and type 3 (0.3%) endoleaks. Overall mortality was 0.5%. Perioperative complications occurred in 12 patients (3.0%). Conclusions: According to this registry data, endovascular repair of PAU is technically feasible with acceptable perioperative outcomes, but further studies investigating mid- and long-term data are needed before invasive treatment of PAU disease in an elderly and comorbid patient population should be recommended.

[Long-term Results after Endovascular and Open Repair of Ruptured Abdominal Aortic Aneurysm - a Propensity Score Matched Analysis]. / Langzeitergebnisse nach endovaskulärer und offener Versorgung des rupturierten Bauchaortenaneurysmas ­ eine Propensity-Score-Analyse.

BACKGROUND: This retrospective propensity score matched study presents the perioperative mortality and long-term survival up to 9 years after endovascular (EVAR) and open (OAR) repair of patients with ruptured abdominal aortic aneurysm (rAAA) in Germany using health insurance data. MATERIALS AND METHODS: 2170 patients treated between January 1st, 2010 and December 31st, 2016, for rAAA within 24 hours of hospital admission and receiving blood transfusions were enrolled in the study and tracked until December 31st, 2018. For better comparability of EVAR and OAR, a 1:1 propensity score matching with 624 pairs according to patient age, sex and comorbidities was carried out using the R program (Foundation for Statistical Computing, Vienna, Austria). RESULTS: In the unadjusted groups, 29.1% (631/2170) of the patients were treated with EVAR and 70.9% (1539/2170) with OAR. EVAR patients had a significantly higher overall rate of comorbidities. After adjustment, EVAR patients showed significantly better perioperative survival (EVAR 35.7%, OAR 51.0%, p = 0.000). Perioperative complications occurred in 80.4% of EVAR patients and 80.3% of OAR patients (p = 1.000). At the end of follow-up, Kaplan-Meier estimated that 15.2% of patients survived after EVAR vs. 19.5% after OAR (p = 0.027). In the multivariate Cox regression analysis, OAR, age ≥ 80 years, diabetes mellitus type 2 and renal failure stages 3 to 5 had a negative impact on overall survival. Patients treated on weekdays had a significantly lower perioperative mortality than patients treated during the weekend (perioperative mortality on weekdays 40.6% vs. 53.4% during the weekend; p = 0.000) and a better overall survival as estimated by Kaplan-Meier. CONCLUSION: Significantly better perioperative and overall survival was observed with EVAR than with OAR in patients with rAAA. The perioperative survival benefit of EVAR was also found in patients older than 80 years. Female gender had no significant influence on perioperative mortality and overall survival. Patients treated on weekends had a significantly poorer perioperative survival than patients treated on weekdays, and this lasted through the end of follow-up. The extent to which this was dependent on hospital structure was unclear.

Sex difference in early mortality after abdominal aortic aneurysm repair.

OBJECTIVE: Although female patients have a lower prevalence of abdominal aortic aneurysm (AAA), they seem to have a worse treatment outcome compared with male patients. Both maximum aneurysm diameter and aortic size index (ASI) are important indicators of the risk of AAA rupture, among which ASI has been shown capable of equalizing sex-related anatomical differences. Our study aimed to investigate whether sex is an independent risk factor for early postoperative mortality and how the diameter or ASI affects the association between sex and mortality. METHODS: We performed a retrospective analysis of patients who enrolled in the AAA registry of the German Society of Vascular Surgery from 2013 to 2019. The patients were treated by either open surgical repair (OSR) or endovascular aneurysm repair (EVAR). The association between sex and 30-day mortality was investigated using logistic regression analysis. The interaction and mediating effects of maximum aneurysm diameter and ASI were investigated to verify their roles in the effect of sex on mortality. The relationships between the diameter (or ASI) and the risk of 30-day mortality in different sexes were demonstrated by the restricted cubic spline. RESULTS: Overall, 23,275 cases were included in our analysis, with 20,130 male (86.5%) and 3139 female (13.5%) patients. Female patients had a smaller maximum aneurysm diameter (OSR, 55.23 ± 10.29 mm vs 58.05 ± 11.28 mm [P < .001]; EVAR, 54.06 ± 9.08 mm vs 56.11 ± 9.38 mm [P < .001]), but a higher ASI (OSR, 3.16 ± 0.71 vs 2.92 ± 0.69 [P < .001]; EVAR, 3.05 ± 0.66 vs 2.80 ± 0.59 [P < .001]) compared with male patients. The 30-day mortality rate was higher for female patients in both OSR (6.6% vs 4.2%; P = .002) and EVAR groups (1.8% vs 0.8%; P < .001). Logistic regression confirmed a significantly higher risk of 30-day mortality for female patients compared with male patients (odds ratio, 1.55; 95% confidence interval, 1.21-1.99; P = .001). No interaction was found between sex and diameter or ASI, but there were mediating effects for diameter and ASI in the effect of sex on 30-day mortality. For female patients, the risk of 30-day mortality linearly increased with the increase of diameter (PNonlinear = .089) or ASI (PNonlinear = .888), whereas the risk for male patients was U-shaped (for diameter, PNonlinear < .001; for ASI, PNonlinear = .020). CONCLUSIONS: Sex is an independent risk factor for 30-day mortality after AAA repair. Both diameter and ASI are mediating factors for the effect of sex on 30-day mortality. The relationship between diameter or ASI and the risk of 30-day mortality is different for male and female patients.

Bibliometric Analysis of Research Areas, Publication Hierarchy and Gender Authorship in German University Orthopaedic Surgery. / Bibliometrische Analyse von Forschungsgebieten, Publikationshierarchie und Autorengeschlecht der deutschen universitären Unfallchirurgie und Orthopädie.

BACKGROUND: The aim of the present bibliometric study was to record the focus of publications, type of study and publication activities depending on the hierarchy level and gender of the authors of German university departments for orthopaedic surgery. MATERIAL AND METHODS: The publication performance of the staff surgeons, consisting of chief and senior physicians, section and division heads of 39 German university departments of orthopaedic surgery university hospitals, was recorded over a period of 10 years (January 1, 2010 to December 31, 2019). All publications were considered that were listed in PubMed and for which the staff surgeons were first or last authors. In addition, the impact factor (IF) and the h-index were determined. RESULTS: 1739 (39.2%) publications were compiled by 180 staff surgeons of university departments for trauma surgery and 2699 (60.8%) publications by 343 surgeons in departments of orthopaedics and trauma surgery. Most publications were related to injuries or impairments of the lower extremity including the hip (n = 1626; 38.1%), followed by the upper extremity (n = 737; 17.3%). These publications focussed on diagnostic testing (25.5%), surgical techniques (19.1%) or special osteosyntheses (16.9%). The highest average IF per publication was achieved by publications on plastics (IF 2.02), on outcome (IF 1.96) and on diagnostic testing (IF 1.93). Heads of departments were first authors in 18.8%, senior physicians with management functions in 40.7% and senior physicians without management functions in 69% of papers and last authors in 81.2%, 49.3% and 31.0% of articles, respectively. 64 of 523 staff surgeons (12.2%) were women. 306 authors (6.1%) were women, corresponding to 4.8 authorships per female surgeon - significantly for male surgeons (10.3 authorships per male surgeon). CONCLUSION: In the present study, among senior physicians with a management function, the share of publishing surgeons was 59.1% for women, but 85.5% for men. In contrast, in the group of senior physicians without management function female and male surgeons were almost equally represented (57.5% vs. 60.5%). It must therefore be asked whether the work life balance is more difficult to meet for women than for men with longer careers. Mentoring programs are required to support the publication activities of the increasing number of female applicants in the future.

Long-Term Outcome of Lower Extremity Bypass Surgery in Diabetic and Non-Diabetic Patients with Critical Limb-Threatening Ischaemia in Germany.

AIM: To present the short- and long-term outcomes of lower extremity bypass (LEB) surgery in patients with critical limb-threatening ischaemia (CLTI), comparing diabetic (DM) and non-diabetic (non-DM) patients. METHODS: Retrospective analysis of anonymised data from a nationwide health insurance company (AOK). Data from 22,633 patients (DM: n = 7266; non-DM: n = 15,367; men: n = 14,523; women: n = 8110; mean patient age: 72.5 years), who underwent LEB from 2010 to 2015, were analysed. The cut-off date for follow-up was December 31, 2018 (mean follow-up period: 55 months). RESULTS: Perioperative mortality was 10.0% for DM and 8.2% for non-DM (p < 0.001). Patients with crural/pedal bypasses (n = 8558) had a significantly higher perioperative mortality (10.3%) than those with above-the-knee (n = 7246; 5.8%; p < 0.001) and below-the-knee bypasses (n = 6829; 8.9%; p = 0.003). The 9-year survival rates in DM patients were significantly worse, at 21.5%, compared to non-DM, at 31.1% (p < 0.001). This applied to both PAD stage III (DM: 34.4%; non-DM: 45.7%; p < 0.001) and PAD stage IV (DM: 18.5%; non-DM: 25.0%; p < 0.001). Patients with crural/pedal bypasses had a significantly inferior survival rate (25.5%) compared to those with below-the-knee (27.7%; p < 0.001) and above-the-knee bypasses (31.7%; p < 0.001). CONCLUSION: Perioperative and long-term outcomes regarding survival and major amputation rate for CLTI patients undergoing LEB are consistently worse for DM patients compared to non-DM patients.

[Perioperative lethality after endovascular and open repair of ruptured abdominal aortic aneurysms: An analysis of administrative data of the AOK health insurance fund]. / Zur perioperativen Letalität des rupturierten Bauchaortenaneurysmas nach endovaskulärer und offener Versorgung: eine Analyse von Routinedaten der AOK Gesundheit.

OBJECTIVE: In this paper we will report the perioperative outcome after endovascular (EVAR) and open (OAR) repair of ruptured abdominal aortic aneurysms (rAAA) in Germany based on data of the AOK health insurance fund. METHODS: Anonymised data of all patients with rAAA (n = 3,227) who were treated from 01/01/2010 to 12/31/2016 were analysed, using SPSS 27 (IBM Deutschland GmbH, Ehningen, Germany). RESULTS: 41.9% (1,353/3,227) of the patients were treated with EVAR and 58.1% (1,874/3,227) with OAR. Patients ≥80 years made up 38.4% for EVAR and 32.9% for OAR (p = 0.002). The proportion of patients undergoing surgery within 24 hours after admission was significantly higher for OAR (87.8%) than for EVAR (73.0%) (p = 0.000). The perioperative lethality rate for OAR was 42.4%, and thus almost twice as high as for EVAR with 21.3% (p = 0.000). Women had higher perioperative lethality rates for both EVAR (perioperative lethality 24.6%) and OAR (perioperative lethality 51.7%) compared to men with 20.6% (EVAR) and 40.2% (OAR), respectively. With EVAR, 35.8% of the patients showed a complication-free postoperative course, with OAR it was 17.7% (p = 0.000). Blood transfusions (whole blood, red cell concentrates, and autotransfusions) were administered in 57.6% of the patients with EVAR, but in 92.3% with OAR (p = 0.000). The highest perioperative lethality was found in EVAR and OAR patients who received both surgery within 24 hours after admission and blood transfusions (perioperative lethality EVAR 36.0%, OAR 46.0%; p = 0.000). In contrast, patients who did not require blood transfusions and were treated later than 24 hours after admission had the lowest perioperative lethality with 3.2% for EVAR vs. 5.4% for OAR (p = 0.623). CONCLUSION: The data confirm the observation that the perioperative mortality of rAAA patients is lower with EVAR than with OAR. However, strict attention must be paid to the time of the intervention. The low perioperative lethality of patients who were treated later than 24 hours after hospital admission and who did not require blood transfusions indicates that cases of symptomatic AAA without rupture have also been recorded in this administrative database under the diagnosis rAAA. One point of criticism is that the decision not to adjust for the patient groups with EVAR and with OAR in order to be able to better analyse the properties of routine data includes a considerable risk of bias in the statements of this work due to confounding variables.

Publication Performance in German Academic Heart Surgery.

BACKGROUND: This study was designed to evaluate the publication performance of management teams consisting of chief and senior physicians in German university cardiac surgery units over a 10-year period and to facilitate benchmarking. METHODS: The cutoff date for consideration of staffing from the unit Web site and publications was July 1, 2017. The literature search was based on an evaluation of the PubMed database. The 5-year impact factor (IF) from 2016 was assigned to each journal. RESULTS: Two thousand five hundred thirty-five publications (average IF 3.02) were registered, published in 323 journals. Of a total of 341 management team members, 235 (68.9%) published as first or last author over the 10-year period. The number of publications from the units divided into quintiles varied considerably with the first six units contributing 39.0% of all publications and the last nine units 9.4%. With a cumulative IF total of 3265, the publications of the first six units accounted for 42.7% of the cumulative IF, the last unit quintile amounted to 621 (8.1%) of the cumulative IF. When considering publications per managing member, the first quintile averaged 11.9 publications (29.6 IF) per managing member, the last quintile 3.3 publications (8.0 IF) per member. CONCLUSIONS: The six units of the first quintile published on average 3.6 times more per managing member than the nine units in the last quintile and the average cumulative IF per member in the first quintile was almost five times higher. Further investigation must show whether this considerable difference in publication activity between the university units is also observed in other operative fields.

Time trends of international English language publication activity by vascular surgeons.

OBJECTIVE: Vascular surgical publication activity in the English-language literature during a 10-year interval could have changed. The present study sought to identify which countries have made the most contributions and whether significant shifts have occurred during a 10-year period. METHODS: The study design was a retrospective study. Screening of 15 international journals in PubMed was performed for the 2006 to 2007 and 2016 to 2017 for studies reported by a first author belonging to a vascular surgery department. Data were collected by country regarding the total number of publications, cumulative impact factors (IFs), publications per inhabitant, IFs per inhabitant, and number of randomized controlled trials, meta-analyses, and systematic reviews per country in both periods. RESULTS: A total of 975 and 1459 reports were found for 2006 to 2007 and 2016 to 2017, respectively. For 2006 to 2007, most reports (n = 400; 41.0%; 1308.3 IFs) had come from the United States, followed by the United Kingdom (n = 168; 17.2%; 462.3 IFs) and The Netherlands (n = 74; 7.6%; 182.6 IFs). For 2016 to 2017, the United States led again with 607 articles (41.6%; 1968.0 IFs), followed by the United Kingdom (n = 119; 8.2%; 640.5 IFs) and The Netherlands (n = 107; 7.3%; 355.6 IFs). Of the top 15 countries, The Netherlands and Sweden contributed the most articles per inhabitant during both periods. During both periods, the United Kingdom reported the most randomized controlled trials, meta-analyses, and systematic reviews. CONCLUSIONS: Vascular surgeons from the United States and United Kingdom were the most productive in terms of the total numbers of English language publications during both periods. However, The Netherlands and Sweden were more active in relation to their population size.

Comparison of open and endovascular repair of juxtarenal abdominal aortic aneurysms.

BACKGROUND: This study compares the perioperative outcome in elective repair of the juxtarenal abdominal aortic aneurysm (AAA), depending upon whether patients received an open (OAR) or endovascular procedure (EVAR). METHODS: The database stems from the 2013-2017 AAA registry of the German Institute for Vascular Health Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine (DGG), with a total of 1603 juxtarenal AAAs. 786 patients (49.0%) were treated with an endovascular (EVAR) procedure, and 817 (51.0%) with an open (OAR) procedure. RESULTS: Patients receiving EVAR had a median age of 73 years and those receiving OAR a median age of 71 years (p < 0.001). The proportion of patients over 80 years of age was 17.0% for EVAR and 9.9% for OAR (p < 0.001). The proportion of women receiving EVAR (16.9%) was slightly lower than that receiving OAR (18.6%). Aneurysm diameter differed significantly (EVAR mean 57.80 mm, OAR 59.07 mm; p = 0.038). Preoperatively impaired renal function stages 3 to 5 were not significantly different (EVAR 12.5%, OAR 14.4%, p = 0.158). Postoperative complications were significantly less with EVAR (31%) than with OAR at 45.7% (p = 0.001). In regard to MACE (major adverse cardiac events = perioperative death, stroke, or myocardial infarction), there were no significant differences between EVAR (8.8%) and OAR (10.3%) (p = 0.191). Hospital mortality was only in trend lower with EVAR than with OAR (5.7% vs. 7.7%, respectively; p = 0.068). This held true for the hospital mortality in the group above 80 years of age as well. Inpatient stay was 9 (13.3) days for EVAR and 14 (18.8) days for OAR (p < 0.001). The hospital mortality for women receiving EVAR was 10.5%, and significantly higher (p = 0.008) than that for men (4.7%). The same held true for OAR (hospital mortality for women was 11.8%, for men 6.8%; p = 0.030). CONCLUSION: In terms of perioperative outcome, the endovascular procedure for treating juxtarenal AAA is more favorable than that documented for OAR. Further investigation is necessary to determine whether EVAR is comparable with OAR in the long term when treating juxtarenal AAA.

Endovascular and Open Repair of Abdominal Aortic Aneurysm.

BACKGROUND: This review presents the surgical indications, surgical procedures, and results in the treatment of asymptomatic and ruptured abdominal aortic aneurysms (AAA). METHODS: An updated search of the literature on screening, diagnosis, treatment, and follow-up of AAA, based on the German clinical practice guideline published in 2018. RESULTS: Surgery is indicated in men with an asymptomatic AAA ≥ 5.5 cm and in women, ≥ 5.0 cm. The indication in men is based on four randomized trials, while in women the data are not conclusive. The majority of patients with AAA (around 80%) meanwhile receive endovascular treatment (endovascular aortic repair, EVAR). Open surgery (open aneurysm repair, OAR) is reserved for patients with longer life expectancy and lower morbidity. The pooled 30-day mortality is 1.16% (95% confidence interval [0.92; 1.39]) following EVAR, 3.27% [2.7; 3.83] after OAR. Women have higher operative/interventional mortality than men (odds ratio 1.67%). The mortality for ruptured AAA is extremely high: around 80% of women and 70% of men die after AAA rupture. Ruptured AAA should, if possible, be treated via the endovascular approach, ideally with the patient under local anesthesia. Treatment at specialized centers guarantees the required expertise and infrastructure. Long-term periodic monitoring by mean of imaging (duplex sonography, plus computed tomography if needed) is essential, particularly following EVAR, to detect and (if appropriate) treat endoleaks, to document stable diameter of the eliminated aneurysmal sac, and to determine whether reintervention is necessary (long-term reintervention rate circa 18%). CONCLUSION: Vascular surgery now offers a high degree of safety in the treatment of patients with asymptomatic AAA. Endovascular intervention is preferred.

Surgical leadership within rapidly changing working conditions in Germany.

INTRODUCTION: An overview of the requirements for the head of a surgical department in Germany should be given. MATERIALS AND METHODS: A retrospective literature research on surgical professional policy publications of the last 10 years in Germany was conducted. RESULTS: Surveys show that commercial influences on medical decisions in German hospitals have today become an everyday, predominantly negative, actuality. Nevertheless, in one survey, 82.9% of surgical chief physicians reported being very satisfied with their profession, compared with 61.5% of senior physicians and only 43.4% of hospital specialists. Here, the chief physician is challenged. Only 70% of those surveyed stated that they could rely on their direct superiors when difficulties arose at work, and only 34.1% regarded feedback on the quality of their work as sufficient. The high distress rate in surgery (58.2% for all respondents) has led to a lack in desirability and is reflected in a shortage of qualified applicants for resident positions. In various position papers, surgical residents (only 35% describe their working conditions as good) demand improved working conditions. Chief physicians are being asked to facilitate a suitable work-life balance with regular working hours and a corporate culture with participative management and collegial cooperation. Appreciation of employee performance must also be expressed. An essential factor contributing to dissatisfaction is that residents fill a large part of their daily working hours with non-physician tasks. In surveys, 70% of respondents stated that they spend up to ≥3 h a day on documentation and secretarial work. DISCUSSION: The chief physician is expected to relieve his medical staff by employing non-physician assistants to take care of non-physician tasks. Transparent and clearly structured training to achieve specialist status is essential. It has been shown that a balanced work-life balance can be achieved for surgeons. Family and career can be reconciled in appropriately organized departments by making use of part-time and shift models that exclude 24-h shifts and making working hours more flexible.