Use of Atherectomy During Index Peripheral Vascular Interventions.

OBJECTIVES: The aim of this study was to describe physician practice patterns and examine physician-level factors associated with the use of atherectomy during index revascularization for patients with femoropopliteal peripheral artery disease. BACKGROUND: There are minimal data to support the routine use of atherectomy over angioplasty and/or stenting for the endovascular treatment of peripheral artery disease. METHODS: Medicare fee-for-service claims (January 1 to December 31, 2019) were used to identify all beneficiaries undergoing elective first-time femoropopliteal peripheral vascular intervention (PVI) for claudication or chronic limb-threatening ischemia. Hierarchical logistic regression was used to evaluate patient- and physician-level characteristics associated with atherectomy. RESULTS: A total of 58,552 patients underwent index femoropopliteal PVI by 1,627 physicians. There was a wide distribution of physician practice patterns in the use of atherectomy, ranging from 0% to 100% (median 55.1%). Independent characteristics associated with atherectomy included treatment for claudication (vs. chronic limb-threatening ischemia; odds ratio [OR]: 1.51), patient diabetes (OR: 1.09), physician male sex (OR: 2.08), less time in practice (OR: 1.41 to 2.72), nonvascular surgery specialties (OR: 2.78 to 5.71), physicians with high volumes of femoropopliteal PVI (OR: 1.67 to 3.51), and physicians working primarily at ambulatory surgery centers or office-based laboratories (OR: 2.19 to 7.97) (p ≤ 0.03 for all). Overall, $266.8 million was reimbursed by Medicare for index femoropopliteal PVI in 2019. Of this, $240.6 million (90.2%) was reimbursed for atherectomy, which constituted 53.8% of cases. CONCLUSIONS: There is a wide distribution of physician practice patterns for the use of atherectomy during index PVI. There is a critical need for professional guidelines outlining the appropriate use of atherectomy in order to prevent overutilization of this technology, particularly in high-reimbursement settings.

Telemedicine platforms and their use in the coronavirus disease-19 era to deliver comprehensive vascular care.

Implementation of telemedicine for patient encounters optimizes personal safety and allows for continuity of patient care. Embracing telehealth reduces the use of personal protective equipment and other resources consumed during in-person visits. The use of telehealth has increased to historic levels in response to the coronavirus disease 2019 (COVID-19) pandemic. Telehealth may be a key modality to fight against COVID-19, allowing us to take care of patients, conserve personal protective equipment, and protect health care workers all while minimizing the risk of viral spread. We must not neglect vascular health issues while the coronavirus pandemic continues to flood many hospitals and keep people confined to their homes. Patients are not immune to diseases and illnesses such as stroke, critical limb ischemia, and deep vein thrombosis while being confined to their homes and afraid to visit hospitals. Emerging from the COVID-19 crisis, incorporating telemedicine into routine medical care is transformative. By leveraging digital technology, the authors discuss their experience with the implementation, workflow, coding, and reimbursement issues of telehealth during the COVID-19 era.

Predictors of Groin Access Pseudoaneurysm Complication: A 10-Year Institutional Experience.

OBJECTIVE: In clinical practice, the incidence of femoral pseudoaneurysms requiring repair is small, but at a tertiary care center, the repair rate is higher due to referrals. We sought to specifically study patients who suffered postcatheterization pseudoaneurysms requiring thrombin injection or operative repair and compare them to our routine transfemoral endovascular patients to identify predictors of clinically significant pseudoaneurysms. The underlying goal would be to identify what makes these patients that develop pseudoaneurysms different. METHODS: A search of our billing records for Current Procedural Technology (CPT) codes of these 2 procedures between January 2008 and April 2018 was combined with our institution's Peripheral Vascular Intervention Vascular Quality Initiative database spanning from January 2013 to December 2017. A comparison was then performed between patients who had the outcome of operative intervention for a pseudoaneurysm complication and those who did not, with the goal of elucidating patient demographics and periprocedural factors that would predict pseudoaneurysm formation using univariate and multivariate analyses. RESULTS: There were 77 patients who required thrombin injection or open repair for access-related pseudoaneurysms and 324 patients who did not. Complications occurred more often in patients who were older than 75 (40.2% vs 21.9%; P = .0009), female (57.1% vs 38.6%; P = .003), obese (59.7% vs 33.3%; P < .001), hypertensive (96.1% vs 79.3%; P = .0005), who received a sheath >6F (32.4% vs 13%; P < .0001), intraoperative and postoperative anticoagulation (77.3% vs 32.7% and 52.1% vs 24.2%, respectively; P < .0001), and periprocedural P2Y12 inhibitors (48.7% vs 28%; P = .0005). Less complications were observed in patients who had a closure device used (42.9% vs 8.45%; P < .0001) and protamine reversal (26.5% vs 13.3%; P = .0163). CONCLUSIONS: Our findings validate published reports that incriminate a larger sheath size, perioperative anticoagulation, and female gender as increasing the rate of access site complications, with the use of a closure device being protective.

Five-year outcomes of the PYTHAGORAS U.S. clinical trial of the Aorfix endograft for endovascular aneurysm repair in patients with highly angulated aortic necks.

OBJECTIVE: Early and midterm outcomes of the Prospective Aneurysm Trial: High Angle Aorfix Bifurcated Stent Graft (PYTHAGORAS) trial in patients with highly angulated aortic necks (≥60 degrees) have already been published and shown comparable outcomes to other endografts in normal anatomy. Herein, we present the long-term outcomes of the PYTHAGORAS trial of Aorfix (Lombard Medical, Irvine, Calif) for patients with highly angulated aortic neck anatomy. METHODS: The Aorfix endograft is a highly conformable nitinol/polyester device designed for transrenal fixation. The U.S. trial enrolled 218 patients and observed all patients at 1 month, 6 months, and 12 months and then annually for a total of 5 years. Endovascular aneurysm repair (EVAR)-specific complications were compared between the standard-angle (<60 degrees) and highly angulated (≥60 degrees) neck groups at 5 years using standard statistical methods. Kaplan-Meier analysis was performed to evaluate the overall 5-year survival and freedom from aneurysm rupture, aneurysm-related mortality, and reintervention. RESULTS: Of the 218 patients enrolled in the trial, there were 67 patients in the standard-angle neck group (I) and 151 patients in the highly angulated neck group (II). Mean proximal neck angle was 45 degrees in group I vs 83 degrees in group II (P < .001). At 5 years, 87% of surviving patients were followed up. The 5-year EVAR-specific results showed no type I or type III endoleak in either group, 4% migration in group I vs 3% in group II, and 4% sac expansion in group I vs 15.0% in group II (P ≥ .27). The 5-year freedom from all-cause mortality was 69% (73% in group I vs 68% in group II; P = .43); from aneurysm-related mortality, 96% (99% vs 95%; P = .44); from aneurysm rupture, 99% (99% vs 99%; P = 1.0); and from device-related secondary intervention, 83% (88% vs 80%; P = .18). None of these differed between groups. CONCLUSIONS: The U.S. PYTHAGORAS trial of the Aorfix endograft is the first EVAR clinical trial to include a majority of highly angulated (≥60 degrees) infrarenal aortic necks and is the first to produce evidence after 5 years of implantation. Despite predictors of worse short- and long-term outcomes, pertinent outcomes were better than or similar to those of trials with less severe anatomy. These results support the use of this "on-label" endovascular option, particularly in patients with highly angulated aortic neck anatomy.

The Impact of Physician Specialization on Clinical and Hospital Outcomes in Patients Undergoing EVAR and TEVAR.

BACKGROUND: Endovascular aneurysm repair (EVAR) and Thoracic endovascular aortic repair (TEVAR) are commonly performed by interventional radiologists, cardiologists, general surgeons, cardiothoracic surgeons, and vascular surgeons, with each specialty having differences in residency structure, operative experience, and subspecialty training. The aim of this study is to evaluate the impact of surgeon specialty on outcomes following EVAR and TEVAR. METHODS: Patients who underwent EVAR and TEVAR were identified from the 2007 to 2009 Nationwide Inpatient Sample (NIS). Physician identifiers in the NIS were used to determine surgical specialty and operative experience. Multivariate analysis adjusted for mortality risk was used to compare differences in demographics, complications, outcomes, and hospital covariates. RESULTS: A total of 5147 EVARs were identified within the NIS, of which 88.3% were completed by vascular surgeons. There were no significant differences in demographics between the specialties. Cardiothoracic surgeons were more likely to have a postoperative stroke (3.1% vs. 0.2%, odds ratio [OR] 14.6, 95% confidence interval [CI] 1.8-117.8, P < 0.05) and cardiac complications (9.4% vs. 2.0%, OR 5.0, 95% CI 1.5-16.6, P < 0.01) compared with other specialties. Costs were lowest for vascular surgeons ($32,094), and highest for cardiothoracic surgeons ($41,663, P < 0.05). Only vascular surgeons completed more than 10 EVARs per year. A total of 2531 TEVAR cases were completed during the study period, of which 73.8% were completed by vascular surgeons, 15.8% by cardiothoracic surgeons, 8.0% by interventional radiologists, and the remainder by interventional cardiologists and general surgeons. Interventional radiologists had significantly more elective cases (77.8%, P < 0.001) than cardiothoracic surgeons (47.2%) or vascular surgeons (53.8%), but had a significantly higher rate of stroke (7.6% vs. 1.1%, P < 0.001) and cardiac events (7.2% vs. 3.6%, P < 0.001). Length of stay (LOS, 10.7 days) and median costs ($52,156) were similar across specialties. Vascular surgeons have a low stroke rate (1.1%, P < 0.05 vs. interventional radiologists) and lower rate of cardiac events (3.6% vs. 6.1%, P < 0.01) despite caring for patients with higher diagnosis-related group mortality scores (3.6 vs. 3.4, P < 0.05). CONCLUSIONS: Vascular surgeons appear to have a comparative advantage over other specialties for EVAR because not only are their complication and mortality rates comparable but overall LOS and hospital charges are lower. Furthermore, primarily only vascular surgeons are performing the high volume of annual EVARs necessary to ensure optimal patient outcomes. For TEVAR, vascular surgeons have the lowest overall morbidity compared with the other specialties, and lower mortality compared with cardiothoracic surgeons. These findings may impact patient referral patterns and hospital privileges for providers.

Predictors of poor outcome after carotid intervention.

BACKGROUND: A variety of patient factors are known to adversely impact outcomes after carotid endarterectomy (CEA) or carotid artery stenting (CAS). However, their specific impact on complications and mortality and how they differ between CEA and CAS is unknown. The purpose of this study is to identify patient and hospital factors that adversely impact outcomes. METHODS: Patients who underwent CEA or CAS between 1998 and 2012 (N = 1,756,445) were identified using the Agency for Healthcare Research and Quality National Inpatient Sample and State Ambulatory Services Databases. A multivariate analysis was completed to evaluate the impact of demographics, patient factors, type of symptoms (transient ischemic attack or cerebrovascular accident), volume of cases (3 per year vs 1-2 interventions), and interventions upon outcomes, perioperative complications (stroke, myocardial infarction, and bleeding), duration of stay, inpatient mortality, and cost. Significant factors were then used as part of a multivariate regression analysis to determine odds ratios. A subgroup analysis using propensity matching evaluating 1:1 risk-matched asymptomatic and symptomatic patients was completed. Patient cohorts were matched on the basis of Charlson scores. RESULTS: Over the study period a total of 1,583,614 asymptomatic CEA, 7317 asymptomatic CAS, 162,362 symptomatic CEA, and 3149 symptomatic CAS patients were included. Symptomatic disease portends a worse outlook after either CEA or CAS. Costs of the procedure increased with complications with stroke adding the most significant cost burden. For risk-matched asymptomatic and symptomatic patients, female gender (P < .001) and performing one or two cases per year (P < .05) were associated with higher cerebrovascular accident risk. In asymptomatic and symptomatic patients, predictors of myocardial infarction included congestive heart failure (P < .001) and peripheral artery disease (P < .05) and predictors of bleeding included peripheral artery disease (P < .05) and chronic obstructive pulmonary disease (P < .01) for symptomatic patients only. For both asymptomatic and symptomatic patients, predictors of mortality included female gender (P < .001) and performing one or two cases per year (P < .01). Female gender was one of the strongest overall predictors of adverse outcome after CAS (odds ratio, 21.39 for death; P < .001). Low volume (<3 cases per year per practitioner) is a predictor of adverse outcome after CAS only. CONCLUSIONS: Higher rates of postoperative stroke and inpatient mortality for women undergoing CAS is an unexpected finding, and may indicate that this population is vulnerable to complications after endovascular management. Low volume is a predictor of complications and subsequent mortality primarily for CAS. Patients who undergo CEA continue to have superior outcomes compared with matched cohorts who undergo CAS.

Impact of consensus statements and reimbursement on vena cava filter utilization.

OBJECTIVE: Pulmonary embolism is the third most common cause of death in hospitalized patients. Vena cava filters (VCFs) are indicated in patients with venous thromboembolism with a contraindication to anticoagulation. Prophylactic indications are still controversial. However, the utilization of VCFs during the past 15 years may have been affected by societal recommendations and reimbursement rates. The aim of this study was to evaluate the impact of societal guidelines and reimbursement on national trends in VCF placement from 1998 to 2012. METHODS: The National Inpatient Sample was used to identify patients who underwent VCF placement between 1998 and 2012. VCF placement yearly rates were evaluated. Societal guidelines and consensus statements were identified using a PubMed search. Reimbursement rates for VCF were determined on the basis of published Medicare reports. Statistical analysis was completed using descriptive statistics, Fisher exact test, and trend analysis using the Mann-Kendall test and considered significant for P < .05. RESULTS: The use of VCFs increased 350% between January 1998 and January 2008. Consensus statements in favor of VCFs published by the Eastern Association for the Surgery of Trauma (July 2002) and the Society of Interventional Radiology (March 2006) were temporally associated with a significant 138% and 122% increase in the use of VCFs, respectively (P = .014 and P = .023, respectively). The American College of Chest Physicians guidelines (February 2008 and 2012) discouraging the use of VCFs were preceded by an initial stabilization in the use of VCFs between 2008 and 2012, followed by a 16% decrease in use starting in March 2012 (P = .38). Changes in Medicare reimbursement were not followed by a change in VCF implantation rates. CONCLUSIONS: There is a temporal association between the societal guidelines' recommendations regarding VCF placement and the actual rates of insertion. More uniform consensus statements from multiple societies along with the use of level I evidence may be required to lead to a definitive change in practice.

EVAR for ruptured aneurysms: are the data complete?

Endovascular abdominal aneurysm repair is now the preferred therapy for many patients with abdominal aortic aneurysms and has been associated with reduced immediate and short-term morbidity and mortality. Because perioperative complications so often compromise the open repair of ruptured aortic aneurysms, EVAR has been considered as an attractive option in these patients. A number of small, typically single-center studies have demonstrated excellent results. In the absence of compelling, objective clinical data, there are certainly many patients with ruptured aortic aneurysms who are well-suited for EVAR. The development of protocols and systems for the expeditious diagnosis and treatment of ruptured aneurysms should further improve therapy for this life-threatening condition.

Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial.

BACKGROUND: In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), the composite primary endpoint of stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke thereafter did not differ between carotid artery stenting and carotid endarterectomy for symptomatic or asymptomatic carotid stenosis. A secondary aim of this randomised trial was to compare the composite endpoint of restenosis or occlusion. METHODS: Patients with stenosis of the carotid artery who were asymptomatic or had had a transient ischaemic attack, amaurosis fugax, or a minor stroke were eligible for CREST and were enrolled at 117 clinical centres in the USA and Canada between Dec 21, 2000, and July 18, 2008. In this secondary analysis, the main endpoint was a composite of restenosis or occlusion at 2 years. Restenosis and occlusion were assessed by duplex ultrasonography at 1, 6, 12, 24, and 48 months and were defined as a reduction in diameter of the target artery of at least 70%, diagnosed by a peak systolic velocity of at least 3·0 m/s. Studies were done in CREST-certified laboratories and interpreted at the Ultrasound Core Laboratory (University of Washington). The frequency of restenosis was calculated by Kaplan-Meier survival estimates and was compared during a 2-year follow-up period. We used proportional hazards models to assess the association between baseline characteristics and risk of restenosis. Analyses were per protocol. CREST is registered with ClinicalTrials.gov, number NCT00004732. FINDINGS: 2191 patients received their assigned treatment within 30 days of randomisation and had eligible ultrasonography (1086 who had carotid artery stenting, 1105 who had carotid endarterectomy). In 2 years, 58 patients who underwent carotid artery stenting (Kaplan-Meier rate 6·0%) and 62 who had carotid endarterectomy (6·3%) had restenosis or occlusion (hazard ratio [HR] 0·90, 95% CI 0·63-1·29; p=0·58). Female sex (1·79, 1·25-2·56), diabetes (2·31, 1·61-3·31), and dyslipidaemia (2·07, 1·01-4·26) were independent predictors of restenosis or occlusion after the two procedures. Smoking predicted an increased rate of restenosis after carotid endarterectomy (2·26, 1·34-3·77) but not after carotid artery stenting (0·77, 0·41-1·42). INTERPRETATION: Restenosis and occlusion were infrequent and rates were similar up to 2 years after carotid endarterectomy and carotid artery stenting. Subsets of patients could benefit from early and frequent monitoring after revascularisation. FUNDING: National Institute of Neurological Disorders and Stroke and Abbott Vascular Solutions.

Predictors of wound complications following major amputation for critical limb ischemia.

OBJECTIVES: For patients with end-stage critical limb ischemia (CLI) who have already suffered over an extended period of time, a major amputation that is free of wound complications remains paramount. Utilizing data from the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP), the objective of this report was to determine critical factors leading to wound complications following major amputation. METHODS: ACS-NSQIP was used to identify patients ≥ 50 years, with CLI, and having an ipsilateral below-(BKA) or above-knee amputation (AKA). The primary outcome was wound occurrence (WO) defined by affirmative findings of superficial infection, deep infection, and/or wound disruption. The secondary outcome was 30-day mortality. Following univariate analyses, a multiple logistic regression was performed to identify predictive factors. RESULTS: Between January 1, 2005 and December 31, 2008, 4250 patients fulfilled inclusion criteria (2309 BKAs and 1941 AKAs). WOs were 10.4% for BKAs and 7.2% for AKAs. For BKAs, increasing elevation in international normalized ratio (INR) predicted more WOs (P = .008, odds ratio [OR] 1.5 for every integral increase in INR) as did age 50 to 59 compared with older patients (P = .002, OR 1.9). For AKAs, being a current smoker predicted more WOs (P = .0008, OR 1.8) as did an increasing body mass index (BMI) (P = .02, OR 1.3 for every 10 kg/m(2) increase in BMI). Mortality was 7.6% for BKAs and 12% for AKAs. Complete functional dependence was most predictive of mortality following AKA (P < .0001, OR 2.5). Medical comorbidities such as history of myocardial infarcation (MI) (OR 1.8), congestive heart failure (CHF, OR 1.6), and chronic obstructive pulmonary disease (COPD, OR 1.6) predicted mortality following BKA, while dialysis use (OR 2.4), CHF (OR 2.3), and COPD (OR 2.1) predicted mortality following AKA. CONCLUSIONS: Wound occurrences and mortality rates after major amputation for CLI continue to be a prevalent problem. Normalization of the INR prior to BKA should decrease WOs. Heightened awareness in higher risk patients with improved preventive measures, earlier disease recognition, better treatments, and increased education remain critical to improving outcomes in an already stressed patient cohort.

Percutaneous mechanical thrombectomy and pharmacologic thrombolysis for renal artery embolism: case report and review of endovascular treatment.

Renal artery embolism (RAE) is an uncommon event that is associated with a high rate of renal loss. We present a case of RAE to a solitary kidney that was treated with combined percutaneous rheolytic thrombectomy, intra-arterial thrombolysis, and supplemental renal artery stent placement.

Comparison of surgical operative experience of trainees and practicing vascular surgeons: a report from the Vascular Surgery Board of the American Board of Surgery.

INTRODUCTION: The Vascular Surgery Board (VSB) of the American Board of Surgery sought to answer the following questions: what is the scope of contemporary vascular surgery practice? Do current vascular surgery residents obtain training that is appropriate for their future career expectations and for successful Board certification? How effectively do practicing vascular surgeons incorporate emerging technologies and procedures into practice? METHODS: We analyzed the operative logs submitted to the VSB by recent vascular surgery residents applying for the Vascular Surgery Qualifying Examination (QE; 2006-2009) or by practicing vascular surgeons applying for the Vascular Surgery Recertification Examination (RE; 1995-2009). The relationship between reported operative experience and performance of the QE and RE was examined. RESULTS: There has been a threefold increase in the mean number of primary cases reported by both RE and QE applicants over the past 15 years and the increase in case volume has been driven largely by an increase in the number of endovascular procedures. Endovascular procedures have been broadly incorporated into the practice of most vascular surgeons applying for recertification. The number of major open surgical cases reported by recent QE applicants has remained unchanged over the period of observation. For QE applicants, the number of endovascular aneurysm repairs (EVARs) has reached a plateau at approximately 50 cases, whereas the mean number of open infrarenal aneurysm repairs has decreased for both QE and RE applicants, reflecting national trends favoring EVAR. There was a significant association between case volume and performance on the QE but not on the RE. CONCLUSION: Over the past 15 years, there has been a significant increase in the total number of operative cases reported to the VSB by both QE and RE applicants. Contrary to popular belief, the volume of major open vascular surgery reported by recent vascular surgery residents has remained relatively stable since 1994. Over the same time period, endovascular procedures have been rapidly incorporated into clinical practice by the majority of vascular surgeons applying for recertification by the VSB. Current vascular surgery residents receive a rich operative experience in both open and endovascular procedures that is reflective of contemporary practice.

The role of embolic protection devices in renal artery stenting.

Renal artery angioplasty and stenting is commonly performed for the treatment of hypertension and ischemic nephropathy. An increasing number of procedures are being undertaken for "renal preservation" despite an associated risk of renal function decline related to the embolization of atheromatous debris liberated during the procedure. Although smaller, more flexible guidewires and stents have been developed to decrease the amount of debris created, interest in the off-label use of embolic protection devices has increased. We review the available embolic protection devices and currently available data regarding their use in renal artery interventions. Although not designed for use in the renal artery, there are at least theoretical reasons to believe that embolic protection during renal artery angioplasty may improve outcomes.

Outcome of a comprehensive follow-up program to enhance maturation of autogenous arteriovenous hemodialysis access.

OBJECTIVE: To examine the outcome of a comprehensive follow-up program for autogenous arteriovenous hemodialysis access (AVF) when performed by the hemodialysis access surgeon. METHODS: Patients with first time AVFs between 2000 and 2005 underwent history and physical examination between the third and sixth postoperative weeks, followed by repeat examination every 6 to 8 weeks until maturation. Primary outcomes included maturation assessment and interventions required prior to maturation. Maturation was defined as 4 consecutive weeks of sustainable AVF hemodialysis access. RESULTS: One hundred thirteen patients had 113 AVFs. Mean age was 64 years (range: 26-94) and 52% were male. AVFs included 8 (7%) radiocephalic, 90 (80%) brachiocephalic, and 15 (13%) basilic vein transposition. Overall, the maturation rate was 72% (failure rate of 28%). Excluding deaths and transplants prior to maturation, the maturation rate was 82% (failure rate 18%). Eighty-three (73%) patients had no intervention prior to maturation and 30 (27%) required intervention. There was no significant difference in failure rate between AVFs not requiring an intervention (13 of 83, 15%) and those requiring intervention (5 of 30, 16%). For AVFs requiring intervention, 23 (61%) patients had an endovascular intervention and 15 (39%) an operative intervention. One intervention was performed in 64%, two in 24%, and three in 12%. Ninety-three percent of AVFs having an endovascular intervention matured compared with 60% having operative intervention (P = .10). AVFs requiring intervention had a maturation time (mean: 35 weeks, range: 10-54) that was significantly longer (P = .003) than those without (mean 11 weeks, range: 6-35). CONCLUSIONS: With a surgeon directed comprehensive follow-up program to assess AVF maturation, a large proportion (30 of 43, 69%) of AVFs with a problem were detected. Of those identified, most (25 of 30, 83%) could be salvaged to maturation with intervention. The Kidney and Dialysis Outcome Quality Initiative (K/DOQI) should consider incorporating a comprehensive follow-up program into its guidelines.

Advanced endovascular training for vascular residents: what more do we need?

In the 25 years that formalized vascular surgery training and certification has been, in effect, the treatment of patients with peripheral vascular disease has undergone dramatic changes, largely due to the emergence of a wide variety of endoluminal techniques and devices that enable minimally invasive treatment of conditions that formerly required operative intervention. Unfortunately, vascular surgeons, for the most part, were painfully slow to embrace these new and evolving technologies, which became increasingly complex as they expanded to treat virtually all vascular maladies in all peripheral vascular territories. Not surprisingly, this left vascular surgeons disadvantaged relative to other disciplines for whom these techniques were more familiar, and we have spent the better part of the last decade playing catch-up to master them and regain our role as the only specialty qualified to offer all types of therapies to our patients with vascular disease. This has caused some to question what changes need to be made in our vascular surgery training paradigm for our new trainees to attain and maintain a preeminent role in the evaluation and treatment of patients with peripheral vascular disease. While the knee-jerk response is to consider special or supplemental training programs for these advanced techniques, or even certificates of added qualifications for the more challenging of them, such as carotid stenting, we believe that all that is really needed is for the vascular surgical community as a whole, and particularly those faculty in training programs, to truly embrace these new technologies and apply them to the patients they are already rendering care to. Given the prevalence of vascular disease and overall wealth of clinical material already present in most training programs, the simple willingness to apply endoluminal therapies to our existing patient populations is all that would really be needed to insure that all future graduates of vascular surgery training programs are fully competent in all of the current endoluminal therapies and well-positioned to continue to evolve with the field. The real question to be considering, which is beyond the focus of this article, is how we are to maintain our open surgical skills in the era of minimally invasive treatment of vascular disease.

Establishment of a varicose vein center in a tertiary vascular surgery practice: urban versus rural differences.

We examined changes in practice patterns after the establishment of a varicose vein center (VVC) within two tertiary university vascular surgery practices and compared differences between urban (U) and rural (R) sites. Practice patterns for the treatment of VVs were compared 3 years before (period 1) and 3 years after (period 2) the formation of a U-VVC and an R-VVC in 2001. Both VVCs were part of similar-sized tertiary vascular surgery practices. Evaluation was specific to VVs, reticular veins, and telangiectasias. Prior to U-VVC, there were 338 office visits, six office procedures, and 114 hospital procedures. After U-VVC, there were 624, 120, and 312, respectively. Prior to R-VVC, there were 85 office visits, five office procedures, and 69 hospital procedures. After R-VVC, there were 528, 163, and 303, respectively. In period 1 for U-VVC and R-VVC, VVC relative value unit (RVU) generation as a percent of total practice RVUs was 1.0% and 0.7%, respectively. In period 2 for U-VVC and R-VVC, VVC RVU generation as a percent of total practice RVUs was 2.6% and 2.5%, respectively. In an effort to provide more coordinated treatment for patients with VVs, establishing a VVC within a tertiary academic vascular surgery practice can lead to rapid expansion of clinical volume by increased office visits, office procedures, and hospital procedures. Clinical demand for evaluation and treatment of VVs showed little variation between R-VVC and U-VVC.