Thoracoabdominal aortic aneurysm life-altering events following endovascular aortic repair in the Vascular Quality Initiative.

OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) has lower rates of postoperative mortality and morbidity when compared with open repair. However, endovascular repair still carries the risk of postoperative dialysis, paralysis, and stroke. This study examined the rates of postoperative mortality and morbidity stratified by type of endovascular aortic aneurysm repair. METHODS: All patients who underwent EVAR in the Vascular Quality Initiative registry from January 2011 to May 2022 were identified. Patients were stratified by repair type: infrarenal EVAR, complex EVAR, thoracic endovascular aortic repair (TEVAR), extent I to III thoracoabdominal aortic aneurysm (TAAA) repair, or aortic arch repair. The primary outcome was postoperative thoracoabdominal aortic aneurysm life-altering events (TALE) across the different treatment groups. TALE was defined as a composite outcome of postoperative mortality, dialysis, paralysis, and/or stroke. Mixed effect logistic regression modeling was used to identify procedural and anatomic factors that were independently associated with TALE. RESULTS: A total of 52,592 EVARs, 3768 complex EVARs, 3899 TEVARs, 1139 extent I to III TAAA repairs, and 479 arch repairs were identified. TALE was observed in 1.2% of EVARs, 4.8% of complex EVARs, 6.0% of TEVARs, 10% of extent I to III TAAA repairs, and 14% of arch repairs. More proximal landing zone was associated with higher odds of TALE after complex EVAR (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-3.1; P = .008), TEVAR (OR, 2.2; 95% CI, 1.4-3.5; P = .001), and extent I to III TAAA repair (OR, 2.7; 95% CI, 1.5-4.9; P = .001). Aortic diameter >65 mm was associated with higher odds of TALE after infrarenal EVAR (OR, 1.8; 95% CI, 1.4-2.3; P < .001), complex EVAR (OR, 1.6; 95% CI, 1.1-2.3; P = .010), TEVAR (OR, 2.7; 95% CI, 2.0-3.8; P < .001), and arch repair (OR, 2.4; 95% CI, 1.3-4.4; P = .007). The use of parallel grafting technique (chimney/snorkel/periscope) during extent I to III TAAA repair was also associated with higher odds of TALE (OR, 1.8; 95% CI, 1.1-3.2; P = .032). Preoperative chronic kidney disease was also associated with higher odds of TALE after infrarenal EVAR (OR, 4.3; 95% CI, 3.0-5.7; P < .001), complex EVAR (OR, 5.2; 95% CI, 3.3-8.2; P < .001), TEVAR (OR, 4.5; 95% CI, 2.8-7.1; P < .001), and extent I to III TAAA repair (OR, 3.2; 95% CI, 1.6-6.7; P = .001). CONCLUSIONS: Although TALE was originally described for TAAA repairs, TALE may occur after complex EVAR, TEVAR, and arch repairs as well. Therefore, TALE and its component parts should be used to evaluate the efficacy of all aortic repairs and for preoperative counseling. Additionally, surgeons should be aware of anatomic and procedural characteristics that are associated with higher odds of TALE. The anticipated need for such interventions during aortic repair should be factored into preoperative risk assessment of patients.

DREAM: Empowering Preclinical Medical Students With Labor Support.

Introduction: Delivery Resources, Experiences, and Advocacy for Moms (DREAM) is an interprofessional service-learning program that empowers preclinical medical students by training them to provide labor support. Boston Medical Center is a safety-net hospital featuring an in-house doula service with limited coverage capacity. Consequently, many patients do not receive continuous labor support, although evidence shows that continuous labor support improves outcomes and may help reduce birth-outcome health disparities. We present a pragmatic approach to integrating preclinical students as labor-support staff and outline the methods and content of the training process as well as the evaluations used to assess program effectiveness. Methods: Students were trained by doulas (Birth Sisters) and midwives to provide prenatal, labor, and postpartum support. Students completed an orientation and training workshop and then partnered with a Birth Sister for one prenatal visit, labor, and postpartum visit prior to working independently. Student leaders provided structure, mentoring, and support for preclinical students. Pre- and postsurveys assessed student confidence and obstetric knowledge acquisition. Budget, logistics, and program evaluation process are reviewed. Results: Students demonstrated increased knowledge, as well as confidence in communication, advocacy, and support. Although balancing DREAM with academics was stressful, students continued to meet academic standards and felt their participation was gratifying and worthwhile. Student reflections and patient statements on their experience show the program was mutually beneficial. Discussion: Preclinical students need gratifying clinical opportunities to develop confidence in communication and advocacy skills. Partnering them with underserved women to provide labor support is a pragmatic and clinically valuable intervention.