Single-specialty versus multispecialty vascular surgery group model.

The shift in employment options for vascular surgeons in the current era of major health care reform is being widely debated. After the decision to seek hospital employment or independent practice, the choice of then practicing in a single-specialty or a multispecialty practice remains a difficult decision. Although the trend is toward medium-sized to large-sized groups, only 1.2% of medical practices currently have >11 physicians. Barring the large multispecialty groups, such as Kaiser Permanente, Cleveland Clinic, or Mayo Clinic, most vascular practices are constituted as small groups. Which format prospers will depend on adroit management of financial and intellectual capital and nimbleness in adapting to rapidly changing market conditions. In this report, two practicing vascular surgeons debate the merits of single or multispecialty practice, with a commentary to follow.

Changing practice paradigms: negotiating your future.

There are many recent and ongoing changes in the practice of medicine from a business standpoint as well as in overall practice management. Economic and lifestyle desires have pushed many physicians to a decision point of whether or not to join a large multispecialty group or to sell their practice and become an employee of a hospital system. There are advantages and disadvantages to both options; however, deciding on the most appropriate path for each individual can be a daunting task. At our recent breakfast session at the vascular annual meeting in Chicago, Illinois, in June 2011, we brought to light these topics to try and help enlighten physicians on which option may be right for them. There is no single answer/option that will fit every practice, but discussion for various practice management designs are outlined and critiqued. This article cannot fully discuss each view in the allotted space, but it is designed to encourage thought and discussion among the vascular surgical community as a whole.

Surveillance after endovascular aneurysm repair: diagnostics, complications, and associated costs.

The purpose of this study is to describe the diagnostic tests used, the complications that occurred the reinterventions performed, and the costs incurred after endovascular aneurysm repair. Retrospective review was performed of 77 consecutive individuals in whom endovascular aortic grafts had been successfully deployed. The series represents a single institution's experience with prospective application of a surveillance program using high-resolution CT scanning. Follow-up was available for all individuals. Mean interval of follow-up was 19.9 months (range 1-72 months), yielding a cumulative follow-up of 1540 months. There were no cases of aneurysm rupture. A total of 315 CT scans were performed during follow-up. On the basis of predetermined criteria, 28 interventions were performed in 21 patients. Indications for intervention included change in aneurysm sac volume (21 procedures), limb ischemia (5 procedures), and infection (2 procedures). Seven individuals were converted to open repair an average of 28.5 months after graft implantation (range 4-69 months). Twenty-one additional procedures were performed in 15 individuals after an average of 14.8 months (range 1-63 months). Cumulative risk of intervention and overall costs were estimated as a function time from implantation. Estimated costs at one and five years were 3631 dollars and 9729 dollars. The cumulative risk of intervention at one year was 7.2%. The frequency and cost of post-implantation procedures after endovascular aortic intervention are substantial. As longer follow-up becomes available, continued postoperative expenses may cancel out the already marginal cost STET benefits of EVAR benefits of EVAR.

Noninvasive evaluation of the effectiveness of endovascular AAA exclusion.

PURPOSE: To evaluate the relationship between aneurysm sac pressure and endograft wall motion in vitro and in vivo and to compare this to sac volume changes after endovascular aneurysm repair. METHODS: In a flow model of an aneurysm with a stent-graft in situ, sac pressure was incrementally increased by adding volume to an otherwise excluded sac; sac pressure waves were registered. Clinically, 43 patients who had unsupported endografts were monitored for stent-graft wall motion using electrocardiographically-guided M-mode ultrasonography. At 3 predetermined points in the cardiac cycle, 2 independent observers measured the maximal endograft diameter. Graft wall motion was then compared to changes in aneurysm thrombus volume (shrinking, static, growth) based on serial spiral computed tomographic angiography measurements. RESULTS: In the in vitro model, as the sac was incrementally pressurized, the initially static pressure waveform changed to a more dynamic waveform identical to that of the systemic pressure. Additionally, graft wall motion was noted visually when the pressure exceeded 40 mm; it became increasingly vigorous at higher pressures. The 0.13-cm wall motion in the growth group (n=5) was significantly larger than the 0.04 cm in the static group (n=19; p=0.012) and the 0.03 cm in the shrinking group (n=19; p=0.002). No significant difference was found between the static and the shrinking groups (p=0.209). CONCLUSIONS: Increases in sac pressure are reflected as increased wall motion in unsupported endografts. Clinically, increased endograft wall motion can be demonstrated by M-mode ultrasound; in growing aneurysms, the significant change in wall motion may suggest increased sac pressures as the etiology of the aneurysm growth.