A cross-sectional national study of burnout and psychosocial work environment in vascular surgery in Denmark.

OBJECTIVE: Little is known about burnout among European vascular surgeons (VSs). In this study, the prevalence of burnout and its associated risk factors were investigated among all VSs and vascular surgeons in training (VSTs) in Denmark. METHODS: An anonymous electronic survey was distributed to all clinical active VSs and VSTs on January 1, 2020. Validated assessment tools were used to measure burnout and aspects of the psychosocial work environment. RESULTS: A total of 104 VSs and VSTs were invited to participate, and 82% (n = 85) completed the survey. The majority of the respondents were male (60%; n = 50) and VSs (67%; n = 61). Of the respondents, 82% (n = 70) reported either light (54%; n = 46), moderate (22%; n = 19), or severe (6%; n = 5) personal burnout. More than 50% (n = 47) reported work-related burnout, light (39%; n = 33), moderate (9%; n = 8), and severe (7%; n = 6), respectively, whereas 35% (n = 30) reported patient-related burnout, light (31%; n = 26), moderate (2%; n = 2), and severe (2%; n = 2), respectively. Respondents with more than four 24-hour on-call shifts per month had significantly higher work-related burnout scores, whereas respondents with home-living children and those aged 45 to 59 years showed significantly higher personal and patient-related burnout, respectively. There were strong associations between personal and work-related burnout and the psychosocial work environment, especially work organization and interpersonal relations, but not job demands. The prevalence of burnout was unevenly distributed across departments, with the most affected department having a burnout occurrence twice the least affected department. CONCLUSIONS: Based on a national survey conducted among all clinical active VSs and VSTs in Denmark, more than 80% (n = 70) suffered from burnout, of whom 28% (n = 24) suffered from moderate to severe personal burnout. The strong association with the psychosocial work environment, and the significant differences between departments, suggest that burnout is modifiable through changes in the work environment.

Simulation-Based Education of Endovascular Scrub Nurses Reduces Stress and Improves Team Performance.

INTRODUCTION: Endovascular procedures have become commonplace in vascular surgery. This development calls for new training strategies for future specialists. Most simulation-based education (SBE) programs have a monodisciplinary focus on physicians, although successful surgery is a multidisciplinary team effort. Mental stress impairs the learning process and surgical performance and heart rate variability (HRV) can be measured as a proxy for both mental and physical stress. This study aims to assess how SBE of endovascular scrub nurses affects team performance and HRV during endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Prospective interventional study in which EVAR-inexperienced scrub nurses followed a focused SBE EVAR program. During real-life EVAR procedures, HRV was continuously recorded with a wireless electrocardiogram patch and multidisciplinary team performance was assessed with the Imperial College Error CAPture (ICECAP) tool, before and after the SBE program, allowing each scrub nurse to serve as their own control. Eight scrub nurses with experience in lower limb endovascular procedures, but not EVAR, were invited to participate. RESULTS: Seven participants completed the study. In five of seven scrub nurses, HRV-derived stress levels during real-time EVAR procedures were lower after SBE compared to before SBE. Mean HRV increased from 24 msec to 35 msec (P < 0.001), indicating stress level reduction. Before SBE, the mean number of errors/hour was 7.3 (standard deviation ± 1.8) compared to 3.6 (standard deviation ± 2.7) after SBE. Most errors were categorized as technical (58 %) and communicative (23 %). CONCLUSIONS: SBE of scrub nurses may improve team performance and may lower mental stress during EVAR procedures. In this small study, we suggest using mental stress, as evaluated with HRV, and multidisciplinary team performance, as evaluated with ICECAP, to assess SBE effectiveness in real-case EVAR procedures. This SBE program and live ICECAP observations and electrocardiogram patches was well-accepted by scrub nurses and the entire team.

Transcutaneous blood gas monitoring and tissue perfusion during common femoral thromboendarterectomy.

BACKGROUND: Improving tissue perfusion can improve clinical outcomes in surgical patients, where monitoring may aid clinicians in detecting adverse conditions and guide interventions. Transcutaneous monitoring (TCM) of oxygen (tcpO2) and carbon dioxide (tcpCO2) is a well-proven technology and could potentially serve as a measure of local circulation, perfusion and metabolism, but the clinical use is not thoroughly explored. The purpose of this proof-of-concept study was to investigate whether TCM of blood gasses could detect changes in perfusion during major vascular surgery. METHODS: Ten patients with peripheral arterial disease scheduled for lower limb major arterial revascularization under general anaesthesia were consecutively included. TcpO2 and tcpCO2 were continuously recorded from anaesthesia induction until skin closure with a TCM monitor placed on both legs and the thorax. Peripheral oxygen saturation was kept ≥94% and mean arterial blood pressure ≥65 mmHg. The primary outcomes were changes in tcpO2 and tcpCO2 related to arterial clamping and declamping during the procedure and analyzed by paired statistics. RESULTS: Femoral artery clamping resulted in a significant decrease in tcpO2 (-2.1 kPa, IQR-4.2; -0.8), p=.017)), followed by a significant increase in response to arterial declamping (5.5 kPa, IQR 0-7.3), p=.017)). Arterial clamping resulted in a statistically significant increase in tcpCO2 (0.9 kPa, IQR 0.3-5.4), p=.008)) and a significant decrease following declamping (-0.7 kPa, IQR -2.6; -0.2), p=.011)). CONCLUSION: Transcutaneous monitoring of oxygen and carbon dioxide is a feasible method for detection of extreme changes in tissue perfusion during arterial clamping and declamping, and its use for improving patient outcomes should be explored. Clinical Trials identifier: NCT04040478. Registered on July 31, 2019.

Adherence to instruction for use after endovascular repair of popliteal artery aneurysm.

OBJECTIVES: Endovascular repair (ER) of popliteal artery aneurysm (PAA) is an alternative to open repair. However, there is no standardized protocol for when to opt for ER and the decision is therefore at the discretion of the clinician. This study aims to evaluate the adherence to the Instruction For Use (IFU) in patients undergoing ER for PAA and factors associated with stent graft patency at one year. METHODS: The adherence to IFU provided by the manufacturer in 55 patients treated with Gore Viabahn® Endoprosthesis with Heparin Bioactive Surface for PAA between 2009 and 2019 were retrospectively analyzed. Duplex follow-up was performed at 30 days and one year. RESULTS: The two groups of patients treated within (n = 10) and not within (n = 45) IFU did not differ in patient demographics, diagnostic assessment, treatment or outcome. Forty-five patients (81.8%) received stent graft placement with at least one deviation according to IFU. Distal oversizing >20% was the most frequent deviation against IFU (n = 22, 40.0%). Primary patency at one year was 72%. Diameter size difference >1 mm between overlapping stent grafts (6/14 [43%], p = 0.013) and renal insufficiency (5/12 [42%], p = 0.0086) were associated with lower primary patency at one year. Age-adjusted analysis of tortuosity index (HR 1.78/SD, 95% CI 1.17-2.71; p = 0.0071) and maximal PAA angle (HR 1.73/SD, 95% CI 1.018-2.95; p = 0.043) were associated with major amputation/mortality at end of follow-up. CONCLUSION: The majority of patients undergoing ER for PAA were not treated within IFU. Diameter size difference >1 mm between overlapping stent grafts was associated with a higher loss of primary patency at one year. Multi-center studies with larger sample size and long-term follow up of patency are warranted.

Acute complications in the post-anaesthesia care unit after infrainguinal surgery for lower limb ischaemia - a prospective observational cohort study.

BACKGROUND: Arterial surgery for lower limb ischaemia is a frequently performed procedure in patients with severe cardio-pulmonary comorbidities, making them high-risk patients for acute postoperative complications with a need for prolonged stay in the post-anaesthesia care unit (PACU). However, detailed information on complications during the PACU stay is limited, hindering mechanism-based interventions for early enhanced recovery. Thus, we aimed to systematically describe acute complications and related risk factors in the immediate postoperative phase after infrainguinal arterial surgery. PATIENTS AND METHODS: Patients transferred to the PACU after infrainguinal arterial surgery due to chronic or acute lower limb ischaemia were consecutively included in a six-month observational cohort study. Pre- and intraoperative data included comorbidities as well as surgical and anaesthetic technique. Data on complications and treatments in the PACU were collected every 15 minutes using a standardised assessment tool. The primary endpoint was occurrence of predefined moderate or severe complications occurring during PACU stay. RESULTS: In total, 155 patients were included for analysis. Eighty (52 %) patients experienced episodes with oxygen desaturation (< 85 %) and moderate or severe pain occurred in 72 patients (47 %); however, circulatory complications (hypotension, tachycardia) were rare. Preoperative opioid use was a significant risk factor for moderate or severe pain in PACU (59 vs. 38 % chronic vs. opioid naïve patients (P = 0.01). CONCLUSIONS: Complications in the PACU after infrainguinal arterial surgery relates to saturation and pain, suggesting that future efforts should focus on anaesthesia and analgesic techniques including opioid sparing regimes to enhance early postoperative recovery.

3-D Contrast-Enhanced Fusion Ultrasound for Accurate Volume Assessment of Vessel Lumen and Plaque in Carotid Artery Disease as Compared With Computed Tomography Angiography.

OBJECTIVE: Three-dimensional contrast-enhanced fusion ultrasound (CEFUS) of atherosclerotic carotid arteries provides spatial visualization of the vessel lumen, creating a lumenography. As in 3-D computed tomography angiography (CTA), 3-D CEFUS outlines the contrast-filled lumen. Plaque and vessel contours are distinguished in 3-D CEFUS, allowing plaque volume quantification as a valid estimate of carotid plaque burden. Three-dimensional CEFUS is unproven in intermodality studies, vindicating the assessment of 3-D CEFUS applicability and comparing 3-D CEFUS and 3-D CTA lumenography as a proof-of-concept study. METHODS: Using an ultrasound system with magnetic tracking, a linear array transducer and SonoVue contrast agent, 3-D CEFUS acquisitions were generated by spatial stitching of serial 2-D images. From 3-D CEFUS and 3-D CTA imaging, the atherosclerotic carotid arteries were reconstructed with lumenography in an offline software program for lumen and plaque volume quantification. Bland-Altman analysis was used for inter-image modality agreement. RESULTS: The study included 39 carotid arteries. Mean lumen and plaque volume in 3-D CEFUS were 0.63 cm3 (standard deviation [SD]: 0.26) and 0.62 cm3 (SD: 0.26), respectively. Lumen volume differences between 3-D CEFUS and 3-D CTA were non-significant, with a mean difference of 0.01 cm3 (SD: 0.02, p = 0.26) and limits of agreement (LoA) range of ±0.11 cm3. Mean plaque volume difference was -0.12 cm3 (SD: 0.19, p = 0.006) with a LoA range of ±0.39 cm3. CONCLUSION: There was strong agreement in lumenography between 3-D CEFUS and 3-D CTA. The interimage modality difference in plaque volumes was substantial because of challenging vessel wall definition in 3-D CTA. Three-dimensional CEFUS is viable in quantifying carotid plaque volume burden and can potentially monitor plaque development over time.

Systematic Review and Meta-Analysis of the Incidence of Rupture, Repair, and Death of Small and Large Abdominal Aortic Aneurysms under Surveillance.

BACKGROUND: The ultimate goal of treating patients with abdominal aortic aneurysms (AAAs) is to repair them when the risk of rupture exceeds the risk of repair. Small AAAs demonstrate a low rupture risk, and recently, large AAAs just above the threshold (5.5-6.0 cm) seem to be at low risk of rupture as well. The present review aims to investigate the outcomes of AAAs under surveillance through a comprehensive systematic review and meta-analysis. METHODS: PubMed, Embase, and the Cochrane Central Register were searched (22 March 2022; PROSPERO; #CRD42022316094). The Cochrane and PRISMA statements were respected. Blinded systematic screening of the literature, data extraction, and quality assessment were performed by two authors. Conflicts were resolved by a third author. The meta-analysis of prevalence provided estimated proportions, 95% confidence intervals, and measures of heterogeneity (I2). Based on I2, the heterogeneity might be negligible (0-40%), moderate (30-60%), substantial (50-90%), and considerable (75-100%). The primary outcome was the incidence of AAA rupture. Secondary outcomes included the rate of small AAAs reaching the threshold for repair, aortic-related mortality, and all-cause mortality. RESULTS: Fourteen publications (25,040 patients) were included in the analysis. The outcome rates of the small AAA group (<55 mm) were 0.3% (95% CI 0.0-1.0; I2 = 76.4%) of rupture, 0.6% (95% CI 0.0-1.9; I2 = 87.2%) of aortic-related mortality, and 9.6% (95% CI 2.2-21.1; I2 = 99.0%) of all-cause mortality. During surveillance, 21.4% (95% CI 9.0-37.2; I2 = 99.0%) of the initially small AAAs reached the threshold for repair. The outcome rates of the large AAA group (>55 mm) were 25.7% (95% CI 18.0-34.3; I2 = 72.0%) of rupture, 22.1% (95% CI 16.5-28.3; I2 = 25.0%) of aortic-related mortality, and 61.8% (95% CI 47.0-75.6; I2 = 89.1%) of all-cause mortality. The sensitivity analysis demonstrated a higher rupture rate in studies including <662 subjects, patients with a mean age > 72 years, >17% of female patients, and >44% of current smokers. CONCLUSION: The rarity of rupture and aortic-related mortality in small AAAs supports the current conservative management of small AAAs. Surveillance seems indicated, as one-fifth reached the threshold for repair. Large aneurysms had a high incidence of rupture and aortic-related mortality. However, these data seem biased by the sparse and heterogeneous literature overrepresented by patients unfit for surgery. Specific rupture risk stratified by age, gender, and fit-for-surgery patients with large AAAs needs to be further investigated.

Symptoms of arteria spinalis anterior syndrome in a patient with ischaemic stroke and Takayasu arteritis.

In Denmark, around 4,500 people are diagnosed with colorectal cancer (CRC) annually. This review investigates that while the efficacy of immunotherapy in CRC is still being studied, immunotherapy is currently only indicated in the treatment of mismatch-repair deficient (dMMR) metastatic CRC, which accounts for 10-15% of patients. Recent studies indicate high rates of pathologic response in dMMR CRC treated with pre-operative immunotherapy while large-scale studies on novel immunotherapy combinations are ongoing.

Ultrasound Transducer Pressure: An Unexplored Source of Abdominal Aortic Aneurysm Measurement Error.

This study was aimed at quantifying the abdominal aortic aneurysm (AAA) compression phenomenon and assessing the use of a new tool to estimate transducer pressure in vivo. In this cross-sectional study, 47 participants with AAA and a median anterior-to-posterior (AP) AAA diameter of 46 mm (range: 30-76 mm) were included. The majority of the patients were overweight with body mass indexes >25 (33/47, 70%). A standardized ultrasound (US)-compatible gel pad, with a pre-defined thickness (15 mm) and mass (150 g), was interposed between the US transducer and participant to estimate the applied transducer pressure. A firm transducer pressure significantly lowered the median AP diameter from 46.1 mm (range: 29.7-76.3) to 39.4 mm (range: 21.7-67.5) (p = 0.001). The mean diameter bias between light and firm transducer pressure was 6.1 mm (95% confidence interval: 4.9-7.3). The applied transducer pressure varied significantly and could be measured by translating the deformation of a low-tech gel pad interposed between the US transducer and the participant.

Validation of an assessment tool for estimation of abdominal aortic aneurysm compression in diagnostic ultrasound.

The study investigated ultrasound (US) transducer push, tantamount to applied transducer pressure, during abdominal aortic aneurysm (AAA) US scanning in a simulated non-clinical setup. During an assessment of maximal AAA diameter on a three-dimensional print-based AAA phantom, US transducer push varied as much as 2000% (range: 0.52-12.45 kPa) amongst 16 experienced sonographers. The mean transducer push was 5.54 ± 3.91 kPa (CV = 0.71). Deformation of a standardized gel-pad allowed for transducer push calculation based on US images; Young's modulus of the gel-pad was estimated to 44,26 N/m2. The method is theoretically validated in a safe and non-clinical environment. Future investigations with the aim of clinical validation of the gel-pad principle on AAA patients are suggested, including the objectification of the magnitude of an eventual transducer push-related error during US AAA diameter measurement.

Full-Volume Assessment of Abdominal Aortic Aneurysms by 3-D Ultrasound and Magnetic Tracking.

Volume assessment of abdominal aortic aneurysms (AAAs) using 3-D ultrasound (US) is an innovative technique reporting good agreement with computed tomography angiography. One major limitation of the current 3-D US technique is a limited field of view, allowing full AAA acquisition in only 60% of patients. This study presents two new US acquisition protocols using magnetic field tracking, providing an "extended field of view" (XFoV-2-D and XFoV-3-D) with the aim of including both the aortic bifurcation and neck for full-volume assessment, and compares these methods with the current standard 3-D US protocol and with computed tomography angiography. A total of 20 AAA patients were included and underwent the current standard 3-D US protocol and the two novel 3-D US "extended field of view" protocols. Four patients were excluded from further analysis because of low image quality, leaving 16 patients eligible for analysis. Full AAA volume was achieved in 8 patients (50%) using the standard 3-D US protocol, in 11 patients (69%) with the XFoV-2-D protocol and in 13 patients (81%) with the XFoV-3-D protocol. In conclusion, this article describes two new and feasible US protocols applicable for full-AAA-volume estimation in most patients and should initiate further research into the added value of full volume in AAA surveillance.

Transendothelial exchange of low-density lipoprotein is unaffected by the presence of severe atherosclerosis.

OBJECTIVE: We tested the hypothesis that transendothelial exchange of low-density lipoprotein (LDL) is influenced by the presence of severe atherosclerosis; we previously found this exchange elevated in diabetes patients. METHODS: By an in vivo isotope method, we compared transendothelial LDL exchange in 24 patients with angiographically verified coronary atherosclerosis, 11 patients with angiographically verified peripheral atherosclerosis, 60 patients with diabetes, and in 42 controls. Autologous 131-iodinated LDL ((131)I-LDL) and 125-iodinated albumin ((125)I-albumin) were injected intravenously (i.v.), and the 1-h fractional escape rates (FER(LDL) and FER(alb)) were taken as indices of transendothelial exchange. RESULTS: Patients with coronary or peripheral atherosclerosis had FER(LDL) similar to that of controls [4.3 (3.5-5.1) and 3.2 (2.3-4.1) versus 4.2 (3.7-4.7)%/h; P>0.05], even after adjustment for LDL distribution volume (DV(LDL)). In contrast, diabetes patients had significantly higher FER(LDL) than controls [5.2 (4.6-5.7) versus 4.2 (3.7-4.7)%/h; P<0.05]. This difference was even more pronounced after correction for the distribution volume of LDL. Compared with controls, FER(alb) was not elevated in patients with coronary atherosclerosis, possibly elevated in patients with peripheral atherosclerosis, but was elevated in diabetes patients. There was a tight positive correlation between FER(LDL) and FER(alb) in all groups of patients and controls. CONCLUSION: Transendothelial exchange of low-density lipoprotein is not elevated in patients having severe atherosclerosis. This suggests that the observed vascular leakiness in diabetes precedes and possibly contributes to accelerated atherosclerosis in diabetes.

[Lower extremity arterial entrapment syndromes]. / Arterielle afklemningssyndromer i underekstremiteterne.

Iliac endofibrosis or iliac kinking and popliteal artery entrapment syndrome are uncommon causes of arterial insufficiency and intermittent claudication in young physically active adults. Diagnostics can be difficult, as the symptoms often are confused with sport injuries and musculoskeletal disorders. Investigation of these patients relies on accurate clinical history and examination as well as both static and dynamic imaging. Early diagnosis and vascular intervention is essential for continued exercise and to prevent thromboembolic complications and, in worst case, limb loss.