Division Of Vascular Surgery Research Articles

Collagen-Based Vascular Closure Device Multicenter Italian Experience in Endovascular Aortic Aneurysm Repair Compared With Suture-Mediated Closure Vascular Device.

The Manta Vascular Closure Device is a novel collagen-based vascular closure device that has been designed specifically for closure of large-bore percutaneous arterial accesses. The aim of this retrospective study is to evaluate the immediate and 30-day outcome of Manta at the completion of endovascular aneurysm repair (EVAR) or thoracic endovascular aortic repair (TEVAR). The hypothesis is that Manta is not inferior in obtaining hemostasis compared with the Perclose ProGlide Suture-Mediated Closure System device. We recruited all the percutaneous accesses for (T)EVAR performed from January 2021 to April 2023 by all the Italian Divisions of Vascular Surgery using Manta at the time of data collection (May 2023). The primary outcome is to evaluate the incidence of complications at the puncture site after Manta implantation and at 1 month, and compare this with ProGlide. We applied the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria for observational studies. Overall, 524 consecutive femoral accesses for (T)EVAR procedures were collected: 355 in the Manta cohort and 169 in the ProGlide cohort, respectively. The size of the sheath was 17.2±2.7 Fr for Manta, 15.7±2.3 Fr for ProGlide (p<0.001). No statistically significant differences between the groups regarding age, sex, body mass index, ultrasound-guided access, femoral calcifications, intraoperative, and 30-day complications. Successful arterial closure at groin puncture sites for (T)EVAR using Manta is 90.5% and 93.1% using ProGlide. Freedom for any reintervention for any complication is 95.5% for Manta and 96% for ProGlide. The 2 vascular closure devices have proved to be similar in terms of complications, without any statistically significant difference, although the median size of the sheaths for (T)EVAR was statistically significantly larger when Manta has been used, compared with ProGlide. Manta® is effective in the hemostasis of the access sites following the completion of (T)EVAR in this multicenter, retrospective, case-control study on 524 percutaneous femoral accesses. Compared to the more popular Proglide®, the average size of the introducers in the Manta® group was significantly larger than in the Proglide® group.

Implementing primary care follow-up for high-risk vascular surgery patients

Background: The Centers for Medicare and Medicaid Services consider the 30-day hospital readmission rate an outcome of care measure; a high rate is associated with high-cost and bed utilization. Purpose: The Division of Vascular Surgery at a large academic medical center implemented a 15-week quality improvement project in the fall of 2022 to reduce readmissions among patients deemed high-risk for readmission and discharged to home. Methods: The discharging provider utilized the “HOSPITAL Score for Readmission” tool to identify patients at high-risk for unplanned 30-day readmission to receive the intervention, which included follow-up with a primary care provider (PCP) within two weeks of hospital discharge to address non-surgical medical conditions that may have been exacerbated during the hospital stay. A hospital based transitional care clinic bridged medical care for identified patients without an established PCP or whose PCP could not accommodate an appointment until PCP assumption of care. Discharging providers included 11 nurse practitioners and 2 surgery residents; each received a one-on-one educational teaching session and a weekly reminder e-mail through week 9. Results: A total of 158 vascular surgery patients (low and high-risk) were discharged home over 15 weeks with 30 patients (19%) having an unplanned readmission within 30-days from discharge. Adherence issues with the intervention among staff allowed for the high-risk group to be divided into those who did not receive the intervention versus those who did. The high-risk patients who did not receive the intervention had a higher readmission rate (30.4%) than the high-risk patients who did receive the intervention (21.4%). Conclusions: Numerous acute and chronic medical problems were treated at the PCP/transitional care clinic visits, which may have contributed to the reduction in rate of readmissions occurring within 30-days for those patients. Increased usage of the transitional care clinic identified a gap that patients continue to require assistance with establishing care with a PCP and further process change in the future is needed to ensure successful transition for all patients.

Preoperative Embolization in Surgical Resection of Cervical Paragangliomas: Usefulness and Current Evidence.

Cervical paragangliomas (CPG) are slow-growing tumours, most of which are highly vascular, making surgical resection challenging. Preoperative embolisation of afferent arteries has been recommended to facilitate operative dissection, reduce perioperative blood loss, and shorten the duration of the operation. However, there is conflicting evidence on the benefits of preoperative embolisation on surgical outcomes, operative time, and bleeding. The objective of this study was to compare the perioperative parameters and outcomes like duration of surgery, blood transfusion, duration of stay in the ICU, cranial nerve injuries, and postoperative stroke between patients who underwent excision of CPGs with and without preoperative embolisation. This is a retrospective study conducted at the Division of Vascular Surgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. The study included a review of the medical records of 32 patients who underwent excision of CPGs.Patients who underwent surgical resection without preoperative embolisation (SR) were compared with those who underwent surgical resection with embolisation (SREMB). Statistical analysis was done in R statistical software (R Foundation for Statistical Computing, Vienna, Austria). Categorical variables were reported in absolute numbers and percentages continuous variables were compared with an unpaired Mann-Whitney U test. The chi-square test was used to compare the categorical data. Out of 32 patients included in this study, 13 (40.6%) patients were included in the SREMB group. Between the two groups, there were no significant differences in operative time (120 vs. 150 minutes; p = 0.59), blood transfusion requirement (0.69 vs. 0.37 units; p = 0.39) and ICU stays (1 vs. 1; p = 0.56).Postoperative cranial nerve injury was significantly more in the SREMB group (6 vs 1; p = 0.01) but stroke (0 vs 2; p = 0.50) was not statistically significant between the two groups. In this study, we found that there was insufficient evidence to support routine preoperative embolisation in CPG.Hence, preoperative embolisation should only be used in a very select group of patients.

The Opportunity for Impactful Integration of Vascular and Podiatric Care.

The importance of collaboration between vascular and podiatric surgeons has been well-established. High-level partnerships are integral to the development of multidisciplinary programs and wound care centers, ultimately resulting in improved patient outcomes. This vascular-podiatric integration is not universal, however, and podiatric surgery may not be aligned within a vascular surgery division at many institutions. As one such institution, we reviewed our single-center experience in order to identify opportunities for the impactful integration of vascular-podiatric patient care. Institutional electronic medical records were retrospectively reviewed for all procedures performed by vascular surgeons at a high volume, safety-net academic medical center. Data were collected on all primary and additional procedures, current procedural terminology (CPT) codes, case type (elective, urgent, emergent), surgeon specialty, and date/time of the procedures performed. CPT codes were linked to the Centers for Medicare & Medicaid Services' Physician Fee Schedule to estimate the work relative value unit (wRVU) per procedure. From 2018 to 2022, vascular surgeons performed a total of 12,206 operations, of which 1102 (9.9%) involved podiatric procedures. The most common vascular-performed podiatry procedures performed were toe amputations (38.1%, n = 420), transmetatarsal foot amputations (20.1%, n = 222), and ankle/foot debridement (16.2%, n = 178). Foot/ankle-specific procedures were identified as the primary procedure in 726 (65.9%) cases and as the adjunct procedure in 376 (34.1%) cases. A substantial proportion of podiatric procedures occurred on an urgent (n = 278, 25.2%) or emergent (n = 28, 2.5%) basis. A total of 163 (14.8%) cases occurred after hours (either before 0600 or after 1800), and 133 (12.1%) cases were performed on a holiday or weekend. Procedure-specific revenue included 4243.39 wRVU for primary procedures and 2108.08 wRVU for additional procedures performed. We report our single-center experience in which vascular surgeons provide a significant proportion of podiatric procedures. Our study underscores the potential for integrating podiatric surgeons within a vascular surgical division and presents opportunities for collaboration and enhanced patient care.

Commonly Used Myh11-CreERT2Strain Carries a Y-Linked Functional Wild-Type Tlr7 Allele.

HomeArteriosclerosis, Thrombosis, and Vascular BiologyAhead of PrintCommonly Used Myh11-CreERT2 Strain Carries a Y-Linked Functional Wild-Type Tlr7 Allele No AccessResearch ArticleRequest AccessAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessResearch ArticleRequest AccessCommonly Used Myh11-CreERT2 Strain Carries a Y-Linked Functional Wild-Type Tlr7 Allele Jie Li, Haiyan Xu, Alex Hung, Muhammad Javad Javed, Gilbert R. UpchurchJr and Zhihua Jiang Jie LiJie Li Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville. Search for more papers by this author , Haiyan XuHaiyan Xu Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville. Search for more papers by this author , Alex HungAlex Hung Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville. Search for more papers by this author , Muhammad Javad JavedMuhammad Javad Javed Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville. Search for more papers by this author , Gilbert R. UpchurchJrGilbert R. UpchurchJr Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville. Search for more papers by this author and Zhihua JiangZhihua Jiang Correspondence to: Zhihua Jiang, PhD, Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, PO Box 100286, Gainesville, FL 32610. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8057-823X Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville. Search for more papers by this author Originally published15 Jun 2023https://doi.org/10.1161/ATVBAHA.122.318919Arteriosclerosis, Thrombosis, and Vascular Biology. 2023;0FootnotesFor Sources of Funding and disclosures, see page XXX.Correspondence to: Zhihua Jiang, PhD, Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, PO Box 100286, Gainesville, FL 32610. Email [email protected]ufl.edu Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/ATVBAHA.122.318919 Originally publishedJune 15, 2023 KeywordsfemalegenotypemaleallelemicePDF download Advertisement SubjectsAneurysmGene Expression and RegulationVascular Disease

Subspecialty nurses as an essential ingredient for modern vascular service

Surgical PracticeAccepted Articles EDUCATION Subspecialty Nurses as Essential Ingredient for Modern Vascular Service Yiu Che Chan, Corresponding Author Yiu Che Chan [email protected] orcid.org/0000-0003-3764-3782 Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, China Author Correspondence Dr. Yiu Che CHAN MB BS BSc MD FRCS(England) FRCS(General Surgery) FCSHK, Associate Professor, Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14 Floor K Block, Queen Mary Hospital, Pokfulam Road, Hong Kong. Tel: +852-2255-4969, FAX: +852-2255-4967, Email: [email protected]Search for more papers by this authorPo-Ching Chan, Po-Ching Chan Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this authorPui-Yan Paine Kong, Pui-Yan Paine Kong Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this authorYee-Ming Tse, Yee-Ming Tse Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this authorStephen W. K. Cheng, Stephen W. K. Cheng Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this author Yiu Che Chan, Corresponding Author Yiu Che Chan [email protected] orcid.org/0000-0003-3764-3782 Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, China Author Correspondence Dr. Yiu Che CHAN MB BS BSc MD FRCS(England) FRCS(General Surgery) FCSHK, Associate Professor, Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14 Floor K Block, Queen Mary Hospital, Pokfulam Road, Hong Kong. Tel: +852-2255-4969, FAX: +852-2255-4967, Email: [email protected]Search for more papers by this authorPo-Ching Chan, Po-Ching Chan Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this authorPui-Yan Paine Kong, Pui-Yan Paine Kong Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this authorYee-Ming Tse, Yee-Ming Tse Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this authorStephen W. K. Cheng, Stephen W. K. Cheng Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this author First published: 25 April 2023 https://doi.org/10.1111/1744-1633.12625 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/1744-1633.12625. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

Vascular training and sub‐specialization in mainland China

Surgical PracticeAccepted Articles EDUCATION Vascular Training and Sub-specialization in Mainland China Hai-Lei Li, Hai-Lei Li Division of Vascular Surgery, Department of Surgery, The University of Hong Kong -ShenZhen Hospital, ShenZhen, ChinaSearch for more papers by this authorYiu Che Chan, Corresponding Author Yiu Che Chan [email protected] orcid.org/0000-0003-3764-3782 Division of Vascular Surgery, Department of Surgery, The University of Hong Kong -ShenZhen Hospital, ShenZhen, China Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, China Author Correspondence Dr. Yiu Che CHAN MB BS BSc MD FRCS(England) FRCS(General Surgery) FCSHK, Associate Professor, Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14 Floor K Block, Queen Mary Hospital, Pokfulam Road, Hong Kong. Tel: +852-2255-4969, FAX: +852-2255-4967, Email: [email protected]Search for more papers by this authorStephen W. Cheng, Stephen W. Cheng Division of Vascular Surgery, Department of Surgery, The University of Hong Kong -ShenZhen Hospital, ShenZhen, China Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this author Hai-Lei Li, Hai-Lei Li Division of Vascular Surgery, Department of Surgery, The University of Hong Kong -ShenZhen Hospital, ShenZhen, ChinaSearch for more papers by this authorYiu Che Chan, Corresponding Author Yiu Che Chan [email protected] orcid.org/0000-0003-3764-3782 Division of Vascular Surgery, Department of Surgery, The University of Hong Kong -ShenZhen Hospital, ShenZhen, China Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, China Author Correspondence Dr. Yiu Che CHAN MB BS BSc MD FRCS(England) FRCS(General Surgery) FCSHK, Associate Professor, Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14 Floor K Block, Queen Mary Hospital, Pokfulam Road, Hong Kong. Tel: +852-2255-4969, FAX: +852-2255-4967, Email: [email protected]Search for more papers by this authorStephen W. Cheng, Stephen W. Cheng Division of Vascular Surgery, Department of Surgery, The University of Hong Kong -ShenZhen Hospital, ShenZhen, China Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, ChinaSearch for more papers by this author First published: 25 April 2023 https://doi.org/10.1111/1744-1633.12627 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/1744-1633.12627. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

Multivariable Cost Frontiers-Qualitative Financial Analyses Using Operational Metrics From the Implementation of a Surgery Fellowship.

We expand the application of cost frontiers and introduce a novel approach using qualitative multivariable financial analyses. With the creation of a 5 + 2-year fellowship program in July 2016, the Division of Vascular Surgery at the University of Vermont Medical Center altered the underlying operational structure of its inpatient services. Using WiseOR (Palo Alto, CA), a web-based OR management data system, we extracted the operating room metrics before and after August 1, 2016 service for each 4-week period spanning from September 2015 to July 2017. The cost per minute modeled after Childers et al's inpatient OR cost guidelines was multiplied by the after-hours utilization to determine variable cost. Zones with corresponding cutoffs were used to graphically represent cost efficiency trends. Caseload/FTE for attending surgeons increased from 11.54 cases per month to 13.02 cases per month ( P = 0.0771). Monthly variable costs/FTE increased from $540.2 to $1873 ( P = 0.0138). Monthly revenue/FTE increased from $61,505 to $70,277 ( P = 0.2639). Adjusted monthly reve-nue/FTE increased from $60,965 to $68,403 ( P = 0.3374). Average monthly percent of adjusted revenue/FTE lost to variable costs increased from 0.85% to 2.77% ( P = 0.0078). Adjusted monthly revenue/case/FTE remained the same from $5309 to $5319 ( P = 0.9889). In summary, we demonstrate that multivariable cost (or performance) frontiers can track a net increase in profitability associated with fellowship implementation despite diminishing returns at higher caseloads.

Исследование ассоциации полиморфизма rs10508336 гена транскрипционного фактора TAF3 с риском развития заболеваний артерий нижних конечностей в российской популяции

Atherosclerosis obliterans (AO) and diabetic angiopathy (DA) are known to be peripheral artery diseases (PAD) of multifactorial origin, in which genetic and environmental factors play a synergetic role. TAF3 is one of the genes that has been found to be associated with PAD. The aim of the study: To analyze the association of the rs10508336 polymorphism of the TAF3 gene with the risk of PAD in the Russian population. Materials and methods: The study involved 1261 patients, including 642 healthy subjects and 619 PAD patients. All patients were recruited at the Vascular Surgery Division of the Kursk Regional Clinical Hospital. Isolation of genomic DNA was carried out by chloroform extraction and precipitation with ethanol. Genotyping was carried out on the basis of the Research Institute of Genetic and Molecular Epidemiology of KSMU using a MassARRAY-4 time-of-flight genomic mass spectrometer (Agena Bioscience, USA). Results: We found that polymorphism rs10508336 is associated with an increased risk of developing bilateral peripheral atherosclerosis exclusively in smokers (P&lt;0.05). The polymorphism was found to be statistically significantly associated with an increased risk of DA (OR=1.59, 95% CI 1.02-2.46, P=0.045). Furthermore, an association of the rs10508336-A allele with an increase in blood glucose levels in PAD was observed (P=0.01). Conclusion: In the Russian population, an association of the rs10508336 polymorphism of the TAF3 gene with an increased risk of AO, hyperglycemia, and diabetic angiopathy was revealed for the first time. The identified associations point out a possible relationship between carbohydrate metabolism and atherosclerotic processes in the determination of peripheral arterial diseases.

Collaboration With Advanced Practice Registered Nurses to Improve Patient Satisfaction in Outpatient Clinic

Patient satisfaction has become an indicator for measuring quality and is linked to clinical outcomes, patient retention, and patient-centered care. A vascular surgery division in a tertiary care referral center found that the increase in the volume of patients necessitated the addition of advanced practice registered nurses (APRNs) to assist in the care of these patients. The Press Ganey Medical Practice Survey was used to track patient satisfaction scores before and after integration of an APRN into the outpatient clinic and showed that having the APRN increased patient satisfaction scores.

How the First Year of the COVID-19 Pandemic Impacted Patients' Hospital Admission and Care in the Vascular Surgery Divisions of the Southern Regions of the Italian Peninsula.

Background: To investigate the effects of the COVID-19 lockdowns on the vasculopathic population. Methods: The Divisions of Vascular Surgery of the southern Italian peninsula joined this multicenter retrospective study. Each received a 13-point questionnaire investigating the hospitalization rate of vascular patients in the first 11 months of the COVID-19 pandemic and in the preceding 11 months. Results: 27 out of 29 Centers were enrolled. April-December 2020 (7092 patients) vs. 2019 (9161 patients): post-EVAR surveillance, hospitalization for Rutherford category 3 peripheral arterial disease, and asymptomatic carotid stenosis revascularization significantly decreased (1484 (16.2%) vs. 1014 (14.3%), p = 0.0009; 1401 (15.29%) vs. 959 (13.52%), p = 0.0006; and 1558 (17.01%) vs. 934 (13.17%), p < 0.0001, respectively), while admissions for revascularization or major amputations for chronic limb-threatening ischemia and urgent revascularization for symptomatic carotid stenosis significantly increased (1204 (16.98%) vs. 1245 (13.59%), p < 0.0001; 355 (5.01%) vs. 358 (3.91%), p = 0.0007; and 153 (2.16%) vs. 140 (1.53%), p = 0.0009, respectively). Conclusions: The suspension of elective procedures during the COVID-19 pandemic caused a significant reduction in post-EVAR surveillance, and in the hospitalization of asymptomatic carotid stenosis revascularization and Rutherford 3 peripheral arterial disease. Consequentially, we observed a significant increase in admissions for urgent revascularization for symptomatic carotid stenosis, as well as for revascularization or major amputations for chronic limb-threatening ischemia.

Drastic increase in hospital labor costs led to a sustained financial loss for an academic vascular surgery division during the coronavirus disease 2019 pandemic.

ObjectiveThe financial effects of the coronavirus disease 2019 (COVID-19) pandemic have fundamentally changed the healthcare environment, with hospitals expected to have lost billions in 2021. A preexisting nationwide nursing shortage became drastically worse during the pandemic amid dramatically increasing labor costs. We examined the evolution and financial effects of these changes during repeated pandemic surges within a vascular surgery division at a tertiary medical center.MethodsOperating room, inpatient unit, and outpatient clinic financial data were examined retrospectively. The monthly averages for a 14-month control cohort before COVID-19 (January 2019 to February 2020) were compared to the averages for seven interval groups of sequential, 3-month cohorts from March 2020 through November 2021 (groups 1-7).ResultsThe monthly relative value unit (RVU) generation had returned to the mean before the COVID-19 pandemic (2520 RVUs) after an isolated decrease early in the pandemic (group 1; 1734 RVUs). The RVUs ranged from 2540 to 2863 per month for groups 2 to 5, with a slight decline in groups 6 and 7. The average monthly RVUs in the COVID-19 period (2437 RVUs) were nearly equivalent (P = .93) to those for the pre–COVID-19 cohort. An analysis of payor mix demonstrated an increase in commercial and Medicaid payors, with a respective decrease in Medicare payors, during COVID-19. The contribution to indirect, or profit, from inpatient hospital and outpatient clinical revenue showed a drastic decrease in group 1, followed by a swift rebound when the government restrictions were eased (group 2). The total monthly vascular nursing unit expense demonstrated a marked increase with each sequential group during COVID-19, with an average monthly upsurge of +$82,171 (+47%; P < .001). An increase in the nursing labor expenses of +$884 per vascular case (from $1630 to $2514; +54%; P < .001) was observed in the COVID-19 era. The nursing labor costs per patient day had increased from $580 to $852 (+$272; +53%; P < .001). The nursing labor cost per RVU had increased from $69.5 to $107.7 (+$38.2; +55%; P < .001). On a system-wide level, the agency-related nursing costs had increased from $4.9 million to $13.6 million per month (+178%; P < .001) in 2021 compared with 2020.ConclusionsThe COVID-19 pandemic has had severe, nationwide effects on healthcare delivery, exacerbating the deleterious effects of an existing, critical nursing shortage. To the best of our knowledge, the present study is the first detailed analysis of this phenomenon and its effects on a surgical division. Our results have demonstrated a progressive, drastic increase in nursing labor costs during the pandemic, with a resultant sustained erosion of financial margins despite a level of clinical productivity, as measured in RVUs, equal to the prepandemic standards. This precarious trend is not sustainable and will require increased, targeted government funding.

25, 50 &amp; 75 years ago

25, 50 &amp; 75 years ago

Drastic Increase in Hospital Labor Costs During the COVID-19 Pandemic Leads to Sustained Financial Loss for an Academic Vascular Surgery Division

The financial impact of the COVID-19 pandemic has fundamentally changed the healthcare environment, with hospitals expected to lose billions in 2021. A preexisting nationwide nursing shortage has drastically worsened during the pandemic, causing a dramatic increase in labor costs and further straining an economically fragile US healthcare system. Although the Medicare Coronavirus Aid, Relief, and Economic Security Act allocated more than $350 billion for distribution in ongoing phases, funds have not been specifically assigned to increased labor costs amid nursing shortages.

The prognostic impact of vascular calcification on abdominal aortic aneurysm progression

ObjectiveThe maximal aortic diameter is currently the only clinically applied predictor of abdominal aortic aneurysm (AAA) progression. It is known that the risk of rupture is associated with aneurysm size; hence, accurate monitoring of AAA expansion is crucial. Aneurysmal vessel wall calcification and its implication on AAA expansion are insufficiently explored. We evaluated the vascular calcification using longitudinal computed tomography angiographies (CTA) of patients with an AAA and its association with AAA growth. MethodsWe conducted a retrospective study of 102 patients with an AAA with a total of 389 abdominal CTAs at 6-month intervals, treated and followed at the Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna. Digitally stored CTAs were reviewed for vascular calcification (volume and score) of the infrarenal aorta and common iliac arteries as well as for morphometric AAA analysis. In the prognostic setting, slow versus fast AAA progression was defined as a less than 2 mm or a 2-mm or greater increase in AAA diameter over 6 months. In addition, to analyze the association of vascular calcification and the AAA growth rate with longitudinal monitoring data, a specifically tailored log-linear mixed model was used. ResultsAn inverse relation of increased abdominal vessel wall calcification and short-term AAA progression was detected. Compared with fast progressing AAA, the median calcification volume of the infrarenal aorta (1225.3 mm³ vs 519.8 mm³; P = .003), the median total calcification volume (2014.1 mm³ vs 1434.9 mm³; P = .008), and the median abdominal total customized Agatston calcium (cAC) score (1663.5 vs 718.4; P = .003) were significantly increased in slow progressing AAA. Importantly, a log-linear mixed model efficiently predicted AAA expansion based on current diameter and abdominal total cAC score (P = .042). ConclusionsWe assessed the prognostic value of CTA-measured vascular calcification for AAA progression. Increased vascular calcification stabilizes the aortic aneurysmal wall and likely protects against progressive AAA expansion, resulting in a significant decrease of aneurysm growth over time. As a consequence, this may have implications for rupture risk, mortality, morbidity, and cost.

C. Walton Lillehei—His Life and Legacy

From the Division of Vascular Surgery, NYU Langone Long Island Hospital and NYU Long Island School of Medicine Mineola NY 11501 The authors have no conflict of interest. Correspondence to: George L. Hines, MD Division of vascular surgery 200 old county road Mineola NY 11501 [email protected] 516-663-1220

Investigating the Link between Alpha-1 Antitrypsin Deficiency and Abdominal Aortic Aneurysms

Alpha-1-Antitrypsin (AAT) is one of the major plasmatic protease inhibitors. In the last decade, an association between Alpha-1-Antitrypsin Deficiency (AATD) and Abdominal Aortic Aneurysms (AAA) has been hypothesized. Multiple factors may be involved in AAA's etiopathogenesis, and an underlying structural defect of the extracellular matrix (ECM) is always present. AATD could be a reasonable risk factor for AAA because it is related to protease/antiprotease imbalance and enhanced ECM degradation of the vessel wall. We performed genotyping of 138 patients hospitalized in the Vascular Surgery Division of the ASST-Spedali Civili di Brescia, Italy, for nontraumatic rupture of AAA. The second purpose was to observe the distribution of main nongenetic risk factors for AAA between patients with and without AATD. Out of 138 patients, 22 were found with AATD: 16 MS, 1 SS, 3 MZ, and 2 with a new rare AAT variant. When compared to the general Italian population, our cohort's frequency of deficient S allele was significantly higher (7.8 vs. 2.2% respectively, P < 0.01), whereas the deficient Z allele was similar (1.1 vs. 1.3% respectively, P > 0.05). Although we found no differences in age, gender, hypertension, diabetes, and smoke habits between AAA patients with and without AATD, hyperlipidemia was significantly less frequent in patients with AATD (46.4 vs. 12.5% respectively, P < 0.05). In our AAA patients' cohort, the S allele frequency was higher than in the general Italian population. Our results support the hypothesis that AATD might be a risk factor for AAA.

Financial implications of coronavirus disease 2019 on a tertiary academic vascular surgery practice

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on the healthcare system in the United States. The redistribution of resources and suspension of elective procedures and other services has resulted in financial stress across all service lines. The financial effects on the practice of vascular surgery have not yet been quantified. We hypothesized that vascular surgery divisions have experienced losses affecting the hospital and professional sides that will not be recoupable without significant productivity increases. MethodsAdministrative claims data for clinical services performed by the vascular surgery division at a tertiary medical center for March and April 2019 and for March and April 2020 were analyzed. These claims were separated into two categories: hospital claims (inpatient and outpatient) and professional claims (professional reimbursement for all services provided). Medicare reimbursement methods were used to assign financial value: diagnosis-related group for inpatient services, ambulatory payment classification for outpatient services, and the Medicare physician fee schedule for professional reimbursement and work relative value units (wRVUs). Reimbursements and productivity (wRVUs) were compared between the two periods. A financial model was created to determine the increase in future productivity over baseline required to mitigate the losses incurred during the pandemic. ResultsA total of 11,317 vascular surgery claims were reviewed. Hospital reimbursement during the pandemic decreased from $4,982,114 to $2,649,521 (−47%) overall (inpatient, from $3,505,775 to $2,128,133 [−39%]; outpatient, from $1,476,339 to $521,388 [−65%]) and professional reimbursement decreased from $933,897 to $430,967 (−54%) compared with the same period in 2019. Professional productivity as measured by wRVUs sustained a similar decline from 10,478 wRVUs to 5386 wRVUs (−51%). Modeling sensitivity analyses demonstrated that if a vascular division were able to increase inpatient and outpatient revenue to greater than prepandemic levels by 10%, 5%, or 3%, it would take 9, 19, or 31 months, respectively, for the hospital to recover their pandemic-associated losses. Similarly, professional reimbursement recovery would require 11, 20, or 36 months with corresponding increases in productivity. ConclusionsThe COVID-19 pandemic has had profound and lasting effects on the world in terms of lives lost and financial hardships. The financial effects on vascular surgery divisions has resulted in losses ranging from 39% to 65% compared with the prepandemic period in the previous year. Because the complete mitigation of losses is not feasible in the short term, alternative and novel strategies are needed to financially sustain the vascular division and hospital during a prolonged recovery period.

Comment on "Efficacy of a Standardized Perioperative Clinical Care Pathway for Below Knee Amputation".

Division of Vascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts. [email protected]. The author declares no conflicts of interest.

The challenge of maintaining necessary vascular and endovascular services at a referral center in Northern Italy during the COVID-19 outbreak

The Padova Hospital Vascular Surgery Division is located in Veneto, one of the area of the Northern Italy most hit by the Coronavirus disease 2019 outbreak. The aim of this paper is to describe the protocols adopted and to evaluate their impact during the acute phase of Coronavirus spread, focusing on the management of elective and urgent/emergent surgery, outpatients activity, and also health staff preservation from intra-hospital Coronavirus disease 2019 infection. Several measures were progressively adopted in the Padova University Hospital to front the Coronavirus disease 2019 outbreak, with a clear strong asset established by 9 March 2020, after the Northern Italy lockdown. Since this date, the Vascular Surgery Unit started a "scaled-down" activity, both for elective surgical procedures and for the outpatient Clinical activities; different protocols were developed for health preservation of staff and patients. We compared a two months period, 30 days before and 30 days after this time point. In particular, emergent vascular surgery was regularly guaranteed as well as urgent surgery (to be performed within 24 h). Elective cases were scheduled for "non-deferrable" pathology. A swab test protocol for COVID-19 was applied to health-care professionals and hospitalized patients. The number of urgent or emergent aortic cases remained stable during the two months period, while the number of Hospital admissions via Emergency Room related to critical limb ischemia decreased after national lockdown by about 20%. Elective vascular surgery was scaled down by 50% starting from 9 March; 35% of scheduled elective cases refused hospitalization during the lockdown period and 20% of those contacted for hospitalization where postponed due to fever, respiratory symptoms, or close contacts with Coronavirus disease 2019 suspected cases. Elective surgery reduction did not negatively influence overall carotid or aortic outcomes, while we reported a higher major limb amputation rate for critical limb ischemia (about 10%, compared to 4% for the standard practice period). We found that 4 out of 98 (4%) health-care providers on the floor had an asymptomatic positive swab test. Among 22 vascular doctors, 3 had a confirmed Coronavirus disease 2019 infection (asymptomatic); a total of 72 swab were performed (mean = 3.4 swab/person/month) during this period; no cases of severe Coronavirus disease 2019 (deaths or requiring intensive care treatment) infection were reported within this period for the staff or hospitalized patients. Elective vascular surgery needs to be guaranteed as possible during Coronavirus disease 2019 outbreak. The number of truly emergent cases did not reduce, on the other side, Emergency Room accesses for non-emergent cases decreased. Our preliminary results seem to describe a scenario where, if the curve of the outbreak in the regional population is flattened, in association with appropriate hospitals containment rules, it may be possible to continue the activity of the Vascular Surgery Units and guarantee the minimal standard of care.