Femoral Artery Exposure Research Articles

Abstract 1124: Sympathetic Denervation Models In Murine Femoral Arteries: Acute To Chronic Effects Of 6-hydroxydopamine

Introduction: The autonomic nervous system (ANS) drives blood flow regulation in peripheral arteries. This study aims to develop novel models of sympathetic denervation in peripheral arteries and to characterize subsequent vascular remodeling. We hypothesize that sympathetic denervation of murine femoral arteries can be achieved through local administration of neurotoxin 6-hydroxydopamine (6-OHDA). Methods: BALB/c mice underwent local administration of 6-OHDA to the left femoral artery, while the contralateral artery received vehicle solution. Two approaches were tested: (1) Acute: a one-time topical application following surgical exposure of femoral arteries (N=8, male, Fig. A ), and (2) Chronic: weekly subcutaneous injections near the femoral arteries (N=11, male and female, Fig. B ). Hindlimb perfusion was assessed with laser Doppler imaging, and arterial structure and remodeling were evaluated with histology and immunohistochemistry at one, two, or four weeks. Results: One-time 6-OHDA application (Acute) led to temporary femoral artery denervation (reduction in tyrosine hydroxylase) for one week ( Fig. C – D ), with inflammation observed in both 6-OHDA and vehicle-treated arteries. No vascular wall remodeling was observed after temporary denervation. Weekly subcutaneous 6-OHDA injections (Chronic) resulted in persistent denervation throughout the four-week period in male mice, while female mice displayed variable outcomes ( Fig. E – F ). Sustained sympathetic denervation in the chronic model led to reduced hindlimb blood perfusion at low core temperatures ( Fig. G – H ), though no significant differences were detected in vascular smooth muscle cell phenotype or extracellular matrix composition. Conclusions: Local administration of 6-OHDA is an effective means of peripheral artery sympathetic denervation with controllable duration. This innovative approach of targeting the ANS unveils new prospects for advancing vascular therapies.

Prophylactic Transversely Hemisected Sartorius Flap for High-Risk Groin Dissections in Vascular Surgery—A Case Series

Groin wound dehiscence and infection are a common complication of femoral artery exposure. In patients with prosthetic conduits placed in the groin, these complications can lead to graft infection or anastomotic dehiscence with hemorrhage. Sartorius flaps can be useful in preventing graft infections or anastomotic breakdown in the setting of wound infections. Prophylactic sartorius flaps have been suggested to be a useful adjunct in patients who are at high risk for groin complications. Standard sartorius flaps can be difficult to perform and increase the operative time. We present our experience with a modified sartorius flap, a Transversely Hemisected Sartorius (THT), which avoids dissection to the anterior superior iliac spine. Patients who received femoral artery exposure and a modified prophylactic sartorius flap were included in this case series. The Penn Groin Assessment Scale (PGAS) was calculated for each patient and our primary outcome was the rate of deep space wound infections. Fifteen patients received a THT muscle flap. The average age of the cohort was 67.5 (35-86) years. Eight (50%) were male. The mean PGAS was 2.5 (0-6). Eight (50%) groins had a prosthetic conduit underlying the flap. Four (25%) patients had infrainguinal bypass, 3 (18.8%) for femoral-femoral bypass, and 1 (6.3%) patient received aortic-bifemoral bypass. Eight (50%) patients received sartorius flap after femoral artery exposure for thromboembolectomy, endarterectomy, or access complications. Six (37.5%) patients developed superficial surgical site infections however no deep space infections or prosthetic graft excisions resulted. This procedure was effective in preventing graft infections in all patients with high-risk features for groin infection in our retrospective case series. The segmental blood supply is maintained while providing good coverage of the femoral vessels with this rotational flap.

Outcomes of Vascular Surgery Performed Jointly With Other Departments.

The purpose of this study is to evaluate the results of vascular surgery performed at our hospital, a tertiary emergency general hospital, in patients undergoing surgery in other departments. The results of the study were reviewed. The study included cases in which cardiovascular surgery was performed at the request of other departments over a 15-year period from January 2006 to October 2022. Patient backgrounds, departments that requested surgery, surgical procedures, use of extracorporeal circulation, and surgical techniques were reviewed. Patients with femoral artery exposure or ECMO removal during transcatheter aortic valve implantation (TAVI) requested by cardiology were excluded. There were 58 vascular surgery cases requested by other departments during the study period. The age was 63±14 years, 43 (74%) were male and 15 (26%) were female. The departments of the patients were urology in 29 (50%), gastroenterology in 18 (31%), orthopedics in seven (12%), emergency department in three (5%), and obstetrics and gynecology in one (2%). The following surgical procedures were performed: tumor resection and reconstruction due to tumor invasion of the inferior vena cava in 27 cases (47%), bypass to secure intraperitoneal arterial blood flow in 15 cases (26%), bypass during resection of the femoral tumor in four cases (7%), hemostasis due to trauma in three cases (5%), intraperitoneal hemostasis in three cases (5%), thrombectomy in two cases (3%), and others in four cases (7%). Extracorporeal circulation was used in six (10%) of the patients. A 15-year case study of vascular surgery supports operations requested by other departments at our hospital. All reconstructed sites were open at the time of discharge.

A Novel Sutureless Anastomotic Device in a Swine Model: A Proof of Concept Study

IntroductionVascular reconstruction requires technical expertise and is often time consuming. As a novel alternative to traditional hand-sewn vascular anastomoses, the VasoLock (VL), is a nonabsorbable, sutureless anastomosis device with traction anchors designed to hold free artery ends together. These anchors do not penetrate the vessel wall but adhere by leveraging the elasticity of the vessels to fasten blood vessels together. This pilot study assesses the performance and patency of this novel device in a porcine model of femoral artery injury. MethodsFemale swine (n = 7) underwent femoral artery exposure for a total of 10 VL implanted. Study animals underwent hemodilution to a target hematocrit of 15% and ROTEM was used to assess coagulopathy, followed by an arterial injury via transection. The VL was inserted without any sutures. Flow-probe monitors were positioned proximal and distal to the device and flow rates were measured continuously for a total of 90 min. Flow was analyzed and presented as a ratio of distal to proximal flow with the slope of this ratio across time subsequently determined. Angiographic assessment was completed to evaluate for patency and technical complications after 90 min of implant. ResultsThe average animal weight was 44.1 ± 3.2 kg. The average mean arterial pressure at the time of implant was 51.2 ± 7.8 mmHg, median heart rate was 77.4 (IQR = 77.25-157.4) beats per minute, and average temperature was 36.1 ± 1.5°C. The baseline hematocrit was 13.5 ± 3.0%, average pH was 7.20 ± 0.1, average clotting time was 154.1 ± 58.7 s and average clot formation time was 103.4 ± 10.9 s all demonstrating the acidotic, hypothermic, and coagulopathic state of the swine at the time of insertion. During the 90-min observation period, the average flow gradient identified across the VL was 0.99 ± 0.24, indicating no significant change in flow across the VL. The average slope of the gradients was 0.0005 (P = 0.22), suggesting the ratio of proximal and distal flow did not change over the 90 min. Following 90 min of dwell time, all VL were patent without technical complication. Angiographic assessment at 90 min demonstrated no evidence of dissection, device migration, arterial extravasation, or thromboembolism with any of the 10 devices. ConclusionsThis pilot study demonstrated technical feasibility of the novel VL device over a 90-min observation period. All VL were patent and no negative events or complications were identified. This technology demonstrated significant promise in a coagulopathic state: additional investigation, involving long-term survival, is warranted for further validation.

Open Femoral Artery Exposure Is Associated with Higher 30-Day Unplanned Readmissions and Wound Complications Than Percutaneous Access for EVAR

Open Femoral Artery Exposure Is Associated with Higher 30-Day Unplanned Readmissions and Wound Complications Than Percutaneous Access for EVAR

Utility of Closed Suction Drains in Groin Incisions after Femoral Artery Exposure

Surgical groin wounds are at risk of delayed healing and infection, leading to costly and prolonged postoperative recoveries. This study assesses the use of closed-suction drains (CSD) as a wound care adjunct in groin incisions to prevent surgical site infections (SSI). A single-center retrospective review was performed on 210 consecutive patients after vascular surgery with common femoral artery exposure from 2016 to 2021. The cohort was divided into two groups, groins with and without CSD, looking for surgical site complications. A subgroup analysis comparing postoperative outcomes between complicated and uncomplicated groin incisions within both groups was also performed. Of 293 surgical groins, 20% (n=59) had drains. Overall, the CSD group had higher SSI rates (14% Vs. 5.6%), but also had higher proportion of smokers (92% vs. 83%; p=0.019), diabetes (56% vs. 36%; p=0.005), coronary artery disease (69% vs. 46%; p=0.001), hyperlipidemia (69% vs. 51%; p=0.01) and previous groin surgery (54% vs. 17%; p<0.001). The higher risk of SSI was not significant after adjustment of these confounders. A separate analysis within each group showed SSI groins with CSD had lower reintervention rates (37.5%) than those without CSD (69%), as well as shorter length of hospital stay (7 [5-11] vs. 22 [7-25] days). Our study suggests that CSDs can be a beneficial adjunct for groin wounds after common femoral artery exposure in patients with comorbidities cited above. CSDs decrease the risk of reintervention and length of hospital stay.

Role of Prophylactic Sartorius Flaps for Preventing Deep Space Infection in Lower Extremity Revascularization.

Groin infections in vascular surgery are common and compromise the goal of limb preservation. Strategies to prevent deep space infection(DSI) include incision orientation and muscle flaps. Literature evaluating prophylactic flaps preventing DSIis scarce. We aimed to compare prophylactic sartorius flaps to layered closure in preventing readmission for DSI, along with the effect of incision orientation. This was a retrospective study of vascular surgery patients at a single institution with femoral artery exposure from 2017-2021. Patients with active groin infections were excluded. Prophylactic sartoriusflaps were compared to those with layered closure regarding 30-day hospital readmission for DSI. Oblique versus vertical incisions wascompared regarding the primary outcome. Fifty-three patients received sartorius flaps, and 122 received layered closure. Seventy patients had oblique incisions, and 105 patients had vertical incisions. Sartorius flaps had a higher rate of previous groin surgery compared to layered closure (45.3% vs. 24.7%, p<0.01). Vertical incisions had a higher rate of previous groin surgery (38.1% vs. 20.0%, p<0.02), while oblique incisions had a higher rate of obesity (24.3% vs. 8.6%, p<0.01). There was a lower rate of DSI in sartorius flaps compared to layered closure (1.9% vs. 6.6%, p=2.80), although not statistically significant due to lack of power. There wasno difference in DSI in the oblique versus vertical incisions (4.3% and 5.7%, p=0.760). Patients with prophylactic sartorius flaps experienced fewer DSI, although further evaluation with increased sample size is required for adequate study power. We believe sartorius flaps are a simple solution to prevent groin complications.

Mini-Surgical Access Prevents Local Complications and Reduces Costs in Endovascular Aortic Repair

This study aims to propose a minimally invasive surgical approach to the common femoral artery in endovascular aortic repair and assess its value by a single-center retrospective study including 118 patients. Between 2017 and 2022, all patients receiving endovascular treatment for thoracic and abdominal aortic aneurysms in our center had the anterior wall of the common femoral artery exposed, through a 2-3cm transverse groin incision, instead of a complete surgical cutdown. We access the artery with a purse-string suture, held tight with a tourniquet. After procedure completion, we tie the purse-string closing the arteriotomy. We retrospectively analyzed the cohort of all consecutive patients treated with endovascular aortic repair in this period and recorded primary and assisted technical success, operative time, in-hospital length of stay, access failure, and access-related complications, comparing the results with the current literature. All procedures were successful, with no perioperative mortality. Primary technical success was achieved in 116 patients; 2 required adjunctive procedures. No access failure or access-related complications (thrombosis, groin hematoma, lymphocele, wound dehiscence, or infection) occurred. Two accesses required conversion to complete femoral artery exposure and endarterectomy. Operatory time and length of in-hospital stay were comparable to the outcomes of the major studies reporting on percutaneous access, saving the costs of the closure devices. Minimally invasive surgical access is safe and feasible for endovascular aortic procedures. Compared to the costs of percutaneous access found in literature, it is cost-effective. It can be chosen whenever the percutaneous approach is not feasible or at a high risk of complications.

Safety of Percutaneous Femoral Access for Endovascular Aortic Aneurysm Repair Through Previously Surgically Exposed or Repaired Femoral Arteries

Objective: Percutaneous femoral artery access is being increasingly used in endovascular aortic repair (EVAR). The technique can be challenging in patients with previously surgically exposed or repaired femoral arteries because of excessive scar tissue. However, a successful percutaneous approach may cause less morbidity than a “re-do” open femoral approach. The aim of this study was to assess the impact of prior open surgical femoral exposure on technical success and clinical outcomes of percutaneous approach. Methods: This study retrospectively reviewed the clinical data of patients who underwent percutaneous EVAR between 2010 and 2020 at 2 major aortic centers. Patients were divided into 2 groups (with or without prior open surgical femoral access) for analysis of clinical outcomes. Only punctures with sheaths ≥12Fr were included for analysis. The access and (pre)closure techniques were similar in both institutions. Primary end points were intraoperative technical success, access-related revision, and access complications. A multivariate analysis was performed to identify determinants of conversion to open approach and femoral access complications in intact and re-do groins. Results: A total of 632 patients underwent percutaneous (complex) EVAR: 98 had prior open surgical femoral access and 534 patients underwent de novo femoral percutaneous access. A total of 1099 femoral artery punctures were performed: 149 in re-do and 950 in intact groins. The extent of endovascular repair included 159 infrarenal, 82 thoracic, 368 fenestrated/branched, and 23 iliac branch devices. No significant differences were seen in technical success (re-do 93.3% vs intact 95.3%, p=0.311), access-related surgical revision (0.7% vs 0.6%, p=0.950), and access complications (2.7% vs 4.0%, p=0.443). For the whole group, significant predictors for access complications in multivariate analyses were main access site (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.07%–5.35%; p=0.033) and increase of the procedure time per hour (OR 1.65; 95% CI 1.34%–2.04%; p<0.001), while increase in sheath-vessel ratio had a protective effect (OR 0.33; 95% CI 0.127%–0.85%; p=0.021). Surgical conversion was predicted by main access site (OR 2.32; 95% CI 1.28%–4.19%; p=0.007) and calcification of 50% to 75% of the circumference of the access vessel (OR 3.29; 95% CI 1.38%–7.86%; p=0.005). Conclusion: Within our population prior open surgical femoral artery exposure or repair had no negative impact on the technical success and clinical outcomes of percutaneous (complex) endovascular aortic aneurysm repair.

Use of fibrin glue in groin wound closure after femoral artery exposure: randomized controlled trial

Objectives Fibrin glue is supposed to seal tissues, lymphatics, and minor bleeders and close the dead space efficiently. This work was designed to show the effect of fibrin glue on groin wound complications after femoral artery exposure, degree of wound infection, time to wound healing, and need for further patient management. Patients and methods It is a prospective randomized controlled study including patients who were submitted to groin incision for femoral artery exposure; patients were randomized into two groups: fibrin-sealant closure group (FS group) or conventional surgery (CS group). FS group patients were submitted to use of fibrin glue sprayed on the femoral sheath before closure of subcutaneous tissue and CS group patients were submitted to conventional surgical closure. The study was conducted from July 2016 to March 2018. The primary outcome was assigned as wound complications like seroma, lymphatic fistula, lymphorrhea, and wound infection. The secondary outcomes were wound-healing time, hospital stay, and need for operative coverage. Results In total, 119 patients were included in the study, 60 in fibrin glue group (10 were lost from follow-up) and 59 conventional surgical closure (nine were lost from follow-up). The mean age was 54.95±3.5 in FS group compared with 60.20±3.7 in CS group (P=0.31). In FS group, 33 were males and 27 were females, while in CS group, 38 were males and 21 were males (P=0.42). Mean BMI was 30.3±0.68 in FS group and 28.63±0.84 in CS group (P=0.42). In FS group, 36 were diabetics versus 30 patients in CS group (P=0.53). In total, 33 patients were hypertensive in FS group versus 30 patients in CS group (P=0.10). In total, six patients were end-stage renal disease in both groups. In total, 30 patients were smokers in FS group versus 32 patients in CS group (P=0.75). The mean follow-up time till ensuring wound healing was 22 days, while the median was 27 days. Wound seroma/lymphorrhea was observed in 12 patients of FS group and 30 patients of CS group (P=0.06). Wound infection developed in 10 patients in the FS group and 17 patients in CS group (P=0.48). Regarding grade-III wound infection, no patient belonged to FS group, while eight patients belonged to CS group; as regards hospital stay, duration/day was 6.15±0.35 in FS group and 10.20±1.2 in CS group (P=0.005), time to wound healing was 15.05 ±10.95 in FS group and 28.40 ±20.85 in CS group (P=0.015), and no patient needed further surgical wound coverage in CS group but seven patients did in CS group. Conclusion Application of FS before groin-wound closure seems to be of benefit to reduce wound complications like degree of infection, accelerate time to wound healing, and need for further surgical coverage and hospital stay.

Fibrin sealant injection through the drain with adjuvant compression as a treatment of groin lymphatic complications after vascular operation

Introduction: Groin lymphatic complications after femoral artery operations are rare, but if developed, they could be a source of severe complications that could be potentially fatal. The novel technique of combining compression and application of Tisseel sealant (Baxter AG, Vienna, Austria) to treat lymphatic fistulas in the groin region after common femoral artery exposure was evaluated. Material and methods: Twelve groins from eleven patients with groin lymphatic complications were enrolled into the study. Patients had femoral artery exposure during one of the following procedures: endovascular aortic aneurysm repair, thrombendarterectomy or extra-anatomic by-pass. Postoperatively, average lymphatic drainage through the drain was 140 ± 60 (range 48–300) mL per day. Intervention was performed at a median of 12 (9–23) days after operation. The drain was cut off close to the skin, a thin double-channel catheter was introduced as deep as possible through the drain and sealant was injected into the wound. Simultaneously, the remaining part of the drain was removed, the orifice in the skin was sutured and a compression dressing was kept in place for 24 hours. The median patient observation period was 13 months (range 2.5–23) and surveillance of the groin was performed using ultrasonography. Results: Early outcomes showed full technical success. None of the patients were readmitted due to lymphorrhea, infection or poor wound healing during follow-up. No lymphoceles were detected by ultrasonography. Conclusion: Fibrin glue injection augmented by compression is an effective method for treating postoperative lymphatic fistulas and to prevent lymphorrhagia and lymphocele formation in the groin region after femoral artery exposure.

Longitudinal versus transverse incision for common femoral artery exposure: a systematic review and meta‐analysis

A longitudinal or a transverse incision is routinely used for common femoral artery (CFA) exposure. Some believe a transverse incision is associated with a lower incidence of postoperative complications. We performed a systematic review and meta-analysis to evaluate the risk of postoperative surgical site infection, lymphatic complications, wound dehiscence and haematoma formation when using a longitudinal or transverse incision for CFA exposure. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were adhered to. We searched various databases such as MEDLINE via PubMed and Embase for relevant studies from inception till 31 May 2020. Relevant search terms such as 'longitudinal', 'transverse', 'vertical', 'horizontal', 'femoral', 'incision' were used. We included both randomized controlled trials and case-controlled studies, and extracted data related to study characteristics and postoperative complications. We assessed risk of bias using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. A random-effects meta-analysis was performed to obtain the pooled proportions and risk ratios (RR) for our study outcomes. We included seven studies with a total of 5922 groin incisions. A longitudinal incision was associated with a significantly higher incidence of wound infection (RR 2.93, 95% confidence interval (CI) 1.12-7.70, P= 0.03) and wound dehiscence (RR 2.87, 95% CI 1.06-7.77, P= 0.04). The risk of lymphatic complications (RR 1.09, 95% CI 0.39-3.05, P= 0.87) and wound haematoma (RR 2.85, 95% CI 0.88-9.21, P= 0.08) were similar. A longitudinal incision may be associated with a higher incidence of wound infection and wound dehiscence, as compared to using a transverse incision for CFA exposure.

Outcomes of Open Versus Percutaneous Access for Patients Enrolled in the GREAT Registry

Arterial access and device delivery in endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have evolved from open femoral or iliac artery exposure to selective percutaneous arterial access. Although regional application of percutaneous access for these 2 procedures varies widely, the use of this technique continues to increase. Currently, differences in the use of percutaneous access between EVAR and TEVAR have not been well explored. The Gore Global Registry for Endovascular Aortic Treatment (GREAT) registry collected relevant data for evaluation of these issues and the comparative results between open and percutaneous approaches in regard to complication rates and length of stay (LOS). This study was performed via a retrospective review of patients from the GREAT registry (Clinicaltrials.gov no. NCT01658787). The primary variable of this study was access site complications including postoperative hematoma, vessel dissection, and pseudoaneurysm. Patients were categorized by abdominal (EVAR) and thoracic (TEVAR) aortic procedures using percutaneous-only, cutdown-only, and combined vascular access techniques for a total of 6 groups. Standard statistical methodology was used to perform single-variable and multivariable analysis of a variety of covariates including LOS, geographical location of procedure, procedural success rate, and access sheath size. Of 4,781 patients from the GREAT registry, 3,837 (80.3%) underwent EVAR and 944 (19.7%) underwent TEVAR with percutaneous-only access techniques being used in 2,017 (42.2%) and cutdown-only in 2,446 (51.2%). There was variable application of percutaneous access by geographic region with Australia and New Zealand using this technique more frequently and Brazil using percutaneous access the least. No significant difference in the rate of access site complications was detected between the 6 groups of patients in the study; however, significantly lower rates of access site complications were associated with percutaneous-only compared with both cutdown-only and combined techniques (P=0.03). In addition, associated with significantly higher rates of access site complications was longer LOS (P<0.01). Average LOS was 5.2days and was higher in the TEVAR group (10.1days) than that in EVAR (4.0days, P<0.05). Increased sheath size does not appear to increase the risk of access site complication. There was no significant difference found in the complication rate between percutaneous and cutdown access techniques. This analysis demonstrates that percutaneous-only access is safe, has low complication rates, and has lower LOS compared with open access or combined access techniques.

Comparative Long-term Outcomes of Patients with Aortoiliac Occlusive Disease Limited to Common Iliac Arteries Who Underwent Endarterectomy versus Bypass Grafting

The objective of this study was to compared outcomes of patients with aortoiliac occlusive disease (AIOD), limited to the common iliac artery, who underwent either aortoiliac thromboendarterectomy (AIE) or aortobiiliac bypass grafting (ABIB). A single-center, retrospective analysis of consecutive patients with AIOD who underwent either AIE or ABIB between 2010 and 2019 from a prospective database. Patients with disease extending to the external iliac or common femoral arteries were excluded. Data collected included demographics, cardiovascular risk factors, indication for surgery, preoperative and postoperative ankle brachial indexes (ABIs), estimated blood loss, major adverse events (MAEs), and long-term patency. The study end point was clinical success, defined as improvement in ABIs with resolution of symptoms. MAEs included return to the operating room for any reason, postoperative myocardial infarction, stroke, pneumonia, or venous thromboembolism. Thirty-three patients, who met inclusion criteria, underwent repair for AIOD (AIE: 13; ABIB: 20) at our institution during this time. In both groups, there were more women than men (AIE: 11, ABIB: 10) with a mean age of 55±7 years and 58±6 years in the AIE and ABIB group, respectively. Indication for surgery included disabling claudication in 19 patients, ischemic rest pain in 13 patients, and tissue loss in one patient. No difference in cardiovascular risk factors or AIOD severity was noted between groups. Patients in the AIE group had slightly higher body mass index (30±5 vs. 26±6, P=0.06). Two patients in each group required concomitant renal/mesenteric artery endarterectomy. One patient in the AIE group required bilateral femoral artery exposure and external iliac thrombectomy. MAEs (4 vs. 0) were higher in the ABIB group including, pneumonia in one patient, myocardial infarction in another, return to the operating room for evacuation of hematoma in the third and bypass graft thrombectomy with lower extremity angiography in the fourth patient. There were no differences in the intensive care unit or hospital length of stay between groups. Patients in both groups achieved return of normal ABI and complete resolution of their symptoms. At mean follow-up time of 43.4±25.2 and 52.9±35.4months in the AIE and ABIB group, respectively, there was no symptomatic recurrence or need for reintervention while two patients in the ABIB group died of non-aortic-related issues. Both procedures were safe, effective, and conferred high long-term primary patency with no need for reintervention in patients with AIOD limited to the common iliac arteries.

Critical errors in infrequently performed trauma procedures after training

BackgroundCritical errors increase postoperative morbidity and mortality. A trauma readiness index was used to evaluate critical errors in 4 trauma procedures. In comparison to practicing and expert surgeon benchmarks, we hypothesized that pretraining trauma readiness index including both vascular and nonvascular trauma surgical procedures can identify residents who will make critical errors. MethodsIn a prospective study, trained evaluators used a standardized script to evaluate performance of brachial, axillary, and femoral artery exposure and proximal control and lower-extremity fasciotomy on unpreserved cadavers. Forty residents were evaluated before and immediately after Advanced Surgical Skills for Exposure in Trauma training, and 38 were re-evaluated 14 months later. Residents were compared to 34 practicing surgeons evaluated once 30 months after training, and 10 experts. ResultsResident trauma readiness index increased with training (P < .001), remained unchanged 14 month later and was higher, with lower variance than practicing surgeons (P < .05). Expert trauma readiness index was higher than residents (P < .004) and practicing surgeons (P < .001). Resident training decreased critical errors when evaluated immediately and 14 months after Advanced Surgical Skills for Exposure in Trauma training. Practicing surgeons had more critical errors and performance variability than residents or experts. Experts had 5 to 7 times better error recovery than practicing surgeons or residents. Trauma readiness index area under the receiver operating curve with Youden Index <0.60 or <6 decile in their cohort, predicts a surgeon will make a critical error. ConclusionLow trauma readiness index was associated with critical errors occurring in all surgeon cohorts and can identify surgeons in need of remedial intervention.

Negative Pressure Wound Therapy for Surgical Site Infection Prevention in Common Femoral Artery Exposure

Negative Pressure Wound Therapy for Surgical Site Infection Prevention in Common Femoral Artery Exposure

Factors Associated with Wound Complications after Open Femoral Artery Exposure for Elective Endovascular Abdominal Aortic Aneurysm Repair.

We identified factors that would lead to wound complications after open femoral exposure for endovascular abdominal aortic aneurysm repair (oEVAR). Using the National Surgical Quality Improvement Program dataset (2005-2014), we examined the patients who underwent oEVAR. Patients were stratified on whether they developed postoperative wound complications. Comparisons were made between group with wound complications and those without and adjusted analyses performed to identify variables that independently increased the risk of wound complications. There were 14,868 patients in the study cohort and 2.6% (384 patients) developed wound complications after EVAR. Among those with wound complications, 94% (360 patients) of patients had superficial and deep surgical site infection. Patients who had wound complication were likely to be younger (72.6 vs. 73.7 years old ( p = 0.02), functionally dependent (5.4 vs. 2.5%) ( p < 0.05), smoker (3 vs. 2.4%, p =0.03), female (4 vs. 2.2%), with significantly higher body mass index (31 vs. 28), and more commonly had diabetes (4 vs. 2.4%, p < 0.001) or renal failure (12 vs. 3%, p < 0.001). Although perioperative survival was similar, patients who had wound complications had significantly longer hospital length of stay (LOS) (7.3 ± 12 vs. 3.4 ± 5 days, p < 0.001). Up to 3% patients developed wound complications after open femoral exposure during EVAR with significantly higher LOS and therefore cost utilization.

Exploration of robotic-assisted surgical techniques in vascular surgery.

Robotic-assisted surgical approaches for vascular surgery are feasible regarding minimally invasive exposure, dissection, ligation and skeletonization for varicose vein ligation, anterior spine exposure, femoral-popliteal bypass, femoral vein harvest and aortic aneurysm repair. The authors performed a cadaveric exploration to demonstrate proof of concept and feasibility for a robotic-assisted approached. Surgeon autonomy over endoscopic vision, robotic instrumentation and retraction were noted as key benefits over existing open vascular approaches. Robotic-assisted approaches for vascular surgery enable innovative minimally invasive approaches to disease states not amenable to endovascular repair. Potential reductions in paresthesia through nerve identification were noted during a cadaveric exploration for varicose vein ligation in the setting of chronic venous insufficiency. Minimally invasive femoral artery exposure via a retroperitoneal approach could potentially reduce the morbidity associated with the traditional groin incision. Further exploration and procedure refinement are warranted.

Treatment of postoperative high-volume lymphatic complications using isosulfan blue

BackgroundLymphocele (LC) and lymphocutaneous fistula (LF) are infrequent but serious complications that occur when lymphatics are disrupted during a vascular procedure. Conservative management with bed rest, extremity elevation, aspiration, and pressure dressing is often ineffective. This study evaluated the effectiveness of isosulfan blue (ISB) to identify disrupted lymphatics for ligation. MethodsBetween 1998 and 2016, there were 33 lymphatic complications treated with ISB-directed ligation in 32 patients. The patients' records were retrospectively reviewed, recording demographics, comorbid conditions, index vascular operation causing the lymphatic complication, details of the procedure done to treat the lymphatic complication, and outcomes. In each patient, between 1 and 3 mL of ISB was injected in the subcutaneous tissue of the interdigital web space. The wound associated with the lymphatic complication was opened. The appearance of dye within the wound identified disrupted lymphatic ducts for suture ligation. ResultsThe lymphatic complications were either LC (11 [33%]) or LF (22 [66%]) and were associated with femoral vein harvest (9), great saphenous vein harvest (8), exposure of femoral arteries (13), creation of an upper extremity fistula (1), repeated femoral access for coronary angiography, or excision of an LC (1). Most patients were male (66%), and the mean age was 56.8 ± 13.1 years. In comparing patients with LF and LC, the diagnosis of LF was made earlier (13.8 ± 7.0 days vs 23.4 ± 14.1 days; P = .02), and treatment occurred sooner for LF than for LC (22.1 ± 8.1 days vs 48.8 ± 51.2 days; P = .02). In all patients, ISB identified one or more disrupted lymphatics. The appearance of the ISB dye within the wound after injection was rapid, often within 5 to 10 minutes. After ligation of the lymphatics, most wounds were closed primarily (26 [79%]), but a muscle flap (5 [15%]), negative pressure dressing (1 [3%]), and dressing changes (1 [3%]) were also used. Wound healing was achieved in all patients on average 32.5 ± 21.5 days after lymphatic ligation. ConclusionsThe current series is one of the largest reported experiences using ISB to identify injured lymphatics responsible for LC or LF. Lymphatic complications after a vascular procedure usually occur within 3 weeks of the index vascular procedure, with LF being identified and treated earlier than LC. ISB injection rapidly identifies disrupted extremity lymphatics. Ligation of these lymphatics results in reliable resolution of the lymphatic complication.

Disparity in Medicaid physician payments for vascular surgery

ObjectiveMedicare reimbursements are standardized nationwide on the basis of resource-dependent inputs of physicians' time, intensity, practice costs, and malpractice costs, whereas Medicaid payments vary and are determined by individual states. Our objectives were to determine Medicaid reimbursement to physicians for common vascular procedures for the seven states in the Northeast that compose the New England Society for Vascular Surgery and to compare Medicaid payments with Medicare. MethodsUsing publicly available data, we obtained Medicaid physician payments in Connecticut, Massachusetts, Maine, New Hampshire, New York, Rhode Island, and Vermont for 10 commonly performed vascular surgery procedures. For comparison, Medicare physician payments for these procedures were adjusted for regional differences using Medicare geographic payment cost indices. Descriptive statistics were calculated by state; Wilcoxon signed rank test was used to compare fees, and one-way analysis of variance was used to compare variance. ResultsMedicaid payments varied widely by state. Within individual states (except Vermont), there was no relationship between Medicaid and Medicare payments. Medicaid reimbursement for common vascular procedures ranged from 25% to 91% of Medicare rates and had up to a threefold variation in payment among states for a single procedure. The mean Medicaid payment was 60% of Medicare payment. The greatest state-to-state variance in payment was for open abdominal aortic repair (standard deviation, $227.31); the least was for femoral artery exposure (standard deviation, $31.86). For a Medicaid-based, frequency-weighted analysis of services, New Hampshire exhibited the lowest payments (43% Medicare) and Vermont the highest (80% Medicare). ConclusionsAmong the seven Northeast states considered, with the exception of Vermont, there is no logical relationship between Medicaid and Medicare payments. Because Medicare payments are determined by the Centers for Medicare and Medicaid Services with consideration of resource-based inputs, we conclude that in six of the seven states, Medicaid payments bear no relationship to resource utilization. With Medicaid expansion, access to vascular procedures may be limited by payments insufficient to meet resource needs.