Open Vascular Procedures Research Articles

Impact of Skin Closure with Staples Versus Sutures on Perioperative Outcomes Following Lower Extremity Bypass Surgery

ObjectivesWound complications are one of the major sources of morbidity after open vascular procedures especially lower extremity bypass (LEB). The preferred skin closure method is based on surgeon preference. Since no data clearly demonstrates superiority of one method over the other, we aimed to compare outcomes of staples versus sutures for skin closure after LEB. MethodsThe Vascular Quality Initiative database was queried for patients who underwent LEB from August 2014 to March 2024. Patients were stratified according to skin closure method: staples vs sutures (which included either absorbable subcuticular or nonabsorbable interrupted sutures). The primary outcome was surgical site infection (SSI). Secondary outcomes were return to operating room (RTOR), prolonged length of stay >7 days (PLOS) and 30-day mortality. After adjusting to baseline and clinically relevant variables, multivariate logistic regression modelling analyzed primary and secondary outcomes. ResultsA total of 18,268 LEB procedures were included [staples [5,676 (31.07%)]; sutures [12,592 (68.93%)]. Compared to suture closure, staples utilization was associated with 57% higher odds of SSI [196 (3.46%) vs 259 (2.06%); OR 1.57, 95% CI 1.21 - 2.04, p=0.001], 30% higher odds of RTOR [860 (15.17%) vs 1,449 (11.53%); OR 1.30, 95% CI 1.12 – 1.50, p=0.001] and PLOS [1,630 (28.72%) vs 2,835 (22.51%); OR 1.30, CI 1.16 – 1.45, p<0.001]. However, there was no significant difference in 30-day mortality among both closure methods (p>0.05). ConclusionsIn this large multi-institutional study, our analysis demonstrates increased risk of SSI, RTOR, and PLOS after wound closure with staples compared to sutures in patients who underwent LEB. Although staple closure might be easier and more time efficient, meticulous wound closure with sutures should be the preferred closure method for lower extremity bypass.

Graduating vascular surgery trainee proficiency in endovascular and open peripheral revascularization procedures

BackgroundEndovascular interventions for peripheral artery disease have increased in prevalence over time given the inherent benefits of minimally invasive approaches. Although it is essential that vascular surgery graduates are facile with endovascular techniques, the results of the BEST-CLI (Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia) trial highlight the equivalent importance of ensuring trainee competence in open skills. Recent studies demonstrate increasing case volume of both endovascular and open procedures during vascular surgery training. Case volume is merely a surrogate marker for competence, however, and the objective competence attained by trainees at the time of graduation is unknown. We sought to investigate operative autonomy and competence of graduating vascular surgery trainees performing endovascular as compared with open peripheral vascular revascularization procedures. MethodsOperative performance and autonomy ratings for infrainguinal endovascular and open revascularizations from the Society for Improving Professional Learning Operative application database were collected for all vascular surgery participating institutions from 2018 to 2023. The distribution for autonomy and performance ratings were determined by training level for endovascular and open procedures, respectively. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and autonomy and performance assessment, adjusting for training level and case complexity. Subsequently, the estimated model was applied to predict the probability of a graduating trainee being rated as meaningfully autonomous or competent while performing endovascular and open procedures across various case complexities. ResultsSixty-nine residents from 23 programs (12 fellowship, 11 residency) were assessed on 706 revascularization procedures (n = 383 endovascular; n = 323 open). When controlling for training level and case complexity, there were no differences in autonomy (odds ratio [OR], 1.11; 95% confidence interval [CI], 0.62-1.99) or competency assessment (OR, 0.86; 95% CI, 0.46-1.59) for endovascular, as compared with open, peripheral revascularization procedures. For average complexity procedures, the predicted probability of a trainee being assessed as competent and autonomous at the time of graduation was high (competent: 88% endovascular, 86% open; autonomous: 96% endovascular, 97% open). The predicted probability of competence and autonomy for complex procedures was lower, but remained similar between groups (competent: 73% endovascular, 70% open; autonomous: 92% endovascular, 92% open). ConclusionsThere is no difference in the graduating level of autonomy and competence of endovascular as compared with open peripheral revascularization procedures for vascular surgery trainees. These findings suggest that vascular surgery trainees enter independent practice with adequate proficiency to use the full scope of techniques to care for patients requiring peripheral revascularization procedures.

Using a novel three-dimensional holographic technology to perform open vascular surgery procedures

Augmented reality technology has been introduced during recent years into everyday clinical practice. Several surgical specialties have begun using such technology for preoperative planning as well as intraoperatively. Regarding vascular surgery, a limited number of reports have described the benefits, mainly for endovascular procedures. We aim to present a novel three-dimensional holographic system we used to perform an open vascular procedure.

Intraoperative workload in elective open vascular and endovascular surgery: A study of procedural drivers

This study investigated vascular surgeon workload and its association with specific procedural drivers over different procedure types. Thirteen attending vascular surgeons (two females) were emailed a survey over a 3-month period. Data from 253 surgical procedures (118 open, 85 endovascular, 18 hybrid, and 32 venous) revealed high physical and cognitive workload among vascular surgeons. Based on the statistically significant findings and similar non-significant trends in the data (significance level of 0.01), open and hybrid vascular procedures showed higher levels of physical and cognitive workload compared to venous cases, while endovascular procedures were relatively more moderate. Additionally, the workload subscales for five subcategories of open procedures (e.g., arteriovenous access) as well as three subcategories of endovascular procedures (e.g., aortic) were compared. The granularity of the intraoperative workload drivers across various vascular procedure types and adjunct equipment could be the key to create targeted ergonomic interventions to reduce workload during vascular surgeries.

18. Pedicled Flaps for High-risk Open Vascular Procedures of the Lower Extremity: An Analysis of the National Surgical Quality Improvement Project (NSQIP) Database

18. Pedicled Flaps for High-risk Open Vascular Procedures of the Lower Extremity: An Analysis of the National Surgical Quality Improvement Project (NSQIP) Database

Comparison of Regional and General Anesthesia Outcome after Peripheral Vascular Surgery

Background: Compared to other non-cardiac surgical procedures, peripheral vascular surgery is more likely to cause cardiac morbidity and mortality. Planning anesthesia and surgery for open vascular procedures on the lower limbs necessitates a careful examination of the patient's physical capacity and, ideally, includes cardiac and pulmonary evaluation and, if possible, optimization. Methods: An investigation of relationships between anesthesia approach and outcomes of 436 cases (GA=218 and RA=218) was provided by this retrospective, propensity score matched, cohort study. Between May 2019 and July 2021, the study was carried out at the Department of Anaestheology in National Institute of Cardiovascular Diseases and Dhaka Medical College Hospital. Result: In both groups most of the patients (80.7% and 84.4%) were aged less than 80 years. Male participants were more prevalent (57.8% and 60.6%) in both groups. In the GA group, the frequency of both general and surgical problems was considerably higher. The GA group experienced significantly more general medical problems than the control group, including post-operative hemorrhage (1.4% vs. 0.9%), ICU &gt;3 days (0.9% vs. 0.5%), cardiac (2.8% vs. 2.3%), and pulmonary (1.4% vs. 0.9%). After multiple regression analysis, the GA group had a significantly higher 30-day mortality rate and greater instances of all complications. The incidence of general and surgical problems was 6.9% and 3.7%, respectively, and the total 30-day mortality was 3.2%. The average length of stay was 5 (3, 9). The overall one-year amputation rate for the same side was 8.3%. Conclusion: This study highlighted the possibility that RA, as opposed to GA, may be associated with a better outcome following open inguinal and infra- inguinal vascular surgery.

High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013–2017)

Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref = 4.67 (LEOPEN) and SCV/SCVref = 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

Eliminating Sex-Based Disparities in Statin Prescriptions Following Open Revascularization for CLTI Through Universal Documentation

Women have been shown to have worse clinical outcomes compared with men following treatment for peripheral arterial disease. Although the reasons for this remain unclear, disparities in evidence-based medical management have been suggested as one potential cause. As a part of the Northern California Vascular Quality Initiative (VQI) regional collaborative, a universal discharge documentation quality improvement initiative was implemented to address discharge medication prescriptions. We hypothesized that implementation of universal discharge documentation would decrease disparities in statin prescription after open vascular procedures for chronic limb-threatening ischemia (CLTI). A single-center retrospective analysis was performed using electronic health record warehouse data extraction with medical record review auditing. Patients with CLTI who had undergone open lower extremity bypass or femoral endarterectomy from 2012 to 2020 were included. The primary end point was a statin prescription within 30 days after the procedure. A time series analysis was performed comparing the primary end point before and after implementation of universal discharge documentation in May 2018. Sex was defined as the birth sex as reported in the medical record. Logistic regression was used to estimate the associated change in statin prescription by sex. A total of 357 cases were included, with 144 women (40%) and 213 men (60%). Before implementation, statins had been prescribed to 87% of the men and 69% of the women (P < .01). After implementation of the universal discharge documentation, there was no difference in statin prescription (88% for men vs 95% for women; P = .19). On logistic regression, men had 3.0 times the odds of being prescribed a statin before implementation (odds ratio, 3.0; 95% confidence interval, 1.6-5.6; P < .01). Following implementation of the initiative, the improvement in the odds of women receiving statins was eight times that of men (odds ratio, 8.2; 95% confidence interval, 1.5-46.1; P = .02). Implementation of universal discharge documentation eliminated sex-based disparities in discharge statin prescription following open revascularization for CLTI. These findings suggest that regional VQI initiatives aimed at improving discharge documentation might also play an important role in addressing disparities in vascular care. Future study is necessary to better understand how universal discharge documentation might affect sex-related and other disparities across VQI modules at the regional level.

Migration of High Cardiac Risk Patients from Open to Endovascular Procedures is Evident within the Society for Vascular Surgery Vascular Quality Initiative

In this study, pre-operative medical complexity is estimated by the independently validated Vascular Quality Initiative VQI Cardiac Risk Index (CRI). This study aims to identify and correlate trends of CRI for open abdominal aortic aneurysm (OAR) with trends in the CRI for corresponding endovascular aortic repair (EVAR). This assessment of differences in estimated procedural risks will be used to support the theory that, patient migration is an important factor contributing to decreased POMI following open vascular procedures. A retrospective review of VQI data from 2003 to 2020 for all patients undergoing elective aortic repairs (OAR and EVAR) was conducted. The CRI scoring developed for the open repair (oCRI) was applied to both the OAR and EVAR cohorts, with variables specific to EVAR translated from similar open repair factors in the model where feasible. To evaluate for changes across time, patients were grouped into Eras based on year of procedure, subsequently, univariate analysis of post-operative myocardial infarction (POMI) rates and CRI scores were perfomed between each era. A total of 56,067 elective aortic repairs were identified (83% EVAR, 17% OAR). Within the OAR cohort, the average oCRI estimate was 7.1% with significant decrease across the studied timeframe (8%±4.6%→6.9%±4.4%, P<0.001), which corresponded to a significant decrease in observed clinical myocardial infarction (MI) rate (4.1%→1.4%, P<0.001). Over that same time period, the open CRI was applied to the EVAR cohort, and the average oCRI estimate was 7.2% and showed a significant increase (6.6%±2.8%→7.2%±4.4%, P<0.001). Within the EVAR cohort, the eCRI estimate did not show any significant changes over time (average 0.48%), while the actual rate of clinical MI showed a significant decrease (1.1%→0.3%, P=0.002). Gap analysis was conducted within the EVAR cohort between CRI estimates of procedural risks from an open operation versus an EVAR, which demonstrated that patients within the EVAR cohort would, on an average, has had 6.7% higher risk of POMI had they undergone an open procedure. Paradigm shifts with regard to patient selection for aortic repair is evident within this large national cohort. Over time, OAR patients had fewer preoperative estimated cardiac comorbidities and there is a corresponding decrease in POMI rates. As high-risk patients migrate from OAR to EVAR, there has been a subsequent increase in EVAR estimated pre-operative risks as the patients become more medically high-risk. Despite increasing complexity, rates of POMI in EVAR significantly decreased, potentially explained by improved operative technique and peri-operative care.

High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013–2017)

Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref= 4.67 (LEOPEN) and SCV/SCVref= 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

Patient-reported physical function as a preoperative predictor of recovery after vascular surgery

ObjectivePreoperative risk assessment in vascular surgery often relies on the clinical subjectivity of providers and assessment tools with poor discrimination. Patient-reported outcome measures (PROMs) may provide a more objective assessment of an individual’s own health status before surgery and ability to recover after a vascular procedure. We designed this study to determine whether PROMs assessed for physical function (PROM-PF) prior to vascular surgery could be used to predict patient risk for postoperative complications and delayed recovery. MethodsWe identified all patients who completed a PROM-PF survey prior to undergoing a vascular surgery procedure captured in the Society for Vascular Surgery-Vascular Quality Initiative registry (carotid endarterectomy, abdominal aortic aneurysm, endovascular aneurysm repair, thoracic endovascular aneurysm repair, peripheral vascular intervention, infra-inguinal bypass, and supra-inguinal bypass) at a single academic institution between January 2016 and June 2020. PROM-PF assessment was obtained electronically using the validated Patient-Reported Outcome Measurement Information System short form (v1.2) instrument. All patient demographics and comorbidities were collected as part of the Society for Vascular Surgery-Vascular Quality Initiative registry. After stratifying patients based on high vs low preoperative PROM-PF, multivariable regression models were used to assess the risk-adjusted odds ratios (ORs) for perioperative complications, extended hospital length of stay (LOS), and discharge to a care facility. ResultsA total of 240 patients (mean age, 68 years; 69% male; and 88% Caucasian) completed a PROM-PF assessment <30 days before a vascular surgery intervention, of which 54% had low PF. Patients with high PF were more likely than those with low PF to undergo an open vascular procedure (43% high PF vs 42% low PF; P < .001). Rates of perioperative complications and/or mortality were similar between groups, although patients with low-PF were more likely to have an extended hospital LOS (48% low PF vs 33% high PF; P < .05) and/or be discharged to a care facility (17% low PF vs 7% high PF; P < .05). These results were confirmed in risk-adjusted models showing that patients with low PF scores were significantly more likely to have an extended LOS (adjusted OR, 1.86; 95% confidence interval, 1.06-3.28) and be discharged to a care facility (adjusted OR, 2.72; 95% confidence interval, 1.06-7.00). ConclusionsLow preoperative PROM-PF was associated with a higher risk of extended inpatient LOS and discharge to a care facility following vascular surgery. PROMs allow patients to provide valuable presurgical information about their own health status that can be used to anticipate postoperative recovery.

Open vascular surgery training in the endovascular era: 5-year experience with cadaver laboratory.

Vascular cadaver laboratory (CAD LAB) courses included vascular exposure techniques and simulations of open procedures. Aim of the study was to demonstrate the benefit of cadaver laboratory (CAD LAB) courses to improve trainees' experience in open surgical vascular procedures. Between 2014 and 2020, 162 vascular surgeons or medical trainees (mean age 28 years) participated in vascular CAD LAB courses in Italy and France. Outcomes were measured using the Linkert survey, performed pre- and postcourse to evaluate self-efficacy/confidence, surgical experience, and resident perception of the course with a range score from 0 to 5 for each point. Anatomical knowledge improvement was measured using a questionnaire with multiple answers pre- and postcourse. The course was considered to have yielded a positive result if the postcourse Linkert Survey Score increased by ≥2 points, or in the case of an increase of at least 30% above the baseline value of the multiple questionnaires. Postcourse questionnaires were positive for all outcomes evaluated. Participants' perception of the usefulness of the CAD LAB evaluation was 4.8 out of 5. For the vascular CAD LAB, participant anatomical knowledge improved overall from an average of 55% to 93% (P<0.001), and self-efficacy/confidence improved from 2.3 to 4.5 out of 5 (P<0.001). Regarding the different operative procedures, the greatest self-efficacy/confidence improvement was recorded in carotid endarterectomy and aortic procedures (+50% and +66% respectively; P<0.001). The city location (Italy vs. France) did not affect the results. CAD LAB courses were shown to be effective in increasing participants' self-efficacy, confidence, and anatomical knowledge in open vascular surgical procedures.

Visceral Debranching Followed by Neoadjuvant Chemotherapy and Pancreatic Resection for Locally Advanced Pancreatic Cancer: A Phase II Clinical Trial

Introduction: Advances in multimodal treatment have led to an increasing number of complex operations for pancreatic cancer . For locally advanced tumors with arterial invasion, only resection with arterial reconstruction offers a chance of cure. However, simultaneous arterial reconstruction and tumor resection is associated with high morbidity and mortality. The study aims to assess feasibility of a novel approach of performing visceral debranching, i. e. arterial reconstruction, prior to neoadjuvant chemotherapy and tumour resection in locally advanced pancreatic cancer. All open vascular procedures can be considered. Examples are aorto-visceral or iliaco-visceral bypasses. Method: The trial is designed as a single-arm multi-center study. After confirming eligibility for pancreatic resection with arterial reconstruction in a multidisciplinary tumor board, patients are offered trial enrolment. At first, patients proceed to undergo visceral debranching. Once the patient has sufficiently recovered from the procedure, neoadjuvant chemotherapy starts. Tumor resection is performed four to six weeks after completion of chemotherapy. After treatment, patients are followed up. The primary outcome is feasibility, measured as the proportion of patients who start neoadjuvant therapy within six weeks of visceral debranching. Using an exact single-stage design (H0=0.7, H1=0.9, alpha=0.05 1-beta=0.8), feasibility of the approach under study is assumed if 24 of the enrolled 28 patients proceed to neoadjuvant chemotherapy. Conclusion: This trial evaluates the feasibility of visceral debranching prior to neoadjuvant chemotherapy and tumor resection in order to avoid the relevant morbidity and mortality associated with simultaneous resection and reconstruction.

Risk Factors for Wound Infections after Vascular Surgery: Kuwait Experience

Introduction: Wound infections represent a serious complication after vascular surgery particularly after vascular reconstructive procedures. We aimed to identify risk factors predisposing patients to these complications. Methods: This was a retrospective review of open vascular surgical procedures performed between April 2014 and March 2019 in Kuwait. Patient demographics, procedures performed and their indications, and post-operative outcomes were collected and analyzed. Patients with pre-operative active infections were excluded from the analysis. Statistical analysis was performed, and odds ratios (ORs) and relative risks were calculated for the outcomes of interest. Fisher’s exact test and two-tailed t test were used where appropriate. Results: 391 patients were identified. The majority (54%) presented with chronic limb threatening ischemia. The mean age was 58 (±10) years, with a male predominance (76%). Wound infection occurred in 53 (14%) patients. The most commonly isolated organism was Staphylococcus aureus (47%). Diabetes (OR 8.03, 95% CI: 1.9142–33.7439, p = 0.0044), hypertension (OR 2.38, 95% CI: 1.2960–4.3684, p = 0.0052), ischemic heart disease (OR 2.30, 95% CI: 1.4349–4.6987, p = 0.0016), hyperlipidemia (OR 2.12, 95% CI: 1.0305–4.3620, p = 0.0412), and chronic renal failure (OR 2.55, 95% CI: 1.0181–6.4115, p = 0.0457) were all found to be significantly associated with the development of post-operative wound infections in vascular surgery patients. Conclusion: Diabetes, hypertension, ischemic heart disease, hyperlipidemia, and chronic renal failure were associated with post-operative wound infections. Anticipation of wound complications in patients with these risk factors may aid early diagnosis and treatment.

Preoperative HbA1c and Outcomes following Lower Extremity Vascular Procedures

BackgroundLimited data exist evaluating preoperative hemoglobin A1c (HbA1c) in patients undergoing vascular procedures for peripheral arterial disease (PAD). This study evaluated the relationship of preoperative HbA1c on outcomes after open and endovascular lower extremity (LE) vascular procedures for PAD. MethodsWe selected patients with PAD admitted for elective LE procedures between September 2008 and December 2015 from the Cerner Health Facts® database using International Classification of Disease, Ninth Edition, Clinical Modification diagnosis and procedure codes. Bivariable analysis and multivariable logistic models examined the association of patient characteristics, procedure type, and preoperative HbA1c (normal < 6.5%, high ≥ 6.5%) with postsurgical outcomes that included infection, renal failure, respiratory or cardiac complications, length of stay, in-hospital mortality, and readmission. ResultsOf 4087 patients who underwent a LE vascular procedure for PAD, 2462 (60.2%) had a preoperative HbA1c recorded. The cohort was mostly male (60%), white (73%), and underwent endovascular intervention (77%). Patients with high HbA1c levels were more likely of black race (P < 0.02) and had significantly higher comorbidities (P < 0.0001). Elevated HbA1c was associated with diabetes (P < 0.0001) and cellulitis (P = 0.05) on unadjusted analysis. Multivariable logistic regression (adjusting for patient, hospital, comorbidity and procedural characteristics) revealed that elevated HbA1c was significantly associated with 30-day readmission (OR = 1.06, 95% confidence interval = 1.00–1.12), but was not associated with the other outcomes. An independent diagnosis of diabetes was not predictive of complications or readmission. ConclusionsHistoric glucose control, as evidenced by a high preoperative HbA1c level, is not associated with adverse outcome, other than readmission, in patients undergoing LE procedures for PAD. Given the known association of high perioperative glucose levels with poor outcome following vascular procedures, this is suggestive of a more important effect of perioperative, as opposed to chronic, glucose control upon outcome. Thus, we suggest focusing efforts on creating standardized goal-directed guidelines for glucose control in the perioperative period for LE vascular procedures to potentially mitigate complications.

Short-Term Pre-Operative Protein Caloric Restriction in Elective Vascular Surgery Patients: A Randomized Clinical Trial.

(1) Background: Vascular surgery operations are hampered by high failure rates and frequent occurrence of peri-operative cardiovascular complications. In pre-clinical studies, pre-operative restriction of proteins and/or calories (PCR) has been shown to limit ischemia-reperfusion damage, slow intimal hyperplasia, and improve metabolic fitness. However, whether these dietary regimens are feasible and safe in the vascular surgery patient population remains unknown. (2) Methods: We performed a randomized controlled trial in patients scheduled for any elective open vascular procedure. Participants were randomized in a 3:2 ratio to either four days of outpatient pre-operative PCR (30% calorie, 70% protein restriction) or their regular ad-libitum diet. Blood was drawn at baseline, pre-operative, and post-operative day 1 timepoints. A leukocyte subset flow cytometry panel was performed at these timepoints. Subcutaneous/perivascular adipose tissue was sampled and analyzed. Follow-up was one year post-op. (3) Results: 19 patients were enrolled, of whom 11 completed the study. No diet-related reasons for non-completion were reported, and there was no intervention group crossover. The PCR diet induced weight loss and BMI decrease without malnutrition. Insulin sensitivity was improved after four days of PCR (p = 0.05). Between diet groups, there were similar rates of re-intervention, wound infection, and cardiovascular complications. Leukocyte populations were maintained after four days of PCR. (4) Conclusions: Pre-operative PCR is safe and feasible in elective vascular surgery patients.

Screening, Management, and Acceptance of Patients with Aorto-Iliac Vascular Disease for Kidney Transplantation: A Survey among 161 Transplant Surgeons

Introduction: Aorto-iliac vascular disease (AVD) is frequently found during the workup for kidney transplantation. However, recommendations on screening and management are lacking. We aimed to assess differences in screening, management, and acceptance of these patients for transplantation by performing a survey among transplant surgeons. Second, we aimed to identify center- and surgeon-related factors associated with decline or acceptance of kidney transplant candidates with AVD. Methods: A survey was sent to transplant surgeons and urologists. The survey contained general questions (part I) and 2 patient-based cases (part II) with Trans-Atlantic Inter-Society Consensus (TASC) D and B AVD supported with videos of their CT scans. Results: One hundred ninety-one (20.3%) participants responded; 171 were currently involved in kidney transplantation: 161 (94.2%) completed part I and 145 (84.8%) part II. Screening for AVD was often (38.5%) restricted to high-risk patients. The majority of respondents (67.7%) rated “technical problems” as the most important concern in case of AVD, followed by “increased mortality risk because of cardiovascular comorbidity” (29.8%). Pretransplant vascular interventions to facilitate transplantation were infrequently performed (71.4% mentioned <10 per year). Ninety (64.3%) respondents answered that an open vascular procedure should preferably be performed prior to kidney transplantation while 42 (30.0%) respondents preferred a simultaneous open vascular procedure. The decline rate was higher in the TASC D case compared to the TASC B case (26.9% and 9.7%, respectively). Respondents from centers with expertise in pretransplant vascular interventions were more likely to accept both patients with TASC D and B for transplantation. Conclusion: There is no uniformity in the screening, management, and acceptance of patients with AVD for transplantation. If a center declines a patient with AVD because of technical concerns, the patient should be referred for a second opinion to a tertiary center with expertise in pretransplant vascular interventions. Multidisciplinary meetings including a vascular surgeon and a cardiologist could help optimize these patients for transplantation.

Living in a Food Desert is Associated With Increased Wound Complications After Major Vascular Procedures

Food deserts (FDs) are regions that lack grocery stores, have unaffordable healthy options, and/or have a density of poor-quality food choices. Living in a FD has been associated with metabolic risks; however, its relationship to wound complications after major vascular surgery remains unexplored. We hypothesized that FD status would be associated with an increased incidence of wound complications after major vascular surgery. We performed a single-center retrospective analysis of open vascular procedures from 2012 to 2020. FD status was determined by matching the patient census tract location to low- income and low-food access metrics from the U.S. Department of Agriculture Food Access Research Atlas. Major vascular procedures included infrainguinal bypass, femoral endarterectomy, aortofemoral bypass grafting, lower extremity bypass, open abdominal aortic aneurysm repair, and thoracoabdominal aortic repair. The Area Deprivation Index (ADI), a validated marker of socioeconomic status, was used to distinguish the effects of FD status from other markers of social disadvantage such as education and housing. Multivariable logistic regression was used to assess the independent association of FD status with wound complications. Among 1417 patients, 119 (8%) resided in a FD. Overall, wound complications occurred in 124 patients (9%): 15%, femoral endarterectomy; 14%, aortofemoral bypass grafting; 13%, infrainguinal bypass; 10%, thoracoabdominal aortic aneurysm repair; and 4%, open abdominal aortic aneurysm repair (P < .01). Patients in an FD were younger (61 vs 67 years; P < .01), more frequently had chronic obstructive pulmonary disease (28% vs 17%; P = .02), and had twice the incidence of wound complications (24% vs 12%; P < .01). On multivariable analysis, FD status was independently associated with increased odds of wound complications (1.9; 95% confidence interval 1.0-3.5; P = .04; Table). On sensitivity analysis, FD status and diabetes interacted, and FD and diabetes combined resulted in a 2.8-fold increased odds (95% confidence interval, 1.1-7.0) of wound complications compared with those without either risk factor. Living in a FD was associated with twice the odds of wound complications after major vascular operations. These results suggest that food insecurity can affect wound healing and should be considered as a potential modifiable perioperative risk factor. Future study of interventions aimed at addressing access to healthy foods is warranted.TableMultivariable analysis of wound complicationsCovariateaORa95% CIP valueFood desert1.91.0-3.5.04Obesity1.61.0-2.5.03CAD1.71.1-2.6.01Area deprivation indexb Medium1.71.0-2.9.03 High1.30.7-2.2.42aOR, Adjusted odds ratio; CAD, coronary artery disease; CI, confidence interval.Boldface P values represent statistical significance.aAdjusted for age ≥70 years, diabetes mellitus, coronary artery disease, area deprivation index, chronic obstructive pulmonary disease, obesity, aspirin, postoperative red blood cell transfusion, chronic kidney disease stage 5, operative indication, and procedure type.bCompared with an area deprivation index reference group of low. Open table in a new tab

Prophylactic Muscle Flaps in Primary Vascular Procedures of the Groin

Complications following vascular procedures involving the groin can lead to significant morbidity. Achieving stable soft tissue coverage over sites of revascularization can help mitigate complications. Prior evidence supports the use of muscle flaps in reoperative groins and in high risk patient populations to reduce postoperative complications. Data regarding the use of prophylactic muscle flap coverage of the groin is lacking. Therefore, the purpose of this study is to evaluate the effect of immediate prophylactic muscle flap coverage of vascular wounds involving the groin. A retrospective cohort study was performed on all patients undergoing primary open vascular procedures involving the groin for occlusive, aneurysmal, or oncologic disease between 2014 and 2020 at a single institution where plastic surgery was involved in closure. Patient demographics, comorbidities, surgical details, and postoperative complications were compared between patients who had sartorius muscle flap coverage of the vascular repair versus layered closure alone. A total of 133 consecutive groins were included in our analysis. A sartorius flap was used in 115 groins (86.5%) and a layered closure was used in 18 (13.5%). Wound breakdown was similar between groups (25.2% sartorius vs. 38.9% layered closure, P=0.26). However, the rate of reoperation was significantly higher in the layered closure group (50.0% vs. 12.2%, P < 0.01). Among patients who experienced wound breakdown (N=36), a larger proportion of layered closure patients required operative intervention (71.4% vs. 20.7%, P=0.02). Other rates of complications were not statistically different between groups. In patients undergoing primary open vascular procedures involving the groin, patients who underwent prophylactic sartorius muscle flap closure had lower rates of reoperation. Although incisional breakdown was similar between the groups overall, the presence of a vascularized muscle flap overlying the vascular repair was associated with reduced need for reoperation and allowed more wounds to be managed with local wound care alone. Consideration should be given to this low morbidity local muscle flap in patients undergoing vascular procedures involving the groin.

Factors influencing medical student choices in the integrated vascular surgery match: Implications for future post-pandemic residency matches

ObjectiveIntegrated vascular surgery residency is among the most competitive specialties, but little is known about the applicant perspective. The coronavirus disease 2019 outbreak impacted the 2021 integrated vascular surgery residency match because of travel restrictions. We sought to better understand pre-pandemic applicant recruitment strategies, logistics of away rotations, and the residency interview process to identify areas for improvement in the application process. MethodsAn anonymous survey was sent to matched students in 2020, inquiring about motivations for pursuing vascular surgery (VS), logistic of away rotations and interviews, and factors influencing students' rank lists. ResultsSeventy of the 73 matched students completed the survey (95.9% response rate). The median age was 27 (range, 25-41); 32.9% were female, 91.4% were U.S. medical students, and 77.1% were from institutions with a VS training program. Factors most strongly influencing the decision to choose VS as a career were interest in open vascular procedures, endovascular procedures, perceived job satisfaction, emerging technologies, and influence of a mentor. The prospect of the job market, future salary, and competitiveness of the application process had the least impact. Of the matched students, 82.9% completed an away rotation (median, 2; range, 1-4), with 51.7% of students paying a total cost of more than $2500. Fifty percent of students matched either at their home institution or where they had performed an away rotation. Students reported application submissions to a median of 50 programs (range, 1-70) and interviewed at 17 (range, 1-28), with 40% of students paying a total of more than $4000 for interview costs. The most significant factors affecting students' rank lists included program culture, open aortic surgical volume, geography, and complex endovascular procedure volume. Tours of facilities, resident salary, and male/female distribution had the least importance. ConclusionsSuccessfully matched applicants in 2020 prioritized operative case volume and program collegiality when ranking programs. Despite their high cost, away rotations played an important role in the Match, suggesting that time spent at potential institutions allowed ideal assessment of factors for students. The high average number of away rotations and in-person interviews performed in 2019-2020 was limited for the 2021 Match due to coronavirus disease 2019 restrictions. Programs will have to continue developing creative alternatives or additions to away rotations and the application processes to assure continued success in future post-pandemic Match cycles.