Open Vascular Surgery Research Articles

Development and Validation of a 30-Day Point-Scoring Risk Calculator for Open Groin Vascular Surgery: The George Washington Groin Score

BackgroundOpen groin vascular surgeries are important in managing peripheral arterial diseases. Given its inherent risks and the diverse patient profiles, there is a need for risk assessment tools. This study aimed to develop a 30-d point-scoring risk calculator for patients undergoing open groin vascular surgeries. MethodsPatients underwent open groin vascular surgery, including aortobifemoral, axillofemoral, femorofemoral, iliofemoral, femoral-popliteal, and femoral-tibial bypass as well as thromboendarterectomy, were identified in American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2021. Patients were randomly sampled into experimental (2/3) and validation (1/3) groups. The George Washington (GW) groin score, a weighted point-scoring system, was developed for 30-d mortality from multivariable regression on preoperative risk variables by Sullivan's method. GW groin score was subjected to internal and external validation. Furthermore, the effectiveness of GW groin score was evaluated in 30-d major surgical complications. ResultsA total of 129,424 patients were analyzed, with 86,715 allocated to experimental group and 42,709 to validation group. GW groin score is derived as follows: aortobifemoral bypass (2 points), axillofemoral bypass (1 point), age (>75 y, 2 points; 65-75 y, 1 point), disseminated cancer (2 points), emergent presentation (1 point), American Society of Anesthesiology score 4 or 5 (1 point), dialysis (1 point), and preoperative sepsis (1 point).GW groin score exhibited robust discrimination (c-statistic = 0.794, 95% CI = 0.786-0.803) and calibration (Brier score = 0.029). The transition from individual preoperative variables (c-statistic = 0.809, 95% CI = 0.801-0.818) to the point-scoring system was successful and external validation of the score was confirmed (c-statistic = 0.789, 95% CI = 0.777-0.801, Brier score = 0.030). Furthermore, GW groin score can effectively discriminate major surgical complications. ConclusionsThis study developed GW groin score, a concise and comprehensive 10-point risk calculator. This well-validated score demonstrates robust discriminative and predictive abilities for 30-d mortality and major surgical complications following open groin vascular surgeries. GW groin score can anticipate potential perioperative complications and guide treatment decisions.

Transfusion and Anemia in Patients Undergoing Vascular Surgery

This cohort study examines the association between blood transfusion and major adverse cardiovascular events and mortality among people undergoing elective open vascular operations.

Percutaneous intervention versus surgery in the treatment of common femoral artery lesions: study protocol for the prospective, multi-center, randomized PESTO-CFA trial

BackgroundEndovascular therapy has become established as a first-line therapy in most arterial regions. However, open vascular surgery (endarterectomy) remains the treatment of choice for common femoral artery (CFA) lesions. The aim of this study is to investigate the acute and mid-term results of directional atherectomy plus drug-coated balloon (DCB) in comparison to endarterectomy in treatment of de novo arteriosclerotic CFA lesions.MethodsThis prospective, randomized, multicenter non-inferiority study will enroll 306 participants with symptomatic (Rutherford category 1 to 5) de novo stenosis of the CFA including the bifurcation. Patients eligible for both treatment groups could be included in this 1:1 randomized trial. Primary efficacy endpoint is patency of the target lesion at 12 months defined as restenosis < 50% without the need of clinically driven target lesion revascularization (cdTLR). Primary safety endpoint is a combined endpoint including death, myocardial infarction, major or minor amputation of the target limb, and peri-procedural complications at 30 days. Secondary endpoints include primary patency of the target lesion at 6 and 24 months, secondary patency, cdTLR 6, 12, and 24 months, change in ankle-brachial index, and Rutherford-Becker class at 6, 12, and 24 months. Limb salvage, change in quality of life measured by Walking Impairment Questionnaire, and major adverse events including death, myocardial infarction, and minor or major amputation of the target limb will be determined at 6, 12, 24, and 36 months.DiscussionEndovascular treatment of CFA lesions is still a matter of debate. Few studies compared modern endovascular therapy methods against the so-called gold standard surgical endarterectomy so far. Based on recent positive results, this study aims to confirm non-inferiority of a “leaving nothing behind” endovascular approach combining directional atherectomy and DCB compared to surgical therapy.Trial registrationClinicalTrials.gov NCT02517827.

Protein-based tissue adhesive reduces time to haemostasis in peripheral vascular surgery.

The aim of this study was to evaluate the effectiveness of protein-based tissue adhesive (Bioglue®) in reducing time to haemostasis in patients undergoing peripheral vascular surgery. From January to December 2021, 100 consecutive patients from 4 centres have been treated with open peripheral vascular surgery including upper and lower limb interventions. Patients have been allocated in each centre into control with no use of Bioglue® (Group no-Bio, 50 patients) or use of Bioglue® (Group Bio, 50 patients) by a block randomization method 10:10 until the required sample size was reached. Perioperative parameters including time to haemostasis, number of adjunctive stitches, and in-hospital bleeding have been analysed and compared in the two groups by means of mean independent-samples tT -test and Gehan-Breslow-Wilcoxon test. Both groups were homogeneous in terms of demographic data, preoperative risk factors, and preoperative medical therapy except for a higher percentage of active smokers in Group Bio (52% vs. 24%, p = 0.004). Femoral endarterectomy was most common in Group Bio (44% vs. 24%, p = 0.03), whilst the percentage of lower limb vein bypasses was higher in Group no-Bio (50% vs. 36%, p = 0.03). Bovine pericardium was the preferred material in Group Bio (20 cases, 40%), whilst autologous vein is mostly used in Group no-Bio (26 cases, 52%) (p = 0.01). Time to haemostasis was faster in Group Bio (4.4 vs. 9.6 minutes, p < 0.001). The need for adjunctive stitches was higher in Group no-Bio (8 cases, 16%, Group Bio vs. 25 cases, 50%, Group no-Bio; p < 0.001). The overall rate of in-hospital bleeding, including those requiring reintervention, was not different between the two groups (9 cases, 18%, Group Bio vs. 7 cases, 14%, Group no-Bio; p = 0.39). The protein-based tissue adhesive Bioglue® reduced time to haemostasis and need for adjunctive stitches in peripheral vascular surgery. However, it did not affect the overall rate of perioperative bleedings. Further studies with larger sample sizes are needed to validate these outcomes.

Perioperative and Mid-Term Outcomes of Bovine Xenografts in Infected Aortic/Iliac Surgery

Abstract Background Various methods of open-surgical treatment of infected aortic and iliac pathologies are available. The use of surgeon-made bovine pericardium grafts in infected aortic/iliac context has been associated with a low re-infection rate as well as high feasibility. Prefabricated (factory pre-sewn) bovine pericardium prostheses have been available for a few years. Studies reporting clinical results are rare. Aims Present the perioperative and mid-term outcomes of a bifurcated and straight bovine pericardium prostheses (BioModiVasc®) in infected aortic and iliac pathologies. Methods Retrospective database analysis of all vascular surgery operations between 2021 and 2023 at our centre. Results 28 BioModiVasc® grafts were implanted in 27 patients due to INAA (40,7%), VGEI (51,9%), trauma (3,7%) or Leriche-Syndrome (3,7%). Patients were predominantly male (85,2%) and often presented arterial hypertension (88,9%). Significant risk factors were infection in a remote site (29,6%), emergency/urgent operations in the past 12 months (22,2%) and previous vascular procedures (44,4%). Elevated CRP (88,9%) and soreness at site (81,5%) were the most common findings at presentation. CT-scan showed infection-typical findings in 96,3%. Pathogen was isolated in 77,8% of the cases. Median operation time was 300 minutes. 88,9% of the operations were emergency/urgent ones. 96,3% of the reconstructions were orthotopic, access was mostly transperitoneal (59,3%). Median hospital/ICU days were 19 and 2 respectively. Infection a/o operation-associated 30-day mortality was 11,1%. 3-deaths occurred at follow-up (median 12 months), non-infection a/o operation related. 1 patient required a re-do due to a duodenal erosion caused by the prosthetic anastomosis. Conclusion Open surgical treatment of aortic/iliac septic pathologies with the BioModiVasc® prosthesis yields good results, which are similar to the reported results of the use of surgeon-made bovine pericardial reconstructions.

Abstract 3009: Progressive Structured Simulation-based Surgical Training Program (PROCESS) - Open Vascular Surgery: Study Protocol For A Cross-over, Randomized, Double-blinded Clinical Trial.

Objective: Vascular surgery has been directed towards endovascular approaches; however, not all patients qualify for these procedures. Open vascular surgery (OVS) remains an alternative, demanding a steep learning curve. Exposure to these procedures has declined resulting in a lack of standardization in acquiring OVS skills. Simulation is a solution to this challenge. However, in OVS, there is scarce evidence for structured programs. The measurement of surgical skills is based on objectively assessable subjective tools; yet, they have limitations as evaluators may introduce inherent individual biases. We aim to compare the effectiveness of technical surgical competencies acquisition between a structured progressive simulation-based training program and isolated experience-based training in OVS. Methods: We will conduct a randomized double-blind crossover clinical trial. A control sequence and an intervention sequence of three subgroups with different exposure levels to the simulation program are proposed using 3D printed models. Group 1: open abdominal aortic repair (AAOR), Group 2: vascular anastomosis (VA) and AAOR, and Group 3: specific micro-surgical skills, VA and AAOR. Surgical residents of general, vascular, or cardiovascular surgery programs will be included. Sample size calculation resulted in 45 participants, 15 in each group. Double blinding will involve participants and external evaluators. Randomization will occur in block randomization and permuted block randomization. Results: We anticipated that the structured and progressive simulation-based training program objectively enhances technical surgical competencies. We expect to determine a significant difference in the acquisition of technical surgical competencies based on the progression through different modules within the program and validate the reliability of an assessment tool based on objective metrics for technical surgical competencies in OVS. Conclusion: We hope this initiative will impact the formation of future vascular surgeons, complementing experience-based training with simulation-based programs in OVS. Ensuring that the trainee obtains all the necessary tools to perform OVS and standardize an objective assessment evaluation method.

Compari̇son of PTFE sutures with polypropylene sutures in suprapopliteal femoropopliteal bypass with PTFE grafts

Aim: Infrainguinal bypass surgery stands as the predominant open surgical procedure for lower limb revascularization and is reserved for cases of intermittent claudication (IC) that have proven unresponsive to maximal medical management. Polypropylene monofilament sutures have been widely used for peripheral vascular surgery operations. Aim of this study is comparing this new type of suture with propylene sutures. Material and Methods: Between January 2022 and December 2022, two cohorts who underwent suprapopliteal femoropopliteal bypass surgery, each comprising 15 patients were included in the study. In Group I (polytetrafluoroethylene (PTFE) Group), PTFE served as the suture material, whereas in Group 2 (Non PTFE Group), polypropylene sutures were employed. All preoperative demographics, perioperative and postoperative data were collected carefully. Results: All patients underwent surgical interventions due to either rest pain or ischemic ulcers. Among the 30 patients, 11 fell into Fontaine class 4, while 19 were categorized as Fontaine class 3. Out of the 30 patients, 18 received cilostazol treatment. The mean age of the patient cohort was 66.97±7.4 years, with a mean body mass index of 29.03±6.2. When we compared the two groups, no statistically significant difference was found between groups according to demographic data. In the evaluation of intraoperative data, the mean operation time was 88.7±9.37 minutes, and the mean hemostasis time was 5.8±2.8 minutes. Group I (PTFE group) exhibited significantly lower hemostasis time and drainage levels on the first and second postoperative days (p&lt;0.0001, p=0.03, and p=0.017, respectively). The use of absorbable hemostats were significantly less in PTFE suture group. Conclusion: The selection of sutures significantly influences the achievement of soft tissue approximation, reduced inflammation, suture hole leakage and capsule formation.

Ruptured Popliteal Aneurysms and the Importance of Open Vascular Surgery

Ruptured Popliteal Aneurysms and the Importance of Open Vascular Surgery

Differences in the association between epidural analgesia and length of stay by surgery type: an observational study

IntroductionDespite a decline in the use of thoracic epidural analgesia related in part to concerns for delayed discharge, it is unknown whether changes in length of stay (LOS) associated with...

Comparison of the results of open vascular surgery interventions in patients with arterial injury caused by penetrating trauma below the knee in the Vascular Surgery Center of Golestan Ahvaz Hospital

Vascular damage is one of the life-threatening emergency situations and is considered one of the most common causes of death worldwide. Considering the frequency of penetrating vascular injuries, especially in our country and Khuzestan province, as well as complications and mortality caused by vascular injuries, this study was designed to investigate the effect of vascular surgery intervention on patients with arterial trauma trauma below the knee. Method: In this descriptive and analytical study, all trauma patients suspected of penetrating arterial injuries below the knee in terms of parameters of age, gender, type of trauma, location of trauma, type of intervention, location of arterial repair, angiographic and clinical findings including damaged arteries, type of injury Arterials were also examined for the presence of fracture or dislocation in the vicinity of vascular damage. Results: The results of this study showed that among the penetrating trauma patients requiring surgical intervention, 89.1% were men and only 10.9% were women. The average age of the patients was 35 years. The most frequent trauma requiring surgical intervention in this study was the trauma caused by firearms (gunshot and shotgun) and the least urban and occupational trauma. There was a significant relationship between trauma. The highest rate of injury was to the popliteal artery below the knee (8.47%), and the most vascular intervention was saphenous vein entrapment. 9.73% of the patients had a fracture injury and 3.16% had a dislocation with vascular injury. Conclusion: According to the results of the present study, the association of vascular injuries with orthopedic fractures was higher and mostly in the popliteal region. Complications including infection, fasciotomy, reperfusion syndrome and amputation have a direct and significant relationship with the type of penetrating trauma.

Prospective Comparison of Wound Complication Rates after Elective Open Peripheral Vascular Surgery - Endovascular Versus Open Vascular Surgeons

Skill and experience of surgeons are likely to influence the incidence of surgical wound complications (SWC) after open lower limb revascularization. Differences in SWC between surgeons with predominantly endovascular or open vascular surgical profiles could be expected. The aim of this study was to compare SWC rates after elective open vascular surgery between primarily endovascular and primarily open vascular surgeons. Prospective data from patients undergoing elective surgery for peripheral artery disease (PAD) was collected between 2013 and 2019. Senior surgeons were assigned to the open-surgeon or the endo-surgeon group based on the percentage of their open surgical case load during the 6year study period. SWC was measured by their clinical impact scale (grade 1-outpatient treatment to grade 6-death). Surgical site infection was defined by Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay (ASEPSIS) criteria. Propensity score adjusted analysis (PSAA) was used to account for differences in baseline and perioperative characteristics and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). The proportion of chronic limb-threatening ischemia (P=0.001), ipsilateral foot wound (P=0.012) and femoro-popliteal bypass procedures (P<0.001) were higher in the open-surgeon group. A lower incidence of SWC according to ASEPSIS criteria (25.6% vs. 38.6%, respectively, P=0.042) and SWC grade ≥1 (33.7% vs. 51.0%, respectively, P=0.010) was found in the endo-surgeon group (n=86) compared to the open-surgeon group (n=153). These differences disappeared after PSAA (OR 0.63, 95% CI 0.27-1.44, and OR 0.60, 95% CI 0.27-1.33, respectively). Patients operated by endo-surgeons had less advanced PAD and lower incidence of SWC compared to those treated by open-surgeons. No difference in SWC remained after PSAA.

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.

Dolichoectatic vertebrobasilar aneurysms: a systematic review and meta-analysis of management strategies and outcomes.

The aim of this study was to describe the efficacy, clinical outcomes, and complications of open cerebrovascular surgery, endovascular surgery, and conservative management of dolichoectatic vertebrobasilar aneurysms (DVBAs). Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane databases according to PRISMA guidelines. A meta-analysis was conducted for clinical presentation, treatment protocols, and clinical outcomes-good (improved or stable clinical status) or poor (deteriorated clinical status or death)-and mortality rates. The 9 identified articles described 41 cases (27.5%) of open cerebrovascular surgery, 61 endovascular procedures (40.9%), and 47 cases (31.5%) of conservative management for DVBAs. The total cohort had a good outcome rate of 51.9% (95% CI 28.3%-74.6%), a poor outcome rate of 45.5% (95% CI 23.0%-70.1%), and a mortality rate of 22.3% (95% CI 11.8%-38.0%). The treatment groups had comparable good clinical outcome rates (open cerebrovascular surgery group: 24.7% [95% CI 2.9%-78.2%]; endovascular surgery group: 69.0% [95% CI 28.7%-92.5%]; conservative management group: 57.7% [95% CI 13.0%-92.5%]; p = 0.19) and poor outcome rates (open vascular surgery group: 75.3% [95% CI 21.8%-97.1%]; endovascular surgery group: 27.2% [95% CI 5.6%-0.70.2%]; conservative management group: 39.9% [95% CI 9.1%-81.6%]; p = 0.15). The treatment groups also had comparable mortality rates (open vascular surgery group: 39.5% [95% CI 11.4%-76.8%]; endovascular surgery group: 15.8% [95% CI 4.4%-43.0%]; conservative management group: 19.2% [95% CI 6.8%-43.5%]; p = 0.23). The current study of DVBAs illustrated poor outcomes and high mortality rates regardless of the treatment modality. The subgroup analysis showed heterogeneity among the subgroups and advice for personalized management.

Chronic Limb-Threatening Ischemia and the Need for Revascularization

Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones. We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis. Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue. The surgeon's experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach.

Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis.

Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis.

Target Balloon-Assisted Antegrade and Retrograde Use of Re-Entry Catheters in Complex Chronic Total Occlusions.

We report data from a retrospective multicenter registry. Eligibility criteria included either antegrade or retrograde use of the OutbackTM or GoBackTM re-entry catheter in combination with a balloon as a target to accomplish wire passage, when conventional antegrade and retrograde recanalization attempts had been unsuccessful. Procedural outcomes included technical success (defined as wire passage though the occlusion and delivery of adjunctive therapy with <30% residual stenosis at final angiogram), safety (periprocedural complications, e.g., bleeding, vessel injury, or occlusion of the artery at the re-entry site, and distal embolizations), and clinical outcome (amputation-free survival and freedom from target lesion revascularization after 12-months follow-up). Thirty-six consecutive patients underwent target balloon-assisted recanalization attempts. Fourteen (39 %) patients had a history of open vascular surgery in the index limb. Fifteen patients were claudications (Rutherford Class 2 or 3, 21 presented with chronic limb threatening limb ischemia (Rutherford Class 4 to 6). The locations of the occlusive lesions were as follows: iliac arteries in 3 cases, femoropopliteal artery in 39 cases, and in below-the-knee arteries in 12 cases. In 15 cases, recanalization was attempted in multilevel occlusions. Retrograde access was attempted in 1 case in the common femoral artery, in the femoropopliteal segment in 10 cases, in below-the-knee arteries in 23 cases, and finally in 2 patients via the brachial artery. In 10 cases, the re-entry devices were inserted via the retrograde access site. Technical success was achieved in 34 (94 %) patients. There were 3 periprocedural complications, none directly related to the target balloon-assisted re-entry maneuver. Amputation-free survival was 87.8 % and freedom from clinically driven target lesion revascularization was 86.6 % after 12-months follow-up. Target balloon-assisted use of re-entry devices in chronic total occlusions provides an effective and safe endovascular adjunct, when conventional antegrade and retrograde recanalization attempts have failed.

Commentary to "Perioperative care in open aortic vascular surgery: A consensus statement by the Enhanced Recovery After Surgery (ERAS) Society and Society for Vascular Surgery"

Angiología es una revista científica bimensual editada desde 1949. Está dedicada al estudio de las enfermedades vasculares, incluyendo todos los aspectos de la medicina vascular, el diagnóstico no invasivo, el tratamiento quirúrgico tradicional arterial y venoso, así como el mínimamente invasivo y/o endovascular.

Trainee Effect on Procedural Efficiency is Limited in Vascular Surgery Operations

Surgical residents prepare during their training for independent operating experience. However, there is a fine balance between supervised intraoperative teaching and the need to keep operations short since this is associated with improved patient safety. We aim to understand if the composition of the vascular surgical team-presence of anesthesia and surgical trainees as well as the number of circulating nurses-affects elective operative times at our institution. As a secondary aim, we analyzed how time of day affects overall operative time. We performed a retrospective review of all vascular surgery elective operations occurring between January 1, 2019, and October 15, 2021. Our reference operation between procedures was the construction of an arteriovenous fistula (AVF). Reference teams included circulating staff (fewer than two nurses), anesthesia (anesthesiologist with certified registered nurse anesthetist [CRNA]), and surgery (surgeon with nurse practitioner). The primary dependent variable was the time interval in minutes from wheels-in to wheels-out of surgery, which was divided into three subintervals: wheels-in to cut, cut to close, and close to wheels-out. Univariate analysis was performed to examine each surgical procedure's distribution of wheels-in to wheels-out time interval. Linear regression was performed to determine the effect of team composition and time of day on operative durations. We included a total of 853 vascular operations. Regarding overall operative time, different procedures took various amounts of time compared with the reference operation (AVF creation). Amputations and arteriograms were shorter (-30min, P=0.03, and -12min, P=0.05, respectively). Other procedures were longer: endarterectomy (+48min, P<0.01), rib resection (+78min, P<0.01), endovascular aorta repair (+120min, P<0.01), lower extremity bypass (+170min, P<0.01), and open aortic repair (+410min, P<0.01). No significant difference was found in carotid artery stent placement. Overall, there was a significant reduction in the close to wheels-out interval for anesthesiologists with a trainee (mean: -2.4min; 95%; CI: -4.7, -0.12; P=0.04). AVF took significantly more time with a surgical resident: wheels-in to cut time (mean: +4.2min; 95%; CI: 0.92, 7.4; P=0.01) and cut to close time (mean: +13min; 3.2, 23; P<0.01). Arteriogram wheels-in to cut time took longer with a surgeon alone (mean: +5.6; 95%; CI: 0.29, 11; P=0.04). There were no other statistically significant findings with change in composition of the surgical team or changes in start time. General surgery residents generally do not add time to vascular surgery cases but may do so in certain cases, perhaps when they are given more autonomy (i.e. AVF creation). Future studies should look at multiple centers, specific vascular procedures, and level of training to explore whether experience among residents (i.e., intern versus senior resident) and case complexity play a role in procedural length, as this may indirectly affect attending surgeon burnout and patient outcomes.

Effects of RIPC on the Metabolome in Patients Undergoing Vascular Surgery: A Randomized Controlled Trial.

Background: remote ischemic preconditioning (RIPC) is a phenomenon in which short episodes of ischemia are applied to distant organs to prepare target organs for more prolonged ischemia and to induce protection against ischemia-reperfusion injury. This study aims to evaluate whether preoperatively performed RIPC affects the metabolome and to assess whether metabolomic changes correlate with heart and kidney injury markers after vascular surgery. Methods: a randomized sham-controlled, double-blinded trial was conducted at Tartu University Hospital. Patients undergoing elective open vascular surgery were recruited and RIPC was applied before operation. Blood was collected preoperatively and 24 h postoperatively. The metabolome was analyzed using the AbsoluteIDQ p180 Kit. Results: final analysis included 45 patients from the RIPC group and 47 from the sham group. RIPC did not significantly alter metabolites 24 h postoperatively. There was positive correlation of change in the kynurenine/tryptophan ratio with change in hs-troponin T (r = 0.570, p < 0.001), NT-proBNP (r = 0.552, p < 0.001), cystatin C (r = 0.534, p < 0.001) and beta-2-microglobulin (r = 0.504, p < 0.001) only in the RIPC group. Conclusions: preoperative RIPC did not significantly affect the metabolome 24 h after vascular surgery. The positive linear correlation of kynurenine/tryptophan ratio with heart and kidney injury markers suggests that the kynurenine–tryptophan pathway can play a role in RIPC-associated cardio- and nephroprotective effects.

Association of Preoperative Glycosylated Hemoglobin Level with 30-Day Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass: an Analysis of the ACS-MBSAQIP Database.

Elevated glycosylated hemoglobin (HbA1c) levels have been associated with increased morbidity and mortality following several cardiac, colorectal, orthopedic, and vascular surgery operations. The purpose of this study was to determine if there is a HgA1c cut-point that can be used in patients undergoing laparoscopic Roux-en-Y gastric bypass to decrease the risk of 30-day wound events and additional 30-day morbidity and mortality. All patients undergoing first-time, elective Roux-en-Y gastric bypass in 2017 and 2018 with a diagnosis of diabetes mellitus (DM) and a preoperative HbA1c level were identified within the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative HbA1c levels with 30-day morbidity and mortality was investigated. A total of 13,806 patients met inclusion criteria. Two natural HbA1c inflection points for composite wound events, including superficial, deep, and organ space surgical site infections (SSI) and wound dehiscence, were found. A HbA1c level of ≤ 6.5% was associated with a decreased odds of experiencing the composite 30-day wound event outcome while a HbA1c level of > 8.6% was associated with an increased odds of experiencing the composite 30-day wound event outcome. The differences in the incidence of the 30-day composite wound event outcomes were driven primarily by superficial and organ space SSI, including anastomotic leaks. Patients with DM being evaluated for RYGB surgery with a HbA1c level > 8.6% are at an increased risk for 30-day wound events, including superficial and organ space SSI.