Open Vascular Surgery Research Articles

Open vascular surgery procedures: how will we learn to do them and will they have the same quality?

Theprogressiontowardendovascularproceduresforprimary treatment of vascular disease, from repair ofabdominalaorticaneurysms(AAA)toendotherapyforallaneurysmalandocclusivevasculardisease,hasgradu-allyoccurredoverthepast15years.Onlyfinanciallimi-tations placed by government agencies and insurancecompanieshaveslowedtheprogressiontowardprimaryendovascular therapy for all vascular diseases. In theUSA, carotid stenting and renal angioplasty are twoareas where limitations have recently been proposed orplaced on the use of endovascular therapy. Patients aredemanding endovascular approaches, and since physi-cians are better reimbursed for endovascular therapythan open surgery, many physicians, as well as patients,areembracingprimaryendovascularapproaches,inspiteof limited long-term data comparing endovascular andopen approaches in many vascular beds. With theincreased use of endovascular approaches, open vascu-lar procedures are performed less frequently and areoften reserved for patients with the most complex vas-cular problems. For example, endovascular repair ofAAA is commonly performed in patients with infrare-nal aneurysms with a long neck, while open surgicalrepair is usually reserved for pararenal and juxtarenalaneurysms which require suprarenal aortic clamping.Somevascularsurgeonshavereducedoperativerisksbylimiting their practices to specific procedures and refer-ringcomplexcasestoothervascularsurgeons,butthereis still a reduced volume of open procedures in manysurgical practices that previously had a large open sur-gical experience.Historically,operativemortalityhasbeenreducedtovery low levels by performing a high volume of casesand focusing practices exclusively on vascular surgery.With the reduced number of cases and the increasedcomplexityof theremainingopencases,whowillbeper-forming these open procedures in the future, and howwill the next generation of open vascular surgeons betrained? Many vascular surgeons who are involved intrainingprogramsareconcernedaboutthisproblem.Theremainingopencasesinmostacademictrainingcentersare often complex and therefore not optimal for train-ing;if trainingisperformedonthesecases,theremaybeasignificantrisktothepatient.Whataretheoptionsforfuturevascularcarethatwillkeeptheoutcomesof opencases as good as they are today and competitive withendovascularprocedures,intermsof outcomes,astheirfrequency decreases?Thereareseveralpossiblescenarios:1)theresultsofopen procedures, which will be performed less fre-quently, will worsen, leading to a more rapid movetoward an all endovascular approach to most vasculardiseases; 2) higher risk open vascular surgery proce-dures will be regionalized to a small group of surgeonswho perform these procedures in high volume; 3) there

Association Between Serum Uric Acid and Perioperative and Late Cardiovascular Outcome in Patients With Suspected or Definite Coronary Artery Disease Undergoing Elective Vascular Surgery

The role of uric acid as an independent marker of cardiovascular risk is unclear. Therefore, our aim was to assess the independent contribution of preoperative serum uric acid levels to the risk of 30-day and late mortality and major adverse cardiac event (MACE) in patients scheduled for open vascular surgery. In total, 936 patients (76% male, age 68 +/- 11 years) were enrolled. Hyperuricemia was defined as serum uric acid >0.42 mmol/l for men and >0.36 mmol/l for women, as defined by large epidemiological studies. Outcome measures were 30-day and late mortality and MACE (cardiac death or myocardial infarction). Multivariable logistic and Cox regression analysis were used, adjusting for age, gender, and all cardiac risk factors. Data are presented as odds ratios or hazard ratios, with 95% confidence intervals. Hyperuricemia was present in 299 patients (32%). The presence of hyperuricemia was associated with heart failure, chronic kidney disease, and the use of diuretics. Perioperatively, 46 patients (5%) died and 61 patients (7%) experienced a MACE. Mean follow-up was 3.7 years (range: 0 to 17 years). During follow-up, 282 patients (30%) died and 170 patients (18%) experienced a MACE. After adjustment for all clinical risk factors, the presence of hyperuricemia was not significantly associated with an increased risk of 30-day mortality or MACE, odds ratios of 1.5 (0.8 to 2.8) and 1.7 (0.9 to 3.0), respectively. However, the presence of hyperuricemia was associated with an increased risk of late mortality and MACE, with hazard ratios of 1.4 (1.1 to 1.7) and 1.7 (1.3 to 2.3), respectively. In conclusion, the presence of preoperative hyperuricemia in vascular patients is a significant predictor of late mortality and MACE.

Invited commentary

Invited commentary

Endovascular Repair of Femoral Artery Pseudoaneurysm After Orthopedic Surgery With Balloon-Expandable Covered Stents

Arterial injury after orthopedic procedures is an uncommon complication that can present clinically in a variety of forms and has conventionally been repaired by open vascular surgery. The case and discussion in this article highlights the usefulness of endovascular repair following a delayed presentation of vascular injury from an orthopedic procedure.

Popliteal Pseudoaneurysm After Total Knee Arthroplasty Secondary to Intraoperative Arterial Injury With a Surgical Pin: Review of the Literature

Pseudoaneurysms of the popliteal artery after total knee arthroplasty are rare. Although many possible explanations are proposed in the literature, no intimate mechanism of injury to the artery is previously described. We report on a case of popliteal pseudoaneurysm after a total knee arthroplasty that presented clinically on the second postoperative day. Open vascular surgery with resection of the pseudoaneurysm and end-to-end bypass of contralateral saphena vein graft was successfully performed. At the time of the surgery, a hole was clearly identified on the anterior wall of the popliteal artery due to a perforation with a pin used during the knee arthroplasty. The patient had no further complications.

Have Endovascular Procedures Negatively Impacted General Surgery Training?

Technological advances in vascular surgery have changed the field dramatically over the past 10 years. Herein, we evaluate the impact of endovascular procedures on general surgery training. National operative data from the Residency Review Committee for Surgery were examined from 1997 through 2006. Total major vascular operations, traditional open vascular operations and endovascular procedures were evaluated for mean number of cases per graduating chief general surgery resident (GSR) and vascular surgery fellow (VSF). As endovascular surgical therapies became widespread, GSR vascular case volume decreased 34% over 10 years, but VSF total cases increased 78%. GSR experience in open vascular operations decreased significantly, as evidenced by a 52% decrease (P < 0.0001) in elective open AAA repair. VSFs have also seen significant decreases in open vascular procedures. Experience in endovascular procedures has increased for both general surgery and vascular residents, but the increase has been much larger in absolute number for VSFs. GSR experience in open vascular procedures has significantly decreased as technology has advanced within the field. Unlike VSFs, this loss has not been replaced by direct experience with endovascular training. These data demonstrate the impact technology can have on how we currently train general surgeons. New educational paradigms may be necessary in which either vascular surgery as an essential component is abandoned or training in catheter-based interventions becomes required.

Vascular surgery training and certification: An international perspective

Vascular surgery (VS) practice has expanded to incorporate interventional procedures, and this has stimulated changes in training. The purpose of this study was to review current VS training and certification in different countries. A survey was completed by vascular surgeons involved with national certification in 34 countries. Results are expressed as the mean +/- SD, with comparisons by chi(2) and t tests. VS is currently an independent specialty in 15 surveyed countries, is a subspecialty of general surgery in 10 countries, and is not recognized as a specialty in nine countries. There has been a clear time trend toward independent certification. In countries with independent VS certification, the length of VS training is 3.7 +/- 0.9 years plus 2.3 +/- 0.7 years of associated core general surgery (GS), for a total training length of 5.9 +/- 1.0 years. In countries with VS subspecialty certification, the length of VS training is 2.4 +/- 0.5 years after 5.0 +/- 1.1 years of GS, for a total training length of 7.4 +/- 1.2 years (each P < .01 vs independent certification). The minimum required volume of major open VS operations during training is 151 +/- 78 in countries with independent VS certification vs 113 +/- 53 in countries with subspecialty certification. Endovascular requirements for training are established in 71% of countries with independent certification vs 37% of countries with subspecialty certification (P < .03). Countries with independent VS certification produce 5.4 +/- 2.8 VS trainees per year per million population 65 years of age or older, vs 3.0 +/- 1.8 in countries with subspecialty certification (P < .02). Considerable variation exists in VS training in different countries. There is an international movement toward independent VS certification, with longer VS specific training but shorter overall residency duration. Counties with independent VS certification produce more trainees per year to serve their elderly population.

Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery

Postoperative convalescence is mainly determined by the extent and duration of postoperative ileus. This randomized clinical trial evaluated the effects of early oral feeding on functional gastrointestinal recovery and quality of life. One hundred and twenty-eight patients undergoing elective open colorectal or abdominal vascular surgery participated in the trial. Of these, 67 were randomized to a conventional return to diet, and 61 to a regimen allowing resumption of an oral diet as soon as tolerated (free diet group). Reinsertion of a nasogastric tube was necessary in 20 per cent of the free diet group and 10 per cent of the conventional group (P = 0.213). The complication rate was similar for both groups, as was return of gastrointestinal function. A normal diet was tolerated after a median of 2 days in the free diet group compared with 5 days in the conventional group (P < 0.001). Quality of life scores were similar in both groups. Early resumption of oral intake does not diminish the duration of postoperative ileus or lead to a significantly increased rate of nasogastric tube reinsertion. Tolerance of oral diet is not influenced by gastrointestinal functional recovery. As there is no reason to withhold oral intake following open colorectal or abdominal vascular surgery, postoperative management should include early resumption of diet.

Endovascular treatment of inadvertent cannulation of the vertebro-subclavian arterial junction

Inadvertent arterial cannulation at a noncompressible site is a highly risky complication of central venous line placement. We present a case of inadvertent placement of a 6-French venous sheath into the right subclavian artery (SCA) at the origin of the vertebral artery (VA), which was treated successfully using endovascular therapy. Due to the complex site of cannulation, and the patient being fully anticoagulated, the use of a percutaneous closure device was not attempted. Open vascular surgery was not a treatment option due to high surgical risk. After determining left VA dominance, the right VA was occluded distal to the catheter entry point with platinum coils. Subsequently, a covered stent was placed into the SCA across the origin of the VA. The sheath was then removed safely without complications. A minor leak was initially present, which was stopped by repeating balloon inflation within the stent above nominal pressure.

Perioperative and Long-Term Cardiovascular Outcomes in Patients Undergoing Endovascular Treatment Compared With Open Vascular Surgery for Abdominal Aortic Aneurysm or Iliaco-Femoro-Popliteal Bypass

Perioperative and Long-Term Cardiovascular Outcomes in Patients Undergoing Endovascular Treatment Compared With Open Vascular Surgery for Abdominal Aortic Aneurysm or Iliaco-Femoro-Popliteal Bypass

Bivalirudin in the Treatment of Patients with or at High-Risk for Heparin-Induced Thrombocytopenia.

Background: The management HIT in pts. with renal and/or hepatic impairment is problematic. Of the two DTI's approved for HIT therapy in non-PCI settings, the utility of lepirudin is limited by renal impairment and argatroban is limited by hepatic impairment. In these settings, bivalirudin (BV), a hirudin analog primarily cleared by serum proteolysis and to a lesser extent, renally, has potential therapeutic advantages.Objective: To describe the clinical/laboratory features, infusion parameters, and outcomes in BV-treated HIT pts.Design: Retrospective case study.Setting: Tertiary-care medical center, IRB-approved HIT Registry.Participants: Twenty-five persons, 45–88 years of age with or at high-risk for HIT accrued from 2.1.03 to 4.30.06.Baseline features: HIT developed in the following pt. cohorts: open heart surgery (n=21), medical (n=3), & vascular surgery (n=1). At HIT presentation, 10 had thrombocytopenia and 3 had active thromboembolic complications (TEC's) (12 had both). The median platelet ct. was 82,500/mm3 (60% baseline decline). A (+) test for heparin-PF4 antibodies by ELISA (GTI) or HIPA was present in 24 (96%); 1 pt. (-) by both assays had a 32% platelet decline after 5 days on UFH. Prior DTI's were administered in 11 (44%) with argatroban (n=9) or lepirudin (n=2) for a mean of 3.8 (0–10) days and 2.5 (1–4) days.Results: At BV initiation, organ dysfunction by objective criteria was present in 16 (64%) pts.: hepatic insufficiency alone (6) or failure (8; 4 with renal failure); renal insufficiency or failure alone (1 each). The mean serum creatinine, total bilirubin and AST was 1.8 (0.8–4.1) mg/dl, 3.74 (0.3–12.1) mg/dl, and 309 (25–1102) U/L, respectively. Nine pts. required mechanical ventilation (4 with dialysis) and 19 pts. initiated BV in an ICU setting. BV was begun at a mean IV dose of 0.21 (0.05–0.50) mg/kg/h, adjusted to achieve an APTT 1.5–2.5× baseline, and maintained (n=24) at a mean IV dose of 0.20 (0.04–0.43) mg/kg/h. BV alone was continued for a mean of 8.5 (0–39) days. Seventeen pts. transitioned to warfarin after a mean BV overlap of 6.2 (1–38) days. The mean time to an initial therapeutic APTT was 15 (1.8–47) hours (46% with initial dose); mean dose adjustments: 1.4 (0–5) in 24 pts. The mean APTT and INR on BV alone was 65 sec and 1.46 (0.9–2.4); mean pre-BV INR: 1.27. The mean % of APTT's/pt. (range; no. of APTT's) within, below and above the therapeutic range were 60 (6–100; n=235) %, 10 (0–41; n=58) %, and 30 (0–94; n=100) %. Among 10/13 pts. with platelets <100,000/mm3 at BV initiation, the mean time to recovery ≥100,000/mm3 and ≥150,000/mm3 was 2.9 (1–6) days and 7.8 (3–18) days. Among 3/4 pts. with platelets ≥100,000/mm3 but <150,000/mm3, the mean time to recovery >150,000/mm3 was 2.7 (2–4) days. New TEC's on BV developed in 3 pts. BV was discontinued in 8 pts. after a mean of 4.9 (1–10) days for evolving organ failure (n=4), bleeding (GI: n=2; open chest: n=1) and concern for drug half-life (n=1). Minor bleeding occurred in 3 pts. and 1 pt. required limb amputation prior to BV. Five pts. (20%) died from progressive HIT-related organ failure: 4 were off BV and received comfort care; 1 on BV with a therapeutic APTT unrelated to BV. The average length of hospitalization was 27 days (mean ICU stay: 17 days).Conclusion: In this HIT patient cohort with predominantly hepatic and/or renal dysfunction, the administration of bivalirudin was effective in achieving an 80% survival rate with an acceptable safety profile.

Malnutrition after vascular surgery: are patients with chronic renal failure at increased risk?

Background The deleterious effects of perioperative malnutrition on recovery after general surgery are established. Since the effects of perioperative malnutrition on recovery after vascular surgery are not known, we examined the effects of nutritional status, and risk factors predictive of malnutrition, on outcome after vascular surgery. Methods The records of all open index vascular cases (abdominal aortic aneurysm [AAA] repair, carotid endarterectomy [CEA], lower extremity bypass) performed at the Veterans Affairs (VA) Connecticut between July 2004 and June 2005 were reviewed. The primary outcome was mortality; secondary outcomes included infection and nutritional risk index (NRI) scores. Results Sixty-eight open vascular cases were performed during the study period. Nutritional depletion developed in 55% of patients and was more likely in patients undergoing AAA (85%) or bypass (77%) than CEA (30%; P = .0005). Patients who developed malnutrition had similar mortality as patients who did not develop postoperative malnutrition (6.1% vs. 3.7%; P = .68); however, malnourished patients had higher rates of postoperative infection (24.2% vs. 3.7%; P = .03). Chronic renal failure was the only patient-associated risk factor predictive of postoperative nutritional depletion (odds ratio 5.9, confidence interval 1.0 to 33.6; P = .04). Conclusions Patients undergoing major open vascular surgery have high rates of postoperative malnutrition, with patients undergoing AAA repair having the highest rates of postoperative malnutrition and infection. Patients with chronic renal failure undergoing vascular surgery are associated with increased risk for postoperative malnutrition and may be a group to target for perioperative risk factor modification and nutritional supplementation.

Neurofibromatosis Type 1: From Presentation and Diagnosis to Vascular and Endovascular Therapy

Neurofibromatosis type 1, also called von Recklinghausen's disease, is an autosomal dominant disorder linked to chromosome 17, characterized by growth impairment of the neural crest cells (ectoderm) manifested by multiple neural tumors, cutaneous pigmentations, and Lisch nodules. Disease phenotype develops with time, making its penetrance almost complete by 5 years of age. Compression of the gastro-intestinal, urinary, or pulmonary tracts by visceral neurofibromas may generate serious complications. Neurofibromatosis type 1 is remarkable for its association with occlusive (stenoses) or aneurysmal arterial disease affecting predominantly the renal arteries and less often the abdominal aorta (middle aortic syndrome), and mesenteric and peripheral arteries. Appraisal of existing literature reveals that timely vascular intervention by way of conventional surgery and/or endovascular therapy may provide patients with effective and durable treatment. The far greater propensity for malignant connective/soft-tissue neoplasms and vascular disease in neurofibromatosis type 1, amid potential complications from the gastro-intestinal, urinary, and pulmonary tracts, leads to a significantly increased morbidity and decreased life expectancy. Neurofibromatosis type 1, from presentation and diagnosis to its treatment, is reviewed, with emphasis on vascular disease and its management with open vascular surgery and endovascular therapy.

Perioperative myocardial ischemic injury in high-risk vascular surgery patients: Incidence and clinical significance in a prospective clinical trial

The purpose of this study was to assess prospectively the incidence, health care resource utilization, and economic burden associated with perioperative myocardial ischemic injury (PMII) in high-risk patients undergoing noncardiac vascular surgery. Two hundred thirty-six patients consented to participate in a pharmacoeconomic substudy as part of a randomized, multicenter clinical trial. Patients were assessed for myocardial ischemic injury by using clinical, biochemical, and electrocardiographic criteria. PMII was defined as fatal or nonfatal myocardial infarction, new or worsened congestive heart failure, or new arrhythmias. Resource utilization parameters were compared for patients with and without PMII. Patients underwent the following index procedures: open abdominal aortic aneurysm repair (n = 44), bypass for aortoiliac disease (n = 29), bypass for femoropopliteal disease (n = 62), bypass for femorotibial disease (n = 71), extra-anatomic bypass (n = 23), and miscellaneous (n = 7). Patients undergoing carotid endarterectomy or only endovascular interventions were excluded. The incremental cost of PMII was estimated by applying the average costs (adjusted to 2004 US dollars) of the hospital ward (dollar 700.00/d) or intensive care unit (dollar 2500.00/d) to the length of stay differences for patients with and without PMII. The overall mortality was 3.4% (8/236), and 7 of 8 deaths were related to PMII. PMII occurred in 42 (17.8%) of 236 patients: 22 myocardial infarctions, 11 congestive heart failures, and 12 new arrhythmias (3 patients had 2 PMII events). There was no evidence of differences in the incidence of PMII among the various index procedures. PMII was associated with a dramatic increase in resource utilization. The mean length of stay was 16.8 and 10.0 days for patients with and without PMII, respectively (P < .001). Intensive care unit care was required by 35 (83.3%) of 42 patients with and 121 (62.4%) of 194 patients without PMII (P < .009). The mean intensive care unit length of stay was 6.6 and 3.7 days for patients with and without PMII, respectively (P < .009). Ten (23.8%) of 42 patients with and 20 (10.3%) of 194 patients without PMII returned to the emergency department for care after discharge (P < .02). In modern vascular surgery practice, PMII remains common despite the availability of beta-blockers and other preventative strategies. PMII is associated with dramatic increases in resource utilization and cost. The increase in resource utilization associated with PMII resulted in an estimated incremental cost per patient of dollar 9980.00. If 250,000 high-risk open vascular operations are performed annually in the United States, the economic burden of PMII in these procedures alone approximates dollar 444 million. Strategies to decrease PMII incidence and severity should be evaluated in large-scale prospective trials.

Recommended clinical competencies for initiating a program in endovascular repair of the thoracic aorta

The continued expansion of endovascular technology has recently led to the availability of endovascular grafts for the treatment of a variety of acute and chronic diseases of the thoracic aorta. Early clinical trials have demonstrated that this technology represents a major advance in the field, with significant reductions in perioperative morbidity and mortality as compared with standard open surgical repair. 1,2 Nonetheless, because clinical experience with endovascular repair of the thoracic aorta remains limited, widespread introduction of endografts mandates their judicious application in a manner that maximizes safe and effective outcomes. As such, a minimum set of cognitive, technical, and clinical skills must be mastered by those who intend to use this technology, so that it is used in a manner commensurate with the best standards of clinical care (Tables I-III). The requisite fundamental knowledge base necessary to care for patients with aneurysmal disease of the thoracic aorta includes a comprehensive understanding of the risk factors, epidemiology, pathology, pathophysiology, natural history, clinical presentation, and therapeutic alternatives. Appropriate decision-making regarding indications, limitations, and complications of the procedure mandates a high level of skill in patient assessment and sound clinical judgment. Knowledge about angiographic equipment, as well as familiarity with the full range of sheaths, catheters, guidewires, stents, and endografts, is critical, as is expertise in a wide range of open vascular surgical procedures. The capacity to anticipate periprocedural and postprocedural issues with appropriate management of these with adjunctive therapies is also essential to optimize both shortand long-term outcomes. For example, use of adjunctive procedures before, during, or after device deployment is routine during the course of endovascular aortic repair (Tables IV-VI). Familiarity with many, if not all, of these procedures may dictate the difference between a successful outcome and treatment failure. In this document, a detailed outlined is provided of areas in which prerequisite technical experience is recommended, including abdominal endovascular aneurysm repair and related catheter and surgical skills, as well as associated cognitive and clinical skills that are necessary for optimal perioperative management of these complex patients.

Perioperative and Long-Term Cardiovascular Outcomes in Patients Undergoing Endovascular Treatment Compared With Open Vascular Surgery for Abdominal Aortic Aneurysm or Iliaco-Femoro-Popliteal Bypass

The aim of the present study was to determine the perioperative and long-term cardiac outcomes of patients who underwent elective open or endovascular major vascular surgery corrected for cardiac risk factors and dobutamine stress echocardiography. Consecutive patients who underwent either endovascular (n = 123) or open (n = 560) vascular surgery from 1996 to 2004 at Erasmus Medical Center were enrolled. Patients were screened for cardiac risk factors (advanced age, gender, angina pectoris, myocardial infarction, heart failure, diabetes, stroke, renal failure), cardioprotective medication, and the presence of stress-induced ischemia by dobutamine stress echocardiography. Postoperative data on troponin release and electrocardiography were routinely collected on days 1, 3, and 7 and before discharge. After discharge, patients were regularly screened at the outpatient clinic. The main outcome measures were perioperative and long-term cardiac death and myocardial infarction. The incidence of perioperative cardiac events was significantly less in endovascular-treated patients compared with conventionally treated patients, also after adjustment for clinical risk factors, dobutamine stress echocardiography, and medication (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.07 to 0.53). In contrast, during long-term follow-up (median 3.8 years, range 0 to 8.4), the incidence of long-term cardiac mortality and myocardial infarction were similar in the 2 groups (HR 0.89, 95% CI 0.52 to 1.52). In conclusion, endovascular stent grafting is associated with a reduced incidence of perioperative complications compared with open vascular surgery. Despite the initial perioperative survival benefit, patients who undergo endovascular surgery remain at high risk for late cardiac events.

Tramadol and Vocal Cord Closure

TRAMADOL is an analgesic acting as both a weak opioid agonist and an inhibitor of monoamine neurotransmitter reuptake. It also provides effective postoperative analgesia. 1 Unlike other opioids, it is well tolerated and has no clinically relevant effects on cardiovascular parameters; therefore, it is widely administered and may prove particularly useful in patients with poor cardiopulmonary function, including the elderly, and in patients with nonsteroidal antiinflammatory drug contraindications.

The Influence of Endovascular Techniques on Our Surgical Practice:A 10-Year View

Endovascular techniques have been used in our practice for more than 3 decades, although the increase in volume of procedures has accelerated during the last few years. The rationale for using these techniques is to lessen operative trauma to the patient by minimizing or eliminating the incision, reducing blood loss, and shortening or avoiding general anesthesia. These features in turn reduce or eliminate the need for postoperative intensive care and allow the patient to ambulate sooner, so that hospitalization is reduced. Very few randomized trials have compared endovascular with open vascular surgery, and there is no level-1 evidence to support most of the endovascular techniques. Nonetheless, the use of endovascular procedures to treat occlusive and aneurysmal diseases has produced results equal to those that can be achieved with open vascular surgery in certain vascular beds. Here, we will focus on some of these regions: aortoiliac stenosis/occlusion, femoral lesions, renal artery stenosis, visceral artery stenotic/occlusive lesions, carotid artery lesions, and aortic aneurysms.

Vascular surgery training in the United States, 1994 to 2003

The purpose of this study was to analyze the use of operative training resources for vascular surgery residents (VSRs) and general surgery residents (GSRs) over the past 10 years in the United States, to address questions concerning adequate endovascular versus open surgical training and the potential to expand the number of VSRs to meet future workforce needs. National operative data from the Residency Review Committee for Surgery (RRC) were analyzed for all vascular surgery (VS) and general surgery (GS) training programs from 1994 to 2003. GSR experience in programs with and without associated VS programs was also compared. Mean total VS volume per VSR increased from 220 operations in 1994 to 368 in 2003, owing to the addition of 140 endovascular procedures by 2003. GSR volume was more stable, with 117 mean total VS operations in 1994 and 122 in 2003. This volume was distributed as approximately 50% major open VS operations for both VSR and GSR. In addition, 39% of VSR experience was endovascular, whereas 32% of GSR experience was vascular access. The average VSR performed 2.7 times more major open VS operations than each GSR, but because of the 10-fold greater number of GSRs, VSRs performed only 20% of the total major operations available for VS training. Selective procedures, such as renal revascularization and open infrarenal abdominal aortic aneurysm repair decreased over time, while endovascular abdominal aortic aneurysm repair increased dramatically, accounting for 46% of aortic aneurysm repairs per VSR in 2003. The mean volume of total interventional procedures per VSR in 2003 was 152 diagnostic and 213 therapeutic. GSRs in programs with and without an associated VS program had very similar operative volumes. Interventional procedures have increased VSR operative volume by 50% in recent years, with only a 12% decrease in major open operations. Nearly all VSRs currently meet RRC minimum requirements for open and endovascular procedures. Mean GSR operative volume has been stable, and far exceeds RRC minimum requirements. Based on the number of major open vascular operations available for training in 2003, the current number of VSR positions could be increased by 50% if GSR operative volume was decreased by 15%. However, increased interventional volume would also be required, for which there is competition with other specialties.

Preoperative risk stratification for aortic surgery using pharmacologic stress myocardial imaging

Background: Not only patients with aortic disease have a high prevalence of coronary artery disease, but also aortic surgery itself is highly invasive. Therefore, preoperative risk stratification for this high-risk subset is essential. We evaluated the usefulness of the perioperative cardiac risk stratification using pharmacologic single photon emission computed tomography (SPECT) in patients undergoing aortic surgery. Methods: Pharmacologic stress SPECT using ATP or dipyridamole was performed in 302 patients: aortic dissection in 56, TAA in 124, and AAA in 122. Open vascular surgery was performed in 75, and endovascular surgery by stent-graft placement in 227. Not only the presence or absence of perfusion defects, but also the 20-segment model analysis was performed. Results: Pharmacologic thallium SPECT revealed negative findings in 210 patients and positive findings in 92. Among 92 patients with positive tests, 33 patients were evaluated by catheterization; 25 out of these 33 patients revealed to have CAD. Of these 25 patients, 9 underwent successful revascularization prior to or during surgery. Perioperative cardiac events occurred in 9 patients; 7 occurred in patients with positive SPECT, whereas only 2 occurred in those with negative SPECT (2/210 vs 7/92; p<0.05). Moreover, no hard event occurred in patients with negative SPECT. Multivariate analysis using logistic regression model revealed that the summed stress score of >13 was the most important factor to identify patients who subsequently had perioperative cardiac events. Conclusions: Pharmacologic stress SPECT has a significant value in the risk stratification of patients before aortic surgery. In patients with positive SPECT, especially extensive myocardial perfusion defects, aggressive approach for preoperative risk reduction is necessary, whereas aortic surgery can be performed safely in patients with negative SPECT.