Open Vascular Surgery Research Articles

Sustainable global surgery

A challenge to surgeons

Clinican Volume and Outcomes for Carotid Artery Stenting (CAS): Is There Any Substitute for Experience with CAS?

Objectives: Prior studies demonstrated improved clinical outcomes for surgeonswith a high volume experience with certain open vascular operations. It is not known whether a high volume experience with carotid artery stenting (CAS) improves clinical outcomes.Moreover, it is not knownwhether experience with other endovascular procedures, including percutaneous coronary interventions (PCI), is an adequate substitute for experience with CAS. Our objective was to assess the impact of increasing clinician volume of CAS, aortic endografting (EVAR/TEVAR), and PCI on the outcomes for CAS. Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing CAS for the years 2005-2009. Clinicians were stratified into tertiles of low-, medium-, and high-volume groups based on annual volume of CAS, EVAR/TEVAR, and PCI. Multiple logistic regression analyses were used to examine the relationship between clinician volume and a composite outcome of in-hospital stroke and death rate after CAS. Results: Between 2005 and 2009, 83,072 elective CAS procedures were performed nationwide with crude in-hospital stroke and death rates of 1.94% and 1.12%, respectively. The median number of CAS procedures performed annually was seven per clinician (interquartile range, 2-17). Stroke and death rates for CAS decreased with increasing volume of CAS performed by a clinician (Table). Similar patterns were noted between clinicians’ volume of EVAR/TEVAR and PCI and outcomes for CAS (Table). After adjusting for patient and hospital characteristics, however, clinician volume was not a significant predictor of outcomes for CAS, while symptomatic status was the dominant predictor of stroke and death after CAS (OR, 20.4; 95% CI, 15.327.3; P < .0001). For asymptomatic patients, clinician volume of CAS remained an independent predictor of stroke and death after CAS (OR, 0.79; 95% CI, 0.64-0.96, per 10 CAS cases; P 1⁄4 .02), whereas clinician volume of EVAR/TEVAR and PCI were not significant predictors of outcome for CAS. Conclusions: When treating asymptomatic carotid stenosis, the stroke and death rate for CAS is 21% lower for every 10 CAS procedures performed by a clinician. Clinicians with wire and catheter skills should be advised that there is no substitute for experience with CAS to optimize outcomes of CAS performed in asymptomatic patients.

Pseudoaneurysms in haemophilia

The incidence of bleeding as a result of a pseudoaneurysm in haemophilia is very low. The diagnosis should be suspected if the patient has a history of arterial trauma. Pseudoaneurysms can appear anywhere where trauma occurs. This can include arterial access for catheterization, blunt trauma or penetrating trauma. The diagnosis should be confirmed using Duplex ultrasonography, computed tomography (CT) angiogram or conventional angiogram. Many options exist for the treatment of pseudoaneurysms. Although surgery was the gold standard treatment in the past (surgical ligation with or without distal bypass), several less invasive treatment options are popular today. They include covered stent, ultrasound probe compression and ultrasound-guided thrombin injection. So far, only 14 pseudoaneurysms have been reported in patients with haemophilia: nine were located in the musculoskeletal system (four in the hand, four in the knee, one in the ankle), whereas five were non-musculoskeletal. Early diagnosis and treatment of this complication is vital. Endovascular treatment offers a minimally invasive treatment option. If arterial embolization fails to solve the pseudoaneurysm, open vascular surgery with surgical ligation with or without distal bypass should be performed. Whatever the procedure, a correct surgical haemostasis must be achieved by the infusion of factor concentrate (recombinant or plasma-derived) at the right dose and tranexamic acid. The advent of activated prothrombin complex concentrates and recombinant factor VIII (rFVIIa) has made invasive procedures possible in haemophilia patients with high-titre inhibitors.

Abstract 265: Perioperative Silent Myocardial Ischemia, the Use of Blood Transfusions and Their Associations With Long-Term Mortality Following Peripheral Vascular Surgery

Objective Thrombotic and bleeding complications during the perioperative period are a major concern during the postoperative period. However, the relationship between perioperative myocardial necrosis and major bleeding with long-term mortality is uncertain. Methods In a retrospective study, we analyzed data from 289 consecutive patients during a one-year period between 2009-2010 who underwent open major vascular surgery (carotid endarterectomy, above/below knee amputation, open aneurysm repair, extremity bypass, and embolectomy). Myocardial necrosis was defined as any cardiac troponin T value ≥ 0.1 ng/ml and major bleeding was defined as requiring ≥2 units of blood within 24 hours of the operation. Lower threshold cutoffs (troponin &gt;0.04 ng/ml and any transfusion) were also investigated. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression. Results During a mean follow-up period of 1.8 years, there were 46 deaths (15.9%). Myocardial necrosis and major bleeding occurred in 25.2% and 14.9% of subjects, respectively. After adjustment for age, sex, smoking, hypertension, diabetes and coronary artery disease, both myocardial necrosis (OR 4.24, 95% CI 1.82-9.87) and major bleeding (OR 2.56, 95% CI 1.28-5.46) were associated with long-term death. Similarly, lower threshold cutoffs of troponin &gt;0.04 ng/ml and any transfusion independently predicted a 6.27-fold and a 6.44-fold increase in long-term mortality (p&lt;0.001 for both). Conclusions Perioperative myocardial necrosis and major bleeding, even at low cutoff levels, are independent and complementary predictors of long-term mortality following major vascular surgery.

Lumbar artery pseudoaneurysm as a late complication of osteomyelitis with vertebral body destruction

We report the case of a 79-year-old patient whose acute back pain revealed a 9-cm nonruptured lumbar artery pseudoaneurysm occurring 5 years after a vertebral body osteomyelitis that induced a significant vertebral destruction. She underwent an urgent percutaneous selective arterial embolization. Lumbar artery false aneurysm should, thus, be suspected as a possible etiology of any new painful symptoms in patients suffering from a chronic vertebral destructive disease.

Contemporary Outcomes in Vascular Patients Who Require Preoperative Coronary Stent

The documented risks of preoperative coronary revascularization prior to vascular surgery have led to a marked reduction in the role of percutaneous coronary intervention (PCI) during preoperative risk stratification. However, many patients with peripheral arterial disease are first identified immediately after a PCI for an acute coronary syndrome. We sought to determine the risks associated with these patients who then go on to have a peripheral arterial intervention (open operation or endovascular procedure). We hypothesized that there was no difference in outcomes in patients whose medical condition required PCI with coronary stent placement prior to a vascular operation compared with a control cohort of nonstented patients who underwent a vascular operation alone. We report the vascular operative outcomes in a contemporary cohort of vascular patients who had PCI with coronary stent placement for an acute event. We performed a retrospective cohort analysis, utilizing administrative data, of 3,678 vascular patients from 2005 to 2010 at a tertiary care hospital. Two groups were defined: patients with preoperative PCI and coronary stent placement within 1 year prior to vascular operation (N = 101, mean age 66 ± 1.22 years, 51.5% men); and patients with no PCI prior to vascular operation (N = 3,577, mean age 60 ± 0.27 years, 46.37% men). Cardiovascular risk factors and complications derived from ICD-9 codes were used to parse data after open peripheral vascular surgery, endovascular repair, or amputation. Primary outcomes were death, nonfatal myocardial infarction, major adverse cardiac event (MACE, defined as death, myocardial infarction, or subsequent coronary revascularization) or bleeding. Univariate analysis showed significant differences in both demographic and outcome analysis in patients with and without prior coronary stent. Patients with a recent PCI followed by a vascular procedure were more likely to undergo an endovascular procedure (75.3% vs. 64.5%, odds ratio = 1.67, P = 0.028). These patients also had 11 of 20 cardiovascular risk factors, significantly higher than in those without a prior PCI. Multivariate subgroup analysis indicated that patients with a prior coronary stent were more likely to have an episode of congestive heart failure (CHF) after 1 year of surgery (16.8%, P = 0.045). In addition, an acute cardiac ischemic event was more likely within 1 year (2.0%, P = 0.036) and beyond 1 year (4.0%, P = 0.022) of surgery. Importantly, there was no significant increase in death, myocardial infarction, MACE, or bleeding in patients with a preoperative coronary stent. Patients who underwent PCI with coronary stent and then went on to require a vascular procedure had significantly more cardiovascular (CV) risk factors and were more likely to have an endovascular procedure than those patients without preoperative PCI. When controlling for CV risk factors and procedure type, there was no significant difference in death, MI, MACE, or bleeding complications between the groups.

Simulator training on pulsatile vascular models significantly improves surgical skills and the quality of carotid patch plasty

Vascular surgeons perform numerous highly sophisticated and delicate procedures. Due to restrictions in training time and the advent of endovascular techniques, new concepts including alternative environments for training and assessment of surgical skills are required. Over the past decade, training on simulators and synthetic models has become more sophisticated and lifelike. This study was designed to evaluate the impact of a 3-day intense training course in open vascular surgery on both specific and global vascular surgical skills. Prospective observational cohort analysis with various parameter measurements of both surgical skills and the technical quality of the finished product, performed before and after 3 days of simulator training of 10 participants (seven male and three female) in a vascular surgery training course. The simulator model used was a conventional carotid endarterectomy with a Dacron patch plasty on a lifelike carotid bench model under pulsatile pressure. The primary end points were assessment of any changes in the participants' surgical skills and in the technical quality of their completed carotid patches documented by procedure-based assessment forms. Scores ranging from 1 (inadequate) to 5 (excellent) were compared by a related-sample Wilcoxon signed test. Interobserver reliability was estimated by Cronbach's alpha (CA). A significant improvement in surgical skills tasks was observed (P < .001). The mean score increased significantly by 21.5% from fair (3.43 ± 0.93) to satisfactory (4.17 ± 0.69; P < .001). The mean score for the quality of the carotid patch increased significantly by 0.96 (27%) from fair (3.55 ± 0.87) to satisfactory (4.51 ± 0.76; P < .01). The median interassessor reliability for the quality of the carotid patch was acceptable (CA = 0.713) and for surgical skills was low (CA = 0.424). This study shows that lifelike simulation featuring pulsatile flow can increase surgical skills and technical quality in a highly sophisticated multistep vascular intervention. This training provides comparatively inexpensive and lifelike training possibilities for the adoption and assessment of surgical skills required to perform delicate vascular surgical procedures.

Impact of Infectious Complications after Elective Surgery on Hospital Readmission and Late Deaths in the U.S. Medicare Population

Whereas the negative impact of infectious complications (IC) during the index hospitalization after elective surgery is well established, the long-term ramifications of hospital-acquired post-operative infections are not well studied. This analysis evaluated the impact of a hospital-acquired IC after open abdominal vascular surgery on the readmission rate and the mortality rates 30 and 90 days after initial discharge. Data from all hospitals in the United States that performed elective open abdominal vascular operations in the Medicare population from 2005 to 2007 were extracted from the national Medicare Provider Analysis and Review database. The cohort consisted of all patients undergoing open abdominal vascular operations, including aortic, iliac, and visceral procedures. The ICs evaluated were pneumonia, urinary tract infection (UTI), postoperative sepsis (sepsis), surgical site infection (SSI), and Clostridium difficile infection (CDI). Patients were categorized as either developing an IC during their initial hospitalization (Index+INF) or not developing an IC (No INF). The rates of 30-day readmission, 30-day IC, and 30- and 90-day mortality after the initial discharge were evaluated longitudinally and compared in patients with and without an IC. A total of 29,549 open abdominal vascular procedures were identified, and 4,016 patients (13.6%) developed an IC during their index hospitalization: Pneumonia (5.1% of the total), UTI (2.7%), sepsis (1.6%), SSI (1.4%), and CDI (0.6%). Additionally, 1.13% of patients developed pneumonia, UTI, SSI, or CDI complicated by sepsis. The hospital mortality rate during the initial hospitalization was 13.7% (Index+INF) versus 4.0% (No INF) (p<0.0002). Infectious processes (pneumonia, UTI, SSI, and CDI) complicated by sepsis had an in-hospital mortality rate significantly higher than patients having an IC alone (50.9% vs. 13.7%; p<0.002). The mortality rate 30 and 90 days after the initial discharge was significantly higher for Index+INF than for No INF (4.4% vs. 1.2% and 8.6% vs. 2.6%, respectively; p<0.0002). The highest 30-day mortality rates after discharge were found after CDI+sepsis (30%), pneumonia+sepsis (12.6%), and postoperative sepsis alone (8.6%). The same rank was found for the 90-day mortality rate: 30%, 22.5%, and 13.8%. Overall, readmission was more likely for Index+INF than for No INF (33.7% vs. 21.5%; p<0.0002). Rates of 30-day readmission after an index IC ranged from 32% to 50%. For Medicare beneficiaries undergoing elective open abdominal vascular procedures, the development of any IC significantly increased not only the in-hospital mortality rate but also the mortality rates 30 and 90 days after discharge from the hospital. Index ICs also were associated with a higher 30-day readmission rate. Hospital-acquired infections have a profound late effect on outcomes after discharge. Future programs targeting high-risk patients may improve long-term survival and minimize readmissions.

Open Vascular Surgery Experience for the General Surgery Resident in the New Millennium

Open Vascular Surgery Experience for the General Surgery Resident in the New Millennium

Expanding the use of simulation in open vascular surgical training

Simulation technology has a well-defined role in nonmedical professions such as aviation and over the last two decades has permeated medical training. The most successful surgical simulation is in the fields of laparoscopic and endovascular surgery. These two-dimensional scenarios, as in the aviation industry, lend themselves to simulation. Open simulators have been met with more resistance than their laparoscopic counterparts because of the difficulties in simulating the three-dimensional field. Engaging in persistent practice is what makes the expert and all trainees should aspire to this. Without knowing, all surgical trainees have engaged in deliberate practice when first learning to tie surgical knots. This deliberate practice should be used in all aspects of vascular surgical practice, and it is no longer acceptable to perform procedures such as arterial anastomoses for the first time on patients. Simulators exist for all aspects of vascular surgical training and vary in complexity and price. Some of these simulators are suitable for use at home or in a skills laboratory whereas others are more suitable for use in a specialized skills center. Training on these simulators can be offered at a local level or at a regional level in the skills center. Where surgical procedures are not commonly performed or expertise is required for a new innovation, it is more appropriate to have national or internationally based workshops under the auspices of surgical boards or societies. Simulation of crisis management, well known in aviation, has also been applied to vascular surgical practice and can offer benefit to senior trainees even when their performance on a noncrisis simulator has reached a plateau. This article identifies the areas where simulation in open vascular surgery can benefit the trainee.

Prophylactic Muscle Flaps in Vascular Surgery

High-risk patients undergoing vascular procedures through inguinal incisions experience significant benefit from undergoing prophylactic muscle flaps. The authors present a risk assessment tool, an evidence-based algorithm for using prophylactic muscle flaps, and a comprehensive cost analysis. Data derived from the authors' previously performed retrospective cohort study of patients undergoing open vascular groin surgery were used to construct an evidence-based risk assessment tool. A multivariate regression analysis identified significant, independent predictors of complications, which were used to construct a scoring system. An institutional cost analysis and preoperative assessment algorithm were derived based on patient risk stratification and statistical analyses. Sixty-eight prophylactic flaps in 53 patients were compared with 195 open femoral access procedures without flaps in 178 patients. Multivariate regression demonstrated that obesity, smoking, reoperation, and prosthetic graft reconstruction are significant predictors of complications. A weighted risk factor score (0 to 7) was devised: obesity, for a value of 1; smoking, 2; reoperation for open groin surgery, 2; and prosthetic graft material, 2. Patients with higher scores had significantly more complications, infections, and more frequently required secondary salvage flap procedures. Using study data, the authors constructed an algorithm to guide preoperative groin assessment and use of prophylactic muscle flaps. The authors provide an assessment tool, called the Penn Groin Assessment Scale, that accurately predicts groin complications. They also describe a simple algorithm to assess for prophylactic muscle coverage. Their results suggest that patients with two or more risk factors will benefit from prophylactic muscle flaps. Risk, II.

Aortoenteric Fistula Treated With Endovascular Aortic Stent-Graft and Bilateral Chimney Stent-Grafts to Renal Arteries

We report a patient with secondary aortoenteric fistula (AEF) presenting with a rectal bleeding. The patient had multiple comorbidities, precluding major open vascular surgery. We opted to perform a two-stage procedure, where an endovascular stent-graft was first deployed to exclude the AEF from the systemic circulation. As the AEF was at the proximal anastomosis of the previous Dacron graft and close to the renal artery ostia, chimney stent-grafts were placed in both renal arteries to maintain their patency. The second stage of the procedure involved a laparotomy to repair the defect in the duodenum to prevent further contamination from bowel contents.

Elective visceral hybrid repair of type III thoracoabdominal aortic aneurysm

According to the classification given by Crawford et al. type III thoracoabdominal aortic aneurysm (TAAA) is dilatation of the aorta from the level of the rib 6 to the separation of the aorta below the renal arteries, capturing all the visceral branch of aorta. Visceral hybrid reconstruction of TAAA is a procedure developed in recent years in the world, which involves a combination of conventional, open and endovascular aortic reconstruction surgery at the level of separation of the left subclavian artery to the level of visceral branches of aorta. We presented a 75-years-old man, with elective visceral hybrid reconstruc tion of type III TAAA. Computerized scanning (CT) angiography of the patient showed type III TAAA with the maximum transverse diameter of aneurysm of 92 mm. Aneurysm started at the level of the sixth rib, and the end of the aneurysm was 1 cm distal to the level of renal arteries. Aneurysm compressed the esophagus, causing the patient difficulty in swallowing act, especially solid food, and frequent back pain. From the other comorbidity, the patient had been treated for a long time, due to chronic obstructive pulmonary disease and hypertension. In general endotracheal anesthesia with epidural analgesia, the patient underwent visceral hybrid reconstruction of TAAA, which combines classic, open vascular surgery and endovascular procedures. Classic vascular surgery is visceral reconstruction using by-pass procedure from the distal, normal aorta to all visceral branches: celiac trunk, superior mesenteric artery and both renal arteries, with ligature of all arteries very close to the aorta. After that, by synchronous endovascular technique a complete aneurysmal exclusion of thoracoabdominal aneurysm with thoracic stent-graft was performed. The postoperative course was conducted properly and the patient left the Clinic for Vascular Surgery on postoperative day 21. Control CT, performed 3 months after the surgery showed that the patient's vascular status was uneventful with functional visceral by-pass and with good position of a stent-graft without a significant endoleak. Visceral hybrid reconstruction represents a complementary surgical technique to that with open reconstruction of TAAA. This approach is far less traumatic to a patient, and is especially important in patients with lot of comorbidities, because there is no need for thoracotomy, and ischemic-reperfusion injury of the body is reduced to a minimum.

Die postoperative Betreuung nach gefäßchirurgischem Eingriff - Sekundärprophylaxe und Richtlinien für den Hausarzt

Patients after major vascular surgery operations present with different problems. Therefore dedicated physicians and good communication between surgeon and physician are required. One of the main goals should be control of cardiovascular risk factors. The following article presents an overview of common vascular operations and proposes guide-lines for postoperative care.

A fresh cadaver laboratory to conceptualize troublesome anatomic relationships in vascular surgery

Opportunities are declining for residents to participate in complex open vascular surgical operations. Open simulation using fresh cadavers potentially can be used to familiarize residents with complex vascular exposures. We evaluated the use of fresh cadavers to assist resident comprehension of complex anatomic relationships in vascular surgery. Twenty-two postgraduate year (PGY) 3 (n = 12) and PGY 4 (n = 10) general surgery residents attended five structured 4-hour cadaver skills laboratories. Residents performed five conceptually difficult and infrequently encountered operative vascular exposures: the supraclavicular subclavian and vertebral arteries, supraceliac aorta, superior mesenteric artery, proximal and distal renal arteries, and common iliac artery bifurcations. Residents were tested (oral board examination style with percentage correct of a predetermined checklist) in their knowledge and understanding of the anatomic relationships before and after the cadaver laboratories. Participants' self-reported confidence in performing these complex vascular exposures was also measured before and after the course using the operative confidence score (1 = not confident; 5 = highly confident) for each exposure. Participation in the course resulted in increases in participant comprehension and self-reported operative confidence in the supraclavicular subclavian and vertebral arteries, supraceliac aorta, superior mesenteric artery, renal arteries, and iliac bifurcation exposures. Before vs after the course, the mean oral examination scores were 5% vs 87%, 26% vs 94%, 19% vs 86%, 30% vs 88%, and 29% vs 87%, respectively (all P < .001), and mean operative confidence scores were 1.1 vs 2.9, 1.3 vs 3.5, 1.2 vs 3.2, 1.2 vs 3, and 1.5 vs 3.9, respectively (all P < 0.001). Fresh cadaver laboratories can provide a learner-centered and safe environment for acquiring procedural understanding and operative confidence of complex vascular exposures. This may allow for the transformational change essential to becoming a competent vascular surgeon.

Prophylactic muscle flaps in vascular surgery

Vascular surgery-related groin complications can lead to catastrophic outcomes and pose a significant healthcare burden. We have taken steps to reduce potential complications at the time of initial surgery by performing prophylactic muscle flaps. The purpose of this study is to evaluate the efficacy and benefit of prophylactic flaps in high-risk patients. A retrospective cohort study was performed on patients undergoing open vascular surgery involving the femoral vessels through a groin incision between 2005 and 2010. Patients receiving prophylactic muscle flaps at their initial surgery were compared with those patients not receiving a flap (control). Sixty-eight prophylactic flaps in 53 patients were compared with 195 open vascular procedures without flaps in 178 patients. The most frequent indication was reoperative bypass surgery with prosthetic reconstruction (63%). The prophylactic patient group exhibited significantly higher rates of comorbidities, including chronic obstructive pulmonary disease (25.0% vs 12.6%; P = .018) and hyperlipidemia (80.9% vs 59.1%; P = .002). Patients receiving prophylactic flaps had lower rates of overall complications (16.2% vs 50.3%; P < .001), infections (1.5% vs 38.5%; P < .001), seroma (0% vs 7.2%; P = .023), and lymphocele (1.5% vs 15.4%; P = .002). Multivariate regression demonstrated that obesity (odds ratio [OR], 2.1 [1.001-4.49]; P = .05), smoking (OR, 2.7 [1.37-5.16]; P = .004), reoperation (OR, 3.5 [1.41-8.63]; P = .007), and prosthetic graft reconstruction (OR, 2.0 [1.03-3.78]; P = .04) were associated with postoperative complications. Additionally, in analyzing all groin complications in all patients, we found that patients who received a prophylactic flap experienced significantly less groin wound complications (OR, 0.17; P < .001). Complications following open groin surgery are common, lead to significant morbidity, and are very costly. Performing prophylactic muscle flaps at the initial surgery to cover the femoral vessels and reduce dead space can significantly reduce complications in select high-risk patients. Prophylactic flaps are safe, effective, and should be considered in patients with multiple comorbidities undergoing high-risk groin surgery, such as reoperative prosthetic bypass surgery.

Remote ischaemic preconditioning versus no remote ischaemic preconditioning for vascular and endovascular surgical procedures.

Despite advances in perioperative care, elective major vascular surgical procedures carry a significant risk of morbidity and mortality. Remote ischaemic preconditioning is initiated by brief, non-lethal periods of ischaemia in a vascular bed different from the one which will be subjected to ischaemic insult during surgery. It has the potential to provide local tissue protection from further prolonged periods of ischaemia. The aim of this review was to compare the outcomes from vascular and endovascular surgical procedures with and without the use of remote ischaemic preconditioning. The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (June 2011) and CENTRAL (2011, Issue 2). The authors searched MEDLINE via PubMed (July 2011), EMBASE (June 2011), and Science Citation Index Expanded (July 2011). We considered for inclusion all randomised controlled trials that evaluated the role of remote ischaemic preconditioning in reducing mortality and systemic injury in patients undergoing open vascular or endovascular surgery. We collected the data on characteristics of the trial, methodological quality, the remote ischaemic preconditioning stimulus used, mortality, morbidity, operating time and hospital stay from each trial. We analysed the data with both the fixed-effect and the random-effects models using RevMan analysis. For each outcome we calculated the risk ratio (RR) or mean difference with 95% confidence interval (CI) based on an intention-to-treat analysis. We included four studies with a total of 115 patients randomised to undergo a vascular procedure with remote ischaemic preconditioning and 117 patients randomised to have the procedure without remote ischaemic preconditioning. None of the trials were of low risk of bias. There was no significant difference in mortality between the two groups (RR 1.70, 95% CI 0.51 to 5.72). Similarly, there was no statistically significant difference between the two groups for all other outcomes except reduced risk of myocardial infarction in the remote ischaemic preconditioning group, which was significant by the fixed-effect model (RR 0.31, 95% CI 0.10 to 0.90) but not by the random-effects model (RR 0.34, 95% CI 0.11 to 1.08). This positive effect was from the results of only one trial and was not consistently observed. Furthermore, it was noted that there was an observed trend of high incidence of unplanned critical care admission in the remote ischaemic preconditioning group, although this was not statistically significant (RR 2.15, 95% CI 0.87 to 5.33). Based on current evidence from small pilot trials, there are too few data to be able to say whether remote ischaemic preconditioning has any beneficial or harmful effects. The safety of this technique needs to be confirmed in adequately powered trials. Therefore, further randomised trials on this technique are required.

Quality Improvement Pilot Program for Vulnerable Elderly Surgical Patients

The elderly are a growing surgical population with more comorbidities and less physiological reserve compared with nonelderly patients. The objective of our study was to implement a quality improvement pilot program targeting the specific needs of the elderly. We prospectively enrolled consecutive patients aged 65 years or older undergoing inpatient general or vascular surgery operations. Patients completed a preoperative assessment including the Vulnerable Elder Survey (VES) to determine baseline functional status and incidence of polypharmacy (five or more medications). They were interviewed postdischarge Day 2 and Day 30 for changes in functional status. An intervention was implemented consisting of an elderly-specific postoperative order set and preoperative risk reports sent to the surgical team with instructions to order physical therapy consults and home health nursing on discharge for VES 3 or greater and geriatrics consults for patients with polypharmacy. The elderly-specific order set was used for 71 per cent of the postintervention group. There were no differences in the percentage of participants receiving physical therapy, geriatric, or home health nursing consults between the two groups. The postintervention group had significantly better functional status on postdischarge Day 30 (P < 0.01). Our preliminary data suggest that individualizing care for elderly patients is feasible and may improve postoperative outcomes.

Defining the type of surgeon volume that influences the outcomes for open abdominal aortic aneurysm repair

Prior studies have reported improved clinical outcomes with higher surgeon volume, which is assumed to be a product of the surgeon's experience with the index operation. We hypothesized that composite surgeon volume is an important determinant of outcome. We tested this hypothesis by comparing the impact of operation-specific surgeon volume versus composite surgeon volume on surgical outcomes, using open abdominal aortic aneurysm (AAA) repair as the index operation. The Nationwide Inpatient Sample was analyzed to identify patients undergoing open AAA repairs for 2000 to 2008. Surgeons were stratified into deciles based on annual volume of open AAA repairs ("operation-specific volume") and overall volume of open vascular operations ("composite volume"). Composite volume was defined by the sum of several open vascular operations: carotid endarterectomy, aortobifemoral bypass, femoral-popliteal bypass, and femoral-tibial bypass. Multiple logistic regression analyses were used to examine the relationship between surgeon volume and in-hospital mortality for open AAA repair, adjusting for both patient and hospital characteristics. Between 2000 and 2008, an estimated 111,533 (95% confidence interval [CI], 102,296-121,232) elective open AAA repairs were performed nationwide by 6,857 surgeons. The crude in-hospital mortality rate over the study period was 6.1% (95% CI, 5.6%-6.5%). The mean number of open AAA repairs performed annually was 2.4 operations per surgeon. The mean composite volume was 5.3 operations annually. As expected, in-hospital mortality for open AAA repair decreased with increasing volume of open AAA repairs performed by a surgeon. Mortality rates for the lowest and highest deciles of surgeon volume were 10.2% and 4.5%, respectively (P < .0001). A similar pattern was observed for composite surgeon volume, as the mortality rates for the lowest and highest deciles of composite volume were 9.8% and 4.8%, respectively (P < .0001). After adjusting for patient and hospital characteristics, increasing composite surgeon volume remained a significant predictor of lower in-hospital mortality for open AAA repair (odds ratio, 0.994; 95% CI, .992-.996; P < .0001), whereas increasing volume of AAA repairs per surgeon did not predict in-hospital deaths. The current study suggests that composite surgeon volume-not operation-specific volume-is a key determinant of in-hospital mortality for open AAA repair. This finding needs to be considered for future credentialing of surgeons.

Development of the Australasian Vascular Surgical Audit

The purpose of this study was to describe the development of the Australasian Vascular Audit that was created to unify audit activities under the umbrella of the Australian and New Zealand Society for Vascular Surgery as a Web-based application. Constitutional change in late 2008 deemed participation in this audit compulsory for Society members. The Web-based application was developed and tested during 2009. Data for all open vascular surgery and for all endovascular procedures are collected at two points in the admission episode: at the time of operation and at discharge, and entered into the application. Data are analyzed to produce risk-adjusted outcomes. An algorithm has been developed to deal with outliers according to natural justice and to comply with the requirements of regulatory bodies. The Audit is protected by legislated privilege and is officially endorsed and indemnified by the Royal Australasian College of Surgeons. Confidentiality of surgeons and patients alike is ensured by a legally protected coding system and computer encryption system. Validation is by a verification process of 5% of members per year who are randomly selected. The application is completely funded by the Society. Data entry commenced on January 1, 2010. Over 40,000 vascular procedures were entered in the first year. The Audit application allows instantaneous on-line access to individual data and to deidentified group data and specific reports. It also allows real-time instantaneous production of log books for vascular trainees. The Audit has already gained recognition in the Australasian public arena during its first year of operation as an important benchmark of correct professional surgical behavior. Compliance has been extremely high in public hospitals but less so in private hospitals such that only 60% of members received a certificate of complete participation at the end of its first year of operation. An Internet-based compulsory audit of complete surgical practice is possible to create and be maintained by a society of surgeons with a membership of just over 200. The 60% compliance rate for complete data entry has created an immediate constitutional challenge for the Society. Future challenges are to improve total participation to an acceptable level and to ensure accurate data entry via a robust validation system.