Vascular Surgery Practice Research Articles

Understanding the Scope of Acute Care Vascular Surgery at a Tertiary Academic Medical System

The restructuring of nonelective general surgery and nationwide implementation of the acute care surgery paradigm has improved patient outcomes and healthcare resource utilization. Although vascular surgery maintains one of the highest acuity rates among surgical specialties, the acute care vascular surgery (ACVS) practice model has not been widely accepted. In the present study, we investigate the scope and burden of ACVS at a tertiary academic medical system. All vascular surgical procedures performed at three hospitals comprising a large tertiary academic medical system were retrospectively queried through electronic medical records. Data were collected on procedure, acuity, timing of intervention, primary service, admission type, and total costs and charges. Patients were stratified by acuity of surgical intervention, with ACVS being defined as urgent or emergent operation. A total of 12,689 vascular surgeries were performed from 2018 to 2022. ACVS procedures comprised 22.1% of this total (n=2,803; 12.5% urgent, 9.6% emergent), with an annual burden ranging from 19.1% to 28.3%. Vascular surgeons served as primary surgeon in 91.3% of ACVS and cosurgeon in 8.7%. Fourteen separate surgical specialties requested acute vascular assistance, with the most frequently consulting specialties, including trauma or acute care surgery (ACS) (n=109, 3.9%) and cardiac surgery (n=74, 2.6%). ACVS cases were more frequently performed during after-hours (30.7% vs 11.6%) and on weekends (27.1% vs 2.0%) compared with elective vascular procedures (P<0.0001 each). The majority of ACVS cases originated from inpatient (n=2,353, 85.0%) and emergency department (n=379, 13.5%) consultations. Overall, ACVS generated $37.5 million in charges, accounting for 14% of total procedure-related charges over the study period. ACVS comprises a substantial portion of modern vascular practice and is associated with significant human and healthcare resource expenditure. These data support the development of practice models dedicated to acute vascular surgical care.

Microsurgical Anatomy of Middle Cerebral Artery in Northwest Indian Population: A Cadaveric Brain Dissection Study

AbstractThe introduction of cadaveric dissection of cerebral vasculature as a part of the neurosurgical training module would help the neurosurgical residents to understand the complex neuroanatomy of the brain vasculature and help gain confdence during the surgical procedure.To the best of our knowledge microsurgical anatomical studies of theMCA have not been done among the Northwest Indian population. Anatomical variations of MCA that have not been described before may come in as a surprise during any surgical intervention. Hence, we intend to record the anatomical variations of the MCA anatomy and its implications in contemporary vascular surgery and neurosurgical practice. The objective of this work was to study and compare the microsurgical anatomy and variations of MCA in Northwest Indian cadavers with the available literature.

Failure of Vascular Surgery to Establish and Elevate Its Quality Brand to The Public – Absence of Quality Reporting on Vascular Surgery Practice Websites

Failure of Vascular Surgery to Establish and Elevate Its Quality Brand to The Public – Absence of Quality Reporting on Vascular Surgery Practice Websites

Mobility Rates After Lower-Limb Amputation for Patients Treated with Physician-Led Collaborative Care Model

Clinical outcomes after major lower-limb amputation have been historically poor. The current care provided to most amputees is often disorganized and without physician supervision. The primary purpose of this study is to examine rates of postamputation mobility achieved with a prosthesis by patients with chronic limb-threatening ischemia and/or diabetes who required major lower-limb amputation and were treated under an established physician-led collaborative care pathway. The secondary purpose is to describe the structure and utilization of the care pathway by multiple independent vascular surgery practices in the United States to enable future exploration of its impact on key clinical outcomes within this patient population. Clinical records of 2,475 patients from 6 vascular practices that adopted this collaborative care pathway between 2017 and 2020 were retrospectively reviewed. Only records with sufficient documented histories of amputation surgeries, prosthetic services, and mobility status were included. Of 2,475 patient records reviewed, 1,787 patients (2,157 major amputations) were eligible for analysis. Sixty-two-point 2 percent (n=1,111) of patients achieved mobility with the collaborative care pathway. Mobility rate varied by amputation level in the study. Prosthetic mobility was achieved in 73.5% of transtibial amputations, 40.4% of transfemoral amputations, and 35.7% of through-knee amputations, regardless of patient laterality, which is superior or equivalent to the best published rates of mobility. The study describes the structure and utilization of a physician-led collaborative care pathway for treating patients who require lower-limb amputation that meets 5 of the 7 recommendations from the 2019 Global Vascular Guidelines on the Management of Chronic Limb Threatening Ischemia. Internal data analysis results suggest that patients treated via this care pathway can potentially achieve improved mobility rates with a prosthesis following amputation. This collaborative care pathway should be further evaluated for its ability to directly improve mobility and other clinically relevant amputation outcomes.

The impact of the first and the second wave of the COVID-19 pandemic on vascular surgery practice in the leading regional center: a comparative, retrospective study

BackgroundWe conducted an analysis of the vascular surgery regional center reorganization in response to the first and the second wave of the coronavirus disease-2019 (COVID-19) pandemic to see what lessons we learned from the first wave.MethodsThe study included a total of 632 patients admitted to the vascular surgery department in three periods: March–May 2020, October–December 2020, and October–December 2019 as a control period.ResultsIn the pandemic periods the number of admitted patients decreased in relation to the control period. There was a reduction in performed procedures. We observed an increase in the ratio of less invasive procedures. There was a significant decline in hospitalization time in comparison to the control period.ConclusionsThe reduction of scheduled admissions and procedures affected vascular centers all over the world. Minimally invasive procedures were more willingly performed to shorten the hospitalization time and reduce the patient's exposure to hospital infection. It allowed us to treat more patients during the second wave. Nevertheless, an increased number of vascular patients should be expected in the future, which will result from the failure to perform elective procedures during the pandemic.

Modern management of ruptured abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysms (rAAA) remain one of the most clinically challenging and technically complex emergencies in contemporary vascular surgery practice. Over the past 30 years, a variety of changes surrounding the treatment of rAAA have evolved including improvements in diagnosis, development of coordinated referral networks to transfer patients more efficiently to higher volume centers, deliberate de-escalation of pre-hospital resuscitation, modification of patient and procedure selection, implementation of clinical pathways, as well as enhanced awareness of certain high-impact postoperative complications. Despite these advances, current postoperative outcomes remain sobering since morbidity and mortality rates ranging from 25%-50% persist among modern published series. Some of the most impactful variation in rAAA management has been fostered by the rapid proliferation of endovascular repair (EVAR) along with service alignment at selected centers to improve timely revascularization. Indeed, clinical care pathways and emergency response networks are now increasingly utilized which has led to improved outcomes contemporaneously. Moreover, evolution in pre- and post-operative physiologic resuscitation has also contributed to observed improvements in rAAA outcomes. Due to different developments in care provision over time, the purpose of this review is to describe the modern management of rAAA, while providing historical perspectives on patient, procedure and systems-based practice elements that have evolved care delivery paradigms in this complex group of patients.

Consolidation trends in vascular surgery

BackgroundPractice consolidation by vertical and horizontal integration is a growing trend in surgery. Practice consolidation has not been previously examined in vascular surgery. MethodsThe Medicare Provider Enrollment, Chain, and Ownership System data were used to identify vascular providers and vascular surgery practices in the United States in 2015 and 2020. Practices were categorized as solo (1 surgeon), small (2), medium (3-5), and large (≥6). The number of providers and the number of practices in each size group were determined. The Hirfendahl-Hirshman index (HHI), a measure of market consolidation, was calculated. Provider count, practice size, and HHI were additionally analyzed by urban and rural regions. All values were calculated for each time point and compared. ResultsVascular providers increased in number from 2929 to 3154 (7.7%) from 2015 to 2020. The number of practices decreased from 1351 to 1090 (19.3%). The number of large practices increased by 49.4%; the number of small or solo practices decreased by 42.1%. The mean HHI increased from 0.486 in 2015 to 0.498 in 2020. Both urban and rural regions had a decrease in solo practices (43.3% and 2.3%, respectively) and an increase in HHI (from 0.499 to 0.509 and 0.793 to 0.818, respectively). All changes were statistically significant. ConclusionsFrom 2015 to 2020, there is a trend toward vascular providers working in larger practice groups and a corresponding increase in measures of market consolidation.

Humans use tools: From handcrafted tools to artificial intelligence

Human evolution is instrument based. Humans created tools >2 million years ago to aid them in hunting, gathering, and defense, allowing them to build shelters and farms and transport goods and people over great distances. Written records preserved our knowledge and experiences for future generations. Instruments have greatly influenced surgery. Knives and needles were used by ancient surgeons, whereas lasers, endoscopes, and robotics are used today. Artificial intelligence (AI) is the future of surgical instruments, increasing precision through self-evaluation, but development remains in the early stages. Vascular surgery research and practice has used AI-powered systems that can track patient progress and identify vascular disease risk using deep learning and pattern recognition, as well as improved radiological interpretation of vascular imaging and medicine. Using insights and data-driven recommendations, AI-powered decision support systems could help surgeons in enhancing patient outcomes by providing guidance to navigate complex anatomy and identify anomalies. Robots can assist surgeons in performing risky, complex operations with optimal outcomes. Human expertise and AI will revolutionize surgery, enhancing its safety, precision, and efficacy. Surgical applications of AI raise numerous questions and debates. Data must be representative of all populations, data management must protect the privacy of patients and physicians, and the AI decision-making process must be clarified to produce validated models that can be used ethically. Vascular surgeons' judgment and experience should not be automated. Instead, AI should contribute to the efficiency and effectiveness of vascular surgeons. Human clinicians must interpret AI-generated data, use clinical judgment, and build empathy, compassion, and shared decision-making to sustain doctor-patient relationships. From simple tools to complex modern technologies, the history of tools reveals human creativity. Our environment has been altered by technology, ensuring our survival and growth. AI is still a half-told tale that will inspire and amaze us for years to come.

Potential limitations of novel efforts to accelerate and streamline urgent inpatient critical limb revascularization in current vascular surgery practice

Potential limitations of novel efforts to accelerate and streamline urgent inpatient critical limb revascularization in current vascular surgery practice

Individual and Program-Related Predictors of Academic Vascular Surgery Practice

Several studies have explored factors affecting academic employment in surgical subspecialties; however, vascular surgery has not yet been investigated. We examined which elements of surgical training predict future academic productivity and studied characteristics of NIH-funded vascular surgery attendings. With approval from the APDVS, the database of recent vascular surgery fellowship (VSF) and integrated vascular surgery residency (IVSR) graduates was obtained, and public resources (Doximity, Scopus, PubMed, NIH, etc.) were queried for research output during and after training, completion of dedicated research years, individual and program NIH funding, current practice setting and academic rank. Adjusted multivariate regression analyses were conducted for postgraduate academic productivity. From 2013-2017, there were 734 graduates. 603 completed VSF and 131 IVSR; 220 (29%) were female. Academic employment was predicted by MD degree, advanced degree, training at a top NIH-funded program, number publications by end of training, and H-index. Dedicated research time before or during vascular training, advanced degree, or graduating from a top NIH-funded program were predictors of publishing >1 paper/year. Number of publications by end of training and years in practice were predictive of H-index ≥5. VSF vs. IVSR pathway did not have an impact on future academic employment, annual publication rate as an attending, or H-index. Characterization of NIH-funded attendings showed that they often completed dedicated research time (72%) and trained at a top NIH-funded program (79%). Mean publications by graduation among this group was 15.82±11.3, and they averaged 4.31±4.2 publications/year as attendings. Research output during training, advanced degrees, and training at a top NIH funded program predict an academic vascular surgery career. VSF and IVSR constitute equally valid paths to productive academic careers.

Exploring the perception of venous disease within vascular surgery

BackgroundBiases and gender disparities influence career pathways within medicine, and vascular surgery is no exception. Venous disease comprises an estimated 1% to 3% of total health care expenditures. However, its value among vascular surgeons is poorly understood. This study aims to investigate the factors that influence vascular surgeons' current perceptions of superficial and deep venous disease treatments. MethodsAn anonymous survey was distributed electronically to practicing vascular surgeons in December 2021. The respondents were stratified by gender and practice breakdown. A venous-heavy practice was defined as a practice with venous work comprising ≥25% of the total volume. Changes in practice patterns over the respondent's career were also explored. Descriptive, univariate, and multivariate analyses were performed using STATA (StataCorp). ResultsA total of 315 practicing vascular surgeons responded, with 81.5% from the United States. Their mean age was 46.6 ± 9.6 years, and most identified as men (63.3%). The race and ethnicity breakdown was as follows: White (non-Hispanic), 63.0%; Asian or Asian Indian, 17.1%; Hispanic, Latinx, or Spanish, 8.4%; Black, 1.6%; and unknown, 9.9%. The practice settings were academic for 47.0%, private practice for 26.5%, hospital employed for 23.3%, and other for 3.2%. The female respondents were significantly younger (P < .0001), with fewer years in practice (P < .0001) and were more likely to perceive a gender bias within a career encompassing venous disease compared with the male respondents (P = .02). Of the 315 participants, 143 (45.4%) had a venous-heavy practice. No differences were found in age or gender between the venous-heavy and venous-light practices. Those with a venous-heavy practice had significantly more years in practice statistically (P = .02), had sought more venous training after graduation (P < .0001), were more likely to be in private practice (P < .0001), and were more likely to desire a practice change (P = .001) compared with those with a venous-light practice. Overall, 74.3% of respondents indicated that venous work might be less “valued” than arterial work in the field of vascular surgery. On multivariable regression, the predictors for the perception of venous work being less valued were female gender (odds ratio, 2.01; 95% confidence interval, 1.14-4.03) and completion of a vascular surgery fellowship (odds ratio, 2.0; 95% confidence interval, 1.15-3.57). ConclusionsVascular surgeons overwhelmingly perceived the management of venous disease to be of less value than that of arterial disease, particularly by women and fellowship-trained vascular surgeons. The prevalence of venous disease, as measured by its proportion of the U.S. healthcare budget, cannot be overstated. Thus, efforts to elevate the importance of chronic venous disease within the scope of vascular surgery practices are essential to ensure patients are provided with appropriate specialty care.

Your New Year’s “resolution”—check your “screen!”

Your New Year’s “resolution”—check your “screen!”

Technical tips and clinical experience with the Terumo Relay®Branch aortic endovascular graft

Advances in thoracic endovascular aortic repair (TEVAR) are enabling the treatment of increasingly proximal pathology. While the practice of vascular surgery has thus far been mostly limited to TEVAR in zone 2 or more distally, there are emerging devices for zone 1 and zone 0 repair that do not require any further arch debranching compared with a zone 2 repair. Moreover, such devices set forth repair options for patients unable to tolerate the insult of open surgery. One zone 0 device under evaluation is the Terumo Relay®Branch (Terumo, Tokyo, Japan) endovascular graft, which is an off-the-shelf device based on the Relay®Pro platform (Terumo). This double branch device uniquely features a large gate, facilitating easy cannulation that contains two locking portal stents for the innominate artery (IA) and left common carotid artery (LCCA) branch grafts. Within our institution, we have had excellent technical success with Relay®Branch (Terumo) device deployments as part of the Early Feasibility Study, and other centers outside of the USA have published results with this device in small patient series. Notably, there is still a concerning stroke rate associated with the Relay®Branch (Terumo) device, with permanent stroke rates higher than expected but similar to those for open repair. Thus, these interventions must be undertaken with careful patient selection, thorough planning, and with the guidance of a proficient endovascular aortic team. In this article, we will outline the necessary preoperative workup, highlight device features, and detail the operative strategy, with tips for technical success. These guidelines from our experience will help facilitate successful utilization of this device when it becomes widely available in practice.

Individual And Program-related Predictors Of Academic Vascular Surgery Practice

Several studies have explored factors affecting academic employment in surgical subspecialties; however, vascular surgery has not yet been investigated. We examined which elements of surgical training predict future academic productivity and studied characteristics of NIH-funded vascular surgery attendings.

Percutaneous mechanical pulmonary thrombectomy: An emerging opportunity for vascular surgeons

ObjectivePercutaneous pulmonary artery (PA) mechanical thrombectomy is a minimally invasive treatment for patients with submassive pulmonary emboli (PE). Recent registry data suggest that only approximately 12% of these procedures are being performed by vascular surgeons. We conducted a single center, 1-year, prospectively collected, retrospectively reviewed original study of all patients who had percutaneous PA aspiration mechanical thrombectomy (PPAAMT) performed by vascular surgeons to treat acute, submassive PE. MethodsBetween January 2020 and January 2021, 5 vascular surgeons performed 21 percutaneous PPAAMTs, representing 72% of all the PPAAMT performed at our institution. The remaining 28% were performed by interventional radiology and cardiology physicians (4 patients each). Vascular surgeons used the Inari Flowtriever aspiration catheter in 90.4% of our cases. For the remaining 10% of cases, the Penumbra Indigo thrombectomy device was used. Device choice was determined by the surgeon. ResultsWe analyzed prospectively collected data and reviewed postprocedural outcomes including PA mean arterial pressures, interval improvement of respiratory function, and mortality. Among the patients treated with PPAAMT by vascular surgeons in this series, 76% demonstrated an improvement in oxygen requirements and 83% saw an improvement in their post-thrombectomy PA mean arterial pressure. There were three mortalities (16%), none of which were procedure related or attributable to the patients' acute presentation or to PE recurrence. ConclusionsIn this prospectively collected, retrospectively analyzed original study, vascular surgeons performed the majority of percutaneous PPAAMT to treat submassive PE at a single institution, with no procedure-related mortality and a high rate of clinical improvement as measured by improvements in oxygen requirements and PA mean arterial pressures. These results suggest that PPAAMT performed by vascular surgeons is safe and effective and can be strategically incorporated into an already busy tertiary care vascular surgery practice.

Exploring the Perception of Venous Disease Within Vascular Surgery

Introduction: Biases and gender disparities influence career pathways within surgical subspecialties and vascular surgery is no exception. This study aimed to investigate specific factors that influence current perception of the treatment of superficial and deep venous disease amongst practicing vascular surgeons. Methods: An anonymous survey was distributed electronically to practicing vascular surgeons. Responders were stratified by gender and practice breakdown. Descriptive, univariate, and multivariate analyses were performed using STATA. Results: 315 practicing vascular surgeons responded. Mean age was 46.6 ± 9.6 years, the majority (63.3%) were male. A majority (63.0%) identified as White, 17.1% Asian or Asian Indian, 8.4% as Hispanic, Latinx or Spanish and 1.6% Black. Primary practice settings were academic (47.0%), private practice (26.5%), hospital employed (23.3%) or other (3.2%). Women respondents were significantly younger (p < 0.0001), with fewer years in practice (p < 0.0001) and were more likely to perceive gender bias within a career encompassing venous disease (p = 0.02) compared with men who responded. Overall, 74.3% of the cohort felt that vascular surgeons feel venous work may be less “valued” than arterial work. On multivariable regression, predictors for perception of venous work being less valued were female gender (OR 2.01, 95%CI 1.14-4.03) and graduating from a vascular surgery fellowship (OR 2.0, 95%CI 1.15-3.57). Conclusion: Vascular surgeons overwhelmingly perceive treatment of venous disease has less value compared with arterial disease, particularly among females and graduating fellows. Recognizing its importance within the scope of vascular surgery practice is essential and needs further prioritization.

Disparity In Telemedicine Utilization By Vascular Surgery Patients

The current COVID pandemic has impacted health care access, resulting in the emergence of telemedicine as an essential modality for care delivery. A significant percentage of a vascular surgery practice consists of chronic care surveillance, for which telehealth is particularly well-suited. This project aimed to study telehealth access at a major academic center that cares for a diverse population.

История применения гомографтов в сосудистой хирургии (литературный обзор)

INTRODUCTION: In the article, problems of use of allografts from a posthumous donor in the practice of a vascular surgeon are analyzed. The need for donor material in special clinical situations is reflected. The main stages of the historical development of the use of homografts are listed. The experience of foreign and domestic authors in reconstructive interventions on the main vessels and aorta using homografts is demonstrated in the historical perspective of the XXth century. Historical milestones in the development of tissue banks in the world are considered on an example of America, Europe, Africa, Asia and Russia. The legal regulation of use of homografts is at present especially relevant for the Russian Federation. The use of homografts as a material for reconstruction is stated to be within the legal framework of the Russian Federation. A large number of modern studies in the 21st century are carried out with choice of cadaveric homografts, both cryopreserved and of wet storage, as the material for reconstruction of the main arteries. Critical ischemia is a probable indication for the use of cadaveric homographs, but their implantation shows ambiguous results. Infection of a permanent vascular access for hemodialysis can also be considered as an indication for the use of a venous homograph as the material for access reconstruction. CONCLUSION: The donor material is currently being actively used in the practice of vascular surgery in many centers, and the hope for the diversification of clinical indications is growing, as well as for homografts finding the place in Russian clinical guidelines in future.

Loss of follow-up after carotid revascularization is associated with worse long-term stroke and death

ObjectivesSociety for Vascular Surgery practice guidelines recommend surveillance with duplex ultrasound scanning at baseline (within 3 months from discharge), every 6 months for 2 years, and annually afterward following carotid endarterectomy or carotid artery stenting. There is a growing concern regarding the significance of postoperative follow-up after several vascular procedures. We sought to determine whether 1-year loss to follow-up (LTF) after carotid revascularization was associated with worse outcomes in the Vascular Quality Initiative (VQI) linked to Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database. MethodsAll patients who underwent carotid revascularization in the VQI VISION database between 2003 and 2016 were included. LTF was defined as failure to complete 1-year follow-up in the VQI long-term follow-up dataset. Data about stroke and mortality were captured in the VISION dataset using a list of Current Procedural Terminology, International Classification of Diseases (Ninth Revision), and International Classification of Diseases (Tenth Revision) codes linked to index procedures in VQI. Kaplan-Meier life-table methods and Cox proportional hazard modeling were used to compare 5- and 10-year outcomes between patients with no LTF and those who were LTF. ResultsA total of 58,840 patients were available for analysis. The 1-year LTF rate was 43.8%. Patients who were LTF were older and more frequently symptomatic, with chronic obstructive pulmonary diseases, chronic kidney diseases, and congestive heart failure. Also, patients who underwent carotid artery stenting were more likely to be LTF compared with carotid endarterectomy patients (54.5% vs 42.3%; P < .001). The incidence of postoperative (30 days) stroke was higher in the LTF group (2.9% vs 1.7%; P < .001). Cox regression analysis revealed that LTF was associated with an increased risk of long-term stroke at 5 years (hazard ratio [HR]: 1.4, 95% confidence interval [CI]: 1.2-1.6; P < .001) and 10 years (HR: 1.3, 95% CI: 1.2-1.5; P < .001). It was also associated with significantly higher mortality at 5 years (HR: 2.5, 95% CI: 2.3-2.8; P < .001) and 10 years (HR: 2.2, 95% CI: 1.9-2.5; P < .001). Stroke or death was significantly worse in the LTF group at 5 years (HR: 2.3, 95% CI: 2.1-2.5; P < .001) and up to 10 years (HR: 2.02, 95% CI: 1.8-2.3; P < .001). ConclusionsOne-year follow-up after carotid revascularization procedures was found to be associated with better stroke- and mortality-free survival. Surgeons should emphasize the importance of follow-up to all patients who undergo carotid revascularization, especially those with multiple comorbidities and postoperative neurological complications.

Use of Telemedicine and Virtual Consultations for Patient Care in the Coronavirus Disease 2019 Era and Beyond for Vascular Surgery Practice: A Systematic Review and Meta-analysis

Use of Telemedicine and Virtual Consultations for Patient Care in the Coronavirus Disease 2019 Era and Beyond for Vascular Surgery Practice: A Systematic Review and Meta-analysis