Applications In Vascular Surgery Research Articles

The rise of artificial intelligence in vascular surgery: A bibliometric analysis (2020-2024)

Aim: This study aims to perform a comprehensive bibliometric analysis of academic publications on AI applications in vascular surgery, identifying key authors, influential journals, prevalent research themes, and international collaborations, focusing on infrastructure, conceptual structure, and social networks within the field. Material and Methods: The analysis covers 815 documents published from 2020 to 2024, retrieved from the Web of Science Core Collection database. Metrics analyzed include publication growth, citation rates, key contributors, leading journals, prevalent themes, and international collaborations. Results: The research output showed a 15% annual growth rate, peaking in 2023. Despite increasing publications, the average citation rate per article declined. The study identified 5039 contributors with significant international co-authorship. Leading authors included Lareyre F and Raffort J, and the "Journal of Vascular Surgery" was the most influential journal. The USA and China led in contributions, reflecting robust research infrastructure. Key themes include risk assessment, diagnostic methods, and patient management, highlighting AI's role in enhancing diagnostic accuracy, treatment planning, and patient outcomes in vascular surgery. Conclusion: The analysis highlights the rapid growth and collaborative nature of AI research in vascular surgery. Key contributors, influential journals, and emerging themes were identified, emphasizing AI's role in improving diagnostics and patient outcomes. Limitations include the focus on one database and a five-year period, suggesting future research should include more databases and a longer timeframe. Exploring high-impact studies and practical applications will further advance the field.

Specialty Exposure Differentiates Successful Integrated Vascular Surgery Applicants

The number of applicants to integrated vascular residencies continues to rise faster than available training positions. Numerous stakeholders in vascular surgery (VS) are invested in improving resources for medical student mentorship and VS exposure throughout medical school. The purpose of our study was to perform a needs assessment of integrated VS applicants from the 2021 application cycle regarding specialty exposure. A 15-question anonymous survey evaluating applicant VS exposure, resources, and match outcome was developed. VS exposure in the following areas was specifically evaluated: VS conference attendance, VS student interest groups, vascular subinternship away rotations, and mentorship by vascular surgeons. The survey was disseminated on the 2021 Integrated VS Applicant Cycle GroupMe chat forum from April to August 2022. Unpaired t test was utilized to compare summary statistics between respondents who self-identified as having successfully matched versus respondents who did not match into an integrated VS program. A total of 125 applicants were identified and 54 applicants (44%) responded, including 48 who successfully matched into an integrated VS residency. Applicants attended on average 1.5 ± 1.7 regional and national VS conferences in person over the preceding year, with greatest attendance reported at the Society for Vascular Surgery Vascular Annual Meeting (57%). A VS away rotation was completed by 78% of applicants, with out-of-pocket expenditure reported as >$1000 and >$3000 by 69% and 21% of these applicants, respectively. If given the opportunity to visit interview sites in person following virtual interviews, applicants would have chosen to visit 3.9 ± 2.9 sites on average. Most of the applicants who matched (77%) had a VS student interest groups at their home institution. Those who matched assigned higher rating of perceived vascular mentorship during the application cycle (9.0 ± 1.8 vs 6.0 ± 3.6 on a 1-10 scale; P = .001). Applicants who matched also endorsed interest in VS earlier in medical school (year 2.1 ± 1.0 vs year 3.0 ± 0; P = .04) and were more likely to have completed a VS away rotation (79% vs 66%). Only 19% of applicants who matched and completed a VS away rotation reported matching at the same institution where they had completed their away rotation. Vascular mentorship, early specialty exposure, and completion of a VS away rotation are variables associated with a successful match into an integrated VS residency. While exposure to an institution occurs with an away rotation, the cost to the applicant is not insignificant and the majority of applicants do not match at the institution where the rotation occurred.

Vascular surgery exposure differentiates successful integrated vascular surgery Applicants

BackgroundThe number of applicants to integrated vascular residencies continues to rise faster than available training positions. Numerous stakeholders in vascular surgery (VS) are invested in improving resources for medical student mentorship and VS exposure throughout medical school. The purpose of our study was to assess VS exposure factors for integrated VS applicants from the 2021 application cycle and determine which factors are related to matching successfully into VS residency. MethodsA 15-question anonymous survey evaluating applicant VS exposure, resources, and match outcome was developed. VS exposure in the following areas was specifically evaluated: VS conference attendance, VS student interest groups, vascular subinternship away rotations, and mentorship by vascular surgeons. The survey was disseminated on the 2021 Integrated VS Applicant Cycle GroupMe chat forum from April 2022 to August 2022. We used χ2 and Wilcoxon rank-sum tests to compare summary statistics between respondents who self-identified as having successfully matched vs respondents who did not match into an integrated VS program. ResultsA total of 125 applicants were identified and 54 applicants (44%) responded, including 48 who successfully matched into an integrated VS residency. The median regional and national VS conference attendance over the preceding year was 1 (interquartile range [IQR], 1-2), with greatest attendance reported at the Society for Vascular Surgery Vascular Annual Meeting (57% of respondents). A VS away rotation was completed by 42 (78%) respondents overall, with out-of-pocket expenditure reported as >$1000 and >$3000 by 69% and 21% of these applicants, respectively. If given the opportunity to visit interview sites in person after virtual interviews, applicants would have chosen to visit median of three 3 sites (IQR, 3-5 sites) on average. Most of the applicants who matched (77%) had a VS student interest group at their home institution. Those who matched assigned higher rating of perceived vascular mentorship during the application cycle (median, 10 [IQR, 9-10] vs median 5.5 [IQR, 4-9] on a 1-10 scale; P = .04). Applicants who matched also endorsed interest in VS earlier in medical school (median, year 2 [IQR, years 1-3] vs median, year 3 [IQR, years 3-3]; P = .03). Only 19% of applicants who matched and completed a VS away rotation reported matching at the same institution where they had completed their away rotation. ConclusionsVascular mentorship and early VS exposure are variables associated with a successful match into an integrated VS residency. Although exposure to an institution occurs with an away rotation, the cost to the applicant is not insignificant and most applicants do not match at the institution where the rotation occurred.

The Influence of Weaving Technologies on the Integral Characteristics of Synthetic Vascular Prostheses.

Ten vascular prostheses manufactured at the Science and Technology Park of the BNTU "Polytechnic" (Minsk, Republic of Belarus) have been analyzed. The prostheses differed in the type of weaving, duration and temperature of thermal fixation during crimping. Three samples had a single-layer structure and 7 samples had a double-layer structure. Tests for water permeability, resistance to radial bending, and porosity of the prostheses have been performed. The single-layer woven prostheses have demonstrated a low level of water permeability: the best result was shown by sample No.1: 80 [77.1; 80.5] ml/min/cm2. A strong direct correlation was revealed for these prostheses: the larger the pore diameter, the greater permeability (r=0.778; p=0.05). The single-layer woven prostheses appeared to be most resistant to radial bending, samples No.1 and 3 had no deformations at the minimum radius of the cylinder (r<4 mm), sample No.2 showed deformation on the cylinder with r=5 mm. For the single-layer prostheses, a strong negative correlation was noted (r=‒0.97; p=0.04) between the density of the warp threads and the kinking radius.All double-layer prostheses have demonstrated higher water permeability and weak resistance to deformation during radial bending. Samples No.4 and 8 were found to have minimum and maximum water permeability of 276.5 [258.3; 288.4] and 538.8 [533.3; 564.3] ml/min/cm2, respectively. The minimum kinking radius (7 mm) was shown by samples No.9 and 10. The worst results were demonstrated by sample No.6, which was deformed with minimal bending. Samples with ordinary plain weave have a low level of water permeability and high resistance to radial deformation, which makes them look most promising for the application in vascular surgery.

Telemedicine and Digital Health Applications in Vascular Surgery.

Background: Telemedicine has the potential to revolutionize healthcare. While the development of digital health technologies for the management of patients with cardiovascular diseases has been increasingly reported, applications in vascular surgery have been far less specifically investigated. The aim of this review is to summarize applications related to telemedicine in vascular surgery, highlighting expected benefits, current limits and future directions. Methods: The MEDLINE database was searched using a combination of keywords to identify studies related to telehealth/telemedicine in three main pathologies, including aortic, peripheral artery and carotid disease. A comprehensive literature review was performed to identify the type of digital application, intended use, expected benefits, strengths and limitations. Results: Telemedicine can improve the management of patients through digital platforms allowing teleconsultation, telemonitoring or telecoaching. Intended use involved remote consultation with a vascular surgeon, applications to enhance education, self-management, follow-up or adherence to treatment or lifestyle changes. Conclusion: Telemedicine offers innovative perspectives to improve access to care in distant locations and optimize care through patients’ empowerment and personalized follow-up, contributing to the development of precision medicine. Huge efforts remain necessary for its implementation in daily clinical practice and involve ethical, legal, technical, economic and cultural considerations.

Integrated vascular surgery applicants' perspectives of virtual residency interviews during the coronavirus disease 2019 application cycle

BackgroundIn agreement with Association of American Medical Colleges guidelines, the 2020 to 2021 integrated vascular surgery (I-VS) residency interviews were conducted virtually. In the present study, we collected data about the virtual interview process from the applicant's perspective, including preferences for interview format and the virtual resources they found most helpful. MethodsAn anonymous, online survey study of medical students who had been accepted into I-VS residencies during the 2020 to 2021 application cycle was performed. The survey contained questions about applicant behavior during the virtual application cycle, their perception of the virtual interviews, the utility of the virtual format, their preferences, and the virtual resources they found the most helpful for determining their rank list. ResultsOf 72 applicants, 38 (18 women, 19 men, and 1 declined to answer) had completed the survey for a 57.2% response rate. The average number of programs interviewed was 25 to 30 (31%). More than one-half (55%) of the respondents had responded that they had interviewed at more programs than they would have had the interviews been in person. More than one-half of the applicants (55%) reported that they preferred remote interviews with the option to visit in-person at their top choice programs compared with the use of all remote interviews (21%) or all in-person interviews (18%). Most had somewhat or strongly agreed (79%) that virtual interviews allowed them to properly gauge a residency program and provided adequate opportunities to interact with the residents (65%). The online resources the applicants found the most helpful in determining their rank lists were attending educational conferences, prerecorded videos from faculty and residents, and the program’s social media platforms. ConclusionsThe results from the present study have illuminated the current trends and attitudes of I-VS applicants for virtual interviews, including the virtual resources they found the most useful. Virtual interviews were a preferred method of interviewing and allowed applicants to assess a residency program and interact with the current residents. These variables should be considered by the program leadership when developing protocols for upcoming application cycles.

Biodegraded PCl and gelatin fabricated vascular patch in rat aortic and inferior vena cava angioplasty.

Novel synthetic prosthesis materials for patch angioplasty are continuously under development and optimization. When a nonwoven-based gelatin membrane is coupled with an electrospun layer of polycaprolactone (PCL), these biohybrid polymer membranes (BHMs) possess higher mechanical properties in aqueous environments. We hypothesized that BHMs can also be used as vascular patches, and we tested our hypothesis in a rat IVC venoplasty and aortic arterioplasty model. Patch venoplasty and arterioplasty were performed in SD rats (200g), the patches were harvested at day 14, and samples were analyzed by immunohistochemistry and immunofluorescence. The BHM patches were almost degraded, with few parts remaining after 14days. There was a line of CD34- and nestin-positive cells on the endothelium, with some cells were CD34 and nestin dual-positive, macrophages and leukocytes also participated in the patch healing process. There were PCNA-positive cells in the neointima and peri-patch area, with some cells were also PCNA and α-actin dual-positive. Arterial neointimal endothelial cells were Ephrin-B2- and dll-4-positive, and venous neointimal endothelial cells were Eph-B4- and COUP-TFII-positive. BHM shares a similar healing process like other patch materials, and BHM may have potential applications in vascular surgery.

Tubular chitosan device for use as prosthesis coating in vascular surgery

Chitosan is a natural, biodegradable, non-toxic and biocompatible polymer, with characteristics such as a healing, hemostatic, antimicrobial agent, among others. Therefore, the aim of this study is to develop a tubular chitosan device for use as a prosthetic coating application in vascular surgery. The chitosan wires were obtained by the spinning method in a 2M sodium hydroxide coagulant solution (NaOH) and used in the form of wires and screens as a reinforcement structure to obtain the tubes. In order to characterize the tubes, optical microscopy, contact angle, degree of swelling, in vitro biodegradation, cytotoxicity and tensile strength were used. The results indicated that the tubes have uniformity over the entire length and as for the resistance to the trace, the tube reinforced with mesh presented greater deformation, while the tube reinforced with wire presented a higher value of rupture stress. The degree of swelling was higher in chitosan tubes with mesh. As for the biodegradation test, it was observed that the lysozyme samples showed greater loss of mass and the cytotoxicity test confirmed the cell viability of the material, concluding that the tubes reinforced with chitosan wires are promising for use in vascular surgeries.

Linguistic Analysis of Letters of Recommendation for Vascular Surgery and Obstetrics and Gynecology Applicants Detects Differences in Attributable Strengths Based on Gender

We asked whether letters of recommendation (LOR) written for applicants to vascular surgery (VS), a field where men have traditionally predominated, differentially highlight attributes based on applicant gender. For comparison, LOR for applicants to Obstetrics and Gynecology (Ob/Gyn), a surgical field where women are highly represented were evaluated. We performed a cross-sectional review of LORs for students applying to VS or Ob/Gyn at our institution from 2017 to2018. Blinded to the gender of both the applicant and the letter author, investigators assessed word count per letter and used published rubrics to quantify how many words in the following categories: communal ("friendly"), able ("competent"), standout ("exceptional"), and grindstone ("hardworking"). Frequencies were reported as a function of specialty and gender. The study was performed at the University of Pittsburgh Medical Center and included letters written for applicants only to the stated residency programs at University of Pittsburgh Medical Center. LOR written for self-identified women and men applying to both residencies from US-based allopathic medical schools were de-identified and evaluated by blinded reviewers. One hundred and ninety-eight letters were reviewed for vascular surgery applicants. Two hundred letters were randomly selected from applications to Ob/Gyn as a comparison. Fifty-four vascular (27.8% women) and 63 Ob/Gyn (77.8% women) applicants were reviewed (p < 0.001 for gender). Licensing exam scores were higher for women than men applying to Ob/Gyn. Honor status was similar across fields and gender. Letters were shorter for VS applicants (p = 0.04). Gender-specific words (i.e., "lady" or "gentleman") were used more in VS letters (0.24 ± 0.50 vs 0.14 ± 0.42, p = 0.048). Ability words were more common (4.7 ± 2.6 vs 3.8 ± 2.1, p = 0.028) and grindstone adjectives were less common (3.4 ± 2.3 vs 4.5 ± 3.1, p = 0.024) in letters written for women compared to men VS applicants. Twenty-nine letters written for students applying to VS had honors status. While none written for women mentioned this achievement, 43% of those written for men did (p < 0.05). Letters for women applicants to Ob/Gyn contained more standout adjectives than those written for men (2.12 ± 2.2 vs 1.39 ± 1.25, p = 0.021). Reference letters for both specialties highlighted attributes differently depending on the gender of the applicant. Although this likely represents an unconscious process, care should be taken to limit potential biases in LOR which are "gatekeepers" to access and advancement.

Machine Learning in Vascular Surgery: A Systematic Review and Critical Appraisal

Background: Machine learning (ML) is a rapidly advancing field with increasing utility in health care. We conducted a systematic review and critical appraisal of ML applications in vascular surgery. Methods: MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to March 1, 2021. Study screening, data extraction, and quality assessment were performed by two independent reviewers, with a third author resolving discrepancies. All original studies reporting ML applications in vascular surgery were included. Publication trends, disease conditions, methodologies, and outcomes were summarized. Critical appraisal was conducted using the PROBAST risk-of-bias and TRIPOD reporting adherence tools. The PROSPERO registration number is CRD42021240310. Findings: We included 212 studies from a pool of 2,235 unique articles. ML techniques were used for diagnosis, prognosis, and image segmentation in carotid stenosis, aortic aneurysm/dissection, peripheral artery disease, diabetic foot ulcer, venous disease, and renal artery stenosis. The number of publications on ML in vascular surgery increased from 1 (1991-1996) to 118 (2016-2021). Most studies were retrospective and single center, with no randomized controlled trials. Area under the receiver operating characteristic curve (AUROC) ranged from 0.61-1.00, with 79.5% [62/78] studies reporting AUROC ≥ 0.80. Out of 22 studies comparing ML techniques to existing prediction tools, clinicians, or traditional regression models, 20 performed better and 2 performed similarly. Overall, 94.8% (201/212) studies had high risk-of-bias and adherence to reporting standards was poor with a rate of 41.4%. Interpretation: Machine learning has been increasingly applied to a broad range of vascular surgical conditions with good predictive value. However, overall risk-of-bias and reporting adherence are suboptimal. Future studies should consider standardized tools such as PROBAST and TRIPOD to improve study quality and clinical applicability. Funding: None. Declaration of Interest: All authors declare no competing interests

A Scoping Review on the Use of Antibiotic-Impregnated Beads and Applications to Vascular Surgery.

Surgical site infection (SSI) presents a ubiquitous concern to surgical specialties, especially in the presence of prosthetic material. Antibiotic-impregnated beads present a novel and evolving means to combat this condition. This review aims to analyze the quality of evidence and methods of antibiotic bead use, particularly for application within vascular surgery. A systematic scoping review was conducted within Embase, MEDLINE, and the Cochrane Registry of Randomized Controlled Trials. Articles were evaluated by 2 independent reviewers. Level of evidence was evaluated using the Oxford Center for Evidence-Based Medicine Criteria and the Cochrane Risk of Bias Tool for Randomized Controlled Trials. The search yielded 6951 papers, with 275 included for final analysis. Publications increased in frequency from 1978 to the present. The most common formulation was polymethyl methacrylate; however publications on biodegradable formulations, including calcium sulfate beads, have been published with increasing frequency. Most publications had positive conclusions (94.2%); however, the data was mainly subjective and may be prone to publication bias. Only 11 randomized controlled trials were identified and all but one was evaluated to be at a high risk of bias. The most common indication was for osteomyelitis (52%), orthopedic prosthetic infections (20%), and trauma (9%). Within vascular surgery, beads have been used primarily for the treatment of graft infection, with freedom from recurrence rates being reported from 41% to 87.5%. Antibiotic-impregnated beads provide a means to deliver high doses of antibiotic directly to a surgical site, without the risks of parenteral therapy. There has yet to be significant high-level quality data published on their use. There is a large body of evidence that suggests antibiotic beads may be used in SSIs in high-risk patients, prosthetic infections, and other complex surgical infections. Important potential areas of application in vascular surgery include graft infection, prevention of wound infection in high-risk patients, and diabetic foot infection.

A Survey of 2018 Integrated Vascular Surgery Applicants and Trends in the Integrated Vascular Surgery Match

The number of integrated “0+5” vascular surgery residency (VS-I) programs and their applicants have increased since 2008. This has resulted in increased cost to both the VS-I applicants and programs. Our objective was to assess the current cost of successfully matching into VS-I while describing the competitive nature of the match process using survey and historical data.

A survey of 0 + 5 vascular surgery residency candidates: Perceptions of an applicant pool.

Applications to integrated (0 + 5) vascular surgery residencies have increased, while total applications have stayed relatively constant. This survey sought to document the perceptions of 0 + 5 vascular surgery applicants. Academic faculty conducted interviews for 0 + 5 residency match at an academic medical center in preparation for the National Resident Matching Program (NRMP) Main Residency Match. Applicant pool (n = 20) perceptions were determined with surveys. Participation was anonymous and voluntary. Nineteen interviewees (26.3% female: 73.7% male), age (26.8 ± 2.6 years) responded (95% response rate). Of 19 respondents, 68% became interested in vascular surgery in their third year with 53% becoming aware of 0 + 5 programs in their third year. All respondents identified a vascular surgery attending at their institution as significant mentors. Forty-seven percent identified their mentor during their third year of medical school. All respondents felt that 0 + 5 training would prepare them adequately for the workforce and board certification exams. Almost all (89%) had plans to seek jobs immediately upon completion of residency. Applicants remained positive about their planned training and career paths. Attending vascular surgeons were identified as the strongest mentors, yet most students decided only in their third and fourth years to pursue 0 + 5 residencies. Educational debt remains a concern, and there may be consideration for a concerted effort to recruit potential candidates sooner.

A comparison of 0 + 5 versus 5 + 2 applicants to vascular surgery training programs

The new integrated 0 + 5 vascular surgery (VS) training paradigm introduced in 2007 required program directors and faculty to reconsider recruiting methods and exposure of medical students to VS. As a means to identify variables important for recruitment of 0 + 5 VS applicants, we sought to analyze national 0 + 5 VS residency application trends and to compare medical school demographics of applicants to both our 0 + 5 residency and 5 + 2 fellowship programs. Electronic Residency Application Service and National Resident Matching Program online public databases were queried to evaluate nationwide trends in the number of applicants to integrated VS residency programs between 2007 and 2010. Demographic data from Electronic Residency Application Service applications submitted to our institution's 0 + 5 and 5 + 2 VS training programs during the same time period were reviewed. From 2008 to 2011, there were 190 applicants to our 0 + 5 VS residency program and 161 applicants to our 5 + 2 fellowship program, with 127 (66.8%) and 122 (75.8%) being United States medical graduates, respectively. Annual application volume to our programs over these years remained stable for both training pathways (range, 39-49 for 0 + 5 integrated; range, 39-43 for 5 + 2 traditional). Nationally, applications to 0 + 5 programs increased sixfold over the same time period (52 in 2007 to 340 applicants in 2010; P < .001), far exceeding the available training positions. Compared with applicants to the 5 + 2 VS fellowships, medical students applying to the 0 + 5 programs are more likely to be female, be slightly older, have additional postgraduate degrees and publications, have higher United States Medical Licensure Examination test scores, and are more likely to be in the top quartile of their medical school class. Nationwide interest in the 0 + 5 vascular surgery residency training paradigm continues to significantly increase. Significant differences exist between the cohorts of 0 + 5 residency and 5 + 2 fellowship program applicants at the completion of medical school, suggesting that 0 + 5 VS residency programs are attracting a different medical student population to the VS specialty. VS program directors should continue to foster interest in this new applicant pool through early exposure, mentorship, and extracurricular research activities.

Computer-Aided Surgery: Concepts and Applications in Vascular Surgery

Computer-aided surgery makes use of a variety of technologies and information sources. The challenge over the past 10 years has been to apply these methods to tissues that deform, as do vessels when relatively rigid flexible objects are introduced into them (Lunderquist rigid guide wire, aortic prosthesis, etc) Three stages of computer-aided endovascular surgery are examined: sizing, planning, and intraoperative assistance. The authors' work shows that an approach based on optimized use of the imaging data acquired during the various observation phases (pre- and intraoperative), involving only lightweight computer equipment that is relatively transparent for the user, makes it possible to provide useful (ie, necessary and sufficient) information at the appropriate moment, in order to aid decision making and enhance the security of endovascular procedures.

A survey of demographics, motivations, and backgrounds among applicants to the integrated 0 + 5 vascular surgery residency

The 0 + 5 integrated vascular surgery (VS) residency has altered the training paradigm for future vascular specialists. Rising interest in these novel programs highlights our need to better understand the applicant pool. We compared demographics and surveyed recent applicants to our integrated program to gain more insight into their background and motivation for accelerated vascular training. Demographics and objective parameters were determined from all 65 applicants to the integrated VS program at Stanford University Medical Center and compared to 58 applicants interviewed by the general surgery (GS) program at Harbor-UCLA Medical Center by querying the Electronic Residency Application System for the programs in 2009. There was no overlap of applicants between programs. An anonymous, voluntary Web-based survey was sent to these cohorts with a response rate of 82% for VS applicants and 60% for GS applicants. Subjects were queried regarding their background, personal experience, prior exposure to VS, and motivations for residency specialty selection. Applicants to integrated VS programs tended to be older, were less likely to be from a US medical school, had a higher number of publications, and a higher percentage of cardiovascular-related publications than the GS applicants. When stratified by the 27 VS applicants (41%) that were offered an interview, this highly selected and desirable group for training was nearly 40% female, more likely to have an additional degree (PhD, master's), just as likely to be in the top quartile of their medical school class (60%), and score equally well on standardized board examinations (90th percentile) than the top GS applicants offered interviews. Survey data revealed that the majority of career choices (65%) were made during the third and fourth years of medical school. Factors most strongly influencing the decision to choose VS as a career were endovascular technologies/devices, challenging open vascular operations, clinical rotations on vascular surgery, the aging patient population, and perceived need for vascular surgeons and vascular surgeon mentorship. The most common reasons cited for particularly pursuing an integrated 0 + 5 VS training program were (1) more focused training/integration of cardiovascular medicine, (2) interest in catheter-based endovascular therapies, and (3) shorter time in training. Of the GS applicants, 58% indicated they would be interested in applying to an integrated residency in their subspecialty of interest, and 45% listed vascular surgery as a potential fellowship option after general surgery. Applicants to 0 + 5 integrated vascular residencies were more likely to have rotated on a vascular surgery service, observed vascular cases, identified a vascular surgery mentor, and been actively involved in cardiovascular research. The quality of the top VS applicant based on class rank and test scores is comparable to the top GS applicants, yet the VS applicant has a higher percentage of advanced degrees, more publications, and more involvement in cardiovascular research. Institutional strategies to increase medical student exposure to vascular surgery clinically and via research programs will optimize our ability to attract and train the best candidates in these new training programs.

Virtual angioscopy assessment for acute type B aortic dissection endovascular repair

Virtual angioscopy 3D reconstruction (VA) based on Multidetector computed tomography (m-CT) can be an important tool in endovascular aortic repair assessment. Here, we present a case of an acute type B aortic dissection, evaluated with preoperative virtual angioscopy 3D reconstruction (VA). A 60 years-old-man presented with type B acute aortic dissection. Due to renal malperfusion and uncontrolled hypertension TEVAR and renal stenting was performed based on m-CT and VA images. Aortic dissection endovascular repair requires an accurate evaluation based on M-CT or magnetic resonance angiography (MRA). VA is a CT-based 3D reconstruction that provides a sort of information comparable to intravascular ultrasound (IVUS) that can be very helpful when it is not available and has many other potential applications in vascular surgery.

Überwachung der zerebralen Integrität

In vascular surgery, intraoperative monitoring of the brain is recommended when the internal carotid artery (ICA) is clamped, because brain damage by ischemia and embolism is possible. Clamping of the ICA results in embolic or ischemic brain lesions in about 7 % of all patients undergoing the procedure. Prophylactic routine insertion of an intraluminal shunt can cause brain embolism and does not reduce the occurrence of complications. Consequently, a shunt should only be inserted, if critical reduction of cerebral perfusion is evident after clamping the ICA. Measurement of carotid stump pressure is an invasive method to estimate perfusion of the brain hemisphere at the clamping side. Transcranial doppler sonography (TCD) measures the mean blood flow velocity in the ACI, but practicability is suffering from technical problems in 20% of all patients. However, TCD is useful for detecting intraoperative embolism and postoperative hyperperfusion. Changes of oxyhaemoglobine and desoxyhaemoglobine concentration in brain tissue can be measured using near-infrared spectroscopy (NIRS) with wavelengths between 700 and 1000 nm. NIRS measurement is easily performed and reacts quickly to changes of brain tissue oxygenation, but there is still lacking evidence and at present a general recommendation of its application in vascular surgery is not justified. Use of somatosensory evoked potentials (SEP) is the most widespread cerebral neuromonitoring during vascular surgery due to its high reliability and simple application. Sensitivity and specifity for ischemic lesions are 100% and 94%-99%, respectively. SEP are regarded as the gold standard for cerebral neuromonitoring in anaesthetized patients.

Invited commentary

The authors’ manuscript reflects an area of growing interest in other specialties and should serve to stimulate research opportunities in vascular surgery. Articles relating to aspirin resistance have been published in the stroke and cardiology literature, where an increasing number of studies have shown an association between the incidence of adverse thrombotic events and aspirin resistance. The subject, however, has not been widely addressed in the vascular literature. While important, the manuscript must be taken in context. As noted by the authors, aspirin resistance is not yet clearly defined, and can be characterized by laboratory measures or adverse clinical events. Laboratory measures of platelet function can include in vivo testing, such as bleeding time. Ex vivo tests include the measurement of arachidonic acid metabolites, such as urinary 11-dehydro TXB2; measures of platelet-platelet interaction, such as optical or impedance aggregometry; point of care cartridge based analyzers, such as the PFA-100; and whole blood flow cytometry, which measures activation dependent changes on the platelet surface (such as CD62p, p-selectin; activated GPIIb/IIIa; leukocyte platelet aggregates), activation dependent signaling, and activation dependent release from platelets. Of concern, however, the reported incidence of aspirin resistance is variable, even using comparable techniques; resistance in studies employing aggregometry has ranged from 0.4% to 9%, and using the PFA-100 from 9% to 35%.1Dalen J.E. Aspirin resistance: Is it real? Is it clinically significant?.Am J Med. 2007; 120: 1-4Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Clinical studies have demonstrated a higher incidence of aspirin resistance among patients with a prior history of transient ischemic attack or stroke; high risk patients with a history of coronary artery disease have increased odds of being aspirin resistant.2Mason P.J. Jacobs A.K. Freedman J.E. Aspirin resistance and atherothrombotic disease.J Am Coll Cardiol. 2005; 46: 986-993Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar Mueller et al.3Mueller M.R. Salat A. Stangl P. Murabito M. Pulaki S. Boehm D. et al.Variable platelet response to low-dose ASA and the risk of limb deterioration in patients submitted to peripheral arterial angioplasty.Thromb Haemost. 1997; 78: 1003-1007PubMed Google Scholar followed 100 patients with intermittent claudication, treated with 100 mg of aspirin per day, for 18 months after balloon angioplasty. Only 40% of male patients showed the expected effect of aspirin using in vitro platelet aggregation. All reocclusions at the site of angioplasty occurred in this group. Higher vascular event rates have also been correlated with measures of aspirin resistance in several prospective studies. Aggregometry, urinary 11-dehydro TXB2 levels, and the PFA-100 have been used to assess platelet function. Interestingly, results from the PFA-100 did not correlate with aggregometry and did not correlate with vascular events.1Dalen J.E. Aspirin resistance: Is it real? Is it clinically significant?.Am J Med. 2007; 120: 1-4Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar The current study uses two techniques to assess laboratory evidence of aspirin resistance in patients on chronic aspirin therapy and illustrates the caution that must be exercised in interpreting results. Measurement of arachidonic acid induced expression of CD62p (P-selectin), using flow cytometry, demonstrates that all patients receiving aspirin show an aspirin effect, while PFA-100 closure times indicate 16% of patients taking aspirin show no effect of aspirin. The PFA-100 can be influenced by multiple variables, including platelet count, platelet function, red blood cells, and von Willebrand factor; and the outcome can be effected by variables, such as von Willebrand factor, that are not influenced by aspirin. None-the-less, the current study is a very nice introduction to the concept of aspirin resistance and provides an example of its application in vascular surgery. While the study demonstrates evidence of laboratory resistance, it has failed to exclude patient noncompliance as a source of “resistance” and has not correlated laboratory resistance with clinical evidence of adverse events. The study also demonstrates that laboratory measures can influence the extent and character of laboratory defined resistance. Future studies could randomize aspirin therapy and laboratory adjusted aspirin therapy, based on identified resistance; verification of compliance and documentation of clinical outcomes should be incorporated.

Analysis of the Current Applicant Pool to Vascular Surgery: Who Are They and Where Do They Come From?

There is a manpower crisis in vascular surgery. There may be too few vascular surgeons to meet the demands imposed by the aging of the "Baby-Boom" generation. More than 20% of vascular surgery positions were not filled through the match in 2004 and 2005. The number of vascular surgery training positions has doubled in the past 15 years, based on manpower studies projecting a need for additional vascular surgeons. During the same time period, the number of vascular surgery applicants has remained static. In addition, the proportion of international medical graduates has increased significantly. Furthermore, medical students appear to be selecting "lifestyle-friendly" specialties, such as emergency medicine, radiology, ophthalmology, anesthesiology, and dermatology, with increasing frequency. Approximately 60% of undergraduates in the United States and almost 50% of graduating medical students are currently women. Yet only about 25% of general surgery residents and less than 20% of current vascular surgery trainees are women. Strategies to expand the applicant pool for vascular surgery are needed and discussed in this article.