Vascular Surgery Practice Research Articles

Arteriovenous hemodialysis access: The Society for Vascular Surgery practice guidelines

Arteriovenous hemodialysis access: The Society for Vascular Surgery practice guidelines

Fool me once, shame on you; fool me twice, shame on me! A perspective on the emerging world of percutaneous heart valve therapy

Fool me once, shame on you; fool me twice, shame on me! A perspective on the emerging world of percutaneous heart valve therapy

A percutaneous arterial closure protocol can decrease complications after endovascular interventions in vascular surgery patients

Complications following percutaneous femoral access are a significant source of morbidity and cost in patients undergoing peripheral vascular interventions. Our purpose in this study is to determine if access complications could be reduced by the use of a standardized protocol. We studied prospectively 210 consecutive patients in our vascular surgery practice undergoing peripheral arterial interventions via percutaneous retrograde femoral access. First, we prospectively collected data to determine current outcomes during a 4-month observation phase. Based on these experiences, we designed and implemented a uniform arterial closure protocol, with closure device use guided by sheath size, arterial calcification, and previous groin scarring. Our main outcome measures were major complications (need for operation) or minor complications (access site bleeding or hematoma). Outcomes were compared between the two phases using chi-squared analysis and analysis of variance (ANOVA). In the observation phase, 119 patients underwent 140 arterial punctures, and in the postprotocol phase, we performed 112 punctures in 91 patients. Between the observation and postprotocol phases, patient demographics were similar; average sheath size was unchanged (sheaths over 6F 6% vs 8%, respectively, P = .55), and percentage of patients receiving heparin did not change significantly (76% vs, 86%, P = .08). No major complications occurred in either the observation or the postprotocol phases. While 24 minor complications occurred in the observation phase, only seven minor complications occurred in the postprotocol phase (17% vs 7%, P < .02). Closure device use decreased with protocol implementation (57% to 32%, P < .01), but closure device failures also decreased from 23% to 7% (P < .01). Process improvement, achieved by instituting a standardized percutaneous arterial closure protocol based on selective closure device use guided by sheath size, arterial calcification, and previous access scarring. Implementation of our protocol resulted in a decrease in the incidence of minor complications at the access site and refined patient selection for closure device use.

Subintimal angioplasty: Our experience in the treatment of 506 infrainguinal arterial occlusions

The treatment of patients with chronic arterial occlusions involving the superficial femoral artery has changed significantly with the incorporation of subintimal angioplasty (SIA) into vascular surgery practice. To more clearly define technical feasibility, patency, and clinical outcomes of SIA, we reviewed our cumulative experience. A retrospective review of all patients who underwent SIA of arterial occlusions originating in the superficial femoral artery was performed. Patient history, demographics, procedural details, and follow-up information were collected and analyzed. Patency, limb salvage, sustained improvement in claudication, freedom from surgical bypass, and survival were determined by Kaplan-Meier analysis. From December, 2002, through July, 2006, 506 infrainguinal SIA procedures were performed in 472 patients with chronic arterial occlusion involving the superficial femoral artery. The mean age of patients treated was 69.4 +/- 11.9 years and the indication for intervention was critical limb ischemia in 63% of limbs (n = 317) and disabling claudication in 37% (n = 189). Forty-seven percent of limbs (n = 237) had isolated SFA occlusions, 40% (n = 205) had femoropopliteal occlusions, and 13% of limbs had occlusions beginning in the SFA and extending into the tibial arteries (n = 64). Technical success was achieved in 87% of procedures. Following successful SIA, the mean ankle-brachial index increased by 54%, from 0.50 +/- 0.16 to 0.77 +/- 0.23 (P < .0001). Median follow-up was 12.4 months (0-48 months) and 30-day mortality was 0.8%. Primary patency at 12 and 36 months was 45% (SE 3.0%) and 25% (SE 3.6%) respectively. Secondary patency was 76% (SE 2.6%) and 50% (SE 4.8%) at 12 and 36 months. Factors associated with reduced primary patency included femorotibial occlusions (HR 1.57, CI 1.05-2.36) and the presence of critical limb ischemia (HR 1.39, CI 1.02-1.89). Limb salvage in patients with critical limb ischemia was 75% (SE 5.9%) at 36 months. Freedom from surgical bypass in patients with either critical limb ischemia or disabling claudication was 77% (SE 4.1%) at 36 months. SIA is an effective percutaneous technique for the revascularization of patients with lower extremity chronic arterial occlusions involving the superficial femoral artery. The procedure is successfully performed in all segments of the lower extremity with minimal morbidity or mortality. Rates of limb salvage and improvement in claudication are similar to those achieved by open surgical bypass, while modest reductions in limb salvage and primary patency are experienced in limbs with femorotibial occlusions.

Operative mortality for renal artery bypass in the United States: Results from the National Inpatient Sample

The mortality rate for renal artery bypass grafting (RABG) is reported to be 0% to 4% for patients with renovascular hypertension and 4% to 7% for patients with ischemic nephropathy. However, these data come from high-volume referral centers known for their expertise in treating these conditions. Because of the relative infrequency of these operations in most vascular surgery practices, the nationwide outcomes for RABG are not known. The purpose of this study was to define the operative mortality rate for RABG in the United States and to identify risk factors for perioperative mortality. The National Inpatient Sample was analyzed to identify patients undergoing RABG for the years 2000 to 2004. Categoric data were analyzed using chi(2) and the Cochran-Armitage trend tests. Multivariate logistic regression analyses were performed to identify risk factors for perioperative mortality after RABG. During the study period, 6608 patients underwent RABG, representing a frequency of 3.51 operations per 100,000 discharges. More than two-thirds were performed at teaching hospitals (4564 vs 2,044; P < .0001). The frequency of RABG decreased by 30.7% between 2000 and 2004 (4.28 vs 2.96 RABGs per 100,000 discharges; P for trend < .0001). The in-hospital mortality for RABG was 10.0%. On univariate analysis, in-hospital mortality after RABG varied with increasing age, race, region of the country, and a preoperative history of chronic renal failure, congestive heart failure, or chronic lung disease. Logistic regression models identified advanced age (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.44-1.72], female gender (OR, 1.20; 95% CI, 1.02-1.41), and a history of chronic renal failure (OR, 2.21; 95% CI, 1.75-2.78), congestive heart failure (OR, 1.94; 95% CI, 1.44-2.62), or chronic lung disease (OR, 1.40; 95% CI, 1.18-1.67) as independent markers of risk-adjusted, in-hospital mortality (P < .0001 for each of these five variables). Nationwide in-hospital mortality after RABG is higher than predicted by prior reports from high-volume referral centers. Advanced age, female gender, and a history of chronic renal failure, congestive heart failure, or chronic lung disease were predictive of perioperative death. For the typical vascular practice, these data may provide a rationale for lower risk alternatives, such as renal artery stenting or referral to high-volume referral centers for RABG.

Invited commentary

In this series of patients receiving an initial, autogenous arteriovenous fistula (AVF), the reported primary patency at 1 year (36%) is low relative to other series. The authors attribute this to an aggressive approach to the placement of autogenous fistulas. In concluding, they note that adherence to the Kidney Disease Outcomes Quality Initiative (K/DOQI) strategy may not result in increased AVF utilization and may prolong catheter dependence. While the manuscript describes their experience after publication of the K/DOQI guidelines, not all elements of the guidelines were followed. For the placement of an AVF to occur in a timely manner: (1) patients must have access to the healthcare system; (2) chronic kidney disease must be recognized by primary providers; (3) patients must be referred to nephrologists for pre-dialysis care; and (4) nephrologists must make timely referral for hemodialysis access assessment and placement. For the patients in this series, there was a breakdown in one or more of these elements, as 78% of those referred for placement of first time vascular access were already dialyzing via central venous catheters. Once surgical referral occurs, K/DOQI emphasizes the importance of preoperative vein mapping, arterial assessment, and the preferred order of access placement to optimize the chance of maturing a functional fistula. Based on current literature and K/DOQI guidelines, arteries should be at least 2 mm and veins at least 2.5 mm, in diameter.1National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines and Clinical Practice Recommendations.http://www.kidney.org/PROFESSIONALS/kdoqi/guideline_upHD_PD_VA/va_guide1.htmGoogle Scholar, 2Silva Jr, M.B. Hobson 2nd, R.W. Pappas P.J. Jamil Z. Araki C.T. Goldberg M.C. et al.A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation.J Vasc Surg. 1998; 27 (discussion 307-8): 302-307Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar The order of preferred AVF placement is radiocephalic > brachiocephalic > brachiobasilic > arteriovenous grafts.1National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines and Clinical Practice Recommendations.http://www.kidney.org/PROFESSIONALS/kdoqi/guideline_upHD_PD_VA/va_guide1.htmGoogle Scholar The authors are to be commended for a critical review of their experience, which highlights opportunities for change that may ultimately impact long-term functional patency. The study indicates that there is, perhaps, a role for a unified approach to dialysis access. It is possible that patency may have been adversely impacted by the disparate approach of the 15 surgeons in this group and their lack of adherence to K/DOQI guidelines. Some of the surgeons proceeded directly to use of a prosthetic graft when patients were not candidates for radiocephalic or brachiocephalic fistulas, instead of attempting a brachiobasilic fistula. Only 76% of patients in this study underwent preoperative mapping. Despite mapping, veins with diameters as small as 1.3 mm were used for fistulas. Even after access had been placed, times to cannulation seem prolonged. While we have a limited understanding of why fistulas fail, we do know that fistulas are more likely to fail when minimum requirements are not met. A standardized approach is crucial not only for clinical outcomes, but for our ability to study access outcomes. The goal is not to simply place an AVF, but to place an access that can be utilized for hemodialysis. The natural history of autologous fistulas as first-time dialysis access in the KDOQI eraJournal of Vascular SurgeryVol. 47Issue 2PreviewPatients on hemodialysis depend on durable, easily maintained vascular access. The autologous arteriovenous fistula (AVF) has been the gold standard since the introduction of the Brecia-Cimino fistula in 1966 and is echoed in the current Kidney Disease Outcomes and Quality Initiative (KDOQI) guidelines. The purpose of this study is to determine the natural history of AVF in patients requiring first-time permanent access in a large academic vascular surgery practice. Full-Text PDF Open Archive

Innovations in the treatment of ruptured AAA may improve future outcome

EditorialInnovations in the treatment of ruptured AAA may improve future outcomeLachat and EnzlerLachat Clinic for Cardiovascular Surgery, University Hospital Zürich Search for more papers by this author and Enzler Gefäß-Zentrum, Klinik Hirslanden, Zürich, Switzerland Search for more papers by this authorPublished Online:March 14, 2013https://doi.org/10.1024/0301-1526.36.4.227PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreFiguresReferencesRelatedDetailsCited byOperative Strategy of Ruptured Abdominal Aortic Aneurysms and Management of Postoperative ComplicationsAnnals of Vascular Diseases, Vol. 12, No. 3Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery AneurysmsEuropean Journal of Vascular and Endovascular Surgery, Vol. 57, No. 1The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysmJournal of Vascular Surgery, Vol. 67, No. 1Western Vascular Society guidelines for transfer of patients with ruptured abdominal aortic aneurysmJournal of Vascular Surgery, Vol. 65, No. 3The Future of EVAR in the Management of Ruptured AAAsJournal of Endovascular Therapy, Vol. 16, No. SupplementI Volume 36Issue 4November 2007ISSN: 0301-1526eISSN: 1664-2872 InformationVasa (2013), 36, pp. 227-228 https://doi.org/10.1024/0301-1526.36.4.227.© 2013Hogrefe AGPDF download

George Kennedy (“Ken”) Hempel Jr., MD: A Conversation with the Editor

Ken Hempel (Figure ​(Figure11) has lived virtually his entire life in Dallas, Texas. He was born on October 25, 1934. He graduated from public schools, including Highland Park High School, where he was a star athlete. He married Ruth Barrett, his sweetheart from the eighth grade, as a senior in high school, and they have been married ever since. Ken attended Southern Methodist University (SMU) and after 3 years there entered Southwestern Medical School, where he obtained his medical degree in 1959. He did a rotating internship at Baylor University Medical Center (BUMC) and then entered the general surgery program of Parkland Hospital after a brief stint in Iowa City. After completing his residency in 1965, he spent 1 year in Houston at Methodist Hospital doing a cardiovascular fellowship under Dr. Michael E. DeBakey and his colleagues. In 1966, he entered the US Army Medical Corps, where he remained for 2 years before returning to Dallas and beginning a private practice of both vascular and general surgery. Within a few years, he became a major player at BUMC, where he has practiced for over 40 years. He and Ruth are the proud parents of three children. Ken is truly a great guy and a pleasure to be around. I met him years ago when we were both attending SMU, and I have kept up with him periodically since that time. It was a pleasure interviewing him; I am grateful he agreed.

The Economics of Vein Disease

The management of cosmetic vein problems requires a very different approach than that for the majority of most other vascular disorders that occur in a vascular surgery practice. This article focuses on the business aspects of a cosmetic vein practice, with particular attention to the uniqueness of these issues. Managing patient expectations is critical to the success of a cosmetic vein practice. Maneuvering within the insurance can be difficult and frustrating for both the patient and the practice. Practices should use cost accounting principles to evaluate the success of their vein work. Vein surgery--especially if performed within the office--can undergo an accurate break-even analysis to determine its profitability.

Prospective decision analysis for peripheral vascular disease predicts future quality of life

Decision making for peripheral vascular disease can be quite complex as a result of pre-existing compromise of patient functional status, anatomic considerations, uncertainty of favorable outcome, medical comorbidities, and limitations in life expectancy. The ability of prospective decision-analysis models to predict individual quality of life in patients with lower extremity arterial occlusive disease was tested. This was a prospective cohort study. The settings were university and Veterans Administration vascular surgery practices. All 214 patients referred with symptomatic lower extremity arterial disease of any severity over a 2-year period were screened, and 206 were enrolled. A Markov model was compared with standard clinical decision-making. Utility assessment and generalized (Short Form-36; SF-36) and disease-specific (Walking Impairment Questionnaire; WIQ) quality of life were derived before treatment. Estimates of treatment outcome probabilities and intended and actual treatment plans were provided by attending vascular surgeons. The main outcome measures were generalized (SF-36) and disease-specific (WIQ) variables at study entry and at 4 and 12 months. Primary intervention consisted of amputation for 9, bypass for 42, angioplasty for 8, and medical treatment for 147 patients. Considering all patients, no improvement in mean overall patient quality of life measured by the SF-36 Physical Component Score (27 +/- 8 vs 28 +/- 8; P = .87) or WIQ (39 +/- 22 vs 39 +/- 23; P = .13) was noted 12 months after counseling and treatment by the vascular surgeons. Individually considered SF-36 categories were improved only for Bodily Pain (40 +/- 23 vs 49 +/- 25; P = .03), with the most significant improvement observed among patients with the most severe pain (68 +/- 25 vs 37 +/- 23; P = .02) and among those undergoing bypass (60 +/- 29 vs 31 +/- 22; P = .02). It is noteworthy that when the treatment chosen was incongruent with the Markov model, patients were more likely to report a poorer quality of life at 1 year (Physical Component Score, 25 +/- 8 vs 29 +/- 8; P < .001). The quality of life predicted at baseline by the Markov model correlated positively with the Physical Component Score (r = 0.23), Bodily Pain (r = 0.33), and Fatigue (r = 0.44) and negatively with WIQ (r = -0.08) observed 1 year later. Prospective application of an individualized decision Markov model in patients with vascular disease was predictive of patient quality of life at 1 year. The patient's outcome was worse when the treatment received did not follow the model's recommendation. This decision analysis model may be useful to identify patients at risk for poor outcomes with standard clinical decision making.

Vascular surgery training and certification: An international perspective

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

Impact on physician workload and revenue following the creation of a specialty vein clinic within an academic vascular practice

To evaluate the impact of creating a new specialty vein clinic within an academic-based vascular practice on clinical volume, physician workload and financial parameters. All patients evaluated and treated for varicose vein related problems within an academic vascular surgery practice were identified from institutional billing databases. Data were stratified according to the time period prior to establishing a vein clinic (PRE-VC) (1999-2001) and after creation of a vein clinic (POST-VC) (2002-2004). Clinical volume, physician workload and financial parameters were evaluated. Comparisons were made between vein (VEIN) and overall vascular (VASC) practice trends. Comparison of clinical volume, physician workload and financial parameters in both the clinic and operative settings showed larger and more rapid expansion of the VEIN practice than VASC practice between PRE-VC and POST-VC time periods (VEIN vs.VASC growth, respectively: new patient clinic volume +162 vs. +18%; clinic relative value units (RVUs) +131 vs. +1%, clinic revenue +201 vs. +44%; procedure volume +348 vs. +19%; procedure RVUs +129 vs. +11%; procedure revenue +93 vs. +10%). Comparing the beginning of PRE-VC to the end of POST-VC time periods, an increasing trend was also present for the percentage of VEIN practice accounting for the total VASC practice (%VEIN PRE-VC to POST-VC, respectively: new patient clinic volume 11.6-30.2%; clinic RVUs 3.2-48.2%; clinic revenue 17.6-31.2%; procedure volume 3.1-14.3%; procedure RVUs 2.8-9.8%; procedure revenue 3.3-11.7%). Establishing a specialty vein clinic within an academic vascular practice can lead to a rapid expansion of clinical volume with associated increase in physician workload and reimbursement at a rate greater than that for the overall vascular practice.

The Evolution of Practice and Training in Vascular Surgery

The Evolution of Practice and Training in Vascular Surgery

Percutaneous Interventions in Dialysis Access

The creation and long-term management of dialysis accesses has been and remains a challenging aspect of vascular surgery practice. Until recently, vascular surgeons relied on open techniques to salvage and maintain dialysis fistulas and grafts. In the last 10 years, percutaneous approaches have become widely adopted and to this day continue to be refined as new devices and techniques are developed. Recent series have found similar technical success rates to open surgery, with the best results seen in the treatment of short-segment and anastomotic stenoses. Percutaneous interventions also allow for treatment of remote and surgically inaccessible lesions such as central vein stenoses. Some of the pitfalls of this approach include the exposure to thrombolytics, intravenous contrast, and radiation. Nevertheless, despite these limitations, a percutaneous approach has become first-line therapy in dialysis access management.

Establishment of a Varicose Vein Center in a Tertiary Vascular Surgery Practice: Urban Versus Rural Differences

We examined changes in practice patterns after the establishment of a varicose vein center (VVC) within two tertiary university vascular surgery practices and compared differences between urban (U) and rural (R) sites. Practice patterns for the treatment of VVs were compared 3 years before (period 1) and 3 years after (period 2) the formation of a U-VVC and an R-VVC in 2001. Both VVCs were part of similar-sized tertiary vascular surgery practices. Evaluation was specific to VVs, reticular veins, and telangiectasias. Prior to U-VVC, there were 338 office visits, six office procedures, and 114 hospital procedures. After U-VVC, there were 624, 120, and 312, respectively. Prior to R-VVC, there were 85 office visits, five office procedures, and 69 hospital procedures. After R-VVC, there were 528, 163, and 303, respectively. In period 1 for U-VVC and R-VVC, VVC relative value unit (RVU) generation as a percent of total practice RVUs was 1.0% and 0.7%, respectively. In period 2 for U-VVC and R-VVC, VVC RVU generation as a percent of total practice RVUs was 2.6% and 2.5%, respectively. In an effort to provide more coordinated treatment for patients with VVs, establishing a VVC within a tertiary academic vascular surgery practice can lead to rapid expansion of clinical volume by increased office visits, office procedures, and hospital procedures. Clinical demand for evaluation and treatment of VVs showed little variation between R-VVC and U-VVC.

Deep Vein Thrombosis Through Remnant Great Saphenous Vein Following Vein Harvest

Great saphenous vein (GSV) harvest is common practice in vascular and cardiothoracic surgery. Thrombosis of the proximal remnant of vein with propagation into the femoral vein has not been reported before. The distal half of the GSV was harvested for remote grafting of an axillary artery injury. Three months later the patient presented with thrombosis of the proximal remnant with extension of the thrombus into the femoral vein. This was successfully treated by high ligation and extraction of thrombus. Leaving a proximal remnant of the GSV in the thigh can lead to thrombosis, and the potential lethal complication of thrombus extension through the sapheno-femoral junction with the possibility of pulmonary embolism. We suggest that if the great saphenous vein is harvested in the distal thigh, the sapheno-femoral junction should be flush-ligated to prevent this complication.

Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia

To examine wound healing and the functional natural history of patients undergoing infrainguinal bypass with reversed saphenous vein for critical limb ischemia (CLI). Consecutive patients undergoing infrainguinal bypass for CLI were retrospectively entered into a technical and functional outcomes database. The patients were enrolled from the tertiary referral vascular surgery practices at the University of Colorado Health Sciences Center and Southern Illinois University Medical School. Main outcome variables included wound healing, self-assessed degree of ambulation (outdoors, indoors only, or nonambulatory), and living status (community or structured) after a mean follow up of 30 +/- 23 months. These outcome variables were assessed relative to the preoperative clinical characteristics (symptom duration before vascular consultation, lesion severity, and serum albumin level) and graft patency. From August 1997 through December 2004, 334 patients (253 men; median age, 68 years) underwent 409 infrainguinal bypasses (157 popliteal, 235 tibial, and 17 pedal) for CLI (159 Fontaine III and 250 Fontaine IV). Perioperative mortality was 1.2%. At 1 and 3 years, respectively, the primary patency was 63% and 50%, assisted primary patency was 80% and 70%, limb salvage was 85% and 79%, and survival was 89% and 74%. Complete wound healing at 6 and 12 months was 42% and 75%, respectively. Thirty-four patients (10%) died before all wounds were healed. Multivariate analysis indicated that extensive pedal necrosis at presentation independently predicted delayed wound healing (P < or = .01). At baseline (defined as the level of function within 30 days before the onset of CLI), 91% of patients were ambulatory outdoors, and this decreased to 72% at 6 months (P < or = .01). Similarly, 96% of patients lived independently at baseline, and this decreased to 91% at 6 months (P < or = .01) Graft patency was associated with better ambulatory status at 6 months. A longer duration of symptoms before vascular consultation was associated with a worse living status at 6 months. Despite achieving the anticipated graft patency and limb salvage results, 25% of patients did not realize wound healing at 1 year of follow-up, 19% had lost ambulatory function, and 5% had lost independent living status. Prospective natural history studies are needed to further define the functional outcomes and their predictors after infrainguinal bypass for CLI.

Proceedings of the TCT: Endovascular Interventional Care Evolves into Multidisciplinary Field

The creation, and expansion, of the heretofore nonexistent field of endovascular intervention has progressed quickly over the past 10-15 years. In a relatively short period of time, it has been instrumental in transforming both the care of the vascular patient and the practice of vascular surgery and cardiology.

Current guidelines produce competent endovascular surgeons

This study was conducted to evaluate the safety of percutaneous endovascular procedures (PEPs) during integration of endovascular skills into an urban academic vascular surgery practice and assess the hypothesis that currently accepted guidelines are a valid benchmark for endovascular competency. From 2000 through 2004, an endovascular training paradigm was instituted to integrate endovascular procedures into an academic endovascular practice. The paradigm involved individual mentoring of vascular surgery faculty by a partner with mature endovascular skills. Mentoring continued until each surgeon achieved a procedural experience of 100 diagnostic angiograms and 50 percutaneous endovascular interventions. Once achieved, privileges were granted for independent endovascular practice. To assess the effectiveness of the training process and competency of the newly trained endovascular practitioner, the surgeon-specific 30-day incidence of major complications and deaths for all PEPs performed during and after the mentoring process was determined. Complications and deaths were assigned to the mentor during the training process and to the individual surgeon once endovascular privileges were granted. Complications were classified as local vascular, local nonvascular, or systemic/remote. From 2000 through 2004, 1208 PEPs were performed. During this time, three faculty surgeons achieved sufficient endovascular procedural experience and were granted endovascular privileges. Major complications consisted of 17 local vascular, three local nonvascular, and four systemic/remote. Three deaths occurred. Renal percutaneous transluminal angioplasty/stent procedures had the highest complication and death rate at 9%. The major complication and death rate per year was 1.8% to 4.9% (P = .32) and did not significantly vary. The major complication and death rate for all 1208 PEPs was 2.2%. The surgeon-specific complication and death rate was 1.9% to 3.6% (P = .14) and did not vary between surgeons. Endovascular skills can be safely transferred using a vascular surgeon-based training paradigm. When the training paradigm is directed at satisfying currently recommended guidelines for endovascular privileging, competent endovascular surgeons are the result.

Meeting AHA/ACC secondary prevention goals in a vascular surgery practice: An opportunity we cannot afford to miss

In an effort to reduce cardiovascular mortality, patients with atherosclerotic arterial disease should undergo risk factor modification according to the American Heart Association/American College of Cardiology (AHA/ACC) Secondary Prevention Guidelines (hereafter, Guideline). We assessed compliance with the Guideline in a group of patients seen in a vascular surgery practice. We evaluated 200 consecutive patients with lower-extremity occlusive disease, cerebrovascular disease, or abdominal aortic aneurysm seen by a university-based vascular surgery practice. The subjects were patients who had been seen previously in our clinic (ESTABLISHED) and new referrals (NEW). Data pertinent to each of the nine AHA/ACC Guideline goals were collected from patient interviews, medication histories, and laboratory records. Compliance with each of the Guideline goals was evaluated. Differences in compliance between ESTABLISHED and NEW patient groups were also compared. We also recorded whether a patient had a previous endovascular or open surgical vascular intervention (EVENT or NO EVENT). Differences in compliance between the EVENT and NO EVENT groups were compared. Most patients did not achieve the secondary prevention goals recommended in the Guideline. Patients who had a prior vascular intervention (EVENT) were significantly more likely to achieve goals for low-density lipoprotein level (43% vs 23%), and for statin (71% vs 39%), beta-blocker (46% vs 27%), angiotensin-converting enzyme inhibitor (53% vs. 35%), and antiplatelet agent (85% vs. 68%) use (P < .05). ESTABLISHED patients were significantly more likely than NEW patients to have a prior EVENT (87% vs 47%, P < .0005). ESTABLISHED patients were significantly more likely than NEW patients to achieve goals for low-density lipoprotein level, beta-blocker, and statin use; however, these differences were likely due to the higher proportion of EVENT patients in the ESTABLISHED group. Compliance with the Guideline is suboptimal in patients with atherosclerotic arterial disease. Secondary prevention goals were more often achieved in the EVENT patient group, suggesting that a vascular intervention may lead to increased patient and physician awareness and compliance with the Guideline. A targeted effort towards risk factor modification in patients with atherosclerotic arterial disease could improve compliance with the Guideline and reduce cardiovascular mortality.