Society For Vascular Surgery Research Articles

Vascular surgery in Germany: results from a survey and analysis of quality reports of the German Society for Vascular Surgery and Vascular Medicine

Vascular surgery in Germany: results from a survey and analysis of quality reports of the German Society for Vascular Surgery and Vascular Medicine

1247 A Service Review to Assess the Liverpool Vascular and Endovascular Services’ (LIVES) Compliance to Targets Set by the Society for Vascular Surgery (SVS) Guidelines for the Care of Ruptured AAA Patients

1247 A Service Review to Assess the Liverpool Vascular and Endovascular Services’ (LIVES) Compliance to Targets Set by the Society for Vascular Surgery (SVS) Guidelines for the Care of Ruptured AAA Patients

Long-term results of fenestrated and branched endovascular aneurysm repair for complex abdominal and thoracoabdominal aortic aneurysms in young and fit patients

BackgroundEndovascular repair of complex abdominal aortic aneurysms (CAAAa) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched devices (F/BEVAR) represents the first-line treatment in old or unfit patients. Currently, the widespread diffusion of these techniques has led to a progressive increase of complex endovascular procedures also in younger and fitter patients, but the related results have been only minimally reported, without long-term data. We investigated the long-term results of F/BEVAR for CAAA and TAAA repair in young and fit patients. MethodsAll consecutive patients, aged ≤70 years, who underwent F/BEVAR for CAAA and TAAA over the last 13 years at two tertiary institutions were included in the study. All subjects presented a low to intermediate risk according to the Society for Vascular Surgery clinical comorbidity grading system. The primary end points were technical and clinical success and late overall and aortic-related survival. Major complications and specific target vessel-related outcomes were investigated as secondary end points. ResultsA total of 183 patients (155 males [84.7%]; mean age, 64.5 ± 5.7 years; range, 33-70 years) underwent F/BEVAR during the study period, for a total of 167 degenerative (91.3%) and 16 postdissection (8.7%) aneurysms, including 44 (24%) juxtarenal, 33 (18%) pararenal, and 106 (58%) TAAAs. Technical and clinical success were achieved in 176 patients (96.2%) and 171 patients (93.4%), respectively. Four patients (2.2%) died perioperatively, of which two (1.1%) operated in emergency. Postoperatively, five patients (2.7%) presented permanent grade 3 spinal cord injury and three (1.6%) renal failure needing permanent dialysis. The mean follow-up was 65.7 ± 39.6 months (range, 1-158 months). The estimated overall and aortic-related survival at 12, 60, and 120 months was 94.0%, 85.1%, 72.2%, and 97.8%, 97.8%, 96.2%, respectively, and reintervention and branch instability-free survival at the same time points were 84.4%, 71.8%, 71.8%, and 93.2%, 86.3%, 72.2%, respectively. An aneurysm growth of >5 mm was detected in six patients (3.3%), and a sac shrinkage of >5 mm was achieved in 118 cases (64.5%). The Cox regression analysis demonstrated the need for unplanned procedure as the only risk factor for overall mortality (odds ratio, 3.331; 95% confidence interval, 1.397-7.940; P < .01]. ConclusionsF/BEVAR in young and fit patients led to low perioperative mortality and major morbidity rates and a favorable overall survival rate in the long-term, making this technique particularly appealing in such a subgroup of patients. The availability of long-term data derived from the results of young patients, may additionally provide helpful information to redefine the indications for treatment and allow future targeted device and technique improvements.

Vascular complications secondary to resuscitative endovascular balloon occlusion of the aorta placement at a Level 1 Trauma Center: Presented at the Fiftieth Annual Symposium of the Society for Clinical Vascular Surgery, Miami, Florida, March 25-29, 2023.

Vascular complications secondary to resuscitative endovascular balloon occlusion of the aorta placement at a Level 1 Trauma Center: Presented at the Fiftieth Annual Symposium of the Society for Clinical Vascular Surgery, Miami, Florida, March 25-29, 2023.

Long-term outcomes in the smoking claudicant after peripheral vascular interventions: Presented at the 2023 Vascular Annual Meeting of the Society for Vascular Surgery, National Harbor, Maryland, June 14-17, 2023.

Long-term outcomes in the smoking claudicant after peripheral vascular interventions: Presented at the 2023 Vascular Annual Meeting of the Society for Vascular Surgery, National Harbor, Maryland, June 14-17, 2023.

Diagnosis and treatment of venous leg ulcers: S2k Guideline of the German Society of Phlebology and Lymphology (DGPL) e.V.

This S2k guideline on venous leg ulcers was created on the initiative and under the leadership of the German Society of Phlebology and Lymphology (DGPL). The guideline group also consisted of representatives from the German Society for Phlebology and Lymphology, German Dermatological Society, German Society for General Medicine, German Society for Angiology, German Society for Vascular Surgery and Vascular Medicine, German Society for Surgery, German Society for Dermatosurgery, German Society for Wound Healing and Wound Treatment, Professional Association of Phlebologists and Lymphologists and Initiative Chronische Wunden. The aim of this guideline is to combine the different approaches and levels of knowledge of the respective professional groups on the basis of consensus, so that a basic concept for the best possible treatment of patients with venous leg ulcers can be provided. A total of 70 specific recommendations were formulated and agreed upon, divided into the subject areas of diagnostics, therapy, prevention of recurrences, and everyday challenges. The guideline thus reflects the current state of scientific knowledge and is intended to be widely used as the best available document for the treatment of patients with venous leg ulcers in everyday clinical practice.

The evolution and impact of the Society for Vascular Surgery Resident and Student Program

ObjectiveThere is an ongoing national shortage in the vascular surgery (VS) workforce. To increase interest in the specialty, the Society for Vascular Surgery (SVS) Resident and Student Outreach Committee (RSOC) developed a dedicated general surgery (GS) resident and medical student (MS) program at the Vascular Annual Meeting (VAM) and invested in a scholarship program to help reduce attendee expenses. This study assesses the program’s effectiveness, correlating recipient feedback with the likelihood of matching into a VS training program. MethodsRecords related to the SVS VAM GS resident and MS program from 2013 to 2023 were reviewed, focusing on attendee evaluations of the program. The program included a simulation session from 2013 to 2019. VS training program match rates among scholarship recipients were determined. The annual average match rate in VS was used to divide the survey responses into two groups: below average (BA) and above average (AA) match rate groups. Survey responses were based on a 5-point Likert scale and allowed for comments. Responses were divided into high value, strongly favoring the activity (scores 4-5), and low value (scores 1-3) categories. The survey responses from the group of years with AA match rates were compared with the group of years with BA rates. ResultsThe SVS awarded 1040 GS resident and MS travel scholarships over the 10 years assessed. Overall, applicants had a 43% success rate in receiving a scholarship. During the study period, the annual number of applicants increased, whereas the number of scholarships and match success rates significantly decreased. The average match rate into VS among scholarship recipients was 50.2%. The survey response rate was 33%. During AA match rate years, evaluations for simulation allotted time and lectures were significantly more likely to be high value compared with BA years. Simulation content and the residency fair consistently had the most favorable evaluations (>90% high value), and overall, the program had a consistently positive impact on recipients’ interest in VS (>90% high value). Trainees in the AA group were significantly more likely to provide positive comments (73% vs 55%; P < .001). Numerous recipients commented on the need for a dedicated space to interact with faculty and mentors and highlighted simulation as the standout aspect of the program. ConclusionsThe SVS VAM RSOC program is positively correlated with attendee interest in VS, with approximately 50% of scholarship recipients matching into the field. The quality of the program and the number of scholarships correlate with VS match rates. Additional investments in similar programs could help close the workforce gap.

Volumetric analysis of acute uncomplicated type B aortic dissection using an automated deep learning aortic zone segmentation model

BackgroundMachine learning techniques have shown excellent performance in three-dimensional medical image analysis, but have not been applied to acute uncomplicated type B aortic dissection (auTBAD) using Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS)-defined aortic zones. The purpose of this study was to establish a trained, automatic machine learning aortic zone segmentation model to facilitate performance of an aortic zone volumetric comparison between patients with auTBAD based on the rate of aortic growth. MethodsPatients with auTBAD and serial imaging were identified. For each patient, imaging characteristics from two computed tomography (CT) scans were analyzed: (1) the baseline CT angiography (CTA) at the index admission and (2) either the most recent surveillance CTA or the most recent CTA before an aortic intervention. Patients were stratified into two comparative groups based on aortic growth: rapid growth (diameter increase of ≥5 mm/year) and no or slow growth (diameter increase of <5 mm/year). Deidentified images were imported into an open source software package for medical image analysis and images were annotated based on SVS/STS criteria for aortic zones. Our model was trained using four-fold cross-validation. The segmentation output was used to calculate aortic zone volumes from each imaging study. ResultsOf 59 patients identified for inclusion, rapid growth was observed in 33 patients (56%) and no or slow growth was observed in 26 patients (44%). There were no differences in baseline demographics, comorbidities, admission mean arterial pressure, number of discharge antihypertensives, or high-risk imaging characteristics between groups (P > .05 for all). Median duration between baseline and interval CT was 1.07 years (interquartile range [IQR], 0.38-2.57). Postdischarge aortic intervention was performed in 13 patients (22%) at a mean of 1.5 ± 1.2 years, with no difference between the groups (P > .05). Among all patients, the largest relative percent increases in zone volumes over time were found in zone 4 (13.9%; IQR, −6.82 to 35.1) and zone 5 (13.4%; IQR, −7.78 to 37.9). There were no differences in baseline zone volumes between groups (P > .05 for all). The average Dice coefficient, a performance measure of the model output, was 0.73. Performance was best in zone 5 (0.84) and zone 9 (0.91). ConclusionsWe describe an automatic deep learning segmentation model incorporating SVS-defined aortic zones. The open source, trained model demonstrates concordance to the manually segmented aortas with the strongest performance in zones 5 and 9, providing a framework for further clinical applications. In our limited sample, there were no differences in baseline aortic zone volumes between patients with rapid growth and patients with no or slow growth.

A patient-centered textbook outcome measure effectively discriminates contemporary elective open abdominal aortic aneurysm repair quality

BackgroundThere is persistent controversy surrounding the merit of surgical volume benchmarks being used solely as a sufficient proxy for assessing the quality of open abdominal aortic aneurysm (AAA) repair. Importantly, operative volume quotas may fail to reflect a more nuanced and comprehensive depiction of surgical outcomes most relevant to patients. Accordingly, we herein propose a patient-centered textbook outcome (TO) for AAA repair that is analogous to other large magnitude extirpative operations performed in other surgical specialties, and test its feasibility to discriminate hospital performance using Society for Vascular Surgery (SVS) volume guidelines. MethodsAll elective open infrarenal AAA repairs (OAR) in the SVS-Vascular Quality Initiative were examined (2009-2022). The primary end point was a TO, defined as a composite of no in-hospital complication or reintervention/reoperation, length of stay of ≤10 days, home discharge, and 1-year survival rates. The discriminatory ability of the TO measure was assessed by comparing centers that did or did not meet the SVS annual OAR volume threshold recommendation (high volume ≥10 OARs/year; low volume <10 OARs/year). Logistic regression and multivariable models adjusted for patient and procedure-related differences. ResultsA total of 9657 OARs across 198 centers were analyzed (mean age, 69.5 ± 8.4 years; female, 26%; non-White, 12%). A TO was identified in 44% (n = 4293) of the overall cohort. The incidence of individual TO components included no in-hospital complication (61%), no in-hospital reintervention or reoperation (92%), length of stay of ≤10 days (78%), home discharge (76%), and 1-year survival (91%). Median annual center volume was 6 (interquartile range, 3-10) and a majority of centers did not meet the SVS volume suggested threshold (<10 OARs/year, n = 148 [74%]). However, most patients (6265 of 9657 [65%]) underwent OAR in high-volume hospitals. When comparing high- and low-volume centers, a TO was more likely to occur in high-volume institutions: ≥10 OARs/year (46%) vs <10 OARs/year (42%; P = .0006). The association of a protective effect for higher center volume remained after risk adjustment (odds ratio, 1.1; 95% confidence interval, 1.05-1.26; P = .003). ConclusionsTOs for elective OAR reflect a more nuanced and comprehensive patient centered proxy to measure care delivery, consistent with other surgical specialties. Surprisingly, a TO was achieved in <50% of elective AAA cases nationally. Although the likelihood of a TO seems to correlate with SVS center volume recommendations, it more importantly reflects elements which may be prioritized by patients and thus offers insights into further improving real-world AAA care.

Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma: Presented at Society for Clinical Vascular Surgery, 48th Annual Symposium, Miami, Florida, March 13-17, 2021.

Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma: Presented at Society for Clinical Vascular Surgery, 48th Annual Symposium, Miami, Florida, March 13-17, 2021.

DETOUR2 trial outcomes demonstrate clinical utility of percutaneous transmural bypass for the treatment of long segment, complex femoropopliteal disease: Presented at the 2022 Vascular Annual Meeting of the Society for Vascular Surgery, Boston, Massachusetts, June 15-18, 2022.

DETOUR2 trial outcomes demonstrate clinical utility of percutaneous transmural bypass for the treatment of long segment, complex femoropopliteal disease: Presented at the 2022 Vascular Annual Meeting of the Society for Vascular Surgery, Boston, Massachusetts, June 15-18, 2022.

Contemporary outcomes of surgical decompression for functional popliteal entrapment syndrome: Presented at the 50th Annual Meeting of the New England Society for Vascular Surgery, Boston, MA, October 6-8, 2023.

Contemporary outcomes of surgical decompression for functional popliteal entrapment syndrome: Presented at the 50th Annual Meeting of the New England Society for Vascular Surgery, Boston, MA, October 6-8, 2023.

Secondary interventions following open vs endovascular revascularization for chronic limb threatening ischemia in the BEST-CLI trial: Presented at the 2023 Vascular Annual Meeting of the Society for Vascular Surgery, National Harbor, Maryland, June 14-17, 2023.

Secondary interventions following open vs endovascular revascularization for chronic limb threatening ischemia in the BEST-CLI trial: Presented at the 2023 Vascular Annual Meeting of the Society for Vascular Surgery, National Harbor, Maryland, June 14-17, 2023.

Perceptions, awareness, and implementation surrounding the assessment of frailty amongst vascular surgeons in Italy: Results from a nationwide cross-sectional survey.

We conducted this survey to gain insight into the real-life application and perceptions regarding the importance of peri-operative frailty assessment amongst vascular surgeons in Italy. Italian vascular surgeons were invited to participate in the survey using the list provided by the Italian Society for Vascular and Endovascular Surgery (1050 invited participants). A dedicated link to the survey was emailed through Google Forms, and reminders were automatically sent on a bi-weekly basis for a total of 8weeks before stopping data collection. The survey was completed by 225 respondents, thereby yielding an overall 21.5% response rate. While the vast majority of respondents stated they were aware of the meaning of frailty (93%) and agreed that its assessment was clinically relevant for patients undergoing vascular surgery (99%), only 44% of surveyed surgeons reported that they used a specific tool for peri-operative frailty assessment. However, most respondents indicated that routine evaluation of frailty was not performed at their institution (87%). The main limitations were identified as being the lack of confidence in choosing the best tool, followed by lack of awareness, lack of skilled operators, and lack of time. Our study showed that whilst most vascular surgeons in Italy are aware of the importance of frailty in affecting surgical outcomes across various interventions in the elective and non-elective settings, there is poor implementation of formal frailty assessment.

Patient Factors Influencing Prescription of Antithrombotic Medication After Lower Limb Endovascular Intervention

There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences in medication choice and duration. Prescriber decision making is complex, and patient factors have been shown to substantially contribute to prescribing variation. To determine the influence of patient factors on antithrombotic prescribing, a discrete choice experiment was distributed to vascular surgeons and trainees across Australia and Aotearoa New Zealand. After pilot testing, the discrete choice experiment questionnaire was distributed to 300 vascular surgeons and trainee members of the Australian and New Zealand Society for Vascular Surgery. Multinomial logistic regression models were used to analyse patient factors that had the most influence on decisions to prescribe a second antithrombotic agent, and the preferred choice of antithrombotic (clopidogrel 75 mg daily or rivaroxaban 2.5 mg twice daily) in addition to aspirin 100 mg daily. The odds ratio (OR) with 95% confidence interval (CI) reported preference strength. A total of 44 questionnaires were completed between September and October 2023, reaching the 15% targeted response rate. Prescribing a second antithrombotic was more likely after femoropopliteal stenting compared withangioplasty (OR 1.89, 95% CI 1.20 - 2.13), and in chronic limb threatening ischaemia compared with intermittent claudication (OR 1.58, 95% CI 1.20 - 2.13). Most respondents preferred clopidogrel over rivaroxaban (62%), with overa third of respondents exclusively prescribing clopidogrel. Patients with stents (OR 1.77, 95% CI 1.32 - 2.37) ormoderate bleeding risk (OR 1.38, 95% CI 0.97 - 1.84) were more likely to receive clopidogrel than rivaroxaban. This study demonstrates that vascular surgeons primarily prioritise antithrombotic prescribing decisionsbyprocedure type. Clopidogrel is more likely to be prescribed than rivaroxaban as a second agent in combination with aspirin, especially after stenting. Knowing these clinician preferences can target implementation strategies towards supporting decision making in subgroups of patients according to individual risk profiles.

Evaluating the Management of Intermittent Claudication Before and After Publication of the Society of Vascular Surgery’s Appropriate Use Criteria

Evaluating the Management of Intermittent Claudication Before and After Publication of the Society of Vascular Surgery’s Appropriate Use Criteria

Scaled performance on the Vascular Qualifying Examination does not correlate with Vascular Certifying Examination first attempt pass in a national cohort of residents and fellows

BackgroundSpecialty board certification is an important indicator of surgeon competence and necessary for residency and fellowship programs to maintain accreditation by the Accreditation Council for Graduate Medical Education. Thus, identification of trainees at risk of board certification failure is important for both vascular surgery graduates and their parent program. We sought to examine the correlation of Vascular Qualifying Examination (VQE) performance on first-time pass achievement of the Vascular Certifying Examination (VCE). MethodsWe used American Board of Surgery data to examine predictive associations of a national longitudinal cohort of all vascular surgery integrated residents (VIRs) and vascular surgery fellows (VSFs) who completed the VQE and VCE from 2016 through 2021. Descriptive statistics were used to examine trends. We used χ2 tests to examine proportional group differences. Predictive associations between VQE scaled score performance and first-time pass achievement on subsequent VCE attempts were examined using logistic regression. ResultsVQE scaled score performance and VCE pass rates were obtained for all VIRs and VSFs (n = 579; 175 residents and 404 fellows) from 151 programs (48 residency and 103 fellowship) during the study period. First-attempt pass rate for the VQE was 96% in the study cohort, and first-attempt pass rate for the VCE was 94%. There were no significant differences in pass-fail rates in VQE and VCE for VIR and VSF candidates (P = .210 and P = .116, respectively). Trainee scaled score performance on the VQE was not predictive of subsequent first-attempt pass achievement on VCE (odds ratio, 1.00; 95% confidence interval, 1.00-1.01; P = .077). Stratified subgroup analyses by VIR and VSF cohorts also showed no significant predictive first-attempt VCE pass achievement (P = .190 and P = .094, respectively). ConclusionsIn this national cohort of vascular trainees taking the VQE and VCE, VQE performance was not predictive of subsequent VCE first-time pass achievement. This finding highlights the necessity to identify other measures of trainee competence to indicate the preparedness of trainees for board certification examinations. Furthermore, this may be reflective of the ability to assess distinctive competencies between the two examinations, with the VQE focused on medical knowledge and the VCE on clinical judgment and interpersonal communication skills, thus broadening assessment of the Accreditation Council for Graduate Medical Education core competencies to ensure certification of vascular surgeons possessing both the knowledge and judgment necessary to maintain high-quality standards within our specialty.

Real-world application of Wound, Ischemia, and foot Infection scores in peripheral arterial disease patients

ObjectiveThe Society for Vascular Surgery (SVS) Wound, Ischemia, and foot Infection (WIfI) classification system aims to risk stratify patients with chronic limb-threatening ischemia (CLTI), predicting both amputation rates and the need for revascularization. However, real-world use of the system and whether it predicts outcomes accurately after open revascularization and peripheral interventions is unclear. Therefore, we sought to determine the adoption of the WIfI classification system within a contemporary statewide collaborative as well as the impact of patient factor, and WIfI risk assessment on short- and long-term outcomes. MethodsUsing data from a large statewide collaborative, we identified patients with CLTI undergoing open surgical revascularization or peripheral vascular intervention (PVI) between 2016 and 2022. The primary exposure was preoperative clinical WIfI stage. Patients were categorized according to the SVS Lower Extremity Threatened Limb Classification System into clinical WIfI stages 1, 2, 3, or 4. The primary outcomes were 30-day and 1-year amputation and mortality rates. Multivariable logistic regression was performed to estimate the association of WIfI stage on postrevascularization outcomes. ResultsIn the cohort of 17,417 patients, 83.4% (n = 14,529) had WIfI stage documented. PVIs were performed on 57.6% of patients, and 42.4% underwent an open surgical revascularization. Of the patients, 49.5% were classified as stage 1, 19.3% stage 2, 12.8% stage 3, and 18.3% of patients met stage 4 criteria. Stage 3 and 4 patients had higher rates of diabetes, congestive heart failure, and renal failure, and were less likely to be current or former smokers. One-half of stage 3 patients underwent open surgical revascularization, whereas stage 1 patients were most likely to have received a PVI (64%). As WIfI stage increased from 1 to 4, 1-year mortality increased from 12% to 21% (P < .001), 30-day amputation rates increased from 5% to 38% (P < .001), and 1-year amputation rates increased from 15% to 55% (P < .001). Finally, patients who did not have WIfI scores classified had significantly higher 30-day and 1-year mortality rates, as well as higher 30-day and 1-year amputation rates. ConclusionsThe SVS WIfI clinical stage is significantly associated with 1-year amputation rates in patients with CLTI after lower extremity revascularization. Because nearly 55% of stage 4 patients require a major amputation within 1 year of intervention, this finding study supports use of the WIfI classification system in clinical decision-making for patients with CLTI.

Increasing early career surgeon engagement in the Society for Vascular Surgery: a report of the Society’s Young Surgeons Section Steering Committee

When examining the United States surgical workforce, a shortage of approximately 30,000 surgeons is predicted by 2030. This shortage is attributed to the increasing surgical needs of the nation’s aging population and the increased rate of retirement in the surgeon workforce. As such, the surgeon workforce will rely on Millennials and Generation Z to grow and expand their role in health care. To address these changes, the Society for Vascular Surgery (SVS) established the Young Surgeons Section (YSS) in 2022 after formal approval by the Society’s Executive Board. The YSS Steering Committee set forth in 2022 with an initial charge focused on identifying the needs of this demographic, beginning to develop educational content focused on early career surgeons, providing and advocating for leadership opportunities within the SVS, and assisting the Society in its membership recruitment efforts. The goal of this report is to provide the context under which the YSS was started, outline the major accomplishments of the Section over its first 2 years, and to begin to discuss the needed next steps for the SVS to ensure continued engagement.

The utilization of podcasts and other free open access medical education resources in vascular surgery

Vascular surgery is a dynamic and complex specialty that requires many years of training and lifelong learning. Traditional education methods may not be sufficient to meet the needs and preferences of learners in this field. Podcasting and other free open-access medical education online materials may provide innovative tools to deliver up-to-date, evidence-based information in an accessible and entertaining format. Many free resources have been developed in the past few years and are now available to vascular surgery learners. The Audible Bleeding podcast is the first and largest podcast in the United States dedicated solely to vascular surgery education. The Society for Vascular Surgery is the leading professional organization for vascular surgeons, with a mission to advance excellence and innovation in vascular health. The Society for Vascular Surgery and the Audible Bleeding podcast have established a successful collaboration that enhances the podcast's quality and promotes the society's mission and vision.