Objective: The Society for Vascular Surgery (SVS) partnered with Phairify, Inc, an organization with experience in physician compensation data compilation for several other medical specialties, to survey its membership and assess factors influencing vascular surgeon compensation.
Methods: The SVS Compensation Study Task Force developed a vascular surgery-specific survey between January 2023 and May 2023 including experience level, academic rank, bonuses, incentives, gender, race, ethnicity, geography, on-call pay, and other factors influencing overall reimbursement. After a soft launch on May 1, 2023, with an initial phase of SVS leadership engagement in completion, the survey was formally introduced to the SVS membership on June 14, 2023. Data were collected from May 1, 2023, to December 21, 2023. The survey was intended to focus on total compensation as well as its components. Mean compensation was analyzed based on respondent demographic characteristics.
Results: Of the 3200 active vascular surgery members of the SVS who were invited to participate in the survey, 708 (22%) completed the survey. The respondents were predominantly men (80%, 564) and white (57%, 403) with relatively equal distribution across regions of the United States. Forty-one percent (292) of vascular surgeons had an academic affiliation. Most respondents (85%, 605) work more than 50 hours per week with 13% (92) reporting working more than 80 hours. The vast majority (93%, 660/708) of vascular surgeons took first call for vascular issues at their institutions, of which 64% (422/660) were on call on average 1 in 4 weekday nights and weekends. Most respondents (80%, 545/682) were not paid for primary call separate from their salary. Although there was no difference between white and non-white respondents, the median total compensation for women was less than men ($475,500 vs. $576,000, p < 0.001). Male gender, years in practice, and being in a practice not owned or run by an academic institution were associated with higher compensation based on multivariate linear regression with ranked transfer of data to normalize values. There was no association between compensation and reported number of hours worked per week.
Conclusion: This study highlights vascular surgery specialty-specific compensation models in a variety of practice settings and career levels with greater detail beyond those seen in traditional models. These data can be a useful tool for vascular surgeons when assessing compensation plans from potential employers and may help achieve greater pay equity and workforce diversity.
Objectives: This study evaluates and compares outcomes of arteriovenous fistulas (AVFs) created in a dialysis access dedicated office-based laboratory (OBL) and outpatient hospital setting.
Methods: All consecutive outpatient surgical autologous AVFs created at an academic hospital, community hospital, and an OBL from 2016-2020 were reviewed. Demographics, comorbidities, surgical procedure, complications, maturation, patency, and procedures for maintenance were assessed from time of surgical evaluation to latest available documentation. Complications, maturation, and patency were compared by location of surgery and post-operative access-related care, creating three groups: surgery and follow-up in hospital (Hospital), surgery in hospital and follow-up in OBL (Hybrid), or surgery and follow-up in OBL (OBL).
Results: 389 AVFs were included. 138 were in the Hospital group, 125 in the Hybrid group, and 126 in the OBL group. Median follow-up time was 34.7 months. Mean age was 59 years. Percentage of male patients was 58%. The three groups did not differ with respect to demographics and comorbidities. Peri-operative complication rate was 6.4% among 263 hospital outpatient procedures and 1.6% among 126 OBL procedures (p=0.043). Maturation rate was lower in the Hospital group (54%) than the Hybrid (86%) and OBL (93%) groups irrespective of AVF type (p<0.001) (Figure 1). Mean time to approval for use was 52 days in the OBL group, 66 days in the Hybrid group, and 98 days in the Hospital group (p<0.001). The OH group had the highest primary patency, but the lowest functional patency (Figure II). During the follow-up period, there was a significant difference in number of procedures per year of functional patency, with 0.7 in the Hospital group, 2.1 in the Hybrid group, and 2.1 in the OBL group (p<0.001).
Conclusions: Surgical AVF creation in a dialysis access dedicated OBL is safe and associated with lower perioperative complications, higher maturation rate, better functional patency, and decreased time to approval for use as compared to patients receiving hospital-based care only. Similar results were seen among hospital created fistula patients who received subsequent care at an OBL. Dialysis access creation and care in AV Access dedicated OBLs is associated with improved outcomes as compared to hospital-based care.
Objective: Post-repair surveillance of ruptured abdominal aortic aneurysm (rAAA) is critical for detecting potential complications. Substantial loss to follow-up has been reported in populations undergoing elective endovascular aortic repair (EVAR); however, there is limited data on follow-up rate among patients presenting with rupture. Thus, we investigated follow-up trends and factors influencing retention at a major academic referral center with a wide service area.
Methods: We included patients with rAAA from 2002-2023 in this retrospective study. Loss to follow-up was defined as absence of vascular surgeon evaluation for 2 years (EVAR) or 5 years (open repair) prior to death or present day. Multivariate regression and survival models assessed the influence of potential factors on follow-up and survival outcomes.
Results: Of 455 patients who presented with rAAA, 60% who underwent EVAR and 39% who underwent open repair were lost to follow-up. 20% of patients who underwent EVAR were lost after initial admission and 40% of patients were lost after the 1-month post-operative follow-up visit. There were no significant differences in baseline demographics. Patients lost to follow-up less commonly had Stage 4 CKD (7.2% vs. 24.3%, p = 0.02) and prior EVAR (10.0% vs 29.2%, p=0.01) at time of rupture. Secondary interventions were less common in patients lost to follow-up (14.5% vs 39.0%, p=0.01). In multivariate analysis of patients who underwent an EVAR, residing more than 10 miles from hospital was associated with loss to follow-up (OR:4.93 [1.14-21.29]). Prior endograft at time of rupture (OR:0.24 [0.06-0.89]), and eGFR < 30 (OR:0.23 [0.06-0.93]) were associated with complete follow-up in patients who underwent EVAR. Patients who were lost to follow up trended towards worse survival (HR 2.04 [0.67-6.26]), while prior endograft was associated with significantly worse survival after EVAR (HR 3.11 [1.20 - 8.04]).
Conclusions: Although most patients with rAAA attend their 1-month post-operative visit, the majority are subsequently lost to follow-up. Geographic proximity to the hospital and higher baseline medical engagement, as indicated by prior endograft and chronic kidney disease, appeared to be protective against such loss. Targeted counseling and engagement at the 1-month post-operative visit, particularly in patients with less comorbid conditions, may enhance retention to long-term follow-up.
Introduction: VM202 is a plasmid encoding two isoforms of hepatocyte growth factor (HGF). In preclinical studies, HGF stimulated angiogenesis and muscle regeneration. This preliminary clinical trial tested the hypothesis that VM202 injections in gastrocnemius muscle would improve walking performance in people with mild to moderate and symptomatic lower extremity peripheral artery disease (PAD).
Methods: In a double-blind clinical trial, people with PAD were randomized to gastrocnemius muscle injections of either 4 mgs of VM202 or placebo every 14 days for four doses. The primary outcome was 6-month change in 6-minute walk distance. Secondary outcomes included 3-month change in treadmill walking time and gastrocnemius muscle biopsy measures. In this preliminary trial, statistical significance was pre-specified as a one-sided P value <0.10.
Results: 39 participants with PAD (64.1% Black, 28.2% female) were randomized. Adjusting for age, race, smoking, and baseline performance, VM202 did not improve 6-minute walk at 6-month follow-up, compared to placebo (-13.5 meters, 90% confidence interval (CI): -38.5,+∞). At 3-month follow-up, VM202 improved maximum treadmill walking time (+2.38 minutes (90% CI: +1.08, +∞), P=0.014) and increased central nuclei abundance in gastrocnemius muscle (+5.86, 90% CI: +0.37,+∞, P=0.088), compared to placebo. VM202 did not significantly improve pain-free walking distance (difference: +0.30 minutes, 90% CI:-1.10,+∞, P=0.39), calf muscle perfusion (difference: +1.80 ml/minute per 100 g tissue, 90% CI: -3.80,+∞, P=0.33), or the WIQ distance score (difference: +2.02, 90% CI: -8.11,+∞, P=0.40). In post-hoc analyses, VM202 significantly improved 6-minute walk in PAD participants with diabetes mellitus at 6-month follow-up (+34.19 (90% CI: 4.04,+∞), P=0.075), but had no effect in people without diabetes (interaction P value=0.079).
Conclusions: These data do not support gastrocnemius injections of VM202 to improve 6-minute walk in PAD. Secondary outcomes suggested potential benefit of VM202 on skeletal muscle measures and treadmill walking, while post-hoc analyses suggested benefit in PAD participants with diabetes.
Background: Acute type A aortic dissection (ATAD) can cause visceral malperfusion. Central aortic repair may resolve malperfusion, but some require further intervention. This study aimed to review outcomes after ATAD presenting with visceral malperfusion and to evaluate the predictive value of true lumen (TL) morphologies in preoperative computed tomography scan for persistent superior mesenteric artery (SMA) ischemia after central repair.
Methods: Open surgical repair of ATAD performed between 2008 and 2023 at our institution was reviewed retrospectively. Patients with central repair first approach were included for analysis. Patients with inadequate computed tomography scan data to assess luminal morphology were excluded. TL morphology was reviewed at the diaphragm level and categorized as concave or convex. The malperfusion pattern, static vs dynamic, was assessed at SMA orifices. Data were analyzed using a contingency table and parametric and nonparametric methods.
Results: A total of 543 open ATAD repairs were performed. Of these, 263 patients were eligible under the inclusion criteria and, subsequently, analyzed. The mean age was 57±14, and 83 (31%) patients were female. SMA malperfusion developed in 42 (16%) of the 263 patients, including 26 patients with dynamic obstruction, 6 patients with static obstruction, and 10 patients with dynamic and static obstruction. Regarding dissection flap morphology, 78 patients (30%) exhibited concave morphology, while 185 patients (70%) had convex morphology. TL diameter was significantly larger in convex than concave (concave: 6 mm vs convex: 16 mm; P < .0001). The prevalence of clinically significant SMA malperfusion was higher in concave-shaped TL (concave 41% vs convex 5%; P < .0001). Dynamic SMA obstruction was more frequently observed in the concave group (concave 72% vs convex 30%; P < .001). However, significantly more patients with convex-shaped TL required bowel resection than concave (concave 13% vs convex 70%; P < .001). The operative mortality was higher in the convex group, although statistically insignificant (concave 19% vs convex 50%; P = .0059).
Conclusions: Central repair first strategy could resolve more than 80% of SMA malperfusion in ATAD when the TL is concave-shaped at the level of the diaphragm. Convex-shaped TL morphology was associated with less incidence of SMA malperfusion but was more frequently associated with static obstruction and higher incidence of bowel resection. The morphology evaluation of the TL at the diaphragm level may be simple and beneficial for surgical planning for ATAD presenting with SMA malperfusion.
Objective: To evaluate the impact of osteoporosis on overall survival following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs).
Methods: This was a retrospective, single-center cohort study on 172 patients who had undergone primary EVAR for AAA between 2016 and 2018. Bone mineral density (BMD) was assessed by measuring the Hounsfield units (HUs) of the 11th thoracic vertebra on preoperative computed tomography; a BMD value of <110 HU was considered osteoporosis. All patients were divided into those with osteoporosis and those without osteoporosis, and long-term outcomes were compared. In addition, hazard ratios of each variable for all-cause mortality were evaluated using univariate and multivariate analysis.
Results: All 172 patients were divided into two groups: 72 patients (41.9%) with osteoporosis and 100 patients (58.1%) without osteoporosis. The mean age was older and the mean BMD was lower in patients with osteoporosis than patients without osteoporosis (mean, 79.2 ± 7.2 years vs 75.0 ± 8.7 years, respectively; P < .05; 78.1 ± 26.7 HU vs 155.1 ± 36.3 HU, respectively; P < .05). During the median follow-up period of 68 months, overall survival was significantly lower in patients with osteoporosis than patients without osteoporosis (osteoporosis: 63.9% and 36.7% at 5 years and 7 years; nonosteoporosis: 83.8% and 74.6% at 5 years and 7 years, respectively; log-rank P < .05); freedom from aneurysm-related mortality did not differ significantly between groups (osteoporosis: 94.3% and 89.0% at 5 years and 7 years; nonosteoporosis: 100.0% and 96.7% at 5 years and 7 years, respectively; log-rank P = .078). In a multivariate analysis for overall survival after EVAR, coexistence of osteoporosis was found to be an independent risk factor for all-cause mortality (hazard ratio, 1.76; 95% confidence interval, 1.01-3.06; P < .05), as well as variables including age, statin use, sarcopenia, and aneurysm diameter.
Conclusions: Patients with osteoporosis showed a higher all-cause mortality after EVAR than patients without osteoporosis. We believe that comorbidity of osteoporosis may be useful in estimating the life expectancy of patients with AAA.
Background: Obesity represents a prevalent and escalating health concern among vascular surgery patients. Evidence pertaining to the influence of body mass index (BMI) on clinical outcomes after fenestrated-branched endovascular aneurysm repair (B/FEVAR) remains unclear. This study aims to assess the effect of obesity on short- and midterm clinical outcomes among individuals undergoing B/FEVAR.
Methods: This was a single-center retrospective analysis of all patients who underwent B/FEVAR from 2007 to 2020, with a median follow-up of 3.3 years (interquartile range, 1.6-5.3 years). Obesity was defined as a BMI of ≥30 kg/m2. Patients were divided into nonobese (NO) and obese cohorts according to their BMI. Outcomes were compared between the two groups subsequently.
Results: A total of 264 patients, 96 obese and 168 NO, were included. Patients with obesity were younger (72.8 ± 6.9 years vs 76.0 ± 7.3 years; P < .001), but had a higher prevalence of diabetes mellitus (27.1% vs 12.0%; P = .01) and dyslipidemia (80.2% vs 68.5%; P = .03). Both cohorts had similar rates of percutaneous access (37.5% for obese vs 35.1%; P = .7), and no significant differences in the rate of conversion to open access (8.3% for obese vs 4.2% for NO; P = .16). Technical success was similar between the cohorts (89% for obese vs 86%; P = .59). Major adverse events (MAEs) were higher in the NO group (13.1% vs 4.2%; P = .02). Patients in the obese cohort suffered more access site related infections (7.3% vs 1.2%; P = .01). All-cause mortality over 5 years was significantly higher in the NO group (35.1% vs 21.9%; P = .02). No statistical differences were found in spinal cord injury or dialysis requirement rates. Furthermore, on follow-up at 5 years, endoleak, branch instability, and reintervention rates were not statistically different between the two cohorts.
Conclusions: Patients with obesity are on average younger; however, they were more likely to suffer access site infections compared with NO patients. They had increased survival rates on follow-up, although rates of reinterventions and endoleaks were similar between the two cohorts. Our study demonstrates that, despite higher comorbidities, patients with obesity had similar intraoperative success with decreased postoperative mortality; however, access site infections remains a significant clinical concern.
Objective: Various pharmaceutical cost options have been developed by multiple companies such as GoodRx, Amazon Pharmacy, Mark Cuban Cost Plus Drugs (CPD), Health Warehouse, and local retail pharmacies) to curb the cost of prescription medications prices that patients are having to bear. Vascular surgeons provide long-term continuity of care to patients with vascular disease who often require long-term medical management. This study sought to compare the different pharmaceutical options available for the most prescribed medications by vascular surgeons to their patients and to understand which of them are the most cost-effective.
Methods: The Medicare Part D catalog and vascular surgical literature were evaluated to identify which medications are most prescribed by vascular surgeons. The average price per tablet being paid by patients was identified using the Agency for Healthcare and Research database. The prices per tablet for each of the above pharmaceutical companies were found using online catalogs or coupons. The prices were then compared using analysis of variance and t-tests.
Results: All four pharmaceutical cost options provide medication cost savings to patients compared with retail pharmacy costs. Analysis of variance showed that there were statistically significant differences among the different pharmaceutical cost options (F 15.44>2.36; P < .001). Mark Cuban CPD provided the most significant cost advantage over the other pharmaceutical options (P < .01). On a national scale, medications prescribed by vascular surgeons through Mark Cuban CPD could provide a 52% cost reduction to patients with vascular disease with a potential annual savings of over $3 billion dollars for the selected medications.
Conclusions: CPD shows a strong potential for cost savings for patients commonly prescribed medications by vascular surgeons. As a specialty that provides long-term care and establishes long-term relationships with its patients, vascular surgeons have the unique ability to impact their overall health in a meaningful way by limiting the financial burdens associated with vascular-based medication acquisition and utilization.
Objective: Major lower limb amputation is a disfiguring operation associated with impaired mobility and high near-term mortality. Informed decision-making regarding amputation requires outcomes data. Despite the co-occurrence of both chronic limb-threatening ischemia (CLTI) and Alzheimer's disease and related dementias (ADRD), there is sparse data on the outcomes of major limb amputation in this population and the impact of frailty. We sought to determine mortality, complications, readmissions, revisions, intensive interventions (eg, cardiopulmonary resuscitation), and other outcomes after amputation for CLTI in patients living with ADRD looking at the modifying effects of frailty.
Methods: We examined Medicare fee-for-service claims data from January 1, 2016, to December 31, 2020. Patients with CLTI undergoing amputation at or proximal to the ankle were included. Along with demographic information, dementia status, and comorbid conditions, we measured frailty using a claims-based frailty index. We dichotomized dementia and frailty (pre-frail/robust = "non-frail" vs moderate/severe frailty = "frail") to create four groups: non-frail/non-ADRD, frail/non-ADRD, non-frail/ADRD, and frail/ADRD. We used linear and logistic regression via generalized estimating equations in addition to performing selected outcomes analyses with death as a competing risk to understand the association between dementia status, frailty status, and 1-year mortality as our primary outcome in addition to the postoperative outcomes outlined above.
Results: Among 46,930 patients undergoing major limb amputation, 11,465 (24.4%) had ADRD and 24,790 (52.8%) had frailty. Overall, 55.9% of amputations were below-knee. Selected outcomes among frail/ADRD patients undergoing amputation (n = 10,153) were: 55.3% 1-year mortality 29.6% readmissions at 30 days, and 32.3% amputation revision/reoperation within 1 year. Of all four groups, those in the frail/ADRD had the worst outcomes only for 1-year mortality.
Conclusions: First, patients with ADRD or moderate/severe frailty suffer an array of very poor outcomes after major limb amputation for CLTI, including high mortality, readmissions, revision, and risks of discharge to higher levels of care. Second, there is a complex relationship between outcome severity and ADRD/frailty status. Specifically, frailty is more often than ADRD associated with the poorest results for any given outcome. These data provide important outcomes data to help align decision-making with health care values and goals.
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