JVS-vascular insights最新文献

This article focuses on the provision of clinical privileges to physicians in the wake of the Centers for Medicare and Medicaid Services updating their National Coverage Decision to cover all carotid stenting procedures. This article emphasizes that participation in nationwide data registries fulfills quality monitoring and improvement requirements under the Centers for Medicare and Medicaid Services National Coverage Decision and, therefore, should be a mandatory requirement in credentialing decisions for all carotid artery stenting procedures at an institutional level. Data from registries such as the Vascular Quality Initiative or National Surgery Quality Improvement Program have been instrumental in comparisons of outcomes and learning curves between carotid procedures. Credentialing guidelines, as outlined by medical societies, already reflect crucial evidence-based differences in learning curves and in volume-outcomes relationships which have critical relevance to the quality of care for patients undergoing carotid stenting procedures.

Open thoracoabdominal aortic aneurysm (TAAA) repair, despite the rise of endovascular approaches, remains a necessary intervention for complex aortic pathologies, particularly in patients with genetically triggered aortopathies or unsuitable anatomy for endovascular grafts. This article describes the surgical techniques and perioperative management protocols. We discuss the importance of patient selection, and intraoperative techniques in open TAAA repair. Our protocol routinely consists of neuromonitoring with motor evoked potentials (MEPs) to detect and address spinal cord ischemia in real-time. The take home lesson from our analysis is that, although endovascular techniques continue to advance and offer less invasive options for TAAA management, open TAAA repair remains a necessary procedure for certain patients. The expertise in open TAAA repair must be maintained and developed in specialized centers to ensure that all patients have access to the most appropriate and effective treatment.

Objective

Proximal humerus fractures are common with a reported neurovascular injury incidence of 0.09% to 5%. This study aimed to synthesize the current evidence on the presentation and management of proximal humerus fractures with associated vascular injury to aid clinical decision-making.

Methods

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration: CRD42023393957) to identify articles reporting proximal humerus fractures with associated vascular injury in adults. Study quality was assessed using the Joanna Briggs Institute critical appraisal tools checklist. Outcomes included presentation, fracture classification, type of vascular injury, method of orthopedic and vascular repair, and complications.

Results

A total of 40 articles representing 55 individuals with a fracture were included. Injuries most commonly occurred after a low-energy mechanism such as a fall from a standing height (n = 32, 58%). The presentation of ischemia included cool limb (n = 29, 53%), pallor (n = 21, 38%), prolonged capillary refill (n = 7, 13%), and an absent or reduced pulse (n = 47, 85%). Concomitant neurological injury was reported in 30 cases (55%) and fracture dislocations were reported in 17 cases (32.7%). Fracture classification was variable; however, when all recorded fracture patterns were described in terms of 2-, 3-, or 4-part fractures, these represented 49% (n = 27), 24% (n = 13), and 18% (n = 10), respectively. Fracture management preceded vascular repair in 30 (55%). Orthopedic management was primarily performed by open reduction internal fixation or wire fixation (n = 33, 60%) and hemiarthroplasty (n = 11, 20%). Isolated arterial injury was the most common vascular injury (n = 52, 95%). Arterial injuries were primarily repaired by an interposition graft (n = 21, 38%), primary repair (n = 11, 20%), or conservative management (n = 9, 16%). Complications such as amputation, compartment syndrome, avascular necrosis, and metalwork failure were reported in 13 cases.

Conclusions

Proximal humerus fractures with associated vascular injuries occur most commonly in the older adults after low-energy mechanisms such as a fall from a standing height. A high index of suspicion is needed as not all injuries present with classical ischemic symptoms, and these injuries carry significant associated morbidity.

Objective

There is a growing emphasis on achieving work-life balance, defined as the balance between work and personal life. However, this concept is gradually shifting towards work-life integration (WLI), which is relevant in the health care sector, particularly surgery. We performed a literature review to evaluate factors that contribute to WLI in the field of surgery, with a particular focus on vascular surgery.

Methods

A literature review of WLI in surgery, specifically vascular surgery, was performed from inception to February 2024. PubMed was searched for papers written in the English and French languages using the MeSH terms “work-life balance” or “work-life integration” in “vascular surgery” or “surgery.” Findings were categorized in a tiered framework focused on faculty or staff, trainees (including medical students, residents, or fellows), and people identifying as underrepresented in medicine (URIM).

Results

Twenty-four articles were identified as relevant for this review. Previous reports have identified a high prevalence of burnout and suicide among the vascular surgery workforce. Collegial support and institutional culture were identified as pivotal in enhancing WLI. Inefficiencies in health care delivery, administrative burdens, and a lack of autonomy were recognized as barriers for WLI. Factors specific to gender and parenthood lead to unequal challenges in achieving WLI. Medical trainees’ WLI perceptions influenced their specialty choices and risk of burnout. Also, URIM trainees encountered additional obstacles like discrimination and attrition, though some reports indicated a resilience advantage among minority physicians.

Conclusions

This review has highlighted differences in challenges related to WLI across faculty and staff, trainees, and individuals identifying as URIM and emphasizes the need for systemic and cultural reforms, flexible work arrangements, and greater support for underrepresented groups to foster a healthier work-life ecosystem in health care.

Objective

Open surgical repair of ruptured thoracoabdominal aortic aneurysms (rTAAAs) carries significant risk of mortality and morbidity; in recent years, endovascular repair has emerged as a suitable alternative. This article aims to review currently available technologies, techniques, and outcomes for endovascular repair of rTAAA.

Methods

A narrative review of current literature was performed.

Results

Off-the-shelf branched endografts are available and are often the first-line endovascular therapy for types I, II, and III rTAAA or type IV rTAAA with a lumen diameter ≥24 mm at the level of the renovisceral vessels. In patients with anatomy unsuitable for off-the-shelf branch devices, particularly those with ruptured type IV or pararenal TAAA with a narrow aortic lumen, endovascular repair with in situ laser fenestration is a reasonable alternative. Physician-modified devices as well as endovascular repair with parallel stent grafts (chimney, periscope, sandwich, or Octopus) have been described by select centers with satisfactory outcomes.

Conclusions

Patients with rTAAA and suitable anatomy who are at high or prohibitive surgical risk can be managed endovascularly with comparable outcomes. Various techniques are described in the literature, and the choice of technique used should depend on patient anatomy and surgeon expertise.

Objectives

Shortages of vascular surgeons are projected through 2050, and vascular surgery fellowships (VSFs) remain a critical pathway for training vascular surgeons. We sought to identify general surgery (GS) residents' perceptions of/attitudes toward VS.

Methods

Anonymous, electronic questionnaires were sent to GS residents. Questions assessed demographics, fellowship preferences, and exposure to and perceptions of VS. Univariate and multivariate analyses were performed.

Results

Of 152 respondents (15% response rate), 20 (13.2%) will apply for VSF, 64 (42.1%) are interested in VS (IVS), 62 (40.8%) are not interested in VS (NIVS), and 6 (3.9%) remain undecided. Overall, among respondents encompassing all postgraduate years, 106 (69.7%) felt comfortable with medical management of vascular disease, 52 (34.2%) felt comfortable with open surgical management, and 14 (9.2%) felt comfortable with endovascular management. Compared with residents NIVS, trainees planning on applying for VSF or IVS reported greater familiarity with diseases treated (97.6%; P = .003) and procedures performed (88.1%; P = .013) by vascular surgeons. Those applying for VSFs were more likely to perceive they were essential members of the vascular team (P = .003), and their time in the operating room was productive (P = .001). Fifty-five (36.2%) respondents believed their exposure to VS in residency was inadequate for a surgeon not pursuing a VSF. More trainees NIVS reported disrespectful treatment by VS attendings, residents, and fellows (P = .043). Stratified by gender, 25 female residents (29.4%) cited male dominant (P < .001) as a reason for not choosing VS. When asked how vascular training programs impacted exposure while on VS rotations, 45 residents (70.3%) at institutions with both a VSF and integrated VS residency indicated diminished experiences owing to the presence of vascular trainees (P = .014), and 25 (39.1%) expressed lower satisfaction with their rotation (P = .012).

Conclusions

Exposure to VS during GS residency may be inadequate for a general surgeon entering practice. Reasons for not pursuing a VSF included disrespectful interactions from VS residents, fellows, and attendings, as well as a male-dominant field. Residents at institutions with vascular training programs expressed lower satisfaction and experiences gained. Improving these factors may increase interest in VSFs.

Objective

Methods

Results

Conclusions

Background

With advances in current therapies, more patients are currently surgical candidates for oncologic resections that were previously deemed unresectable owing to vascular invasion. We analyzed our institution's outcomes of patients undergoing oncovascular resection of truncal malignancies with vascular invasion to identify factors associated with vascular reconstruction complications and oncologic recurrence.

Methods

A retrospective chart review of all adult patients between January 1, 2002, and June 1, 2022, who underwent a surgical resection of a neoplasm at Northwestern Memorial Hospital and required vascular surgery intraoperative assistance was performed. Data on patient demographics, tumor anatomy and pathology, operative details, and clinical outcomes were extracted. Primary end points included 30-day and 1-year mortality, and 1-year primary patency of the vascular reconstruction. Secondary end points included vascular reintervention and tumor recurrence, both local and metastatic disease.

Results

A total of 104 patients (43.3% females) with a mean age of 58 years were included in the study. The median follow-up was 22.1 months (range, 0-207 months). The most common tumor pathology included advanced renal cell carcinoma (n = 58) and soft tissue and primary vascular sarcomas (n = 24). Vascular procedures included 98 venous interventions and 6 arterial interventions. The overall 30-day mortality was 1% and 1-year mortality was 14.4%. Primary vascular patency at 1 year among patients with ≥12 months of follow-up was 98.5%. No patients underwent a vascular reintervention. In total, 34 patients (38%) developed recurrent malignant disease (23.5% local and 76.5% metastatic) during the study period. The median time to tumor recurrence was 11.4 months (range, 1.2-100.0 months).

Conclusions

Oncovascular resections of truncal tumors involving major vascular structures can be performed safely with a low incidence of vascular complications; tumor recurrence remains the major contributor to morbidity. Further investigation of the factors associated with tumor recurrence in these patients may help to refine surgical techniques.

After the publication of the BEST-CLI trial results, there has been a renewed emphasis on the importance of open lower extremity procedures in the practice of vascular surgery. As endovascular procedures have increased in volume, vascular surgery trainees are expected to be equally well-trained in both endovascular and open techniques. Certification in vascular surgery by the American Board of Surgery does not currently require a technical assessment. Rather, board certification is based on a combination of a written examination, oral examination, and review of case logs during training. As endovascular techniques have become more prominent, there has been a greater variety of techniques and equipment for trainees to master within the same duration of subspecialty training. Considering developments in the training paradigm such as work hour restrictions and the advent of the primary certificate in vascular surgery, ensuring that trainees have sufficient exposure to concepts in open peripheral vascular surgery is crucial. Various educational techniques are currently used to supplement intraoperative learning.

Objective

To evaluate the feasibility of same-day discharge (SDD) after open peripheral arterial surgery (OAS) in a veteran population.

Methods

This is a single-center, retrospective study. Starting September 2021, veterans who underwent elective OAS were selectively chosen for planned SDD. Eligible procedures included popliteal artery aneurysm repair, common femoral/superficial femoral/popliteal artery endarterectomy ± concurrent endovascular intervention, bypass graft revision, femoral-femoral bypass, and axillofemoral bypass. All patients who underwent eligible procedures were compared across three eras based on the primary location of postoperative admission: intensive care unit era (ICUE, September 2016-December 2018), inpatient ward era (WARDE, January 2019-August 2021), and SDD era (SDDE, September 2021-December 2022). Demographics, comorbidities, indication for procedures, operative times, complications, readmissions, and length of stay (LOS) were analyzed.

Results

Ninety-nine male patients underwent eligible procedures during the 6-year study period (ICUE: 32, WARDE; 41, and SDDE: 26). ICUE had higher rates of tobacco use (P = .04) with no differences in age or other comorbidities between the eras. Indications were claudication, bypass graft stenosis, popliteal aneurysm, ischemic rest pain, and tissue loss. Twenty patients were selected for SDD, and 18 were successfully discharged same day. Operative times were not significantly different between the eras. SDDE patients were more likely to undergo monitored anesthesia care (P = .04). The mean LOS was significantly lower in SDDE (0.54 days, P < .001) compared with WARDE (2.9 days) and ICUE (2.8 days). The mean ICU LOS was lower in SDDE (0.2 days, P <.001) compared with ICUE (1.1 days). There was no difference in postoperative complications (P = .30), reoperation (P = .51), or readmission rates (P = .35).

Conclusions

SDD is safe and feasible after elective OAS in a veteran population with a low unplanned admission rate.