JVS-vascular insights最新文献

Background

Endoscopic vein harvesting (EVH) is considered the standard of care for coronary bypass procedures given the lower early morbidity from surgical wound complications. However, the use of EVH for lower extremity (LE) bypass remains controversial owing to concerns about decreased graft patency. In 2022, the BEST-CLI Trial (Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia) demonstrated patients undergoing surgical bypass with adequate great saphenous vein quality experienced a lower incidence of major adverse limb events and mortality than those who underwent endovascular repair. Despite these results, wound complications from large harvest site incisions remain a significant barrier preventing surgical bypass as being the preferred initial treatment. To mitigate wound complications, our practice has adopted EVH as the standard approach for harvesting bypass conduit. Here, we report our recent 5-year experience using EVH for LE bypass.

Methods

One hundred sixty-eight LE bypasses with EVH were evaluated from 2017 to 2022. The cohort included 14 vascular surgeons in 8 hospitals. The primary end point was 30-day surgical wound complications. Secondary end points included bypass patency, need for major amputation, 30-day morbidity and mortality, length of operation, and length of hospitalization. Wound complications were measured using Szilagyi's method, with class I characterized by erythema necessitating antibiotics, class II having drainage or superficial dehiscence, and class III threatening graft integrity and requiring surgical intervention.

Results

A total of 168 LE bypasses with EVH were performed on 166 patients. Of these, 65.48% were male with a median age of 68.4 ± 9.7 years. There were no wound complications related to saphenectomy. Surgical site infections occurred in 22 patients (13.10%). Seven patients (4.17%) had class I complications, 12 (7.14%) had class II complications, and 3 (1.79%) had class III complications. Primary patency at 30 days was 96.10% and 86.84% at 1 year). Seven patients (4.17%) required major amputation at 30 days. The 1-year amputation-free survival was 89.39%. The 30-day postoperative stroke, myocardial infarction, and death rates were 0.60%, 0.60%, and 2.38%, respectively. The median operative time was 3.30 ± 1.18 hours. The median length of hospitalization was 3.00 ± 3.56 days.

Conclusions

EVH minimizes saphenectomy wound complications without compromising patency and limb salvage rates. Older studies suggesting lower patency rates after EVH may have been limited by older technology and inexperienced operators. Whether EVH should be the standard of care for LE bypass warrants further investigation.

Objective

Traditional views on carotid artery atherosclerosis have largely focused on the degree of stenosis as a predictor for embolic stroke. However, recent evidence highlights the significance of nonstenotic, vulnerable plaques in stroke pathophysiology. This article synthesizes current knowledge on the epidemiology, pathophysiology, and potential treatments of nonstenotic carotid plaques.

Methods

Google Scholar, PubMed, and Scopus were used to search for articles regarding “nonstenotic carotid plaques,” “embolic stroke of unknown source,” “cryptogenic stroke,” and “high-risk carotid imaging findings.” Here we conduct a narrative review of recent literature, focusing on studies published over the past decade, to understand the role of nonstenotic carotid plaques in ischemic strokes, particularly those classified as embolic strokes of unknown source. We present a representative case demonstrating these features.

Results

Nonstenotic plaques are increasingly recognized in patients with embolic strokes of unknown source, with vulnerable characteristics more prevalent on the symptomatic side. There is a higher risk of recurrent stroke in patients with these plaques, prompting reconsideration of therapeutic approaches, including the potential usefulness of carotid endarterectomy and stenting in certain cases.

Conclusions

The growing body of evidence on nonstenotic carotid plaques challenges existing paradigms in stroke management.

Lack of diversity in biomedical science and clinical medicine is well documented but persists even despite evidence to suggest that scientific discovery, generalizability of treatments, access to equitable health care, and clinical outcomes are limited without a diverse workforce. The science, technology, engineering, and mathematics workforce is severely under-represented in terms of females, under-represented minorities, and people with disabilities. Common barriers to entering science and medical fields include lack of mentorship, overt discrimination, compensation differences, and lack of early exposure. However, the lack of diversity does not end with the workforce and persists within clinical trials and databases leading to differences in health care accessibility and outcomes. Although there have been strides taken over the past several decades in improving diversity among medicine, research, and specifically vascular surgery science, the work is clearly not yet done. By increasing awareness of the problem of lack of diversity within vascular surgery, the future is bright regarding not only the vascular surgery workforce but also the patients treated within the health care system.

Background

Burnout affects the quality of patient care by increasing the probability of medical errors and decreasing patient satisfaction. An environmental approach has been implemented to address burnout, recognizing that burnout can be triggered by conditions in the workplace, particularly when work bullying occurs repeatedly over an extended period of time and undermines an individual’s character, integrity, or dignity. Multiple studies have examined the prevalence of burnout among vascular surgeons, with estimates ranging from 34% to 41%. However, work bullying has not been studied as a cause of burnout. This study aimed to determine the relationship between work bullying and increased burnout rates among Mexican vascular surgeons.

Methods

This study consisted of a survey of Mexican vascular surgeons currently in practice. The Maslach Burnout Inventory was used to assess burnout, and the modified Leymann Inventory of Psychological Terrorism-60 was used to assess work bullying tactics. The study additionally aimed to identify vulnerable groups that are more susceptible to burnout, such as gender, age, working long hours, and type of practice, in order to determine if they are equally affected by work bullying.

Results

Burnout symptoms were found in 41% of the 142 completed surveys examined, with emotional exhaustion being the most common component. Positive work bullying strategies affected 32% of the population. The study demonstrated a strong association between burnout and work bullying, with work bullying victims having a greater risk of developing burnout (odds ratio = 2.9; 95% confidence interval [1.41; 5.98]; P < .01). In addition, female gender, younger generation, working more than 60 hours per week, and practicing in the public sector were also related to a greater prevalence of burnout and work bullying.

Conclusions

This study found a significant correlation between burnout and work bullying among Mexican vascular surgeons. These findings suggest that preventative measures against work bullying may reduce the incidence of burnout among this population.

Background

Radiation exposure is a known risk to both patients and providers during endovascular aortic aneurysm repair (EVAR). Complex EVAR procedures, such as fenestrated and branched EVAR, inherently involve longer fluoroscopy times and increased radiation doses. While adhering to the as low as reasonably achievable principles and ensuring appropriate personal protective equipment for all operating room staff remains essential, the use of intraoperative techniques and adjuncts to decrease radiation specifically during complex EVAR is necessary. This review aims to summarize intraoperative radiation reduction techniques to provide valuable insights to vascular surgeons and interventional proceduralists to enhance radiation safety during complex EVAR.

Methods

This review focused on intraoperative techniques and adjuncts that have been used to decrease intraoperative radiation exposure to patients and operators. Published and presented preclinical results, prospective and retrospective study data, and future directions are presented.

Results

We highlight several intraoperative adjuncts and techniques for reducing radiation exposure during complex EVAR including image fusion, digital zooming, intravascular ultrasound examination, Fiber Optic RealShape (FORS) technology, and robotic navigation systems. Short-term outcomes suggest that these techniques are safe, feasible, and effective and decrease radiation exposure to both patients and operators.

Conclusions

Decreasing radiation exposure during complex EVAR remains of critical importance. The presented techniques offer promising avenues for significantly decreasing radiation exposure to both patients and providers while maintaining procedural efficacy during complex EVAR.

Objective

Three-dimensional (3D)-printed endovascular models can be an accessible alternative to expensive, state-of-the-art endovascular simulators but currently lack the rigorous validation needed to be dependable educational tools. This study describes the manufacture of a 3D-printed endovascular model of an aorta and determines the construct validity and preliminary content and face validity of the model.

Methods

A 3D-printed aorta was created using segmented data from a patient computerized tomography scan and a FormLabs 3B 3D printer with FormLabs Clear resin. Participants were asked to perform two tasks from a femoral access point: catheterize the contralateral common iliac artery and the superior mesenteric artery. Participants were assessed for task completion, technique, and time. Performance was compared between levels of education (medical student vs lower-year resident vs upper-year resident vs attending) and levels of endovascular experience (<5 procedures vs 6-20 procedures vs 21-100 procedures vs >100 procedures). Users completed questionnaires assessing the face and content validity of the simulator after their participation.

Results

48 participants were recruited (12 medical students, 19 lower-year residents, 13 upper-year residents, and 4 attendings). Of these, 26 participants had performed <5 procedures, 10 had performed 6 to 20 procedures, 7 had performed 21 to 100 procedures, and 5 had performed >100 real-world procedures. Neither education level nor experience level correlated with task completion. Increasing levels of training progressively increased rates of correct technique for both tasks combined (8% vs 21% vs 46% vs 75%, P = .032) and decreased cumulative time (307.3 vs 252.2 vs 185.8 vs 139 seconds, P = .005). Similarly, increased levels of experience progressively increased rates of correct technique for both tasks combined (7% vs 50% vs 71% vs 80%, for increasingly experienced groups, P < .001) and decreased cumulative completion times (276 vs 237 vs 187 vs 113 seconds, P = .003) for both tasks. Multivariate analysis showed that training level was not a predictor for time taken to complete any task, while experience level was a predictor for superior mesenteric artery cannulation time (P < .02). Participants rated the model as having somewhat realistic haptics, dissimilar “look and feel” to the operating room, and strongly believed that the model was valuable for practicing endovascular surgery.

Conclusions

These findings verify the construct validity of this endovascular simulator, as those with the most real-world experience used a correct technique more often and completed the tasks the fastest. Survey results supported the content validity of the model. Basic 3D-printed endovascular models should be considered as an affordable, readily accessible adjunct to su