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Thoracic Outlet Syndrome (TOS) is a rare condition caused by compression of the neurovascular structures of the thoracic outlet. Patients with TOS are found to have a greater prevalence of supernumerary or abnormal first ribs compared to the general population. Symptoms can sometimes be incited by a neck injury, especially in patients with abnormal cervical anatomy. This case report highlights a unique patient with bilateral cervical ribs who presented with complicated symptoms following a neck injury who required a series of surgical interventions to improve.

Objective Opiate use, dependence, and the associated morbidity and mortality are major current public health problems in the United States. Little is known about patterns of opioid use in patients with peripheral arterial disease (PAD). The purpose of this study was to identify the prevalence of chronic preoperative and postoperative prescription opioid use in patients with PAD. A secondary aim was to determine the demographic, comorbid conditions, and operative characteristics associated with chronic opioid use. Methods Using a single-institution database of patients with PAD undergoing open or endovascular lower extremity intervention from 2013 to 2014, data regarding opiate use and associated conditions were abstracted for analysis. Patients were excluded if they did not live in North Carolina or surgery was not for PAD. Preoperative (PreCOU) and postoperative chronic opioid use (PostCOU) were defined as consistent opioid prescription filling in the 3 months before and after the index procedure, respectively. Opioid prescription filling was assessed using the North Carolina Controlled Substance Reporting System. Demographics, comorbid conditions, other adjunct pain medication data, and operative characteristics were abstracted from our institutional electronic medical record. Associations with PreCOU were evaluated using the t test, Wilcoxon test, or two-sample median test (continuous), or the χ2 or Fisher exact tests (categorical). Results A total of 202 patients undergoing open (108; 53.5%) or endovascular (94; 46.5%) revascularization for claudication or critical limb ischemia were identified for analysis. The mean age was 64.6 years, and 36% were female. Claudication was the indication for revascularization in 26.7% of patients, and critical limb ischemia was the indication in 73.3% of patients. The median preoperative ankle-brachial index (ABI) was 0.50. Sixty-eight patients (34%) met the definition for PreCOU. PreCOU was associated with female gender, history of chronic musculoskeletal pain, benzodiazepine use, and self-reported illicit drug use. Less than 50% of patients reported use of non-opiate adjunct pain medications. No association was observed between PreCOU and pre- or postoperative ABI, or number of prior lower extremity interventions. Following revascularization, the median ABI was 0.88. PreCOU was not associated with significant differences in postoperative complications, length of stay, or mortality. Overall, 71 patients (35%) met the definition for PostCOU, 14 of whom had no history of preoperative chronic opiate use. Ten patients with PreCOU did not demonstrate PostCOU. Conclusions Chronic opiate use was common in patients with PAD with a prevalence of approximately 35%, both prior to and following revascularization. Revascularization was associated with a termination of chronic opiate use in less than 15% of patients with PreCOU. Additionally, 10% of patients who did not use opiates chronically before their revascularization did so afterwards. Patients with PAD requiring intervention represent a high-risk group with regards to chronic opiate use. Increased diligence in identifying opioid use among patients with PAD and optimizing the use of non-narcotic adjunct pain medications may result in a lower prevalence of chronic opiate use and its attendant adverse effects.

Objective Work-related pain and disability have been reported in the literature among surgeons. This national survey was designed to identify the prevalence and severity of these symptoms in vascular surgeons. Methods A survey was emailed to the 2910 members of the Society for Vascular Surgery. Physical pain was evaluated based on body part, and type of vascular procedure performed using the Borg 0 to 10 pain scale. Wellness questions were also queried. Results A total of 775 of Society for Vascular Surgery members responded, with a 26.6% response rate. Retirees were excluded from the study (n = 39). Among those actively working (n = 736), surgeons have been practicing surgery, on average, for 17.2 ± 11.6 years, with a mean age of 51.4 ± 10.9 years, and 83.6% are male. After a full day of open surgery, the majority of the responding vascular surgeons are in a moderately strong amount of pain (mean score, 4.4 ± 2.3). After a full day of endovascular procedures, most vascular surgeons are in a moderately strong amount of pain (mean score, 3.9 ± 2.4). Pain after open surgery is greatest in the neck, and after endovascular surgery pain is highest in the lower back. Surgeons performing endovenous procedures demonstrated the lowest pain scores (2.0 ± 2.0). In total, 36.9% (242/655, 81 missing responses) have sought medical care for work-related pain, with 8.3% (61/736) taking time away from the operating room. Of those, 26.2% (193/736) report pain severe enough that it interferes with sleep. Seventy-two (10%) required surgery or other significant medical procedures. Of the 39 retirees, 26% ended their careers owing to physical disabilities from work-related pain. Out of the entire cohort, 52.7% (334/633,103 missing responses) feel that physical discomfort will affect the longevity of their careers. Additionally, we found that high work-related physical discomfort is significantly associated with burnout (burnout vs no burnout; P Conclusions Our study shows that the majority of practicing vascular surgeons responding to the survey are in pain after a day of operating. Addressing work-related pain serves to improve the lives and careers of vascular surgeons and enhance surgical longevity.

Free digital platforms are smartphone-compatible and permit self-directed curriculum development based on learners' interests and educational needs. We developed a free mobile vascular surgery handbook initiated, authored, and edited by surgical house officers and surveyed on the content and users.Using a free digital platform, house officers developed a vascular surgery handbook. Initiated by a single user for conference preparation and clinical care, the use expanded through sharing among residents. The handbook was then deployed at a second medical center, with free access granted to users after completing a survey. Handbook and content use were evaluated based on user ratings ≥4 on a Likert scale from 1 to 5, where 1 = "strongly disagree" and 5 = "completely agree." Domains assessed included handbook ease of use, content, and relevance to a variety of learning environments and goals (e.g., preparation for the operating room, rounds, clinic, teaching conferences, and examinations). Analytic methods included qualitative analysis, graphical evaluation, and categorical tests.The handbook is organized into sections, with each consisting of multiple pages and/or posts related to the section topic. Sections with the most content included lower extremity arterial disease, endovascular aneurysm repair/thoracic endovascular aortic repair, venous disease, anticoagulation, and anatomy/exposures. Fifty-four users participated in the evaluation phase, including different types of surgical residents (35%), medical students (30%), and anesthesia residents (22%). Sixty-nine percent of participants were in their position for2 years. The average age was 29.1 years, and 57% were women. Preferred learning styles among users at the time of enrollment primarily included question banks (52%), followed by slide-based lectures (15%) and "chalk talk" lectures (13%). Of the users who participated in the presurvey, 43 users participated in the postsurvey with a general agreement on the handbook being an easy-to-use resource that was useful for gaining overall knowledge and contained accurate information. Users generally agreed they would recommend the handbook to a colleague.References customized to user needs can be developed through crowdsourcing and published with free digital resources. These approaches allow mobile access to useful information during conferences and clinical care. House officers' self-perceived educational needs can be targeted for tailored educational initiatives.

Surgeons report higher burnout and suicidal ideation (SI) rates than the general population. This study sought to identify the prevalence and gender-specific risk factors for burnout and SI among men and women vascular surgeons to guide future interventions.In 2018, active Society for Vascular Surgery members were surveyed confidentially using the Maslach Burnout Index embedded in a questionnaire that captured demographic and practice-related characteristics. Results were stratified by gender. Univariate and multivariate logistic regression models were developed to identify predictors for the end points of burnout and SI.Overall survey response rate was 34.3% (N = 878) of practicing vascular surgeons. A higher percentage of women responded (19%) than compose membership in the Society for Vascular Surgery (13.7%). Women respondents were significantly younger, with fewer years in practice, and were less likely to be in private practice than the men who responded. Women were also less likely to be married/partnered, or to have children. The prevalence of burnout was similar for women and men (42.3% and 40.9%; P = nonsignificant); however, the prevalence of SI was significantly higher in women (12.9% vs 6.6%; P .007). Whereas there was no difference in mean hours worked or call taken, women were more likely to have had a recent conflict between work and home responsibilities and to have resolved this conflict in favor of work. Although men and women had the same incidence of reported recent medical errors, women were less likely to self-report a recent malpractice suit or to think that a fair resolution was reached. There was no gender difference in reported work-related pain. Multivariable analysis revealed that not enough family time and work-related pain were predictors for burnout in both men and women. Additional factors were associated with burnout in men, such as malpractice and electronic medical record dissatisfaction. Multivariable analysis revealed that work-related pain was an independent predictor for SI for the entire cohort.The prevalence of burnout among vascular surgeons is high. Women vascular surgeons have double the rates of SI compared with male vascular surgeons. Taken together, this study demonstrated that many of the same factors are associated with burnout in women and men, which include not enough family time, conflict between work and personal life, and work-related pain. Additional factors in men included conflict between work and family, work-related pain, and electronic medical record dissatisfaction.

Two female vascular surgeons reflect on their personal experiences and journeys in academic medicine leadership—one from the perspective of CEO and Dean and the other from a developing leader standpoint. Through their firsthand narratives, they share strategies for building resilience, inclusion, teamwork, and mentorship as they navigate the opportunities and challenges of leadership development.

OBJECTIVE: Burnout is prevalent among vascular surgery trainees. Here we aim to identify modifiable risk factors for burnout in vascular surgery training, to facilitate the development of programs to enhance and sustain trainee well-being. METHODS: The Association of Program Directors in Vascular Surgery issued the Annual Training survey in the fall of 2018 to all trainees. The survey contained items to assess frequency of burnout, as well as mentorship, training environment, and stress coping mechanisms using an abbreviated COPE (Coping Orientation to Problems Experienced) inventory. RESULTS: Of 628 surveys issued, the response rate was 30% (n = 188). Respondents indicated that the majority of programs offer mentorship opportunities (n = 150 [83%]) that are longitudinal throughout the duration of training (n = 140 [77%]). Fifty-eight percent (n = 109) indicated there was an appropriate balance between learning and productivity in their program, with more respondents leaning toward too much clinical productivity (n = 57) and fewer toward too much learning (n = 19). Forty-five percent of respondents indicated feeling burnout at least weekly (n = 81). The burnout group was less likely to report an appropriate balance between clinical productivity and learning (49.4% vs 67.7%; P < .001), as well as a lower frequency of mentorship opportunities (72.1% vs 92.7%; P < .001). Certain coping skills were used more frequently in the burnout group, including self-distraction, disengagement, humor, self-blame, and substance use. In multivariate analysis, frequent use of self-blame conferred a 9.847-fold increased risk (95% confidence interval, 2.114–45.871) of burnout (P = .003), while feeling appropriately challenged by the faculty was significantly protective (odds ratio for burnout, 0.158; 95% confidence interval, 0.031–0.820; P = .03). CONCLUSIONS: The protective effect against vascular surgery trainee burnout conferred by the availability of mentorship suggests that an expansion and emphasis on mentorship in training may help to mitigate trainee burnout. Mentorship may also be a suitable channel to assess for an appropriate level of challenge, as well as for an appropriate balance between clinical productivity and learning that, when present, are also protective against burnout. Furthermore, the correlation between the frequent use of certain coping skills and burnout highlight this as an area for intervention, potentially through a combination of mentor modeling and formal training on healthy stress-related coping strategies.

Physician burnout has been linked to medical errors, decreased patient satisfaction, and decreased career longevity. In light of the increasing prevalence of cardiovascular disease, vascular surgeon burnout presents a legitimate public health concern owing to the impact on the adequacy of the vascular surgery workforce. The aims of this study were to define the prevalence of burnout among practicing vascular surgeons and identify factors that contribute to burnout to facilitate future Society for Vascular Surgery (SVS) initiatives to mitigate this crisis.In 2018, active SVS members were surveyed electronically and confidentially using the Maslach Burnout Inventory. The survey was tailored to explore specialty-specific issues, and to capture demographic and practice-related characteristics. Emotional exhaustion (EE) and depersonalization (DP) were analyzed as dimensions of burnout. Consistent with convention, surgeons with a high score on the DP and/or EE subscales of the Maslach Burnout Inventory were considered to have at least one manifestation of professional burnout. Risk factors associated with symptoms of burnout were identified using bivariate analyses (χOf 2905 active SVS members, 960 responded to the survey (34% participation rate). After excluding retired surgeons and incomplete submissions, responses from 872 practicing vascular surgeons were analyzed. The mean age was 49.7 ± 11.0 years; the majority of respondents (81%) were male. Primary practice settings were academic (40%), community practice (41%), veteran's hospital (3.3%), active military practice (1.5%), or other. Years in practice averaged 15.7 ± 11.7. Overall, 41% of respondents had at least one symptoms of burnout (ie, high EE and/or high DP), 37% endorsed symptoms of depression in the past month, and 8% indicated they had considered suicide in the last 12 months. In unadjusted analysis, factors significantly associated with burnout (P .05) included clinical work hours, on-call frequency, electronic medical record and documentation requirements, work-home conflict, and work-related physical pain. On multivariate analysis, age, work-related physical pain and work-home conflict were independent predictors for burnout.Symptoms of burnout and depression are common among vascular surgeons. Advancing age, work-related physical pain, and work-home conflict are independent predictors for burnout among vascular surgeons. Efforts to promote vascular surgeon well-being must address specialty-specific challenges, including the high prevalence of work-home conflict and occupational factors that contribute to work-related pain.

Diabetes mellitus is a major risk factor for peripheral arterial disease and lower extremity amputation (LEA). We evaluated the effects of intensive glucose control (IGC) on risk of LEA in patients with type 2 diabetes during a randomized-controlled multicenter trial.The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial randomized patients with type 2 diabetes to IGC (HbA1c target6.0%) or standard glycemic control (SGC; HbA1c target 7.0% to 7.9%). Using analysis of mean HbA1c, we examined relationships between glycemic control and incident/recurrent LEA during the clinical trial/follow-up.Mean post-randomization HbA1c over the course of the trial and post-trial follow-up was 7.3% ± 0.9% (6.8% ± 0.8% in the IGC arm, 7.7% ± 0.7% in the SGC arm). There were 124 participants who had at least 1 LEA during the study period; 73 were randomized to the SGC arm and 51 to the IGC arm (p = 0.049). Randomization to IGC was associated with decreased LEA rate (HR 0.69, 95% CI 0.483 to 0.987, p = 0.042). In multivariable models, mean HbA1c was a powerful predictor of LEA (HR 2.07 per 1% increase in HbA1c, 95% CI 1.67 to 2.57, p0.0001). Post-randomization mean HbA1c remained a strong predictor of LEA after controlling for other important covariates and competing risk of death (HR 1.94 per 1% increase in HbA1c, 95% CI 1.52 to 2.46, p0.0001).In patients with type 2 diabetes, IGC was associated with a reduction in the risk for LEA. After 3.7 years of IGC, there was an enduring protective effect against LEA. Improved glycemic control was a strong predictor of decreased risk for subsequent LEA. This study suggests that tight glycemic control, even over a short time period, has potential to reduce risk of limb loss.

Objective Frailty is associated with adverse events, length of stay, and nonhome discharge after vascular surgery. Frailty measures based on walking-based tests may be impractical or invalid for patients with walking impairment from symptoms or sequelae of vascular disease. We hypothesized that grip strength is associated with frailty, comorbidity, and cardiac risk among patients with vascular disease. Methods Dominant hand grip strength was measured during ambulatory clinic visits among patients with vascular disease (abdominal aortic aneurysm [AAA], carotid stenosis, and peripheral artery disease [PAD]). Frailty prevalence was defined on the basis of the 20th percentile of community-dwelling population estimates adjusted for age, gender, and body mass index. Associations between grip strength, Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI), and sarcopenia (based on total psoas area for patients with cross-sectional abdominal imaging) were evaluated using linear and logistic regression. Results Grip strength was measured in 311 participants; all had sufficient data for CCI calculation, 217 (69.8%) had sufficient data for RCRI, and 88 (28.3%) had cross-sectional imaging permitting psoas measurement. Eighty-six participants (27.7%) were categorized as frail on the basis of grip strength. Frailty was associated with CCI (odds ratio, 1.86; 95% confidence interval, 1.34-2.57; P = .0002) in the multivariable model. Frail participants also had a higher average number of RCRI components vs nonfrail patients (mean ± standard deviation, 1.8 ± 0.8 for frail vs 1.5 ± 0.7 for nonfrail; P = .018); frailty was also associated with RCRI in the adjusted multivariable model (odds ratio, 1.75; 95% confidence interval, 1.16-2.64; P = .008). Total psoas area was lower among patients categorized as frail vs nonfrail on the basis of grip strength (21.0 ± 6.6 vs 25.4 ± 7.4; P = .010). Each 10 cm2 increase in psoas area was associated with a 5.7 kg increase in grip strength in a multivariable model adjusting for age and gender (P Conclusions Grip strength is useful for identifying frailty among patients with vascular disease. Frail status based on grip strength is associated with comorbidity, cardiac risk, and sarcopenia in this population. These findings suggest that grip strength may have utility as a simple and inexpensive risk screening tool that is easily implemented in ambulatory clinics, avoids the need for imaging, and overcomes possible limitations of walking-based measures. Lower mean psoas diameters among patients with PAD vs other diagnoses may warrant consideration of specific approaches to morphomic analysis.

Background Endovascular intervention is considered the first-line treatment for chronic mesenteric ischemia (CMI) when feasible. Two-vessel revascularization is most definitive when celiac (CA) and superior mesenteric arteries (SMA) are diseased, but single-vessel intervention may be performed in patients with 2-vessel disease due to anatomic/technical factors. We evaluated anatomic predictors of clinical outcomes associated with endovascular treatment of CMI among patients with occlusive SMA lesions. Methods Patients with CMI treated with endovascular revascularization over 10 years were identified. Patients with SMA occlusions were selected for analysis. Between-group comparisons based on inclusion of an SMA revascularization were evaluated using t -test and chi-squared test. Freedom from symptomatic recurrence or repeat intervention was analyzed using proportional hazards regression. Results Fifty-four patients with CMI were analyzed. Sixteen (29.6%) patients had CA-only intervention, and 38 (70.4%) patients had SMA revascularization with or without CA intervention. No significant differences in demographics or comorbidity were identified between groups. In the CA-only intervention group, 8 of the 16 (50%) patients developed symptomatic recurrence compared with 8 of the 31 (21.1%) patients whose intervention included the SMA. Patients treated without SMA intervention also had decreased freedom from both symptomatic recurrence (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.2–8.6, P = 0.016) and repeat intervention (HR 5.5, 95% CI 1.8–16.3, P = 0.001). Conclusions Among patients with CMI and occlusive SMA lesions, SMA revascularization appears to be the key determinant for symptomatic outcomes and repeat intervention. Patient counseling should include potential future need for surgical revascularization if endovascular SMA treatment cannot be accomplished.

Background: Sleep disturbance is an important determinant of both mental and physical health-related quality of life (QOL). Associations between sleep disturbance and subclinical cardiovascular disease have been described but little is known about it among patients with symptomatic PAD. We studied sleep disturbance in symptomatic PAD patients using a wearable device for 30 days. Methods: Patients with claudication confirmed by ABI Results: Twenty participants enrolled and completed the study; 35% were female; 30% were African American. Mean age was 69±9 years; mean ABI was 0.69±0.14. Over a mean study period of 34±6 days, sleep data were recorded an average of 28±6 days and walking activity on 12±10 days. Mean nights of interrupted sleep was 1.3±1.8; 8 participants (40%) had sleep interruption at least one night. No associations were observed between daily walking activity or VascuQol-6 scores and sleep disturbance. Increases in sleep disturbance were associated with higher (i.e., more severe) WIQ distance (P=0.02) and stair (P=0.03) scores at baseline, and WIQ distance (P=0.03), speed (P=0.002) and overall (P=0.009) scores at study completion. Conclusions: These observations suggest that sleep disturbance impacts walking, disability and QOL among people with symptomatic PAD. Further investigation is warranted to characterize sleep disturbance among patients with both claudication and critical limb ischemia, evaluate associations with disease severity, and explore utility as a treatment outcome.

Objectives Frailty is associated with adverse outcomes among patients with vascular disease. Grip strength measurement is a comparatively simple, quick, and inexpensive screening test for weakness (a component of frailty) that is potentially applicable to clinical practice. We hypothesized that grip strength and categorical weakness are associated with clinical outcomes among patients with vascular disease. To test this hypothesis, we conducted a longitudinal cohort study evaluating associations between grip strength measured during outpatient clinic visits for vascular disease and clinical outcomes, including survival and perioperative outcomes. Methods Adult patients recruited from outpatient vascular surgery and/or vascular medicine clinics underwent dominant hand grip strength measurement using a hand dynamometer. Participants were categorized as weak based on grip strength, sex, and body mass index. Multivariable logistic models were used to evaluate perioperative outcomes. Mortality was evaluated using Cox proportional hazards models adjusted for sex, age, and operative intervention during follow-up. Results We enrolled 321 participants. The mean patients age was 69.0 ± 9.4 years, and 33% were women. Mean grip strength was 32.0 ± 12.1 kg, and 92 participants (29%) were categorized as weak. The median follow-up was 24.0 months. Adverse perioperative events occurred in 32 of 84 patients undergoing procedures. Grip strength was associated with decreased risk of perioperative adverse events (hazard ratio [HR], 0.41 per 12.7 kg increase; 95% confidence interval [CI], 0.20-0.85; P = .0171) in a model adjusted for open versus endovascular procedure (HR, 12.75 for open; 95% CI, 2.54-63.90; P = .0020) and sex (HR, 3.05 for male; 95% CI, 0.75-12.4; P = .120). Grip strength was also associated with a lower risk of nonhome discharge (HR, 0.34 per 12.7 kg increase; 95% CI, 0.14-0.82; P = .016) adjusted for sex (HR, 2.14 for male; 95% CI, 0.48-9.50; P = .31) and open versus endovascular procedure (HR, 10.36 for open; 95% CI, 1.20-89.47; P = .034). No associations between grip strength and length of stay were observed. Mortality occurred in 48 participants (14.9%) during follow-up. Grip strength was inversely associated with mortality (HR, 0.46 per 12.5 kg increase; 95% CI, 0.29-0.73; P = .0009) in a model adjusted for sex (HR, 5.08 for male; 95% CI, 2.1-12.3; P = .0003), age (HR, 1.04 per year; 95% CI, 1.01-1.08), and operative intervention during follow-up (HR, 1.23; 95% CI, 0.71-2.52). Categorical weakness was also associated with mortality (HR, 1.81 vs nonfrail; P = .048) in a model adjusted for age (HR, 1.06 per year; P = .002) and surgical intervention (HR, 1.36; 95% CI, 1.02-0.09; P = .331). Conclusions Grip strength is associated with all-cause mortality, perioperative adverse events, and nonhome discharge among patients with vascular disease. These observations support the usefulness of grip strength as a simple and inexpensive risk screening tool for patients with vascular disease.

Timely placement of an arteriovenous (AV) vascular access (native AV fistula [AVF] or prosthetic AV graft [AVG]) is necessary to limit the use of tunneled central venous catheters (TCVC) in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD). National guidelines recommend placement of AVF as the AV access of first choice in all patients to improve patient survival. The benefits of AVF over AVG are less certain in the older adults, as age-related biological changes independently modulate patient outcomes. This manuscript describes the rationale, study design and protocol for a randomized controlled pilot study of the feasibility and effects of AVG-first access placement in older adults with no prior AV access surgery. Fifty patients age ≥65 years, with incident ESKD on HD via TCVC or advanced kidney disease facing imminent HD initiation, and suitable upper extremity vasculature for initial placement of an AVF or AVG, will be randomly assigned to receive either an upper extremity AVG-first (intervention) or AVF-first (comparator) access. The study will establish feasibility of randomizing older adults to the two types of AV access surgery, evaluate relationships between measurements of preoperative physical function and vascular access development, compare vascular access outcomes between groups, and gather longitudinal assessments of upper extremity muscle strength, gait speed, performance of activities of daily living, and patient satisfaction with their vascular access and quality of life. Results will assist with the planning of a larger, multicenter trial assessing patient-centered outcomes. Keywords: arteriovenous access, Fistula, Graft, Hemodialysis, Older patients, Word count, abstract, 240, Text: 4,526, Figures: 1, Tables: 4

Background Outcome disparities associated with lower extremity bypass (LEB) for peripheral artery disease (PAD) have been identified but are poorly understood. Marital status may affect outcomes through factors related to health risk behaviors, adherence, and access to care but has not been characterized as a predictor of surgical outcomes and is often omitted from administrative data sets. We evaluated associations between marital status and vein graft patency following LEB using multivariable models adjusting for established risk factors. Methods Consecutive patients undergoing autogenous LEB for PAD were identified and analyzed. Survival analysis and Cox proportional hazards models were used to evaluate patency stratified by marital status (married versus single, divorced, or widow[er]) adjusting for demographic, comorbidity, and anatomic factors in multivariable models. Results Seventy-three participants who underwent 79 autogenous vein LEB had complete data and were analyzed. Forty-three patients (58.9%) were married, and 30 (41.1%) were unmarried. Compared with unmarried patients, married patients were older at the time of their bypass procedure (67.3 ± 10.8 years vs. 62.2 ± 10.6 years; P = 0.05). Married patients also had a lower prevalence of female gender (11.6% vs. 33.3%; P = 0.02). Diabetes, hypertension, hyperlipidemia, and smoking were common among both married and unmarried patients. Minimum great saphenous vein conduit diameters were larger in married versus unmarried patients (2.82 ± 0.57 mm vs. 2.52 ± 0.65 mm; P = 0.04). Twenty-four-month primary patency was 66% for married versus 38% for unmarried patients. In a multivariable proportional hazards model adjusting for proximal and distal graft inflow/outflow, medications, gender, age, race, smoking, diabetes, and minimum vein graft diameter, married status was associated with superior primary patency (hazard ratio [HR] = 0.33; 95% confidence limits [0.11, 0.99]; P = 0.05); other predictive covariates included preoperative antiplatelet therapy (HR = 0.27; 95% confidence limits [0.10, 0.74]; P = 0.01) and diabetes (HR = 2.56; 95% confidence limits [0.93–7.04]; P = 0.07). Conclusions Marital status is associated with vein graft patency following LEB. Further investigation into the mechanistic explanation for improved patency among married patients may provide insight into social or behavioral factors influencing other disparities associated with LEB outcomes.

Background Inferior lower extremity bypass (LEB) outcomes have been reported among women with peripheral arterial disease (PAD), but the mechanisms responsible for this disparity are unknown. Great saphenous vein (GSV) is considered the conduit of choice for LEB; GSV diameter is associated with graft patency and therefore is often used as a criterion for suitability for use as bypass conduit. We hypothesized that gender-based differences in GSV may contribute to LEB outcomes disparities. To explore this hypothesis, we performed a gender-based analysis of GSV anatomic characteristics among patients with PAD who were studied with duplex ultrasound vein mapping during evaluation for LEB. Methods Consecutive patients undergoing ultrasound vein mapping for planned LEB were analyzed. Minimum above- and below-knee GSV diameters were obtained in addition to demographic, procedural, and clinical data. Associations between gender and GSV diameter were evaluated using multivariate mixed models adjusting for anatomic location and within-patient correlation. Results One hundred five patients were analyzed. Mean patient age was 65 ± 11 years, 25% were women, and 78% were white. Mixed model estimates of minimum GSV diameters were 3.14 ± 0.09 mm above knee and 2.74 ± 0.09 below knee for men versus 3.23 ± 0.14 above-knee and 2.49 ± 0.14 below knee for women. A gender-based interaction between anatomic location and GSV diameter was identified, with women having a greater difference between above- and below-knee GSV diameters (or taper; mean difference of 0.73 ± 0.12 vs. 0.41 ± 0.17 mm; P = 0.017). Conclusions GSV taper (difference between above- and below-knee diameters) is greater in women and may contribute to inferior patency after LEB with vein conduit, particularly for below-knee target vessels. Further research is necessary to evaluate specific hemodynamic effects of graft taper and links with other clinical endpoints. In addition to minimum diameter, vein graft taper may warrant consideration when planning LEB.

We analyzed gender-based differences in preoperative factors, procedural characteristics, and 30-day outcomes after lower extremity bypass (LEB). LEB procedures were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant User File. Groupwise comparisons of preoperative and procedural variables were made using chi square, t tests, and nonparametric methods; gender influences on mortality, systemic, and surgical site complications were evaluated using logistic regression. Women (4,107 of 11,011 [37.3%]) were older and had greater prevalence of hypertension, diabetes, chronic obstructive pulmonary disease, rest pain, dialysis, previous stroke, open/infected wound, and dependent functional status ( P < 0.01 for all comparisons). Women more commonly underwent emergent and extra-anatomic procedures but had lower rates of venous conduit or tibial level outflow use. Univariable associations between female gender and risk of 30-day mortality, systemic, and surgical site complications were identified; only the association with surgical site complications remained significant in multivariable modeling (OR, 1.8; 95% CI, 1.6 to 2.1; P < 0.0001). Gender-based differences in demographic, comorbidity, and procedural factors may contribute to disparities in perioperative outcomes associated with LEB. Female gender may be associated with increased risk for surgical site complications, but 30-day mortality and systemic complication rates in women may reflect effects of confounding factors rather than gender-specific influence.

Over half of all gallbladder carcinoma (GBC) is discovered incidentally after cholecystectomy for benign disease. There are scant data comparing presentation and outcome for patients with incidental versus suspected GBC. The goal of this study is to determine the clinical differences between these two entities.Patients with GBC were identified retrospectively from records at academic healthcare institutions in Temuco, Chile; Atlanta, GA; and Rochester, MN between 1984 and 2008. Overall survival was compared for patients with and without preoperative suspicion using Kaplan-Meier curves and a multivariate Cox proportional hazards model.Of 571 patients, 128 (22.4%) had preoperative suspicion of malignancy, and 443 (77.6 %) were discovered incidentally. Incidental tumors were of lower stage, better differentiated, and with lower rates of metastases. Median survival for incidentally discovered GBC was 32.3 versus 5.8 months for suspected GBC (p0.0001). In a Cox proportional hazards model controlling for operation extent, T stage, differentiation, and other factors, preoperative suspicion remains a strong risk factor (odds ratio, 2.0; confidence interval, 1.5-2.9; p0.0001).Tumor characteristics differed significantly between patients with incidentally discovered versus preoperatively suspected GBC. Incidental GBC has a significantly better median survival.