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Objective: This study was conducted to evaluate the safety of percutaneous endovascular procedures (PEPs) during integration of endovascular skills into an urban academic vascular surgery practice and assess the hypothesis that currently accepted guidelines are a valid benchmark for endovascular competency., Methods: From 2000 through 2004, an endovascular training paradigm was instituted to integrate endovascular procedures into an academic endovascular practice. The paradigm involved individual mentoring of vascular surgery faculty by a partner with mature endovascular skills. Mentoring continued until each surgeon achieved a procedural experience of 100 diagnostic angiograms and 50 percutaneous endovascular interventions. Once achieved, privileges were granted for independent endovascular practice. To assess the effectiveness of the training process and competency of the newly trained endovascular practitioner, the surgeon-specific 30-day incidence of major complications and deaths for all PEPs performed during and after the mentoring process was determined. Complications and deaths were assigned to the mentor during the training process and to the individual surgeon once endovascular privileges were granted. Complications were classified as local vascular, local nonvascular, or systemic/remote., Results: From 2000 through 2004, 1208 PEPs were performed. During this time, three faculty surgeons achieved sufficient endovascular procedural experience and were granted endovascular privileges. Major complications consisted of 17 local vascular, three local nonvascular, and four systemic/remote. Three deaths occurred. Renal percutaneous transluminal angioplasty/stent procedures had the highest complication and death rate at 9%. The major complication and death rate per year was 1.8% to 4.9% (P = .32) and did not significantly vary. The major complication and death rate for all 1208 PEPs was 2.2%. The surgeon-specific complication and death rate was 1.9% to 3.6% (P = .14) and did not vary between surgeons., Conclusion: Endovascular skills can be safely transferred using a vascular surgeon-based training paradigm. When the training paradigm is directed at satisfying currently recommended guidelines for endovascular privileging, competent endovascular surgeons are the result.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.

A clinical trial of clindamycin 900 mg q8h admixed with gentamicin 1.5 mg/kg (eight-hourly group) versus clindamycin 600 mg q6h with gentamicin 1.5 mg/kg given separately (six-hourly group) was analyzed for relative cost containment. Acquisition costs were significantly higher for the six-hourly group for intravenous supplies ($181.5 +/- 47.8) when compared with the eight-hourly group ($67.6 +/- 21.6) (p less than 0.05). Nursing administration costs were greater for the six-hourly group ($28.6 +/- 7.5) compared with ($10.7 +/- 3.4) for the eight-hourly group (p less than 0.05). Also, significantly higher cost (p less than 0.05) was noted for pharmacist and technician manufacturing cost for the six-hourly group ($15.4 +/- 4.0) compared with the eight-hourly group ($13.3 +/- 4.3). Incorporating all appropriate costs, the mean total drug therapy costs were significantly greater (p less than 0.05) for clindamycin 600 mg q6h ($527.4 +/- 143.0) compared with clindamycin 900 mg q8h ($433.3 +/- 99.2). The dosing of clindamycin 900 mg q8h admixed with gentamicin 1.5 mg/kg is a more cost-effective method of drug delivery with similar efficacy and safety when compared with clindamycin 600 mg q6h with gentamicin given separately.