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Objective: Our aim was to better understand attitudes towards parental leave from the perspective of both surgeon faculty and current surgical trainees. We hypothesized that support for trainees to take parental leave would vary by year of residency graduation and by parental status., Design: We conducted a web-based survey regarding opinions on trainee parental leave. Quantitative and conventional content qualitative analyses were performed., Participants: Surveys were sent to surgeon faculty and current trainees from 5 large academic surgical residency programs., Results: Survey response rates were 11.5% for surgeon faculty (68/589), and 17.7% for trainees (50/281). There were 80/118 (67.8%) respondents who reported they had or were currently expecting children, 40/80 (50%) of whom were the gestational carrier. Most thought that 6-12 weeks of parental leave should be given to child-bearing trainees (62/118, 52.5%); another 32.2% (38/118) thought >12 weeks should be given. Responses were similar amongst surgeon faculty and trainees, parents and nonparents, and respondents who identified as men and women. Qualitative analysis revealed that most respondents felt parental leave did not put unreasonable strain on other trainees and felt support could be shown both informally and with formal written policies facilitating patient care coverage. Current surgeon faculty were less likely to feel moderately/extremely supported by their faculty compared to trainees (39% vs 77%, p = 0.004). Less than a third (37/117, 31.6%) of respondents knew the current leave policies., Conclusions: Amongst survey respondents, there was broad support for parental leave for surgical trainees of at least 6 weeks amongst trainees and faculty, and those with and without children. Current trainees felt more supported than current surgical faculty, suggesting that parental leave is increasingly more accepted. Support can be shown both informally and through easily accessible written policies and procedures that facilitate patient care coverage., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Anatomy is critical in risk stratification and therapeutic decision making in coronary disease. The relationship between anatomy and outcomes is not well described in PAD. We sought to develop an angiographic core lab within the VOYAGER-PAD trial. The current report describes the methods of creating this core lab, its study population, and baseline anatomic variables. Methods: Patients undergoing lower-extremity revascularization for symptomatic PAD were randomized in VOYAGER-PAD. The median follow up was 2.25 years. Events were adjudicated by a blinded Clinical Endpoint Committee. Angiograms were collected from study participants; those with available angiograms formed this core lab cohort. Angiograms were scored for anatomic and flow characteristics by trained reviewers blinded to treatment. Ten percent of angiograms were evaluated independently by two reviewers; inter-rater agreement was assessed. Clinical characteristics and the treatment effect of rivaroxaban were compared between the core lab cohort and noncore lab participants. Anatomic data by segment were analyzed. Results: Of 6564 participants randomized in VOYAGER-PAD, catheter-based angiograms from 1666 patients were obtained for this core lab. Anatomic and flow characteristics were collected across 16 anatomic segments by 15 reviewers. Concordance between reviewers for anatomic and flow variables across segments was 90.5% (24,417/26,968). Clinical characteristics were similar between patients in the core lab and those not included. The effect of rivaroxaban on the primary efficacy and safety outcomes was also similar. Conclusions: The VOYAGER-PAD angiographic core lab provides an opportunity to correlate PAD anatomy with independently adjudicated outcomes and provide insights into therapy for PAD. (ClinicalTrials.gov Identifier: NCT02504216) ., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Drs Rogers, Hogan, Nehler, Capell, Berkowitz, Hess, Yčas, and Bonaca receive salary support from CPC, a nonprofit academic research organization affiliated with the University of Colorado that receives or has received research grant/consulting funding between February 2021 and June 2023 from the following organizations: Abbott Laboratories, Adamis Pharmaceuticals Corporation, Agios Pharmaceuticals, Inc., Alexion Pharma, Alnylam Pharmaceuticals, Inc., Amgen Inc., Angionetics, Inc., ARCA Biopharma, Inc., Array BioPharma, Inc., AstraZeneca and Affiliates, Atentiv LLC, Audentes Therapeutics, Inc., Bayer and Affiliates, Beth Israel Deaconess Medical Center, Better Therapeutics, Inc., BIDMC, Boston Clinical Research Institute, Bristol-Meyers Squibb Company, Cambrian Biopharma, Inc., Cardiol Therapeutics Inc., CellResearch Corp., Cook Medical Incorporated, Covance, CSL Behring LLC, Eidos Therapeutics, Inc., EP Trading Co. Ltd, EPG Communication Holdings Ltd, Epizon Pharma, Inc., Esperion Therapeutics, Inc., Everly Well, Inc., Exicon Consulting Pvt Ltd, Faraday Pharm-aceuticals, Inc., Foresee Pharmaceuticals Co. Ltd, Fortress Biotech, Inc., HDL Therapeutics Inc., HeartFlow Inc., Hummingbird Bioscience, Insmed Inc., Ionis Pharmaceuticals, IQVIA Inc., JanOne Biotech Holdings Inc., Janssen and Affiliates, Kaneka, Kowa Research Institute, Inc., Kyushu University, Lexicon Pharm-aceuticals, Inc., LSG Kyushu University, Medimmune Ltd, Medpace, Merck & Affiliates, Novartis Pharmaceuticals Corp., Novate Medical, Ltd, Novo Nordisk, Inc., Pan Industry Group, Pfizer Inc., PhaseBio Pharmaceuticals, Inc., PPD Development, LP, Prairie Education and Research Cooperative, Prothena Biosciences Limited, Regeneron Pharmaceuticals, Inc., Regio Biosciences, Inc., Rexgenero, Sanifit Therapeutics S.A., Sanofi-Aventis Groupe, Silence Therapeutics PLC, Smith & Nephew plc, Stealth Bio-Therapeutics Inc., State of Colorado CCPD Grant, The Brigham & Women’s Hospital, Inc., The Feinstein Institutes for Medical Research, Thrombosis Research Institute, University of Colorado, University of Pittsburgh, VarmX, Virta Health Corporation, WCT Atlas, Worldwide Clinical Trials Inc., WraSer, LLC, and Yale Cardiovascular Research Group. Dr Bonaca receives support from the AHA SFRN under award numbers 18SFRN3390085 (BWH-DH SFRN Center) and 18SFRN-33960262 (BWH-DH Clinical Project). Dr Bonaca also reports stock in Medtronic and Pfizer.

Purpose: Medical Knowledge for general surgery residents' is assessed by the American Board of Surgery In- Training Examination (ABSITE). ASBITE score reports contain many metrics residency directors can utilize to assess resident progress and perform program evaluation. The purpose of this study was to develop a framework to evaluate program effectiveness in teaching specific subtest and subtopic areas of the ABSITE, using ABSITE score reports as an indicator. The aim is to demonstrate the identification of topic areas of weakness in program-wide performance on the ABSITE to guide proposed modification of the general surgery residency program curriculum, and to initiate development of a data visualizing dashboard to communicate these metrics., Methods: A single institution retrospective study was performed utilizing ABSITE score reports from general surgery residents at a large academic training program from 2017 to 2020. ABSITE performance metrics from 320 unique records were entered into a database; statistical analysis for linear trends and variance were conducted for standard scores, subtest standard scores, and incorrect subtest topics. Deviation from national average scores were calculated by subtracting the national average score from each subtest score for each trainee. Data were displayed as medians or proportions and are displayed to optimize visualization as a proof-of-concept for the development of a program dashboard., Results: Trends and variance in general surgery program and cohort performance on various elements of the ABSITE were visualized using figures and tables that represent a prototype for a program dashboard. Figure A1 demonstrates one example, in which a heatmap displays the median deviation from national average scores for each subtest by program year. Boxplots show the distribution of the deviation from national average, range for national average scores, and the recorded scores for each subtest by program year. Trends in median deviation from the national average scores are displayed for each program year paneled by subtest or for each exam year paneled by cohort. Median change in overall test scores from one program year to another in a cohort is visualized as a table. Bar graphs show the most often missed topics across all program years and heatmaps were generated showing the proportion of times each topic was missed for each subtest and exam year., Conclusions: We demonstrate use of ABSITE reports to identify specific thematic areas of opportunities for curriculum modification and innovation as an element of program evaluation. In this study we demonstrate, through data analysis and visualization, feasibility for the creation of a Program ABSITE Dashboard (PAD) that enhances the use of ABSITE reports for formative program evaluation and can guide modifications to surgery program curriculum and educational practices., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Use of traditional scoring metrics for residency recruitment creates racial and gender bias. In addition, widespread use of pass/fail grading has led to noncomparable data. To adjust to these challenges, we developed a holistic review (HR) rubric for scoring residency applicants for interview selection., Design: Single-center observational study comparing the proportion of underrepresented in medicine (URM) students and their United States Medical Licensing Exam (USMLE) scores who were invited for interview before (2015-2020) and after (2022) implementation of a holistic review process., Setting: General surgery residency program at a tertiary academic center., Participants: US allopathic medical students applying for general surgery residency., Results: After initial screening, a total of 1514 allopathic applicants were narrowed down to 586 (38.7%) for HR. A total of 52% were female and 17% identified as URM. Based on HR score, 20% (118/586) of applicants were invited for an interview. The median HR score was 11 (range 4-19). There was a fourfold higher coefficient of variation of HR scores (22.3; 95% CI 21.0-23.7) compared to USMLE scores (5.1; 95% Cl 4.8-5.3), resulting in greater spread and distinction among applicants. There were no significant differences in HR scores between genders (p = 0.60) or URM vs non-URM (p = 0.08). There were no significant differences in Step 1 (p = 0.60) and 2CK (p = 0.30) scores between those who were invited to interview or not. On multivariable analysis, USMLE scores (OR 1.01; 95% CI 0.98-1.03), URM status (OR 1.71 95% CI 0.98-2.92), and gender (OR 0.94, 95% CI 0.60-1.45) did not predict interview selection (all p > 0.05). There was a meaningful increase in the percentage of URM interviewed after HR implementation (12.9% vs 23.1%, p = 0.016)., Conclusion: The holistic review process is feasible and eliminates the use of noncomparable metrics for surgical applicant interview invitations and increases the percentage of URM applicants invited to interview., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The reported risk of a cranial nerve (CN) injury is up to 1 in 4 patients in large registries of carotid body tumor (CBT) resection. Functional outcome for this population is unknown., Methods: We evaluated consecutive patients who underwent CBT resection from November 2013 through October 2020. Demographics, intraoperative details, complications, and outcomes were recorded from the medical record. Permanent CN nerve injury was defined as deficits lasting >6 months. Frequency statistics, averages, chi-squared test, and multiple logistic regression were completed for primary end points of complications and disease-free survival. Patient-reported outcomes were gathered via telephone survey of patients conducted in September 2021., Results: Fifty-one patients presented with CBTs and the following Shamblin classes: I (n = 7; 14%), II (n = 36; 69%), and III (n = 9; 17%). Head and neck oncology and vascular surgery jointly did 52% of CBT resections, including 6 of 9 Shamblin III cases. Eight patients (15.3%, all Shamblin II or III) suffered a total of 12 CN injuries - 8 CN XII (5 temporary and 3 permanent), 3 CN X (all permanent), and 1 CN XI (permanent). Seven of the CN injury subgroup had preoperative embolization and 5 were joint oncology/vascular cases. In addition, 4 separate carotid injuries required repair. Notably, all patients had disease-free survival postoperatively at a mean follow-up of 6 months. Patient-reported outcomes obtained in 70.6% of patients 1 year or more from index operation demonstrated that two-thirds of patients live without any permanent functional deficits, and the majority of those with continued deficits rate the symptoms as daily but mild in severity., Conclusions: In a series of complex CBT patients treated with preoperative embolization capabilities and multidisciplinary surgical approach, disease-free survival was achieved in all patients despite a high rate of iatrogenic CN injuries, most commonly CN XII. Patient-reported outcomes survey results indicate that injuries identified on clinical exam underreport patients' true postoperative CN deficits - especially branches of CN X. This data support the practice of aggressive primary resection of CBTs while providing guidance for expected functional outcomes due to CN injury risk., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The use of thoracic endovascular aortic repair (TEVAR) for the management of acute uncomplicated type B aortic dissection (TBAD) has increased. Although the results from early studies were promising, larger randomized trials evaluating TEVAR are lacking. It is also unclear where sufficient equipoise exists for such trials. In the present study, we evaluated the number of readmissions and unplanned operations after TEVAR vs those after medical management as the initial treatment of acute uncomplicated TBAD and the frequency of each treatment in this population., Methods: We performed a multi-institutional retrospective review of patients with acute TBAD from 2015 to 2020 with the 1-year outcomes available, excluding patients with prior aortic intervention or chronic, iatrogenic or traumatic etiologies. The primary exposure was TEVAR vs medical management at the index admission. The patient demographics, clinical presentation, and imaging findings were analyzed using bivariate and multivariate logistic regression for the primary outcomes of unplanned readmission and/or operation after the initial admission. The secondary outcomes were mortality, myocardial infarction, stroke, renal failure requiring dialysis, retrograde type A dissection, and length of stay. We hypothesized that the readmissions would be higher with medical management., Results: A total of 216 patients with TBAD (47 with complicated and 169 with uncomplicated) from two large academic centers were identified. Of the 169 patients with uncomplicated TBAD, 83 (49%) had been treated medically and 86 (51%) had undergone TEVAR at the initial admission. No differences were found in the demographics or high-risk imaging features at presentation. The medically managed patients had had higher rates of unplanned readmission (34% vs 9%; P = .0001) and operation (28% vs 8%; P = .0007) but shorter lengths of stay (6.3 vs 13.1 days; P < .0001). No differences were found in mortality, although the rate of myocardial infarction was higher in the medically managed group (10.8% vs 2.3%; P = .02). Although 28% of the medically managed patients had later required operation, they had had morbidity and mortality similar to those of patients who had undergone initial TEVAR. Initial medical management was associated with unplanned readmission (odds ratio, 8.3; P = .02) and the need for operation (odds ratio, 4.56; P = .006). No differences were found in the outcomes according to the involved aortic zones., Conclusions: In the present study, medical management of acute uncomplicated TBAD was associated with higher rates of readmission and the need for unplanned operation compared with TEVAR. However, no differences were found in the 1-year mortality for the patients for whom medical management had failed. Because one half of the patients had undergone medical management and one half had undergone early TEVAR, this finding suggests clinical equipoise for the treatment of acute uncomplicated TBAD. Therefore, a larger randomized trial appears warranted to determine whether a clear benefit exists for early TEVAR., (Published by Elsevier Inc.)

Background: Peripheral artery disease (PAD) is associated with high morbidity and mortality, particularly once patients develop critical limb threatening ischemia (CLTI). Minorities and vulnerable populations often present with CLTI and experience worse outcomes. The use of directional atherectomy (DA) and drug-coated balloon (DCB) during lower-extremity revascularization (LER) has not been previously described in a safety-net population., Objective: To review demographic and clinical characteristics, and short- intermediate term outcomes of patients presenting to a safety-net hospital with PAD treated with DA and DCB during LER., Methods: In this retrospective, observational cohort study, chart review was performed of all patients who underwent DA and DCB during LER for PAD from April 2016 to January 2020 in a safety-net hospital., Results: The analysis included 58 patients, with 41% female, 24% Black/African American, and 31% Hispanic. From this group, 17% spoke a non-English primary language and 10% reported current or previous housing insecurity. Most (65%) presented with CLTI and had undergone a previous index leg LER (58%). The combination of DA and DCB was efficacious, resulting in low rates of bail-out stenting (16%) and target-vessel revascularization (26%) at 2 years. Low complication rates (tibial embolism in 12% and vessel perforation in 2% of cases) were also observed. Most patients (67%) with Rutherford category 5 experienced wound healing by 2 years., Conclusion: In this safety-net population, the majority presented with CLTI and a previous LER of the index leg. The combination of DA and DCB resulted in low complication rates, and good short-intermediate outcomes in this frequently undertreated population.

Background: Patients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) have a high risk of adverse limb and cardiovascular events. The results from the VOYAGER PAD (efficacy and safety of rivaroxaban in reducing the risk of major thrombotic vascular events in subjects with symptomatic peripheral artery disease undergoing peripheral revascularization procedures of the lower extremities) trial have demonstrated that rivaroxaban significantly reduced this risk with an overall favorable net benefit for patients undergoing surgical revascularization. However, the efficacy and safety for those treated by surgical bypass, including stratification by bypass conduit (venous or prosthetic), has not yet been described., Methods: In the VOYAGER PAD trial, patients who had undergone surgical and endovascular infrainguinal LER to treat PAD were randomized to rivaroxaban 2.5 mg twice daily or placebo on top of background antiplatelet therapy (aspirin 100 mg to be used in all and clopidogrel in some at the treating physician's discretion) and followed up for a median of 28 months. The primary end point was a composite of acute limb ischemia, major amputation of vascular etiology, myocardial infarction, ischemic stroke, and cardiovascular death. The principal safety outcome was major bleeding using the TIMI (thrombolysis in myocardial infarction) scale. The index procedure details, including conduit type (venous vs prosthetic), were collected at baseline., Results: Among 6564 randomized patients, 2185 (33%) had undergone surgical LER. Of these 2185 patients, surgical bypass had been performed for 1448 (66%), using a prosthetic conduit for 773 patients (53%) and venous conduit for 646 patients (45%). Adjusting for the baseline differences and anatomic factors, the risk of unplanned limb revascularization in the placebo arm was 2.5-fold higher for those receiving a prosthetic conduit vs a venous conduit (adjusted hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.65-3.90; P < .001), and the risk of acute limb ischemia was three times greater (adjusted HR, 3.07; 95% CI, 1.84-5.11; P < .001). The use of rivaroxaban reduced the primary outcome for the patients treated with bypass surgery (HR, 0.78; 95% CI, 0.62-0.98), with consistent benefits for those receiving venous (HR, 0.66; 95% CI, 0.49-0.96) and prosthetic (HR, 0.87; 95% CI, 0.66-1.15) conduits (P interaction  = .254). In the overall trial, major bleeding using the TIMI scale was increased with rivaroxaban. However, the numbers for those treated with bypass surgery were low (five with rivaroxaban vs nine with placebo; HR, 0.55; 95% CI, 0.18-1.65) and not powered to show statistical significance., Conclusions: Surgical bypass with a prosthetic conduit was associated with significantly higher rates of major adverse limb events relative to venous conduits even after adjustment for patient and anatomic characteristics. Adding rivaroxaban 2.5 mg twice daily to aspirin or dual antiplatelet therapy significantly reduced this risk, with an increase in the bleeding risk, but had a favorable benefit risk for patients treated with bypass surgery, regardless of conduit type. Rivaroxaban should be considered after lower extremity bypass for symptomatic PAD to reduce ischemic complications of the heart, limb, and brain., (Copyright © 2022 Society for Vascular Surgery. All rights reserved.)

Objective: Coaching can provide learners with space to reflect on their performance while ensuring well-being and encouraging professional achievement and personal satisfaction outside of traditional mentorship and teaching models. We hypothesized that a proactive coaching program for general surgery interns coupled with individualized learning plans would help build foundational skills necessary for residency success and facilitate the incorporation of well-being practices into resident professional life. Here, we present the development, implementation, and outcomes of a novel well-being coaching program for surgical interns., Design and Setting: A well-being coaching program was developed and implemented from July 2020 through June 2021 at a single university-based surgical residency program. To assess impact of the coaching program, we designed a mixed-methods study incorporating end-of-program survey results as well as participant narratives from commitment-to-act statements for thematic content., Participants: All 32 general surgery interns participated in aspects of the coaching program., Results: The end-of-program survey was completed by 19/32 (59%) interns and commitment-to-act statements were completed by 22/32 (69%). The majority (89%) of survey respondents "agreed" or "strongly agreed" that the longitudinal intern coaching program helped them reach goals they had set for themselves this academic year; 15/19 (79%) noted that the coaching experience was effective in promoting well-being practices in their life. Well-being and professional goals were identified as major themes in the end-of-the-year commitment-to-act statements. Statements specifically mentioned resources highlighted and skills taught in our coaching program such as mindfulness techniques, gratitude journals, and self-compassion strategies., Conclusions: Our study illustrates the effectiveness of a coaching pilot program on promoting well-being practices in a university-based general surgery internship and can be a roadmap with proven efficacy and measurable outcomes., Competing Interests: Conflicts of Interest Dr. Fainstad is a certified professional coach and coaches clients outside of her academic role in an independently owned and operated LLC. In that capacity, she does not recruit or coach medical trainees., (Published by Elsevier Inc.)

Background: Cancer results in a hypercoagulable state that is associated with both venous and arterial thromboses. However, little is known about the effects of acute limb ischemia (ALI) in this cohort of patients. In the present systematic review and meta-analysis, we analyzed the available clinical data on cancer and its association with ALI and evaluated the outcomes in these patients after a diagnosis of ALI., Methods: Three databases, including PubMed, EMBASE, and the Cochrane Library, were queried. Studies that met the inclusion criteria were included regardless of the publication year, language, sample size, or follow-up length. All the steps of the meta-analysis were conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) and MOOSE (meta-analysis of observational studies in epidemiology) guidelines., Results: Seven studies from 6222 references with a total of 2899 patients were included. Of the 2899 patients, 1195 (41%) had had a diagnosis of ALI before their cancer diagnosis, and 1704 (59%) had presented with ALI after a cancer diagnosis. Nearly three quarters of ALI events were among patients with cancer of the skin and soft tissue (19%), genitourinary (18%), lung (17%), and gastrointestinal (16%) systems. ALI recurrence was similar between the two groups, and major amputation was more likely in patients with a diagnosis of ALI after a cancer diagnosis (7.4% vs 4.6%; P < .01). The incidence of mortality at 1 year was significantly greater for patients with established cancer who had presented with ALI compared with the patients who had presented with ALI before a cancer diagnosis (50.6% vs 29.9%; P < .01). After adjusting for study variability using the random effects model, the mortality at 1 year for all patients was 52.3% (95% confidence interval, 37.7%-66.5%). No significant heterogeneity (P = .73) was found between the two groups of patients, which varied by the timing of the ALI diagnosis in relation to the cancer diagnosis., Conclusions: The 1-year mortality after the development of ALI in patients with cancer was >50%. For patients presenting with ALI of unclear etiology, the presence of an underlying cancer should be considered., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate deficiencies in knowledge and education in opioid prescribing and to compare surgical resident opioid-prescribing practices to Opioid Prescribing Engagement Network (OPEN) procedure-specific guidelines., Design: Anonymous web-based survey distributed to all general surgery residents to evaluate prior education received and confidence in knowledge in opioid prescribing. The number of 5 milligram oxycodone tablets prescribed for common procedures was assessed and compared with OPEN for significance using Wilcoxon signed rank tests., Setting: General surgery residency program within large university-based tertiary medical center., Participants: Categorical general surgery residents of all postgraduate years., Results: Fifty-six of 72 (78%) categorical residents completed the survey. Few reported receiving formal education in opioid prescribing in medical school (32%) or residency (16%). While 82% of residents felt confident in opioid side effects, fewer felt the same with regards to opioid pharmacokinetics (36%) or proper opioid disposal (29%). Opioids prescribed varied widely with residents prescribing significantly more than recommended by OPEN in 9 of 14 procedures., Conclusions: Tackling the evolving opioid epidemic requires a multidisciplinary approach that addresses prescribing at all steps of the process, starting with trainee education., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine if surgeons and non-surgeons agree on the importance of surgical topics covered in the surgical clerkship to the daily practice of non-surgeons., Design: An IRB-approved anonymous survey ranking the relative importance of 35 topics drawn from surgical clerkship curricula asking physicians to rank the relative importance of each topic, using a five-point Likert scale, to the daily practice of non-surgeons., Setting: Online anonymous survey., Participants: Convenience sample of practicing physicians and trainees. The survey was offered to physicians in all specialties via social media and professional connections, responders identified their practice specialty., Results: 295 physicians completed the survey. Two hundred thirty-one (85%) were from non-surgical specialties: emergency medicine (EM, n = 100); primary care (PC, n = 71 - included internal medicine, family medicine, and pediatrics); a variety of others (n = 60).  Surgeons and non-surgeons agreed on the relative importance of the acute abdomen, breast disease, inguinal hernias, inflammatory bowel disease, morbid obesity, sinusitis, thyroid and parathyroid disease, and wound care; surgeons believed colorectal cancer and diverticulitis to be more important. Surgeons rated all other topics as less important to non-surgeons than non-surgeons. EM rated most acute problems more important that PC; both groups ranked most topics higher importance to the practice of a non-surgeon than surgeons (p < 0.05)., Conclusions: Surgeons consistently underestimate the importance non-surgeons place on surgical topics in their practice.  These results reinforce the perceived importance of a wide exposure to surgery in the surgical clerkship to all medical students - but topics could be focused differently depending on acute or non-acute non-surgical care career plans., (Copyright © 2020 Association of Program Directors in Surgery. All rights reserved.)

Background: The magnitude of student debt plaguing our nation is a major topic in political and academic spheres with median medical student debt of $200,000. This is compounded by poor financial health during training. This study evaluates how debt and financial wellness influence resident perceived stress, mental health, career plans, and relationships., Methods: General surgery trainees at an academic institution were surveyed regarding financial parameters, perceived stress, and the impact of finances on their career and family life. A validated stress assessment instrument, the Perceived Stress Scale, was used to evaluate trainee stress. The median perceived stress score was compared for groups using a Wilcoxon rank-sum test., Results: Fifty-eight (61% response rate) residents responded to the survey. The median (range) student loan debt was $200,000-500,000 ($0-750,000) and savings was $5000-10,000 ($0-20,000+). 18 (31%) trainees had monthly credit card debt. Half of the respondents did not have enough liquid assets for an emergency fund, defined as 3 mo of living expenses. The median perceived stress score was 16 (1-30) or moderate stress. Perceived stress score was significantly associated with the trainee's response to how finances impacted their future career choice, practice style, and relationships (P < 0.005 for all). However, the perceived stress score was not associated with objective measures of financial wellness, such as the overall level of medical school debt, savings, or having an emergency fund., Discussion: The trainee's subjective perception of financial wellness, rather than objective financial parameters was associated with higher levels of perceived stress, the strain on relationships, and a greater impact on future practice styles. The majority of surgery residents did not have enough liquid assets for an emergency fund, independent of the level of debt, which emphasizes how financially leveraged residents are during training. Although burnout during surgical training is multifactorial, formal financial education incorporated into graduate medical education programs could increase financial literacy, help to mitigate financial risk, and ultimately decrease some of the perceived stress residents possess., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Aims: Polyvascular disease (PVD) affects approximately 20% of patients with atherosclerosis and is a strong independent risk factor for ischemic outcomes. However, guidelines do not address screening or treatment for PVD, and there have been no PVD-specific trials. We reviewed subgroup analyses of large randomized controlled trials of more intense antithrombotic therapy to determine whether increased intensity of therapy improved ischemic outcomes in patients with PVD., Methods: MEDLINE, MEDLINE in-Process, EMBASE, and the Cochrane Library were queried for randomized controlled trials larger than 5000 patients evaluating secondary prevention therapies in patients with coronary artery disease or lower extremity peripheral artery disease., Results: Thirteen trials were included ranging in size from 7243 to 27,395 patients. In 9 trials (CHARISMA, TRA 2°P-TIMI 50, PEGASUS-TIMI 54, VOYAGER PAD, TRACER, EUCLID, TRILOGY ACS, PLATO, and COMPASS), patients in the PVD subgroup treated with increased-intensity antithrombotic therapy had similar or greater relative risk reductions for ischemic events in comparison with the general trial cohorts. In four trials (DAPT, THEMIS, APPRAISE-2, and ATLAS ACS 2 TIMI 51), the PVD subgroup had an increased hazard of ischemic events with increased-intensity therapy compared with the general trial cohorts., Conclusions: More intense antithrombotic therapy in patients with PVD was associated with a similar relative risk reduction for ischemic events compared with patients without PVD. Therefore, patients with PVD benefit from a larger absolute risk reduction because of their higher baseline risk. Future trials in patients with atherosclerotic cardiovascular disease should intentionally include PVD patients to adequately assess treatment options for this under-studied, under-treated population., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Acute limb ischemia (ALI) carries significant overall morbidity and mortality. Pregnant and postpartum women are physiologically hypercoagulable, but little is known about the impact of ALI in this cohort of patients. The goal of this systematic review was to gather available data on diagnosis and treatment of ALI during pregnancy and the postpartum period., Methods: A systematic review of studies on patients with ALI during pregnancy and the puerperium was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases including PubMed MEDLINE, Embase, and Cochrane Library were queried. Manuscripts that provided data on diagnosis and treatment of ALI in pregnant and postpartum patients were included regardless of language or study design. Outcomes of interest included type of treatment for ALI (open and endovascular), morbidity, and mortality., Results: Fourteen manuscripts of 6222 references were included with a total of 14 patients. The median age of patients was 31.5 years. Embolism, present in eight (57%) patients, was slightly more common than thrombosis. All patients had a pregnancy complication or concomitant medical condition that might have predisposed to arterial occlusion either directly or indirectly by leading to iatrogenic arterial injury; peripartum cardiomyopathy, the most common, occurred in six (43%) patients. Open surgery was the preferred treatment option in 11 (79%) patients, followed by anticoagulation alone. No endovascular procedures were described. One patient underwent major amputation on presentation, and an additional patient required major amputation for recurrent ALI. No deaths occurred. Twelve (86%) patients had complete recovery with no other ALI-associated sequelae., Conclusions: ALI is rare in pregnant and postpartum women despite their transient physiologic hypercoagulability and is almost uniformly associated with pregnancy complications. Open surgical revascularization or anticoagulation alone appears to have acceptable outcomes as most patients present with embolism or thrombosis without underlying systemic arterial disease., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Digital rock physics combines microtomographic imaging with advanced numerical simulations of effective material properties. It is used to complement laboratory investigations with the aim to gain a deeper understanding of relevant physical processes related to transport and effective mechanical properties. We apply digital rock physics to reticulite, a natural mineral with a strong analogy to synthetic open-cell foams. We consider reticulite an end-member for high-porosity materials with a high stiffness and brittleness. For this specific material, hydro-mechanical experiments are very difficult to perform. Reticulite is a pyroclastic rock formed during intense Hawaiian fountaining events. The honeycombed network of bubbles is supported by glassy threads and forms a structure with a porosity of more than 80%. Comparing experimental with numerical results and theoretical estimates, we demonstrate the high potential of in situ characterization with respect to the investigation of effective material properties. We show that a digital rock physics workflow, so far applied to conventional rocks, yields reasonable results for high-porosity rocks and can be adopted for fabricated foam-like materials with similar properties. Numerically determined porosities, effective elastic properties, thermal conductivities and permeabilities of reticulite show a fair agreement to experimental results that required exeptionally high experimental efforts.

Patients with peripheral artery disease (PAD) have an increased risk of cardiovascular (CV) and limb events, but the disease is frequently underdiagnosed and treatment options are limited. This review examines the disease burden of symptomatic PAD as well as key guideline recommendations. Publications were identified using the ProQuest portal to access the Medline, Medline In-Process, and Embase databases. Search terms for symptomatic PAD were combined with terms relevant to epidemiology, burden, treatment practice, and physiopathology. Articles in English published between January 2001 and September 2016 were screened according to the population, interventions, comparator, outcomes, and study design criteria. Relevant publications (n = 200) were identified. The reported incidence and prevalence of PAD varied depending on the definitions used and the study populations. Patients generally had a poor prognosis, with an increased risk of mortality, CV, and limb events and decreased quality of life. Guideline recommendations included ankle-brachial index measurements, exercise testing, and angiography for diagnosis and risk factor modification, antiplatelets, cilostazol, exercise therapy, or surgical interventions for treatment, depending on the patient profile. The clinical, humanistic, and economic burden of disease in patients with symptomatic PAD is substantial and needs to be reduced through improved PAD management.

Background: Pediatric traumatic vascular injuries are rare. Given the paucity of data to guide anti-coagulation (AC) management of these injuries in children, who have a lower overall risk for thrombosis compared to their adult counterparts, we sought to examine and summarize our recent experience., Method: We conducted a retrospective review of all patients (<18 years old) who sustained traumatic vascular injuries between 2010-2018 at a Level 1 and Level 2 Pediatric Trauma Center., Results: Ninety-nine patients had traumatic vascular injuries. Eighty-four patients sustained a major arterial injury, 26 had a major venous injury, and 11 had both arterial and venous injuries. The arterial injury cohort had a median age of 13.3 years. Most of the arterial injury patients (65/84, 77%) required vascular repair. In-hospital AC management for the arterial injury patients consisted of a post-operative heparin drip (18%, 15/84), aspirin (39%, 26/84), enoxaparin (23%, 19/84), or none (42%, 43/84). Approximately one-half of the patients with arterial injuries (54%, 45/84) were discharged home on AC therapy, most commonly aspirin. Fifty-six patients (66%) followed up post-injury, of which 25% (14/56) had experienced complications., Conclusion: Pediatric traumatic arterial injuries that require surgical intervention other than ligation should be considered for discharge AC - most commonly aspirin - in the absence of contraindications. Pediatric patients with vascular injuries to the aorta, carotid artery, inferior vena cava, portal vein, or lower extremities that are managed non-operatively should also be considered for AC. The preferred AC for pediatric venous injuries is enoxaparin, in the absence of contraindications., Study Type: Treatment Study LEVEL OF EVIDENCE: IV., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aims/hypothesis: The primary analysis of the Canagliflozin cardioVascular Assessment Study (CANVAS) Program showed canagliflozin to have a beneficial effect on cardiovascular and renal outcomes in people with type 2 diabetes at high cardiovascular risk, but also an unexpected increased risk of major or minor lower extremity amputation. These secondary analyses explore this finding in more detail., Methods: The effect of canagliflozin on amputation risk in the CANVAS Program was calculated for amputations of different types and proximate aetiologies and different canagliflozin doses. Univariate and multivariate associations of baseline characteristics with amputation risk were determined and proportional and absolute effects of canagliflozin were compared across subgroups., Results: There were 187 (1.8%) participants with atraumatic lower extremity amputations (minor 71%, major 29%); as previously published, rates were 6.30 vs 3.37 per 1000 participant-years with canagliflozin vs placebo (HR 1.97 [95% CI 1.41, 2.75]). Risk was similar for ischaemic and infective aetiologies and for 100 mg and 300 mg doses. Overall amputation risk was strongly associated with baseline history of prior amputation (major or minor) (HR 21.31 [95% CI 15.40, 29.49]) and other established risk factors. No interactions between randomised treatment and participant characteristics explained the effect of canagliflozin on amputation risk. For every clinical subgroup studied, numbers of amputation events projected were smaller than numbers of major adverse cardiovascular events averted., Conclusions/interpretation: The CANVAS Program demonstrated that canagliflozin increased the risk of amputation (mainly minor) in this study population. Anticipated risk factors for amputation were identified, such as prior history of amputation, peripheral vascular disease and neuropathy, but no specific aetiological mechanism or at-risk subgroup for canagliflozin was identified.

The most common causes of ischaemic stroke are represented by carotid artery atherosclerotic disease (CAAD) and atrial fibrillation. While oral anticoagulants substantially reduce the incidence of thromboembolic stroke (< 1%/year), the rate of ischaemic stroke and other cardiovascular disease events in patients with CAAD remains high, ranging from 8.4 to 18.1 events per 100 patient-years. Similar to any other atherosclerotic disease, anti-thrombotic therapies are proposed for CAAD to reduce stroke and other cardiovascular events. The 2017 European Society of Cardiology (ESC)/European Society for Vascular Surgery (ESVS) guidelines recommend for patients with asymptomatic CAAD ≥60% the use of aspirin 75 to 100 mg once daily or clopidogrel 75 mg once daily at the exception of patient at very high bleeding risk. For patients with symptomatic CAAD ≥50%, the use of aspirin 75 to 100 mg once daily or clopidogrel 75 mg once daily is recommended. New perspectives for anti-thrombotic therapy for the treatment of patients with CAAD come from the novel dual pathway strategy combining a low-dose anticoagulant (i.e. rivaroxaban) and aspirin that may help reduce long-term ischaemic complications in patients with CAAD. This review summarizes current evidence and recommendations for the anti-thrombotic management of patients with symptomatic or asymptomatic CAAD or those undergoing carotid revascularization., Competing Interests: Rupert Bauersachs: Funding from Bayer, BMS, Boehringer Ingelheim, Daiichi-Sankyo and Pfizer for consulting work and speaker bureaus. He also provides research support, as a principal investigator, for Bayer, BMS, Boehringer, Daiichi-Sankyo, Leo Pharma and Portola Pharmaceuticals.John W Eikelboom: Grants and personal fees from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, Daiichi-Sankyo, Janssen, AstraZeneca, Eli Lilly, GlaxoSmithKline and Sanofi Aventis.Victor Aboyans: Honoraria from Bayer, Bristol-Myers Squibb, Pfizer, Novartis, Merck and Sharp & Dohme.Sonia S. Anand: Personal fees from Bayer and Novartis.Sigrid Nikol: Consulting and function as presenter for Bayer, Daichii-Sankyo and Pfizer.Manesh R. Patel: Advisory boards/consultant to Bayer, Janssen and AstraZeneca.Jean-Francois Tanguay: In-kind and financial support for physician-initiated grants from Spartan Bioscience, Roche Diagnostics, Aggredyne and Eli Lilly Canada; has received institutional research funding from Abbott Vascular, Novartis, Bayer, Biosensors and AstraZeneca; and has received honoraria for speaker/consultation/advisory board service from Abbott Vascular, AstraZeneca, Bayer, Servier and Eli Lilly.Eike Sebastian Debus: Personal fees from Bayer AG and institutional fees from Cook Ltd. and Vascutek.Lucia Mazzolai: Personal fees from Bayer Health Care, Pfizer, Bristol-Myers Squibb and Daiichi-Sankyo.Peter Verhamme: Grants and honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi-Sankyo, Pfizer, Sanofi and LEO Pharma.Jackie Bosch, Jean-Baptiste Ricco and Francesco Violi: Advisory board fees from Bayer.Daniele Pastori and Mark Nehler: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Fault zone permeability and the real 3D-spatial distribution of the fault-related fracture networks are critical in the assessment of fault zones behavior for fluids. The study of the real 3D-spatial distribution of the microfracture network, using X-ray micro-computed tomography, is a crucial factor to unravel the real structural permeability conditions of a fault-zone. Despite the availability of several commercial software for rock properties estimation from X-ray micro-computed tomography scanning, their high cost and lack of programmability encourage the use of open-source data treatment. This work presents the implementation of a methodology flow for the quantification of both structural and geometrical parameters (fractures density, fractures aperture, fractures porosity, and fractures surface area), and the modeling of palaeopermeability of fault-related fractured samples, with focus in the proper spatial orientation of both the sample and the results. This is performed with an easy to follow step-by-step implementation, by a combination of open-source software, newly implemented codes, and numerical methods. This approach keeps track of the sample's spatial orientation from the physical to the virtual world, thus assessing any fault-related palaeopermeability anisotropy., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: The majority of surgery programs roster non-designated preliminary (NDP) residents. We and others have reported on the success of NDP resident mentoring with regard to categorical position placement. Lacking is a focus on the candidates themselves and differences based on initial career of choice., Methods: NDP residents' files since the institution of SOAP were reviewed for demographics, initial career choice, financial burden, region of medical school of origin, application and interview history, and pre-screen interview candidate score (high score of 22 - data includes USMLE scores, major clerkship grades, and AOA) used for categorical recruitment., Results: From 2012-16 79 NDP residents have been recruited at UCDenver (82% via SOAP). Median age was 28 years, majority were single (73%), and male (82%). Thirty percent belonged to an under-represented minority group. Mean debt was $156,000 but 20% owe over $250,000. 90% attended US medical schools with 65% from the NRMP "South" region. 86% were recruited as fourth year students. NDPs were categorized as failing to match in general surgery (38%), surgical subspecialties (47%), or other (15%). NDPs applied to median of 68 programs (range 7-200) and granted a median of 8 interviews (range 0-24). NDPs had a mean pre-screening interview score of 13 out of 22 and only 9% would have met the standard threshold to obtain a categorical surgery interview. There were no differences in pre-screening scores in the three groups. 95% NDPs (excluding present year) successfully completed their R1 year (three resigned - one obtained a general surgery spot mid-year and two after matching in non-general surgery fields). 68% NDPs placed in categorical positions after the R1 year. The placement was better for the surgical subspecialty group compared to the other two., Conclusions: The bias is that due to a more competitive applicant pool recruiting NDPs from surgical subspecialties would be optimal. However, those unmatched surgical subspecialty candidates are no better academically than the unmatched general surgery group, often have career interests that do not always align with scheduled rotations, and may not feel compelled to complete the year if they match. They place minimally better when accounting for those unmatched general surgery NDP R1s continuing as NDP R2s. Ultimately the success in a non-designated preliminary R1 surgery program is alignment of clinical educational opportunities with the needs of the trainee., (Published by Elsevier Inc.)

Importance: Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear., Objectives: To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate., Design, Setting, and Participants: This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses., Main Outcomes and Measures: Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared., Results: The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons.", Conclusions and Relevance: The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

Background: Atherosclerotic peripheral artery disease (PAD) is common and results in limitations in quality of life and potential progression to limb loss. Options for therapy include medical therapy, supervised exercise, surgical revascularization, and, more recently, endovascular therapies to restore arterial perfusion to the limb. Endovascular revascularization has evolved over the past 2 decades, from percutaneous transluminal angioplasty (PTA) to self-expanding stents, atherectomy, laser angioplasty, and drug-eluting stents. Despite impressive technologic advances, PTA remains the standard of care at many institutions and is the recommended primary treatment modality for femoral-popliteal PAD according to current American College of Cardiology Foundation/American Heart Association guidelines. However, restenosis after PTA is common. Therefore, a significant clinical need remains for a device that is able to achieve more durable patency than PTA but does not require a permanent implant. Drug-coated balloons (DCBs) have the potential to address this need. Several randomized controlled clinical trials of PTA balloons coated with different formulations of paclitaxel have been conducted in Europe (N Engl J Med 2008;358:689-699) (Circulation 2008;118:1358-1365) (Circ Cardiovasc Interv 2012;5:831-840) (JACC Cardiovas Interv 2014;7:10-19) and demonstrated more durable efficacy than PTA with comparable safety. These studies were limited by small sample sizes and powered solely for an angiographic primary end point. The pivotal LEVANT 2 trial was designed in collaboration with the US Food and Drug Administration to demonstrate safety and efficacy in a large population and to obtain US Food and Drug Administration approval., Methods: A prospective, multicenter, single-blind trial comparing the Lutonix DCB (Bard Lutonix; New Hope, MN) versus PTA for treatment of femoropopliteal PAD (LEVANT 2) is the first US-based 2:1 randomized controlled trial of 476 patients with femoral-popliteal PAD designed to demonstrate superior efficacy and noninferior safety of a novel paclitaxel DCB compared with PTA. The primary efficacy end point is primary patency at 12 months. The primary safety end point is composite freedom at 12 months from perioperative death, index limb amputation, reintervention, and limb-related mortality. A series of important secondary end points include physical functioning, quality of life, revascularizations, and alternative measures of patency. To minimize bias potential for confounding variables, LEVANT 2 (1) excluded patients stented after predilation before randomization, (2) incorporated very stringent criteria for bailout stenting, (3) did not count bailout stenting as a target lesion revascularization or failure of any end point, (4) required a blinded clinician to perform clinical evaluations at follow-up, and (5) required clinical assessment before review of duplex ultrasound results., Conclusions: LEVANT 2 represents the first US-inclusive multicenter, randomized controlled trial to assess the safety and efficacy of a novel DCB compared with PTA as primary therapy for symptomatic PAD on the background of standard medical therapy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Trauma is the leading cause of injury and death for individuals aged 1-44 years. Up to 8% of the US population participates in winter sports, and although vascular injuries are uncommon in these activities, little is published in this area. We sought to identify the incidence, injury patterns, and outcomes of vascular injuries resulting from winter sports trauma., Methods: Patients with winter sports trauma and the subset with vascular injuries were identified by accessing the National Trauma Data Bank querying years 2007-2010. Patients with and without vascular injuries were then compared. Admission variables included transport time, emergency department hypotension (systolic blood pressure < 90), Glasgow Coma Scale ≤ 8, Injury Severity Score ≥ 25, fractures, solid organ injury, and vascular injury. Outcomes were analyzed and associations with vascular injuries were determined., Results: A total of 2,298 patients were identified with winter sports-related trauma and 28 (1.2%) had associated vascular injuries. Overall, the top 3 injuries were head trauma (16.7%), thoracic vertebral fractures (5.5%), and lumbar vertebral fractures (5.1%). The most common associated vascular injures were to the popliteal artery (17.7%), splenic artery (14.7%), and brachial blood vessels (14.7%). In the entire cohort, 1 patient (0.04%) suffered an amputation and 15 patients (0.7%) died. There were no amputations in the vascular injury group. Mortality was 0.6% in patients without a vascular injury compared with 7.1% of those with a vascular injury (P = 0.01)., Conclusions: Although vascular injury is an uncommon associated finding in winter sports trauma, it is associated with a significant increase in mortality. These findings highlight the need for rapid identification of traumatic vascular injuries, which predicts worse overall outcomes in this patient population., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To examine the postoperative complications and death rate of major elective vascular surgery procedures in patients with end-stage renal disease (ESRD)., Background Data: Patients with ESRD undergoing elective major vascular surgical procedures are thought to have a high rate of postoperative complications and death., Methods: The American College of Surgeons-National Surgical Quality Improvement Program database was used to select ESRD and non-ESRD patients who had elective major vascular surgical procedures between 2004 and 2008. Multivariable logistic regression analysis was used to examine the impact of ESRD on 30-day surgical outcomes adjusted for age, race, sex, work relative value units, American Society of Anesthesiology class, and recent operations (within the past 30 days)., Results: ESRD patients undergoing elective major vascular surgery were significantly more likely than non-ESRD patients to develop surgical site infection, unplanned intubation, ventilator dependence, combined pulmonary outcome, and a need for reoperation within 30 days of surgery. Importantly, ESRD patients undergoing elective major vascular surgery were also at higher risk for composite outcome and death within 30 days from surgery. ESRD patients above age 65 years undergoing elective major vascular surgery had far worse 30-day outcomes when compared with the younger ESRD cohort. Examining these data by their anatomic site (carotid, aortic, and peripheral) demonstrated elevated rates of postoperative complications and death in patients with ESRD undergoing open abdominal aortic aneurysm repair, carotid endarterectomies, and peripheral vascular operations compared with the non-ESRD cohort. Endovascular abdominal aortic aneurysm repair in ESRD patients had complications and death rates comparable with non-ESRD patients., Conclusions: Patients with ESRD undergoing elective vascular surgery have a significantly elevated risk of postoperative complications and death after major vascular surgical operations--particularly in patients over age 65. These data, in combination with well-established reduced survival for the older ESRD population, call into question the utility of most carotid and aortic operations in these patients in the absence of symptoms or a rapidly enlarging aneurysm.