Search

Background: Autologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, a vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below-knee popliteal and tibial bypasses compared to prosthetic bypass alone., Methods: A retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjuncts were compared. Inclusion criteria included age ≥18 years, and bypass to below-knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below-knee popliteal and tibial subgroups., Results: A cohort of 3,939 patients underwent bypass to the below-knee popliteal artery, with 287 (7.3%) receiving vein adjuncts. More patients were male (68.8 vs. 57.8%, P < 0.001) and had higher rates of congestive heart failure (21.1 vs. 16.0%, P = 0.040) within the below-knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs. 17.1%, P = 0.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjuncts. Within the tibial group, patients were similar in age, body mass index, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, P = 0.005) and amputation (20.5 vs. 15.9%, P = 0.048) rates at 2 years were worse for patients who did not receive a distal vein adjunct to tibial arteries., Conclusions: Distal vein adjuncts are associated with improved freedom from occlusion, amputation, major adverse limb events, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the Vascular Quality Initiative. A vein adjunct was not associated with improved freedom from occlusion in below-knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Investigate readmission rates, diagnoses associated with readmission, and associations with mortality through 90 days postoperatively after elective endovascular thoracic and thoracoabdominal aortic repair overall and by extent of coverage., Methods: A cohort of index elective nontraumatic endovascular thoracic and thoracoabdominal aortic cases from 2010 to 2018 was derived from the Vascular Implant Surveillance and Interventional Outcomes Network. Cohort readmissions within 90 days postoperative were examined both overall and by Crawford extent (CE) of aortic coverage. Postoperative mortality was examined by reason for readmission and CE., Results: The cohort consisted of 2,105 patients who underwent endovascular thoracic and thoracoabdominal aortic repair (1,550 CE 0A/0B; 242 CE 1-3; 313 CE 4-5). Cumulative risk for 90-day readmission was 34.3% in CE 0A/0B repairs, 33.4% in CE 4-5 repairs, and 47.4% in CE 1-3 repairs. Compared with CE 0A/B, patients with CE 1-3 repairs experienced an increased risk of readmission within 90 days postoperatively after adjusting for preoperative factors (adjusted hazard ratio [HR] 1.27 [1.00, 1.61]), while the readmission risk for CE 4-5 repairs did not differ significantly (adjusted HR 0.83 [0.64, 1.06]). Significant risk factors for 90-day readmission included chronic obstructive pulmonary disease, dialysis dependence, limited ambulation, visceral/spinal ischemia, and in-hospital stroke. Discharge to home was protective against readmission (HR 0.65, confidence interval 0.54-0.79). Patients with a readmission within 90 days had a 7.89-fold increase in 90-day mortality (HR 7.84; 5.17, 11.9) compared with those not readmitted., Conclusions: Increasing extent of endovascular thoracic and thoracoabdominal aortic repair was associated with higher 90-day readmission rates. Readmission for all CE was associated with near 8-fold increased risk of mortality. Risk factors associated with increased risk for readmission included pulmonary insufficiency, renal disease, and poor functional status. These findings can inform stakeholders about investment of resources to improve processes of care that both target prevention and mitigate risk of readmission after elective endovascular thoracic and thoracoabdominal aortic repair., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To determine the association of Enhanced Recovery Program (ERP) implementation with length of stay (LOS) and perioperative outcomes after lower-extremity bypass (LEB)., Background: ERPs have been shown to decrease hospital LOS and improve perioperative outcomes, but their impact on patients undergoing vascular surgery remains unknown., Methods: Patients undergoing LEB who received or did not receive care under the ERP were included; pre-ERP (January 1, 2016-May 13, 2018) and ERP (May 14, 2018-July 31, 2022). Clinicopathologic characteristics and perioperative outcomes were analyzed., Results: Of 393 patients who underwent LEB [pre-ERP: n = 161 (41%); ERP: n = 232 (59%)], most were males (n = 254, 64.6%), White (n = 236, 60%), and government-insured (n = 265, 67.4%). Pre-ERP patients had higher Body Mass Index (28.8 ± 6.0 vs 27.4 ± 5.7, P = 0.03) and rates of diabetes (52% vs 36%, P = 0.002). ERP patients had a shorter total [6 (3-13) vs 7 (5-14) days, P = 0.01) and postoperative LOS [5 (3-8) vs 6 (4-8) days, P < 0.001]. Stratified by indication, postoperative LOS was shorter in ERP patients with claudication (3 vs 5 days, P = 0.01), rest pain (5 vs 6 days, P = 0.02), and tissue loss (6 vs 7 days, P = 0.03). ERP patients with rest pain also had a shorter total LOS (6 vs 7 days, P = 0.04) and lower 30-day readmission rates (32%-17%, P = 0.02). After ERP implementation, the average daily oral morphine equivalents decreased [median (interquartile range): 52.5 (26.6-105.0) vs 44.12 (22.2-74.4), P = 0.019], while the rates of direct discharge to home increased (83% vs 69%, P = 0.002)., Conclusions: This is the largest single-center cohort study evaluating ERP in LEB, showing that ERP implementation is associated with shorter LOS and improved perioperative outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: End-stage kidney disease (ESKD) is an established risk factor for chronic limb-threatening ischemia (CLTI). Procedural location for ESKD patients has not been well described. This study aims to examine variation in index procedural location in ESKD versus non-ESKD patients undergoing peripheral vascular intervention for CLTI and identify preoperative risk factors for tibial interventions., Methods: Chronic limb-threatening ischemia (CLTI) patients were identified in the Vascular Quality Initiative (VQI) peripheral vascular intervention dataset. Patient demographics and comorbidities were compared between patients with and without ESKD and those undergoing index tibial versus nontibial interventions. A multivariable logistic regression evaluating risk factors for tibial intervention was conducted., Results: A total of 23,480 procedures were performed on CLTI patients with 13.6% (n = 3154) with ESKD. End-stage kidney disease (ESKD) patients were younger (66.56 ± 11.68 versus 71.66 ± 12.09 y old, P = 0.019), more often Black (40.6 versus 18.6%, P < 0.001), male (61.2 versus 56.5%, P < 0.001), and diabetic (81.8 versus 60.0%, P < 0.001) than non-ESKD patients. Patients undergoing index tibial interventions had higher rates of ESKD (19.4 versus 10.6%, P < 0.001) and diabetes (73.4 versus 57.5%, P < 0.001) and lower rates of smoking (49.9 versus 73.0%, P < 0.001) than patients with nontibial interventions. ESKD (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.52-1.86, P < 0.001), Black race (OR 1.19, 95% CI 1.09-1.30, P < 0.001), and diabetes (OR 1.82, 95% CI 1.71-2.00, P < 0.001) were risk factors for tibial intervention., Conclusions: Patients with ESKD and CLTI have higher rates of diabetes and tibial disease and lower rates of smoking than non-ESKD patients. Tibial disease was associated with ESKD, diabetes, and Black race., (Published by Elsevier Inc.)

Background: End-stage kidney disease (ESKD) is a risk factor for peripheral arterial disease and major adverse limb events following infra-inguinal bypass. Despite comprising an important patient population, ESKD patients are rarely analyzed as a subgroup and are underrepresented in vascular surgery guidelines. This study aims to compare the long-term outcomes of patients with and without ESKD undergoing endovascular peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI)., Methods: CLTI patients with and without ESKD from 2007-2020 were identified in the Vascular Quality Initiative PVI dataset. Patients with prior bilateral interventions were excluded. Patients undergoing femoral-popliteal and tibial interventions were included. Mortality, reintervention, amputation, and occlusion rates at 21 months following intervention were examined. Statistical analyses were completed with the t-test, chi-square, and Kaplan-Meier curves., Results: The ESKD cohort was younger (66.4 ± 11.8 vs. 71.6 ± 12.1 years, P < 0.001) with higher rates of diabetes (82.2 vs. 60.9%, P < 0.001) the non-ESKD cohort. Long-term follow-up was available for 58.4% (N = 2,128 procedures) of ESKD patients and 60.8% (N = 13,075 procedures) of non-ESKD patients. At 21 months, ESKD patients had a higher mortality (41.7 vs. 17.4%, P < 0.001) and a higher amputation rate (22.3 vs. 7.1%, P < 0.001); however, they had a lower reintervention rate (13.2 vs. 24.6%, P < 0.001)., Conclusions: CLTI patients with ESKD have worse long-term outcomes at 2 years following PVI than non-ESKD patients. Mortality and amputation are higher with ESKD, while the reintervention rate is lower. Development of guidelines within the ESKD population has the potential to improve limb salvage., (Published by Elsevier Inc.)

Background: Enhanced recovery pathways (ERPs) aim to lower perioperative stress to facilitate recovery. Limited fasting combined with carbohydrate loading is a common ERP element. The effect of limited fasting has not been elucidated in patients with diabetes. Given the known deleterious effects of poor glycemic control in the perioperative period, such as increased rates of surgical site infection, the associations of preoperative limited fasting with perioperative glycemic control and early outcomes after lower extremity bypass (LEB) were investigated., Methods: A single institutional retrospective review of patients who underwent infrainguinal LEB from 2016 to 2022 was performed. The ERP was initiated in May 2018. Patients were stratified by diabetes diagnosis and preoperative hemoglobin A1C (HbA1C) levels. Perioperative glycemic control was compared between the limited fasting and traditional fasting patients (nil per os at midnight). Limited fasting was defined as a clear liquid diet until 2 hours before surgery with recommended carbohydrate loading consisting of 400 cc of a clear sports drink (approximately 30 g of carbohydrates). All limited fasting patients were within the ERP. Early perioperative hyperglycemia (EPH) was defined as blood glucose of >180 mg/dL within the first 24 hours of surgery. Perioperative outcomes such as surgical site infection, readmission, reinterventions, and complications were also compared., Results: A total of 393 patients were included (limited fasting patients N = 135; traditional fasting patients N = 258). A trend toward EPH was seen in all limited fasting groups. Evaluating limited fasting within diabetic patients revealed that 74.5% of limited fasting-diabetic patients had EPH compared with 49.6% of traditional fasting-diabetic patients (P = .001). When stratified by the HbA1C level, a significantly higher rate of EPH was seen in the HbA1c >8.0% groups, with 90.5% in the limited fasting patients compared with 67.9% in traditional fasting patients (P = .05). Limited fasting-diabetic patients experience a longer postoperative length of stay at 5.0 days (interquartile range: 3, 9) vs 4.0 days (2, 6) in nondiabetic patients (P = .016)., Conclusions: ERP limited fasting was associated with early perioperative hyperglycemia after LEB, particularly in patients with HbA1C >8.0%. Due to the high prevalence of diabetic patients undergoing LEB under ERP, the role of limited fasting and common glycemic elements of ERP may need to be re-evaluated in this subpopulation., (Published by Elsevier Inc.)

Objectives: The COVID-19 pandemic has significantly affected the 2021 match application cycle as in person sub-internships and interviews have been halted. Given the abrupt change, we aimed to characterize the utilization of social media and virtual open house platforms by integrated vascular surgery residency programs for outreach and networking during the pandemic for the 2021 cycle., Methods: A list of accredited integrated vascular surgery residency programs was compiled using the Electronic Residency Application Service (ERAS) website provided by the Academic Medical Colleges (AMC). The social media platforms Twitter, Instagram, and Facebook were queried for accounts associated with the training programs or their associated institutional vascular surgery divisions. Each discovered account was surveyed for date of creation as well as posts outlining virtual interactive events such as open houses, meet-and-greets, and virtual sub-internship opportunities. Slopes of the curves representing total account numbers and account numbers on each platform were compared from pre-COVID to current day using linear regression and t-statistics., Results: There were 64 integrated vascular surgery residency programs participating in the 2021 match cycle. 70.3% ( N = 45) of programs had a social media presence on at least one of the three platforms. 54.7% ( N = 35) of programs had an associated Twitter account. 43.9% ( N = 28) of programs had an associated Instagram account. Six (9.4%) programs were found on Facebook. The number of social media accounts significantly increased from March 2020 (37 vs 69, p < .001) to March 2021., Conclusions: Vascular surgery residency programs have significantly increased use of social media platforms over a 12-month period beginning in March 2020, indicating adaptation to the restrictions prompted by the pandemic.

This retrospective cohort study analyzes venous thromboembolism (VTE) incidence, morbidity, and mortality amongst postsurgical patients with and without VTE chemoprophylaxis within a quality collaborative. Postoperative thromboprophylaxis was broadly applied, yet was associated with no decrease in VTE, without affecting transfusion or mortality. Predictors of breakthrough VTE development despite evidence-based thromboprophylaxis are identified., Objective: We hypothesized that a high rate of prescription of VTE chemoprophylaxis would be associated with decreased VTE incidence and mortality., Summary Background Data: Recommendations for VTE prevention in surgical patients include chemoprophylaxis based upon preoperative risk stratification., Methods: This retrospective cohort study analyzed VTE incidence, morbidity, and mortality amongst postsurgical patients with and without VTE chemoprophylaxis between April 2013 and September 2017 from 63 hospitals within the Michigan Surgical Quality Collaborative. A VTE risk assessment survey was distributed to providers. Bivariate and multivariate comparisons were made, as well as using propensity score matched cohorts to determine if VTE chemoprophylaxis was associated with decreased VTE events. Hospitals were compared using risk-reliability adjusted VTE prophylaxis and postoperative VTE event rates., Results: Within the registry, 80% of practitioners reported performing formal VTE risk assessment. Amongst 32,856 operations, there were 480 (1.46%) postoperative VTE, and an overall mortality of 609 (1.85%) patients. Using a propensity matched cohort, we found that rates of VTE were similar in those receiving unfractionated heparin or low molecular weight heparin compared to those not receiving chemoprophylaxis (1.22 vs 1.13%, P = 0.57). When stratified further by VTE risk scoring, even the highest risk patients did not have an associated lower VTE rate (3.68 vs 4.22% P = 0.092). Postoperative transfusion (8.28 vs 7.50%, P = 0.057) and mortality (2.00% vs 1.62%, P = 0.064) rates were similar amongst those receiving and those not receiving chemoprophylaxis. No correlation was found between postoperative VTE chemoprophylaxis application and hospital specific risk adjusted postoperative VTE rates., Conclusions: In modern day postsurgical care, VTE remains a significant occurrence, despite wide adoption of VTE risk assessment. Although postoperative VTE chemoprophylaxis was broadly applied, after adjusting for confounders, no reduction in VTE was observed in at-risk surgical patients., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Aortic remodeling of the thoracic aorta has been studied in patients treated with medical or endovascular therapy for the treatment of acute aortic dissections; however, particular attention has not yet focused on identifying specific growth patterns and rates across all aortic zones. Additionally, previous studies have not delineated between dissections with and without visceral aortic involvement, and we hypothesize that these two cohorts may exhibit distinct differences. The aim of this study is to investigate aortic behavior over time in medically managed acute Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) type B dissections with visceral aortic involvement and identify potential associations of subsequent aortic behavior with clinical outcomes., Methods: A single-center retrospective review was performed of all patients between 2010 and 2020 with acute SVS/STS type B aortic dissections with visceral aortic involvement that were not surgically managed. Short-axis centerline measurements of the true/false lumen and total aortic diameter (TAD) were taken at standardized locations relative to aortic anatomy within each aortic zone, including nondissected zones. Measurements were taken at the time of diagnosis and at six subsequent yearly intervals. Diameter changes over time were evaluated using repeated measures mixed models linear growth analysis. Aortic enlargement was classified by growth in TAD ≥5 mm in either the thoracic (thoracic segment enlargement [TSE], zone 0-4) or visceral segments (visceral segment enlargement [VSE], zone 5-9)., Results: A total of 78 patients were identified with a median length of follow-up of 3.3 years (interquartile range [IQR], 1.3-6.6 years). Follow-up past 5 years was seen in 31% of the cohort. For the entire cohort, mean thoracic growth in TAD was 2.0 ± 2.0 mm/year, and visceral growth in TAD was 2.5 ± 2.4 mm/year. TSE was observed in 65% of patients, with a median time until onset of 0.8 years (IQR, 0.4-2.3 years). VSE was observed in 57% of the cohort, with a median time until onset of 1.6 years (IQR, 0.9-3.3 years). Repeat measures mixed models linear growth analysis identified significant predictable linear growth in all aortic zones except for the nondissected zones 0-2. Odds for TSE are significantly increased in patients with known genetically triggered aortic conditions (odds ratio [OR], 2; 95% confidence interval [CI], 1.8-4.5; P = .044) and in cases where the dissection entry tear was in either zone 1 or 2 (OR, 4.8; 95% CI, 1.2-8.4; P = .044). In adjusted regression analysis, odds for intervention in the thoracic aorta were significantly increased in patients with rapid TSE in zone 3 (OR, 3.6; 95% CI, 1.1-8.4; P = .045). Similarly, odds for intervention targeting the visceral aortic segment were significantly increased in patients with zone 9 VSE (OR, 9.3; 95% CI, 1.1-13.3; P = .014). Odds for 5-year all-cause mortality were significantly increased in cases with large thoracic aneurysms (OR, 6.1; 95% CI, 1.1-14.9; P = .042)., Conclusions: Aortic enlargement was present in the majority of patients with medically managed acute SVS/STS Type B aortic dissections with visceral aortic involvement, with analysis demonstrating predictable linear growth in all dissected zones. Patients with aortic enlargement demonstrated higher gross changes in diameter in addition to higher yearly rates of change compared with all comers. Odds for enlargement were impacted by both patient demographic and anatomic dissection characteristics. Growth in zone 3 and zone 9 significantly increased odds for aortic intervention. Odds for 5-year mortality were significantly increased in the presence of large thoracic aneurysms. Results highlight risk of progressive degeneration beyond acute phase in SVS/STS Type B aortic dissections with visceral aortic involvement, with life-long surveillance remaining crucial in management of dissections., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To assess practice patterns and short-term outcome after thoracic endovascular aortic repair (TEVAR), based on an international vascular registry collaboration., Summary Background Data: TEVAR has become the primary surgical treatment modality for descending aortic pathologies, and has expanded to new patient cohorts, including the elderly., Methods: Data on thoracic aortic aneurysms (TAA), type B aortic dissections (TBAD), and traumatic aortic injuries (TAI) treated with TEVAR from 2012 to 2016 were retrieved from registries and centers in 13 countries., Results: Nine-thousand five-hundred eighteen TEVAR for TAA ( n = 4436), TBAD ( n = 3976) and TAI ( n = 1106) were included. The distribution of TEVAR procedures per pathology varied, with TAA repair constituting from 40% of TEVARs in the US to 72% in the UK ( P < 0.001).Mean intact TAA (iTAA) diameter varied from 59 (US) to 69 mm (Nancy, France) ( P < 0.001), 25.3% of patients having a diameter of <60 mm. Perioperative mortality after iTAA repair was 4.9%; combined mortality, stroke, paraplegia, and renal replacement therapy outcome was 12.8%. 18.6% of iTAA patients were ≥80 years old. Mortality was higher in this group (7.2%) than in patients <80 (3.8%) ( P < 0.001). After rTAA repair, perioperative mortality was 26.8%.Mortality was 9.7% after acute (within 14 days from onset of dissection) and 3.0% after chronic TBAD repair ( P < 0.001). Mortality after TAI was 7.8%, and depended on injury severity (grade IV (free rupture) 20.9%)., Conclusions: This registry collaboration provides a unique platform to evaluate cross-border patterns of use and outcomes of TEVAR. A common core dataset is proposed, to achieve harmonization of registry-based quality outcome measures for TEVAR., Competing Interests: Conflicts of interest and source of funding: AWB: Contracted research: Cook Medical; Medtronic, Inc.; Terumo Aortic; W.L. Gore & Associates. Consulting: Cook Medical, Cryolife, Medtronic, Inc.; Terumo Aortic. KM: Consulting: Cook Medical Inc., Institutional funds: Cook Medical Inc. and Gore Medical., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Therapeutic anticoagulation with either a vitamin K antagonist (VKA) or direct anticoagulant (DOAC) is often newly prescribed to patients undergoing lower extremity bypass (LEB) to aid in graft patency when risk factors for thrombosis are present or to treat postoperative venous thromboembolism or atrial fibrillation. There is a gap in knowledge as to how DOAC usage impacts postoperative outcomes compared with the standard-of-care VKAs., Study Design: To determine temporal trends in DOAC prescription after infrainguinal LEB, impact on length of stay (LOS), and associated bleeding and thrombotic complications, patients undergoing elective LEB were identified from the Vascular Quality Initiative between January 2013 and May 2019. Postoperative bleeding, LOS, and graft occlusion for patients receiving VKA compared with DOAC were evaluated., Results: A total of 24,459 LEBs were performed during the study period. Among 2,656 patients newly prescribed an anticoagulant, 78.0% (n = 2,072) received VKA and 22.0% (n = 584) received a DOAC, with DOAC use increasing throughout the study period. There was no significant difference in postoperative bleeding (VKA 2.3%, DOAC 1.7%, p = 0.413) or graft occlusion (VKA 1.2%, DOAC 1.4%, p = 0.762) between the anticoagulant classes. LOS was shorter in the DOAC group than in the VKA group (5.7 vs 6.8 days; p &lt; 0.001)., Conclusions: This analysis demonstrates that DOAC use is increasing with time in Vascular Quality Initiative centers. DOACs are a safe and comparable alternative to VKAs in the postoperative setting with similar rates of bleeding complications and early graft patency and are associated with a reduced postoperative LOS., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: We investigated the clinical practice and volume trends of inferior vena cava filter (IVCF) usage at a single institution for an extended period and identified the potential factors affecting the clinical decision for placement, follow-up, and retrieval., Methods: An institutional database was queried for IVCFs placed from 2000 to 2018 using the Current Procedural Terminology codes. The medical records were reviewed to evaluate the demographics, economic status, placement indication, IVCF type, follow-up evaluation for retrieval, and retrieval success rates. Statistical analysis was performed using SPSS, and t tests for continuous and χ 2 for categorical variables., Results: A total of 3915 IVCFs were placed from 2000 to 2018. The placement of IVCFs had increased steadily from 2000 (127 IVCFs/y), peaking in 2010 at 371 IVCFs/y and representing a 292% increase in IVCF usage. Since 2010, the number of IVCFs placed has steadily declined until 2016 to 2018, with a 426% decrease from the peak. In a subgroup of IVCFs placed for prophylaxis, the total volume trends paralleled a shift in clinical indications, peaking in 2010 and accounting for 45% of all IVCFs placed and then decreasing from 2013 to 2018 to ≤10%. Overall, 989 permanent IVCFs (25.3%) and 2926 retrievable IVCFs (74.7%) were placed during the entire study period. Before dedicated efforts to implement retrieval follow-up visits, the successful retrieval rate was ∼1% from 2000 to 2006 and had increased to ∼10% to 15% from 2007 to 2015, 36.7% in 2016, 40.2% in 2017, and 40.3% in 2018 after implementation of more active retrieval follow-up protocols. The predictors for the lack of evaluation for IVCF retrieval included an extended length of stay (P = .004) and geographic distance (P < .001)., Conclusions: The use of IVCFs during the past 19 years at our institution reflected increased usage from 2000 to 2010, corresponding to an increase in prophylactic placement, followed by a decreasing total volume from 2011 to 2018, largely attributable to decreased prophylactic IVCF placement. Improved retrieval rates were seen after implementation of an active IVCF retrieval program., (Copyright © 2022. Published by Elsevier Inc.)

Background: Statin therapy has been associated with improved clinical outcomes in patients undergoing treatment for vascular disease. Current guidelines do not address statin therapy in isolated abdominal aortic aneurysm (AAA) in the absence of other atherosclerotic cardiovascular disease (ASCVD). This study aims to elucidate effects of statin therapy, either as monotherapy or combined with antiplatelet agents, on the long-term mortality of patients with and without ASCVD who undergo elective AAA repair., Methods: A retrospective review was performed on all AAA patients treated electively with endovascular (EVAR) and open aortic repair (OAR) in the Society for Vascular Surgery Vascular Quality Initiative from 2003-2020. Long-term mortality was evaluated based on the presence of statin and antiplatelet medication use at discharge stratified by those with and without a history of ASCVD. Unadjusted survival was estimated by Kaplan Meier methodology. Cox proportional hazards modeling was used to determine mortality risk after adjusting for key factors., Results: A total of 47,012 AAA repairs were selected for analysis: 80.7% EVAR (N = 40,153) and 19.3% OAR (N = 6,859). EVAR patients on combined statin/antiplatelet (AP) therapy had significantly better survival irrespective of whether they had known ASCVD. In the presence of ASCVD, EVAR patients on statin alone had improved survival compared to those not on a statin (10.9 ± 0.5 vs. 10.5 ± 0.4 years, Log Rank < 0.001), with survival being even greater among those receiving combined statin/AP therapy (12.2 ± 0.2 vs. 10.5 ± 0.4 years, Log Rank < 0.001). In the absence of ASCVD, EVAR patients on statin alone also had better mean survival compared to patients not on a statin (8.7 ± 0.5 vs. 8.4 ± 0.4 years, Log Rank<.001), with higher survival among statin/AP therapy patients (9.4 ± 0.2 years vs. 8.7 ± 0.5 years, Log Rank < 0.001). Comparison of adjusted survival via Cox multivariable regression demonstrated a protective effect of statins (HR = 0.737, P = 0.04, vs. no medication) and combined statin/AP therapy (HR = 0.659, P = 0.001, vs no medication) in patients with ASCVD history. A similar protective effect (statin: HR 0.826, P = 0.05. Combination statin/AP: HR 0.726, P < 0.001, vs. no medication) was identified in patients without ASCVD history. Within the OAR cohort, statin therapy was not associated with improved survival among patients without ASCVD; however, combined statin/AP therapy had a protective effect for patients with a known ASCVD diagnosis. Based on KM analysis, OAR patients with ASCVD on combined statin/AP therapy had significantly higher mean survival compared to isolated statin therapy (12.7 ± 0.2 vs. 10.3 ± 0.65 years) and no medical therapy (10.5 ± 0.8 years, Log Rank < 0.001). In KM analysis, OAR patients without known ASCVD indications (N = 3591) had no significant survival differences based on the presence of combined statin/AP therapy (8.4 ± .07 vs. 8.5 ± .11 years, Log Rank = 0 638)., Conclusion: Isolated statin therapy and combined statin/AP therapy showed significant survival benefit in all EVAR and OAR patients with ASCVD indications, as well as among EVAR patients without a known ASCVD diagnosis. OAR patients without ASCVD did not have a significant survival benefit from statin therapy, but low numbers in this group may have confounded the findings. Combined statin/AP therapy appears to have significant post-repair survival benefits even in isolated AAA without ASCVD, as demonstrated in post-EVAR patients in this study. Expansion of statin use recommendations within aneurysm treatment guidelines may be warranted., (Copyright © 2022. Published by Elsevier Inc.)

Background: Vascular complications remain a prevalent and devastating complication of extracorporeal membrane oxygenation (ECMO). Risks for vascular complications have risen as the volume and medical complexity of ECMO cases has rapidly increased in recent years. This study assesses occurrence and clinical impact of vascular complications across all ECMO modes and cannulation methods in a high-volume academic center., Methods: A retrospective single-institution review was performed of all ECMO cannulations for central or peripheral venovenous (VV) or venoarterial (VA) ECMO in 2019-2020. Patients who expired during cannulation were excluded. Primary outcomes of vascular consultation rates at or after ECMO placement, limb loss, and mortality were assessed during index hospitalization., Results: A total of 229 patients were identified during the 2-year study period. VA ECMO was used in the majority of patients (n = 137, 60%), with 83% (N = 114) undergoing peripheral cannulation. Vascular surgery was consulted in 54 (23.6%) patients. Complication rates ranged from 33.9% in peripheral VA cannulation to 7% in jugular VV cannulation. Overall, 65% of vascular consults required operative intervention; interventions were highest in peripheral VA ECMO (n = 30 of 114, 26.3%). Across all ECMO types, acute limb ischemia (ALI) was the most common complication (n = 38, 16.5%), with rates ranging from 26.1% in central VA ECMO to 4.8% in jugular VV ECMO. Distal antegrade perfusion catheters (DPCs) were employed in n = 68 of 114 (59.6%) of all peripheral VA ECMO cases. Prophylactic DPCs were found to be incorrectly placed in 10.2% (n = 7 of 68) of cases, which obscured the ability to fully evaluate the effect of prophylactic DPCs on reducing rates of ALI. Major amputation (Below Knee Amputation/Above Knee Amputation) occurred in six peripheral VA patients (5.3%), two central VA patients (8.65), and two femoral-femoral VV patients (4%). Patients with ALI experienced significantly lower rates of in-hospital survival in Kaplan-Meier analysis (32.5% vs 54%, log-rank = 0.023)., Conclusions: This study highlights the prevalence of vascular complications, and their associated mortality impact, across all modes of ECMO and additionally identifies several areas for institutional performance improvement. ALI was the most common complication across all cohorts and was associated with decreased in-hospital survival. The impact of DPC on ALI was difficult to elucidate due to nonstandardized placement patterns and selective use. In the care of these medically complex patients on multidisciplinary teams, review of outcomes and group discussions targeting areas for improvement are critical to success; in this study, findings resulted in the development of a lower extremity perfusion management protocol., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Female medical students outnumber males with increasing representation in the workforce. However, women remain underrepresented in surgical leadership. Suggested reasons for this discrepancy are lack of female role models, mentorship, and gender discrimination. Thus, we set out to examine the change in leadership over time in our Department., Methods: Leadership data was gathered from a Department of Surgery in 2016 and 2020. Demographics including gender, age, and leadership position were compared using chi-squared testing., Results: Female representation in leadership roles increased from 2016 to 2020 at each professor rank(professor 0-100%, p < .001; associate professor 25-90%, p < .001, and assistant professor 7-71%, p < .001). In 2020, there were more female faculty(19.8 vs 26.4%, p = .270)., Conclusions: Female leadership in the Department has increased since 2016. Promoting females to leadership roles provides role models for upcoming female surgeons. Resources should be allocated to promote gender equity in surgical leadership., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Workplace diversity is beneficial and results in new ideas and improved performance. Within surgery leadership, the gender gap is improving, but still present. Given the increasing number of women surgery department chairs, we aimed to examine the association of surgery chair gender with division and residency program director gender. We hypothesized that surgery departments with female leadership would have an increase in gender diversity compared to departments led by male chairs., Materials and Methods: A list of all surgery departments were compiled from the Society of Surgical Chairs website. Gender of department chair, division director and residency program director were examined and compared. Chair position term length was determined based on online public announcements, publicly available curriculum vitae, and institutional profile biographies., Results: Of 178 department chairs included, 10.7% were female, and 89.3% were male. There was no difference in female residency program director leadership between female versus male led programs (42.1 versus 26.1%, P= 0.147). Of the programs with female department chairs, only 29.4% had any female division directors compared to 54.6% led by male chairs (P= 0.055). When examining departments with ≥5 division directors, there was no difference in the average number of female division directors within departments led by female versus male chairs. There was a significant difference in length of surgery chairship, with female chairs holding the position for fewer years than male chairs (median time 5.3 (IQR = 3.4-5.8) versus 7.0 (IQR=4.3-12.3) years, P= 0.032)., Conclusions: Female department chair leadership was not associated with increased diversity in divisional leadership compared to departments of surgery led by males., (Copyright © 2021. Published by Elsevier Inc.)

Background: Spinal cord ischemia (SCI) is a dreaded complication of thoracic and complex endovascular aortic repair (TEVAR/cEVAR). Controversy exists surrounding cerebrospinal fluid drain (CSFD) use, especially preoperative prophylactic placement, owing to concerns regarding catheter-related complications. However, these risks are balanced by the widely accepted benefits of CSFDs during open repair to prevent and/or rescue patients with SCI. The importance of this issue is underscored by the paucity of data on CSFD practice patterns, limiting the development of practice guidelines. Therefore, the purpose of the present analysis was to evaluate the differences between patients who developed SCI despite preoperative CSFD placement and those treated with therapeutic postoperative CSFD placement., Methods: All elective TEVAR/cEVAR procedures for degenerative aneurysm pathology in the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2019 were analyzed. CSFD use over time, the factors associated with preoperative prophylactic vs postoperative therapeutic CSFD placement in patients with SCI (transient or permanent), and outcomes were evaluated. Survival differences were estimated using the Kaplan-Meier method., Results: A total of 3406 TEVAR/cEVAR procedures met the inclusion criteria, with an overall SCI rate of 2.3% (n = 88). The SCI rate decreased from 4.55% in 2014 to 1.43% in 2018. Prophylactic preoperative CSFD use was similar over time (2014, 30%; vs 2018, 27%; P = .8). After further exclusions to evaluate CSFD use in those who had developed SCI, 72 patients were available for analysis, 48 with SCI and prophylactic CSFD placement and 24 with SCI and therapeutic CSFD placement. Specific to SCI, the patient demographics and comorbidities were not significantly different between the prophylactic and therapeutic groups, with the exception of previous aortic surgery, which was more common in the prophylactic CSFD cohort (46% vs 23%; P < .001). The SCI outcome was significantly worse for the therapeutic group because 79% had documented permanent paraplegia at discharge compared with 54% of the prophylactic group (P = .04). SCI patients receiving a postoperative therapeutic CSFD had had worse survival than those with a preoperative prophylactic CSFD (50% ± 10% vs 71% ± 9%; log-rank P = .1; Wilcoxon P = .05)., Conclusions: Prophylactic CSFD use with TEVAR/cEVAR remained stable during the study period. Of the SCI patients, postoperative therapeutic CSFD placement was associated with worse sustained neurologic outcomes and overall survival compared with preoperative prophylactic CSFD placement. These findings highlight the need for a randomized clinical trial to examine prophylactic vs therapeutic CSFD placement in association with TEVAR/cEVAR., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI)., Methods: Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level., Results: Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R 2  = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R 2  = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001)., Conclusions: A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Thoracofemoral bypass (TFB) has been used infrequently but is an alternative for select patients with aortoiliac occlusive disease. Limited data are available in the reported data regarding TFB, with all studies small, single-center series. We aimed to describe the perioperative and long-term survival, patency, and rate of major perioperative complications after TFB in a large national registry., Methods: The Vascular Quality Initiative suprainguinal bypass module was used to identify patients who had undergone TFB for occlusive disease from 2009 to 2019. A descriptive analysis was performed to provide the rates of survival, patency, major complications, and freedom from major amputation in the perioperative period and at 1 year of follow-up. Major complications were compared by procedure indication, with categorical variables analyzed using χ 2 tests and continuous variables using analysis of variance. Kaplan-Meier curve analysis was used to estimate survival at the 1- and 5-year follow-up intervals and freedom from major amputation at 1 year., Results: A total of 154 TFB procedures were identified. Of the 154 patients, 59 (38.3%) had undergone previous inflow bypass and 22 (14.2%) had undergone previous leg bypass. The procedure indications included claudication (n = 66; 42.9%), rest pain (n = 59; 38.3%), tissue loss (n = 19; 12.3%), and acute limb ischemia (n = 10; 6.5%). Major complications (eg, wound infection, respiratory, major stroke, new dialysis, cardiac, embolic, major amputation, occlusion) occurred in 31.2% of the cohort. When examined by indication, the acute limb ischemia and claudication cohorts had an increased rate of major complications (acute limb ischemia, 60.0%; claudication, 34.8%; critical limb ischemia, 24.4%; P = .05). The survival rate at 30 days was 95.5%, with a Kaplan-Meier estimated 1-year survival rate of 92.7% ± 2.2%. Primary patency at discharge from the index hospitalization was 92.9% and 89.0% at 1 year. Postoperative major amputation was required for 1 patient during the index hospitalization, for a Kaplan-Meier estimated freedom from major amputation at 1 year of 97.1% ± 2.2%. Two patients developed in-hospital bypass occlusion and three patients developed occlusion within 1 year, for an overall freedom from occlusion rate of 96.8% at 1 year., Conclusions: TFB is associated with a high rate of perioperative major complications; however, the long-term survival and patency after TFB remained acceptable when performed for limb salvage. The high perioperative complication rates of TFB procedures performed for claudication suggest TFB should be used rarely in this population. These data can be used to counsel patients and aid in decision making before operative intervention., (Copyright © 2020 Society for Vascular Surgery. All rights reserved.)

Objective: Traditional open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) has historically resulted in 30-day mortality rates ranging from 6% to 20%, depending on the Crawford anatomic extent. Although short-term survival is important, long-term survival is essential for patients to benefit from these often elective and potentially morbid procedures. The aneurysm extent affects the long-term survival after open repair; however, effect on endovascular repair is unknown and could influence the decision process for repair. We evaluated the association between aneurysm extent and survival and identified patient and perioperative factors associated with mortality after endovascular repair., Methods: A retrospective cohort of patients treated for TAAAs recorded in the Society for Vascular Surgery Vascular Quality Initiative thoracic and complex endovascular aneurysm repair registry were evaluated. All patients treated for asymptomatic degenerative aneurysms from 2010 to 2019 were included. Crawford extent I to V was defined according to the proximal and distal landing zones documented in the registry. Patients without extension into the visceral aorta were used for comparison and categorized as having extent 0a or 0b, depending on the distal landing zone in the thoracic aorta. Kaplan-Meier plots were used to estimate survival, and Cox proportional hazard regression models were created to identify the predictors of mortality., Results: From 2010 to 2019, 15,333 patients were entered into the registry, of whom 2062 met the inclusion criteria. The Crawford extent was 0a for 379, 0b for 848, I for 81, II for 98, III for 130, IV for 454, and V for 72. Three groups were created in accordance with the similar outcomes noted on a preliminary analysis: (1) extent 0a and 0b; (2) extent I, II, and III; and (3) extent IV and V. The mean survival time for the extent 0a and 0b group was 70.7 ± 1.43 months and was 48.6 ± 1.65 months for the extent I, II, and III group and 57.6 ± 1.24 months for the extent IV and V group. The corresponding 1-year mortality was 8.4%, 18.4%, and 7.8%. Cox regression analysis identified the following preoperative factors were associated with mortality: chronic obstructive pulmonary disease (odds ratio [OR], 1.70; P < .001), Crawford extent I to III (OR, 1.64; P = .015), preexisting chronic kidney disease (OR, 1.37; P = .024), and age per year (OR, 1.03; P < .001). A number of postoperative factors were also associated with mortality., Conclusions: Similar to open TAAA repair, patients with more extensive aortic disease treated with endovascular repair had worse 1-year and long-term survival. The extent of aortic disease and anticipated postoperative survival should factor prominently into the surgical decision-making process for elective endovascular TAAA repair., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to measure the efficacy of a novel faculty and resident educational bundle focused on development of faculty-resident behaviors and entrustment in the operating room., Summary Background Data: As surgical training environments are orienting to entrustable professional activities (EPAs), successful transitions to this model will require significant faculty and resident development. Identifying an effective educational initiative which prepares faculty and residents for optimizing assessment, teaching, learning, and interacting in this model is critical., Methods: From September 2015 to June 2017, an experimental study was conducted in the Department of Surgery at the University of Michigan Health System (UMHS). Case observations took place across general, plastic, thoracic, and vascular surgical specialties. A total of 117 operating room observations were conducted during Phase I of the study and 108 operating room observations were conducted during Phase II following the educational intervention. Entrustment behaviors were rated for 56 faculty and 73 resident participants using OpTrust, a validated intraoperative entrustment instrument., Results: Multiple regression analysis showed a significant increase in faculty entrustment (Phase I = 2.32 vs Phase II = 2.56, P < 0.027) and resident entrustability (Phase I = 2.16 vs Phase II = 2.40, P < 0.029) scores following exposure to the educational intervention., Conclusions: Our study shows improved intraoperative entrustment following implementation of faculty and resident development, indicating the efficacy of this innovative educational bundle. This represents a crucial component in the implementation of a competency-based assessment framework like EPAs., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The American Heart Association guidelines instruct use of postoperative telemetry (POT) should be reserved for patients undergoing cardiac procedures and/or those with ischemic cardiac symptoms, but acknowledge that major vascular procedures deserve unique consideration. Telemetry remains a limited resource in many hospitals; however, it has been poorly defined which vascular patients have greatest need for POT. The purpose of this study is to define the rates of postoperative arrhythmias (POAs) after major vascular operations using the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry, identify independent predictors of POA, and determine the effect of POA on mortality to guide the use of POT in vascular patients., Methods: A retrospective cohort study was performed using the following VQI modules: open abdominal aortic aneurysm repair (oAAA), complex endovascular aneurysm repair (EVAR) (thoracic endovascular aortic repair [TEVAR]/c-EVAR), EVAR, suprainguinal bypass (SIB), and infrainguinal bypass (IIB). POA was defined in the VQI as a new rhythm disturbance requiring treatment with medication or cardioversion. The incidence of POA, preoperative risk factors, and demographics were determined for each procedure., Results: A total of 121,652 procedures were identified with an overall POA event rate of 5.1% (n = 6,265). Procedure-specific event rates for POA among VQI registries are as follows: oAAA 14.4%, TEVAR/c-EVAR 8.5%, EVAR 2.7%, SIB 6.2%, and IIB 3.8%. Across all procedure types, POA was associated with emergent operations and increased procedure time. Procedure-specific multivariable regression revealed additional independent preoperative intraoperative factors associated with POA that were unique with each procedure. Across all procedural groups, the presence of POA was associated with increased rates of clinical myocardial infarction and decreased survival on Kaplan-Meier analysis., Conclusions: Rates of POA in patients undergoing vascular procedures appear higher than previously reported, and POA is associated with decreased survival. Our study elucidated patient- and procedure-specific predictor factors associated with POA that can be used to inform the use of POT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Surgical site infection (SSI) is an important complication of lower extremity bypass (LEB) and the rate of SSI after LEB varies widely in the existing literature, ranging from 4% to 31%. Prolonged length of stay (LOS) has been implicated in the occurrence of SSI across multiple surgical disciplines. The impact of preoperative LOS in patients with chronic limb-threatening ischemia (CLTI) undergoing LEB is unknown. We examined the association of preoperative LOS on SSI after LEB., Methods: A retrospective analysis of the Society for Vascular Surgery Vascular Quality Initiative Infrainguinal Bypass Registry identified patients undergoing elective LEB for chronic limb-threatening ischemia from 2003 to 2019. Patients undergoing LEB for acute limb ischemia, urgent/emergent procedures, aneurysm, or who had concomitant suprainguinal bypass were excluded. The primary outcome measure was postoperative SSI. Multivariable forward stepwise logistic regression was then performed including all variables with a P value of less than .10 in both matched and unmatched cohorts to evaluate for demographic and perioperative predictors of SSI. Propensity score matching was used to create matched cohorts of patients for each LOS group., Results: A total of 17,883 LEB procedures were selected for inclusion: 0 days (12,362 LEB), 1 to 2 days (1737 LEB), and 3 to 14 days (3784 LEB). Patients with the greatest preoperative LOS were more likely to have vein mapping (0 days preoperative LOS, 66.3%; 1-2 days, 65.2%; 3-14 days, 73.2%; P < .01) or computed tomography angiography/magnetic resonance angiography (0 days, 32.1%; 1-2 days, 34.4%; 3-14 days, 38.4%; P < .01). Patients with 3 or more days of preoperative LOS had longer procedure lengths (0 days, 244 minutes; 1-2 days, 243 minutes; 3-14 days, 255 minutes; P < .01) and were more likely to have completion angiogram (0 days, 27.1%; 1-2 days, 29.5%; 3-14 days, 31.6%; P = .02). Multivariable logistic regression demonstrated that preoperative LOS of 3 to 14 days was associated with increased rate of SSI (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.20-3.07; P = .01). Transfusion of 3 or more units (OR, 2.87; 95% CI, 1.89-4.36; P < .01) and prolonged procedure length (>220 minutes; OR, 1.86; 95% CI, 1.26-2.73; P < .01) were also significantly associated with postoperative SSIs., Conclusions: Many factors including preoperative comorbidities and operative complexity covary with preoperative LOS as risk factors for SSI. However, when patients are matched based on comorbidities and factors that would predict overall clinical complexity, preoperative LOS remains important in predicting SSI., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Few studies have investigated outcomes after truncal endovenous ablation in patients with combined deep and superficial reflux and no studies have evaluated patient-reported outcomes., Methods: We investigated the short- and long-term clinical and patient-reported outcomes among patients with and without deep venous reflux undergoing truncal endovenous ablation from 2015 to 2019 in the Vascular Quality Initiative. Preprocedural and postprocedural comparisons were performed using the t-test, χ 2 , or their nonparametric counterpart when appropriate. Multivariable logistic regression models were used to assess for confounding., Results: A total of 4881 patients were included, of which 2254 (46.2%) had combined deep and superficial reflux. The median follow-up was 336.5 days. Patients with deep reflux were less likely to be female (65.9% vs 69.9%; P = .003), more likely to be Caucasian (90.2% vs 86.5%; P = .003) and had no difference in BMI (30.6 ± 7.5 vs 30.6 ± 7.2; P = .904). Additionally, no difference was seen in rates of prior varicose vein treatments, number of pregnancies, or history of deep venous thrombosis; however, patients without deep reflux were more likely to be on anticoagulation at the time of the procedure (10.9% vs 8.1%; P < .001). Patients without deep reflux had slightly higher median preprocedural Venous Clinical Severity Score (VCSS) scores (8 [interquartile range (IQR), 6-10]) vs 7 [IQR, 6-10]; P = .005) as well as postprocedural VCSS scores (5 [IQR, 3-7] vs 4 [IQR, 2-6]; P < .001). The median change in VCSS from before to after the procedure was lower for patients without deep reflux (3 [IQR, 1.0-5.5] vs 3.5 [IQR, 1-6]; P = .006). Total symptom score was higher for patients without deep reflux both before (median, 14 [IQR, 10-19] vs median, 13.5 [IQR, 9.5-18]; P = .005) and postprocedurally (median, 4 [IQR, 1-9] vs median, 3.25 [IQR, 1-7]; P < .001), but no difference was seen in change in symptom score (median, 8 [IQR, 4-13] vs median, 9 [IQR, 4-13]; P = .172). Patients with deep reflux had substantially higher rates of complications (10.4% vs 3.0%; P < .001), with a particular increase in proximal thrombus extension (3.1% vs 1.1%; P < .001). After controlling for confounding, this estimate of effect size for any complication increased (odds ratio, 5.72; 95% confidence interval, 2.21-14.81; P < .001)., Conclusions: No significant difference is seen in total symptom improvement when patients undergo truncal endovenous ablation with concomitant deep venous reflux, although a greater improvement was seen in VCSS score in these patients. Patients with deep venous reflux had a significantly increased rate of complications, independent of confounding variables, and should be counseled appropriately before the decision for treatment., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Carotid endarterectomy (CEA) with concomitant distal endovascular intervention (CEA+D) is infrequently necessary but has often been used as a salvage maneuver when complications occur during CEA. The present study aimed to determine whether preoperative risk factors associated with CEA requiring CEA+D exist and to evaluate the outcomes compared with isolated CEA., Methods: The Vascular Quality Initiative CEA registry was used to identify patients who had undergone CEA or CEA+D for asymptomatic or symptomatic carotid stenosis from 2013 to 2019. Data regarding distal intervention included whether angioplasty or stenting of the distal internal carotid artery (ICA) and/or bifurcation had been required. However, information regarding the indication or whether the intervention had been planned was not included. The χ 2 test and analysis of variance were used to evaluate the categorical and continuous perioperative variables. Variables with P < .20 on univariate analysis were included in the multivariable analysis to assess for preoperative predictors of the need for CEA+D and the association with perioperative stroke., Results: From 2013 to 2019, 327 CEA+D cases were identified and compared with 105,192 isolated CEA cases. The CEA+D patients were more likely to have undergone previous ipsilateral CEA (CEA, 1.8%; CEA+D, 4.9%; P < .01) and contralateral ICA occlusion (CEA, 4.6%; CEA+D, 11.0%; P < .01) but were less likely to have had ipsilateral stenosis ≥70% (CEA, 88.3%; CEA+D, 80.6%; P < .01). The preoperative factors associated with the need for CEA+D on multivariable analysis included previous peripheral vascular intervention, American Society of Anesthesiologists class ≥4, contralateral ICA occlusion, low-volume surgeon, and previous ipsilateral CEA. CEA+D was associated with significantly increased rates of stroke in both asymptomatic (CEA+D, 3.9%; CEA, 0.9%; P < .01) and symptomatic (CEA+D, 9.4%; CEA, 1.9%; P < .01) patients. CEA+D was associated with decreased rates of 30-day survival in both asymptomatic (CEA+D, 98.3%; CEA, 99.4%; P = .02) and symptomatic (CEA+D, 94.8%; CEA, 99.1%; P < .01) cohorts. On multivariable analysis, CEA+D remained significantly associated with stroke (odds ratio, 3.17; 95% confidence interval, 1.80-5.60; P < .01). Other factors significantly associated with perioperative stroke included procedure length >135 minutes, diabetes, hypertension, shunt for indication, symptomatic status, previous ipsilateral CEA, contralateral ICA occlusion, urgent or emergent procedure, intravenous medications for hemodynamic instability, and re-exploration at the initial operation., Conclusions: Although markers of more significant cardiovascular disease burden were associated with the use of CEA+D, their power to predict CEA+D use was limited. In cases in which CEA+D was used, CEA+D was associated with significantly greater rates of perioperative stroke and mortality compared with isolated CEA for both asymptomatic and symptomatic patients, which could be useful for framing the expected outcomes after these procedures., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Vascular surgery has seen rapid increase in the use of less invasive endovascular therapies along with advancements in cardiac perioperative optimization in the past 2 decades. However, a recent American College of Surgeons National Surgical Quality Improvement Program database study found no improvement in postoperative myocardial infarction (POMI) over a 10-year period in high-risk procedures. The national Society for Vascular Surgery Vascular Quality Initiative (VQI) registry provides a more in-depth characterization of vascular surgery procedures. Here, we sought to evaluate long-term trends in POMI using VQI registry data for patients undergoing carotid endarterectomy (CEA), thoracic endovascular aortic repair (TEVAR), endovascular aortic repair (EVAR), open abdominal aortic aneurysm repair (oAAA), suprainguinal bypass (SIB), and infrainguinal bypass (IIB)., Methods: A retrospective cohort study was performed using data on elective procedures from 2003 to 2017. Procedures were subdivided by date of operation into 3-year era consecutive groups for subanalysis (2003-05, 2006-08, 2009-11, 2012-14, and 2015-17). The incidence of POMI, preoperative risk factors (including individual patient VQI cardiac risk index (CRI)), and demographics were determined over time., Results: A total of 227,837 elective procedures were identified: CEA (n = 88,805, 39.0%), TEVAR (n = 7,494, 3.3%), EVAR (n = 34,376, 15.1%), oAAA (n = 7,568, 3.3%), SIB (n = 11,354, 5.0%), and IIB (n = 34,661, 15.2%). Across all procedures, the overall rate of POMI was 1.3%. POMI rates from 2003-05 to 2015-17 for CEA decreased from 0.9% to 0.7% (P = 0.21), EVAR from 2.0% to 0.7%, P = 0.003, oAAA from 6.8% to 5.1% (P = 0.12), and IIB from 3.8% to 2.4% (P = 0.003). SIB POMI decreased from 3.06% to 2.95%, P = 0.85 from 2009 to 17. While POMI after TEVAR increased from 2.40% to 2.56% from 2009 to 17, P = 0.91. Over these same time periods, only EVAR and IIB had a reduction in CRIs (P = 0.059 and P < 0.001, respectively). CEA, EVAR, IIB, and oAAA all showed a significant (P < 0.001) increase in preoperative statin use., Conclusions: Except for TEVAR, the incidence of POMI has remained unchanged or decreased over the past 15 years in VQI registries. Patients undergoing IIB and EVAR demonstrated decreases in POMI rates that correspond with a reduction in CRIs and increased preoperative statin use. CEA and SIB had no significant change in POMI rates nor CRIs. The etiology of decreased POMI rate is uncertain, but increasing statin use, patient-specific factors, and patient selection for procedures may be important drivers of this improvement., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The regulatory focus theory (RFT) posits that people can pursue goals with a promotion or prevention focus. Greater alignment of RFT motivational styles between faculty and residents may enhance resident operative autonomy. This study establishes a set of faculty behaviors residents can identify to infer faculty motivational styles., Methods: 10 behaviors associated with promotion and prevention motivational styles were identified. General surgery residents rated faculty on how strongly they exhibit these behaviors. Faculty conducted a self-assessment of how strongly they exhibit these behaviors., Results: There is a positive correlation between resident and faculty ratings for the promotion-associated behaviors of "works quickly," "high energy," and "mostly provides broad oversight," and for the prevention-associated behaviors of "works slowly and deliberately," "quiet and calm," and "preference for vigilant strategies.", Conclusion: Residents can observe faculty operative behaviors to infer faculty motivational styles. Residents may use this knowledge to adjust to faculty motivational styles and enhance operative interactions., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Although endovascular peripheral vascular interventions (PVI) are typically limited to vessels above the knee in intermittent claudication (IC), some patients have concomitant or isolated infrapopliteal disease with IC. The benefits and risks of undergoing tibial intervention remain unclear in IC patients. The purpose of this study is to evaluate the prevalence and outcomes of infrapopliteal PVI for IC., Methods: The Vascular Quality Initiative was queried for PVI procedures performed for IC between 2003 and 2018. Patients were divided into 3 groups: isolated femoropopliteal (FP), isolated infrapopliteal (IP), and combined above and below knee interventions (COM). Multivariable logistic regression models identified predictors of minor and major amputation, as well as freedom from reintervention. Kaplan-Meier plots estimate amputation-free survival., Results: We identified 34,944 PVI procedures for IC. There were 31,110 (89.0%) FP interventions, 1,045 (3.0%) IP interventions, and 2,789 (8.0%) COM interventions. Kaplan-Meier plots of amputation-free survival revealed that patients with any IP intervention had significantly higher rates of both minor and major amputation (log rank <0.001). Freedom from reintervention at 1-year was 89.2% for the FP group, 91.3% for the IP group, and 85.3% for the COM group (P < 0.0001). In multivariable analysis, factors associated with an increased risk of major amputation included isolated IP intervention (OR 6.47, 95% CI, 6.45-6.49; P < 0.0001), COM interventions (OR 2.32, 95% CI, 2.31-2.33; P < 0.0001), dialysis dependence (OR 3.34, 95% CI, 3.33-3.35; P < 0.0001), CHF (OR 1.86, 95% CI, 1.85-1.86; P = 0.021) and, nonwhite race (OR 1.64, 95% CI, 1.63-1.64; P = 0.013)., Conclusions: PVI in the infrapopliteal vessels for IC is associated with higher amputation rates. This observation may suggest the need for more careful patient selection when performing PVI in patients with IC where disease extends into the infrapopliteal level., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Venous insufficiency is commonly bilateral, and patients often prefer single-episode care compared with staged procedures. Few studies have investigated clinical outcomes after unilateral vs bilateral venous ablation procedures or between staged and concurrent bilateral procedures. Here, we report data from the Vascular Quality Initiative regarding truncal venous ablation for chronic venous insufficiency., Methods: Using data from the Vascular Quality Initiative, we investigated immediate postoperative as well as long-term clinical and patient-reported outcomes of patients undergoing unilateral vs bilateral truncal endovenous ablation from 2015 to 2019. We further investigated outcomes between staged bilateral and concurrent bilateral ablations. Preprocedural and postprocedural comparisons were performed using t-test, χ 2 test, or their nonparametric counterpart when appropriate. Multivariable ordinal logistic regression was performed on ordinal outcome variables., Results: A total of 5029 patients were included, of whom 3782 (75.2%) underwent unilateral procedures. Median follow-up was 227 days (interquartile range [IQR], 55-788 days). Unilateral patients were less likely to be female (67.0% vs 70.3%; P = .031) and white (86.3% vs 91.2%; P < .001) and had lower body mass index (30.3 ± 7.3 kg/m 2 vs 31.8 ± 7.6 kg/m 2 ; P < .001) compared with patients undergoing bilateral procedures. In addition, unilateral patients had fewer prior varicose vein treatments (23.0% vs 15.7%; P < .001) and had higher median preprocedural Venous Clinical Severity Score (VCSS; 8 [IQR, 6-10] vs 7 [IQR, 5.5-9]; P < .001). No difference was seen in complications (6.9% vs 8.2%; P = .292), and systemic complications were rare in both groups. No difference was seen in VCSS improvement after treatment (median, 3 [IQR, 1-6] for unilateral; median, 3 [IQR 1-5] for bilateral; P = .055). In comparing staged with concurrent bilateral procedures, there was no difference in overall complications (7.5% vs 12.2%; P = .144). Staged bilateral patients were older (56.9 ± 13.3 years vs 54.2 ± 12.9 years; P = .002), less likely to have had prior varicose vein treatment (14.3% vs 19.8%; P = .020), and more likely to be therapeutically anticoagulated (10.8% vs 6.5%; P = .028) compared with concurrent bilateral patients. Staged patients also have higher preprocedural VCSS compared with concurrent patients (median, 8 [IQR, 6-10] vs 7 [IQR, 5.5-9]; P < .001). In multivariable analysis, there was no difference in the likelihood of VCSS improvement for concurrent compared with staged procedures (odds ratio, 0.70; 95% confidence interval, 0.40-1.24; P = .226)., Conclusions: Concurrent bilateral truncal endovenous ablation can be performed safely without increased morbidity compared with staged bilateral or unilateral ablations., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Widespread adoption of direct oral anticoagulants (DOACs) for atrial fibrillation and venous thromboembolism treatment has resulted in peripheral bypass patients receiving therapeutic anticoagulation with DOACs postoperatively. This study was undertaken to evaluate patient outcomes after open peripheral bypass based on anticoagulation treatment., Methods: Postoperative treatment and outcomes of patients undergoing peripheral bypass operations between January 2012 and December 2017 from a statewide multicenter quality improvement registry were examined. Surgeons participating in the registry were surveyed on practice patterns regarding DOACs in bypass patients. Multivariate logistic regression was performed for 30-day transfusion outcomes, and multiple linear regression was performed for length of stay., Results: Among 9682 patients, 7685 patients received no anticoagulation, whereas 1379 received a vitamin K antagonist (VKA) and 618 received a DOAC postoperatively. Patients receiving anticoagulation compared with no anticoagulation had a higher body mass index and were more likely to have preoperative anemia, congestive heart failure, and atrial fibrillation (all P < .001). Compared with patients receiving VKAs, patients receiving DOACs were less likely to have chronic kidney disease (P = .002) and more likely to have atrial fibrillation (P < .001). The shortest length of stay was among patients receiving no anticoagulation (median, 5 days; interquartile range, 3-9 days; P < .001), followed by DOACs (median, 6 days; interquartile range 3-11 days; P < .001) and VKAs (median, 8 days; interquartile range, 5-13 days; P < .001). Compared with patients receiving VKAs postoperatively, there was no difference in readmission for anticoagulation complications, bypass thrombectomy or thrombolysis, major amputation, or graft patency at 1 year among patients receiving DOACs. On multivariate logistic regression, patients receiving a DOAC (odds ratio, 0.743; confidence interval, 0.59-0.94; P = .011) or no anticoagulation (odds ratio, 0.792; confidence interval, 0.69-0.91; P = .001) were less likely to require transfusion within 30 days than patients taking VKAs. Approximately 70% of the surveyed surgeons reported that they "sometimes" or "always" use DOACs instead of VKAs for protection of a high-risk bypass., Conclusions: Among patients undergoing lower extremity surgical bypass, those receiving a DOAC postoperatively had a shorter length of stay and were less likely to receive a transfusion in 30 days without compromising graft patency and readmission for anticoagulation complications, thrombectomy, or thrombolysis or affecting amputation rate compared with those receiving a VKA. A majority of surgeons within the quality collaborative have adopted the use of DOACs after peripheral bypass, suggesting the need for a prospective trial evaluating DOAC safety and efficacy in patients requiring anticoagulation for high-risk bypass grafts., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Given the increasing availability of large data set, small single-institutional series raise decreasing attention. Rapid expansion of technology from electronic medical records to easily accessible internet access, and widespread use and acceptance of registries in the medical world has allowed for research and quality improvement efforts using 'big data'. Big data, although technically not defined, typically refers to large databases that can be used to investigate common or rare disease processes or outcomes, describe variation in clinical practices across and between different specialties at various practice location, whilst allowing important information about trends over time. Big data have allowed investigators to quickly assimilate cohorts of patients and/or procedures to answer current questions, with more complete population representation and improved generalizability whilst decreasing the likelihood of power problems and type II errors. On the other hand, pitfalls still exist with the growing problem of hypothesis fishing, lack of granularity and the fear by many clinicians that registry transparency may have already gone too far, where surgery groups or individual surgeon outcomes are readily available to patients and referring providers. Within vascular surgery specifically, big data have expanded over the last decade and now includes regional, national and global registries that have major benefits of gathering specific clinical and procedural information within vascular surgery. In this review, we highlight the main vascular surgery registries and recap a few success stories of how the registries have been leveraged to benefit discovery, quality improvement and ultimately patient care. Additionally, we outline future directions that will be imperative for continued expansion, acceptance and adoption of 'big data' utilization inpatients with vascular disease., (© 2020 The Association for the Publication of the Journal of Internal Medicine.)

Objective: In the past decade, treatment of abdominal aortic aneurysm (AAA) has dramatically shifted from open repair to an endovascular approach. The decreasing number of open AAA repairs (OAR) has raised concerns regarding future vascular surgeons' competence to perform this complex and high-risk procedure. Prior work has documented decreasing open aortic volume among surgical residents. However, these studies report average national case volume with a limited understanding of the variation in OAR exposure among training programs and trainees. We sought to evaluate the current open AAA repair trends among individual accredited vascular surgery training programs and vascular surgery residents to better evaluate trainees' exposure to OAR., Methods: We identified elderly Medicare beneficiaries undergoing OAR and endovascular aneurysm repair (EVAR) between 2010 and 2014. Accredited vascular surgery training program hospitals were identified. OAR and EVAR volume was aggregated at the program level and the number of senior vascular surgery trainees per year at each program was captured. The training program all-payer total AAA repair volume was calculated based on the national proportion of patients undergoing AAA covered by Medicare in the Vascular Quality Initiative. Temporal trends in program and vascular surgery trainee OAR and EVAR volume were calculated., Results: A total of 119,408 (77%) EVAR and 35,042 (23%) were identified in the Medicare database between 2010 and 2014. Of these, 21% were performed among the 111 training programs, including 22,227 (73%) EVAR and 8416 (27%) OAR. The total OAR volume among training programs decreased by 38% during the study period, from a median of 29.1 to 18.2 OAR. In 2014, 25% of programs performed fewer than 10 OARs annually. Among senior vascular surgery trainees, the median number of OAR decreased from 10.0 in 2010 to 6.4 in 2014 and approximately one-half of senior trainees had exposure to fewer than five OAR in 2014., Conclusions: Exposure to OAR among vascular surgery training programs has dramatically decreased, with nearly one-half of senior trainees performing fewer than five OAR in 2014. The variable and diminishing OAR exposure among vascular surgery training program highlights growing concerns surrounding competence in complex open repairs and suggest that only a small proportion of current trainees have ample opportunity to develop confidence and proficiency in this high-risk operation., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Longitudinal contact between faculty and residents facilitates greater faculty entrustment. The purpose of this study is to assess the relationship between faculty familiarity with residents and faculty entrustment., Materials and Methods: Researchers observed and rated entrustment behaviors using OpTrust, September 2015-June 2017 at Michigan Medicine. Faculty familiarity with resident was measured on a 1-4 scale (1 = not familiar, 4 = extremely familiar). ANOVA and Sidak adjusted multiple comparisons were used to assess the relationship between faculty familiarity and faculty entrustment., Results: 56 faculty and 73 residents were observed across 225 surgical cases. Faculty entrustment scores increased to 2.48 when resident familiarity was reported as "slightly familiar". Faculty entrustment scores for "moderately familiar" increased to 2.57. Faculty entrustment scores for "extremely familiar" increased to 2.84., Conclusions: We found a positive relationship between faculty familiarity and entrustment. These findings support greater continuity in faculty/resident relationships. Longitudinal contact allows learners to be granted progressive entrustment., Summary: This study demonstrates a positive relationship between faculty familiarity with residents and an increase in intraoperative entrustment. These findings support greater continuity in faculty/resident relationships., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: Patients undergoing vascular surgery are at high risk of postoperative myocardial infarction (POMI). Postoperative myocardial infarction is independently associated with significant risk of in-hospital mortality., Objective: To examine the association of patient and procedural characteristics with the risk of POMI after vascular surgery and determine the association of evidence-based therapies with longer-term outcomes., Design, Setting, and Participants: A retrospective cohort study of prospectively collected data within a statewide quality improvement collaborative database between January 2012 and December 2017. Patient demographics, comorbid conditions, and perioperative medications were captured. Patients were grouped according to occurrence of POMI. Univariate analysis and logistic regression were used to identify factors associated with POMI. The collaborative collects data from private and academic hospitals in Michigan. Patients undergoing major vascular surgery, defined as endovascular aortic aneurysm repair, open abdominal aortic aneurysm, peripheral bypass, carotid endarterectomy, or carotid artery stenting were included. Analysis began December 2018., Main Outcomes and Measures: The presence of a POMI and 1-year mortality., Results: Of 26 231 patients identified, 16 989 (65.8%) were men and the overall mean (SD) age was 69.35 (9.89) years. A total of 410 individuals (1.6%) experienced a POMI. Factors associated with higher rates of POMI were age (odds ratio [OR], 1.032 [95% CI, 1.019-1.045]; P < .001), diabetes (OR, 1.514 [95% CI, 1.201-1.907]; P < .001), congestive heart failure (OR, 1.519 [95% CI, 1.163-1.983]; P = .002), valvular disease (OR, 1.447 [95% CI, 1.024-2.046]; P = .04), coronary artery disease (OR, 1.381 [95% CI, 1.058-1.803]; P = .02), and preoperative P2Y12 antagonist use (OR, 1.37 [95% CI, 1.08-1.725]; P = .009). Procedurally, open abdominal aortic aneurysm (OR, 4.53 [95% CI, 2.73-7.517]; P < .001) and peripheral bypass (OR, 2.375 [95% CI, 1.818-3.102]; P < .001) were associated with the highest risk of POMI. After POMI, patients were discharged and received evidence-based therapy with high fidelity, including β-blockade (296 [82.7%]) and antiplatelet therapy (336 [95.7%]). A high portion of patients with POMI were dead at 1 year compared with patients without POMI (113 [37.42%] vs 993 [5.05%]; χ2 = 589.3; P < .001)., Conclusions and Relevance: Despite high rates of discharge with evidence-based therapies, the long-term burden of POMI is substantial, with a high mortality rate in the following year. Patients with diabetes mellitus, coronary artery disease, congestive heart failure, and valvular disease warrant additional consideration in the preoperative period. Further, aggressive strategies to treat patients who experience a POMI are needed to reduce the risk of postoperative mortality.

Background: Volume-outcome relationships exist for many complex surgical procedures, prompting institutions to adopt surgical volume standards for credentialing. The current Leapfrog Group Hospital volume standard for open abdominal aortic aneurysm repair (OAR) is 15 per year. However, this is primarily based on data from the 1990s and may not be appropriate given the dramatic decline in OAR. We sought to quantify the proportion of hospitals meeting volume standards, the difference in perioperative outcomes between low-volume and high-volume hospitals, and the potential travel burden of volume credentialing on patients., Methods: We identified Medicare beneficiaries for individuals aged ≥65 years undergoing OAR in 2013-2014. Hospital "all-payer" annual volume was estimated based on the national proportion of patients undergoing OAR covered by Medicare in the Vascular Quality Initiative. Hospital annual OAR volume was characterized as <5/year, 5-9/year, 10-14/year, and ≥15/year (high volume). Adjusted rates of postoperative morbidity, reoperation, failure to rescue, and mortality in 2014 were compared across volume cohorts. Distance between patients' home zip code and high-volume hospitals was calculated., Results: A total of 21,191 OARs were performed at 1,445 hospitals between 2013 and 2014. The average hospital OAR annual volume was 7.8 (standard deviation [SD] ± 9.3) with a median of 4.5. Among the 1,445 hospitals, only 190 (13.1%) performed ≥15 OARs per year whereas 756 hospitals (53.3%) performed <5 per year. Among patients who underwent OAR in 2014, 5,395 (53.3%) received care at a hospital that performed <15 per year. There was no difference in complication, reoperation, or failure to rescue rates between high-volume and low-volume hospitals. Mortality did not significantly differ among OAR volume cohorts. Hospitals performing <5 OARs per year had a mortality rate of 5.7% compared with 5.6% at high-volume hospitals (P = 0.817). One-quarter of patients who received care at a low-volume hospital would have had to travel more than 60 miles to reach a high-volume hospital., Conclusions: By conservative estimates, only 13% of hospitals performing OAR meet current volume standards. Triaging all patients to high-volume hospitals would require shifting over 5,000 patients annually with no associated improvement in perioperative outcomes. Implementation of the current OAR hospital volume standard may significantly burden patients and hospitals without improving surgical outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: A ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition that carries a high mortality rate. Recent guidelines have recommended a goal "door-to-intervention" time of ≤90 minutes despite a paucity of evidence to support this goal. The aim of this study was to analyze recent trends in door-to-intervention time for rAAAs and determine the effect of the 90-minute door-to-intervention benchmark on postoperative complications., Methods: A retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) of a rAAA in the Vascular Quality Initiative database (2003-2018) was performed. Variation in door-to-intervention time was analyzed at the patient and hospital level. Patients were dichotomized into ≤90 or >90 minute door-to-intervention time cohorts. Hierarchical modeling controlling for the hospital random effect and multivariate logistic models was used to analyze the association on 30-day mortality and major in-hospital complications., Results: A total of 3,630 operative cases for rAAA were identified (1696 OAR and 1934 EVAR). For the OAR cohort, 1035 patients (61%) had a door-to-intervention time of ≤90 minutes. However, at the hospital level, a minority of hospitals (49%) reliably achieved the OAR goal door-to-intervention time. For OARs, there was no difference in 30-day risk-adjusted major complications or mortality between the ≤90- and > 90-minute cohorts. For EVAR, 1014 patients (53.8%) had a door-to-intervention time of ≤90 minutes and a minority of hospitals (40%) upheld the recommended ≤90 minute door-to-intervention threshold. In the EVAR group, patients with a ≤90 minute door-to-intervention time had higher rates of postoperative myocardial infarction (12.0% vs. 8.5%; P < 0.05) but no difference in 30-day risk-adjusted mortality., Conclusions: A low percentage of rAAAs are being treated within the recommended door-to-intervention time. Despite this deficiency, the ≤90-minute benchmark has minimal impact on postoperative morbidity and mortality. Based on these findings, alternative quality metrics should be identified to improve the clinical care of patients with rAAA., (Copyright © 2019. Published by Elsevier Inc.)

Objective: To determine the association between intraoperative entrustment and personality alignment., Summary Background Data: For surgical residents, achieving operative autonomy has become increasingly difficult. The impact of faculty-resident operative interactions in accomplishing this goal is not well understood. We hypothesized that if operative dyads (faculty and resident) had personality alignment or congruency, then resident entrustment in the operating room would increase., Methods: We completed a retrospective analysis of 63 operations performed from September 2015 to August 2016. Operations were scored using OpTrust, a validated tool that assesses progressive entrustment of responsibility to surgical residents in the operating room. All dyads were classified as having congruent or incongruent personality alignment as measured by promotion or prevention orientation using the regulatory focus questionnaire. The association between personality congruence and OpTrust scores was identified using multivariable linear regression., Results: A total of 35 congruent dyads and 28 incongruent dyads were identified. Congruent dyads had a higher percentage of "very difficult" cases (33.3 vs. 7.4%, P = 0.017), female residents (37.1 vs. 14.3%, P = 0.042) and faculty with fewer years of experience (10.4 vs. 14.8%, P = 0.028) than incongruent dyads. In addition to post-graduate year level, dyad congruency was independently associated with a 0.88 increase (95% CI [0.27-1.49], P = 0.006) in OpTrust scores (overall range 2-8), after adjusting for case difficulty, faculty experience, and post-graduate year., Conclusions: Congruent operative dyads are associated with increased operative entrustment as demonstrated by increased OpTrust scores. Developing awareness and strategies for addressing incongruence in personality in the operative dyad is needed.

Background: 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., Methods: 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., Results: 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 for <2 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., Conclusions: 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., (Published by Elsevier Inc.)

Background: As patient care is being increasingly transitioned out of the hospital and into the outpatient setting, there is a growing interest in developing office-based angiography suites, that is, office-based laboratories. Office-based care has been associated with increased efficiency and greater patient satisfaction, with substantially higher reimbursement directly to the physicians providing care. Prior studies have demonstrated a shift of revascularization procedures to office-based laboratories with a concomitant increase in atherectomy use, a procedure with disproportionately high reimbursement in comparison to other peripheral revascularization techniques. We sought to determine provider trends in endovascular procedure volume, settings, and shifts in practice over time, specific to atherectomy., Methods: Using Centers for Medicare & Medicaid Services Provider Utilization and Payment Data Public Use Files from 2013 to 2015, we identified providers who performed diagnostic angiography (DA), percutaneous transluminal angioplasty (PTA), stent placement (stent), and atherectomy, and procedures were aggregated at the provider level. Trends in procedures performed in office-based laboratory and facility-based settings were analyzed. Atherectomy was specifically analyzed using the total number and proportion of office-based laboratory procedures, and providers were stratified into quintiles by case volume., Results: Between 2013 and 2015, 5,298 providers were identified. Over this time period, the number of providers performing atherectomy increased 25.7%, with the highest quintile of atherectomy providers performing an average of 263 cases (range 109-1,455). The proportion of physicians who performed atherectomy only in the office increased from 39.8% to 50.7% from 2013 to 2015, whereas only 20.8% of physicians who performed DA, PTA, or stent in 2015 did so only in an office-based laboratory. Of the physicians with the highest atherectomy volume, 77.8% operated only in the office in 2015, and these physicians increased their atherectomy volume to 114.1% during the study period. Of those physicians who transitioned to a solely office-based laboratory practice over the study period, atherectomy volume increased 63.4%, which was disproportionate compared with the growth of their DA, PTA, and stent volume., Conclusions: Over this short study period, a rapid shift into the office setting for peripheral intervention occurred, with a concomitant increase in atherectomy volume that was disproportionate to the increase in other peripheral interventions. This increase in office-based laboratory atherectomy occurred in the setting of increased reimbursement for the procedure and despite a lack of data supporting superiority over PTA/stent., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Faculty entrustment decisions affect resident entrustability behaviors and surgical autonomy. The relationship between entrustability and autonomy is not well understood. This pilot study explores that relationship., Methods: 108 case observations were completed. Entrustment behaviors were rated using OpTrust. Residents completed a Zwisch self-assessment to measure surgical autonomy. Resident perceived autonomy was collected for 67 cases used for this pilot study., Results: Full entrustability was observed in 5 of the 108 observed cases. Residents in our study did not report full autonomy. Spearman's rank correlation coefficient identified that resident entrustability was positively correlated with perceived resident autonomy (ρ = 0.66, p < 0.05). Ordinal logistic regression assessed the relationship between resident entrustability and autonomy. The relationship persisted while controlling for PGY level, gender, and case complexity (OR = 8.42, SEM = 4.54, p < 0.000)., Conclusions: Resident entrustability is positively associated with perceived autonomy, yet full entrustability is not translating to the perception of full autonomy for residents., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Optimizing intraoperative education is critical for development of autonomous residents. Faculty decisions concerning intraoperative entrustment determine the degree to which a resident gains intraoperative responsibility. Accordingly, residents exhibit entrustable behaviors that further faculty entrustment in the operating room. Little empiric evidence exists evaluating how the sex of a resident influences faculty-resident decisions of entrustment. Studies involving perception-based measurements of autonomy report inequities for women residents. We sought to assess faculty behaviors in entrustment in relation to resident sex using OpTrust, a third-party objective measurement tool., Methods: From September 2015 to June 2017 at the University of Michigan, surgical cases were observed and entrustment behaviors were rated using OpTrust. Critical case sampling was used to generate variation in operation type, case difficulty, faculty-resident pairings, faculty experience, and the level of the resident's training. Independent sample t-tests were conducted to compare faculty entrustment scores, as well as resident entrustability scores., Results: A total of 56 faculty and 73 residents were observed across 223 surgical cases from 4 surgical specialties: general, plastic, thoracic, and vascular. There was no difference in faculty entrustment or entrustability scores between women and men (2.54 vs 2.35, P = .117 and 2.32 vs 2.22, P = .393, respectively)., Conclusion: Using OpTrust scores, we found that a resident's sex does not appear to influence faculty entrustment in the OR. Faculty entrustment scores for women and men residents are similar across cases. This observation suggests that during the intraoperative interaction, faculty are not extending entrustment or opportunities for autonomy differently to women or men. Future research is needed to identify and measure perioperative elements that inform resident autonomy, which may contribute to inequities for women residents., (Published by Elsevier Inc.)

Background: There is a growing interest in providing high quality and low-cost care to Americans. A pursuit exists to measure not only how well hospitals are performing but also at what cost. We examined the variation in costs associated with carotid endarterectomy (CEA), to determine which components contribute to the variation and what drives increased payments., Materials and Methods: Patients undergoing CEA between 2009 and 2012 were identified in the Medicare provider and analysis review database. Hospital quintiles of cost were generated and variation examined. Multivariable logistic regression was performed to identify independent predictors of high-payment hospitals for both asymptomatic and symptomatic patients undergoing CEA., Results: A total of 264,018 CEAs were performed between 2009 and 2012; 250,317 were performed in asymptomatic patients in 2302 hospitals and 13,701 in symptomatic patients in 1851 hospitals. Higher payment hospitals had a higher percentage of nonwhite patients and comorbidity burden. The largest contributors to variation in overall payments were diagnosis-related groups, postdischarge, and readmission payments. After accounting for clustering at the hospital level, independent predictors of high-payment hospitals for all patients were postoperative stroke, length of stay, and readmission ,whereas in the symptomatic group, additional drivers included yearly volume and serious complications., Conclusions: CEA Medicare payments vary nationwide with diagnosis-related group, readmission, and postdischarge payments being the largest contributors to overall payment variation. In addition, stroke, length of stay, and readmission were the only independent predictors of high payment for all patients undergoing CEA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Changes in the surgical training landscape have sparked an interest in developing new educational models anchored on entrustment assessment. We sought to optimize the validated OpTrust entrustment assessment tool by comparing ratings from short-course video reviews to previously validated intraoperative assessments., Methods: Entrustment assessment scores for video-based and 1-h (short-course) observations were compared to previously validated intraoperative assessment scores. Faculty and residents were surveyed for their perceptions related to operative observation., Results: There was a strong association between entrustment scores when comparing in-person to video-based observations (R 2  = 0.76-0.84, p < 0.01) as well as short-course to full-duration observations (R 2  = 0.65-0.76, p < 0.01). The majority of faculty and residents (>97%) felt observation did not negatively impact operative experience., Conclusions: Assessment of entrustment behaviors using short-course video review provides a feasible approach to intraoperative assessment. This latest application of OpTrust allows for the tool to be incorporated into surgical training programs across a variety of environments., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Whereas chronic venous insufficiency and varicose veins (VVs) are a universally recognized problem, they are frequently underappreciated as major contributors to long-term morbidity in the elderly despite the increasing prevalence with age. Previous studies have demonstrated that chronic venous insufficiency and VV treatments in patients ≥65 years old yield an overall benefit; however, there have been few data as to whether octogenarians are undergoing these procedures and with what success. As such, our objectives were to investigate the procedures selected, to examine clinical outcomes after VV procedures in elderly patients ≥80 years old, and to explore complication rates (both systemic and leg specific) after VV procedures in patients ≥80 years old., Methods: We performed a retrospective review using the Vascular Quality Initiative Varicose Vein Registry of all VV procedures performed for ≥C2 disease from January 2015 to February 2017. We divided all procedures into three age groups: patients <65 years, patients ≥65 to 79 years, and patients ≥80 years. Statistical testing included χ 2 test for categorical variables and Student t-test for continuous variables. Two comparisons were performed: first, comparing patients <65 years old with patients ≥65 to 79 years old; and second, comparing patients ≥65 to 79 years old with patients ≥80 years old., Results: There were a total of 12,262 procedures performed, with 8608 procedures in the patients <65 years, 3226 in patients 65 to 79 years, and 428 procedures in patients ≥80 years. A total of 22,050 veins were treated during the 12,262 procedures. Almost half of procedures (46.51%; n = 5703) had only one vein treated during a single procedure. Between age groups, the percentage of one vein treated increased as the patient's age increased, ranging from 45.39% (n = 3875) for patients <65 years to 48.55% (n = 1555) for patients between 65 and 79 years and 64.08% (n = 273) for patients ≥80 years. Patients in the group ≥80 years had an overall lower average body mass index and were more likely to be receiving anticoagulation and to undergo truncal procedures alone compared with the other groups. The group ≥80 years had a significant improvement in both Venous Clinical Severity Score (4.37 ± 4.16; P < .001) and patient-reported outcomes (8.79 ± 7.27; P < .001) from before to after the procedure. Overall complications were low in all age groups. The octogenarians had no higher risk of systemic complications., Conclusions: Vascular specialists are performing VV procedures in octogenarians and are more likely to perform truncal only therapy. In addition, octogenarians have statistically significant improvement of Venous Clinical Severity Score and patient-reported outcomes with a low risk of complications despite more advanced venous disease at presentation., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There is a large body of evidence documenting better outcomes for abdominal aortic aneurysm (AAA) repairs performed in high-volume centers. However, it remains unknown if the strength of this volume-outcome relationship is moderated by race or socioeconomic status (SES)., Methods: This is a cross-sectional retrospective cohort study evaluating 60,618 Medicare fee-for-service beneficiaries undergoing open AAA repair across 1,649 hospitals between 2005 and 2009. We selected, a priori, black race and low SES as vulnerable populations based on previous reports showing each is independently associated with higher mortality. Next, we divided hospitals into quintiles of procedural volume and used logistic regression to compare risk-adjusted rates of inpatient mortality across volume quintiles for the overall study population and separately by race (black versus nonblack) and SES (low, middle, and high)., Results: Overall, patients treated in the lowest-volume hospitals (LVHs) had higher risk-adjusted inpatient mortality rates than patients treated in the highest-volume hospitals (HVHs) (15.3% vs. 10.6%, P < 0.001). Higher mortality was associated with black versus nonblack race (12.9% vs. 11.7%, P < 0.001) and low SES versus high SES (12.2% vs. 11.6% P < 0.001). While nonblack patients treated in LVHs had higher odds of mortality (versus HVHs, adjusted odds ratio (aOR) 1.83 [1.59-2.11]), this volume-outcome effect was greater for black patients (aOR 2.60 [1.63-4.16]). In contrast, high and low SES patients experienced similar differences in mortality when treated in LVHs (aOR 1.79 [1.49-2.12]; aOR 1.72 [1.28-2.30], respectively)., Conclusions: While a volume-outcome effect was observed in all patients, black patients appeared to derive a disproportionate benefit from undergoing open AAA repair in HVHs. The mechanism underlying these disparate outcomes remains unclear but warrants further evaluation of contributing hospital and patient factors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Importance: A critical balance is sought between faculty supervision, appropriate resident autonomy, and patient safety in the operating room. Variability in the release of supervision during surgery represents a potential safety hazard to patients. A better understanding of intraoperative faculty-resident interactions is needed to determine what factors influence entrustment., Objective: To assess faculty and resident intraoperative entrustment behaviors and to determine whether faculty behaviors drive resident entrustability in the operating room., Design, Setting, and Participants: This observational study was conducted from September 1, 2015, to August 31, 2016, at Michigan Medicine, the University of Michigan's health care system. Two surgical residents, 1 medical student, 2 behavioral research scientists, and 1 surgical faculty member observed surgical intraoperative interactions between faculty and residents in 117 cases involving 28 faculty and 35 residents and rated entrustment behaviors. Without intervening in the interaction, 1 or 2 researchers observed each case and noted behaviors, verbal and nonverbal communication, and interaction processes. Immediately after the case, observers completed an assessment using OpTrust, a validated tool designed to assess progressive entrustment in the operating room. Purposeful sampling was used to generate variation in type of operation, case difficulty, faculty-resident pairings, faculty experience, and resident training level., Main Outcomes and Measures: Observer results in the form of entrustability scores (range, 1-4, with 4 indicating full entrustability) were compared with resident- and faculty-reported measures. Difficulty of operation was rated on a scale of 1 to 3 (higher scores indicate greater difficulty). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and observation duration, observation month, and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients., Results: Twenty-eight faculty and 35 residents were observed across 117 surgical cases from 4 surgical specialties. Cases observed by postgraduate year (PGY) of residents were distributed as follows: PGY-1, 21 (18%); 2, 15 (13%); 3, 17 (15%); 4, 27 (23%); 5, 28 (24%); and 6, 9 (8%). Case difficulty was evenly distributed: 36 (33%) were rated easy/straightforward; 43 (40%), moderately difficult; and 29 (27%), very difficult by attending physicians. Path analysis showed that the association of PGY with resident entrustability was mediated by faculty entrustment (0.23 [.03]; P < .001). At the univariate level, case difficulty (mean [SD] resident entrustability score range, 1.97 [0.75] for easy/straightforward cases to 2.59 [0.82] for very difficult cases; F = 6.69; P = .01), PGY (range, 1.31 [0.28] for PGY-1 to 3.16 [0.54] for PGY-6; F = 22.85; P < .001), and faculty entrustment (2.27 [0.79]; R2 = 0.91; P < .001) were significantly associated with resident entrustability. Mean (SD) resident entrustability scores were highest for very difficult cases (2.59 [0.82]) and PGY-6 (3.16 [0.54])., Conclusions and Relevance: Faculty entrustment behaviors may be the primary drivers of resident entrustability. Faculty entrustment is a feature of faculty surgeons' teaching style and could be amenable to faculty development efforts.