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Objective/background: With increased collaboration between surgeons and industry, there has been a push towards improving transparency of conflicts of interest (COIs). This study aims to determine the accuracy of reporting of COIs among studies in major vascular surgery journals., Methods: A literature search identified all comparative studies published from January 2018 through December 2018 from three major United States vascular surgery journals (Journal of Vascular Surgery, Vascular and Endovascular Surgery, and Annals of Vascular Surgery). Industry payments were collected using the Centers for Medicare and Medicaid Services Open Payments database. COI discrepancies were identified by comparing author declaration statements with payments found for the year of publication and year prior., Results: A total of 239 studies (1642 authors) were identified. Two hundred twenty-one studies (92%) and 669 authors (63%) received undisclosed payments when utilizing a cut-off payment amount of $250. In 2018, 10,778 payments (totaling $22,174,578) were made by 145 companies. Food and beverage payments were the most commonly reported transaction (42%), but accounted for only 3% of total reported monetary values. Authors who accurately disclosed payments received significantly higher median general payments compared with authors who did not accurately disclose payments ($56,581 [interquartile range, $2441-$100,551] vs $2361 [interquartile range, $525-$9,699]; P < .001). When stratifying by dollar-amount discrepancy, the proportions of authors receiving undisclosed payments decreased with increasing payment thresholds. Multivariate analysis demonstrated that first and senior authors were both significantly more likely to have undisclosed payments (odds ratio, 2.0; 95% confidence interval, 1.1-3.6 and odds ratio, 2.9; 95% confidence interval, 1.6-5.2, respectively)., Conclusions: There is a significant discordance between self-reported COI in vascular surgery studies compared with payments received in the Centers for Medicare and Medicaid Services Open Payments database. This study highlights the need for increased efforts to both improve definitions of what constitutes a relevant COI and encourage a standardized reporting process for vascular surgery studies., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Randomized allocation of treatment options is not well accepted within the clinical community. Some methods of implementation may be received more favorably than others. Prerandomization may be an acceptable means to facilitate recruitment in some clinical trials., Methods: We first compare randomization and prerandomization using illustrative neurovascular trials. We review some problems with conventional trials, Zelen's prerandomization as an alternative method, and the ethical issues that have surrounded prerandomization since its inception in a historic trial. Conventional and Zelen's randomization are then compared with other means to provide and verify care in the context of clinical uncertainty., Results: The major problem with conventional randomization is that consent is requested for 2 management options, one of which the patient will not receive. The problem with prerandomization is that treatment is allocated before the patient has consented to trial participation. Prerandomization may trade recruitment difficulties for excessive crossovers. However, other ways to practice under uncertainty and verify patient outcomes, such as case series and registries, are more ethically and scientifically problematic., Conclusions: Until the ethical functions of randomized allocation of selected treatment options in the care of patients are recognized by the neurovascular community, Zelen's prerandomization may help recruitment into difficult trials and contribute a means to provide best possible care in the presence of uncertainty., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction Subjects who undergo haemodialysis are living longer, which necessitates increasingly complex procedures for formation of arteriovenous fistulas. Basilic veins provide valuable additional venous 'real estate' but surgical transposition of vessels is required, which required a cosmetically disfiguring incision. A minimally invasive transposition method provides an excellent aesthetic alternative without compromised outcomes. Methods A retrospective review was made of minimally invasive brachiobasilic fistula transpositions (using two short incisions of <4 cm) between February 2005 and July 2011. Primary endpoints were one-year patency as well as the perioperative and late complications of the procedure. Results Thirty-one patients underwent 32 transposition procedures (eight pre-dialysis cases; 24 haemodialysis patients). All patients were treated with a minimally invasive method. Thirty-one procedures resulted in primary patency, with the single failure refashioned successfully. The only indication for a more invasive approach was intraoperative complications (two haematomas). All other complications presented late and were amenable to intervention (one aneurysm, one peri-anastomotic stricture). Conclusion Formation of arteriovenous fistulae using minimally invasive methods is a novel approach that ensures fistula patency with improved aesthetic outcomes and without significant morbidity.

Patients undergoing major surgery are at risk for postoperative cognitive dysfunction (POCD). The consciousness of the POCD arises new ethical and medico-legal issues that should be identified, managed and, if possible, prevented. Elderly patients still represent a real challenge for physicians and medical science. This challenge can be surmounted not only through technical progress but also by safeguarding the correct ethical behavior at the base of each relationship between a patient and his physician. Effective communication with the elderly patient is a prerequisite for clear and complete information, involving family members and caregivers when necessary. In every case, the identification of patients with pre-existing risk factors of POCD, shortening the period of time preceding the surgery and a proper technique of the procedure as well as physical and intellectual exercises, nutrition and medication play an important role in decreasing the incidence of neurocognitive deficits in the elderly.

An experienced vascular surgeon, Dr Al Wright, specializing in venous disease, often sees self-referred patients seeking second opinions primarily for ablation therapy and is deeply disturbed at what he finds. Some patients have no reflux on ultrasound examination and, thus, no treatment is indicated. Others were told they need a ludicrous three to seven ablations in each leg where only one or at most two are needed. Several advertise their services in the media. Dr Wright asked esteemed colleagues from the American Venous Forum what they recommended and they suggested sending a copy of his consultation to the first consultant with the goal of shaming him. He also notified the state medical board 2 years ago about one egregious repeat offender, without action. What should he do? A. Do as suggested, send your consult along with a harsh letter. B. Do nothing. It is none of your business. C. Notify the state medical board, again. D. Notify the insurance companies and regulators. E. There is no good venue to deal with the problem., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

A younger vascular surgeon has been recruited to start a new program at a suburban hospital outside of a large city hosting a world-class medical center. The new program will provide state-of-the-art equipment, including robotics, free office space, and a generous salary guarantee. Dr Ready obtained a license in the state where he is relocating and is preparing to move. He is an excellent technical surgeon but is uncomfortable with complex aneurysm surgery. This morning he went to sign a contract with the hospital and found that a clause that prevents him from referring patients to physicians outside the hospital in strong legalese is included. How should he proceed?, (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

During your preoperative visit, a very wealthy patient, Gill Bates, who donated a wing to the large teaching hospital in which you practice, has an unusual request: He does not want any residents involved with his care. He is scheduled for an open infrarenal aneurysmectomy. He explains that his decision is based on the experience of a relative many years ago who was harmed by a resident's error. You clarify that you will do the procedure but that this is a teaching hospital and residents provide excellent assistance and postoperative care. He is resolute in demanding that only grown-up surgeons provide his care., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

An elderly woman was brought to the emergency room (ER) hypotensive in a confused mental state from what turned out at exploration to be a ruptured splenic artery aneurysm. You are in the operating room, and the anesthesiologist has just hung the first unit of blood but has not started infusion when the ER calls. The patient and her husband were visiting their children and live in another state. Her husband, an elder in a Jehovah's Witness congregation, arrived and is adamant that she have no transfusions. Her blood pressure is dangerously low. It is being maintained by a high-dose Levophed (leave-um dead) drip and continues to slip. You have avoided operating on Jehovah's Witness patients because of the added unnecessary risk they pose. Your assistant is of like mind. What is the best ethical course at this time?, (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

The patient, a 55-year-old female Jehovah's Witness who had suffered type B aortic dissection since the age of 53 years, presented with enlargement of the false lumen in the distal aortic arch and was subsequently admitted to our hospital. While hospitalized, her enlarged false lumen ruptured and she underwent replacement of the distal aortic arch and descending thoracic aorta without blood transfusion. Blood conservation strategies for this patient included the following: 1) meticulous hemostasis when incising muscle or soft tissue, 2) minimal use of gauze and discard suckers, 3) exclusive use of a cell salvage device "from skin to skin," 4) low-prime cardiopulmonary bypass, 5) minimal laboratory blood sampling, and 6) preoperative and postoperative erythropoietin treatment. Hemoglobin (Hb) values were 12.5, 15.5, 10.0, and 9.7 g/dL on admission, before rupture, after rupture, and just after the operation, respectively. The patient had an uneventful postoperative course, except for prolonged rehabilitation. The postoperative lowest Hb value was 5.2 g/dL on postoperative day 5, and the Hb value at hospital discharge (postoperative day 55) was 11.0 g/dL. Our experience with blood conservation surgery on this Jehovah's Witness patient suggests that ruptured chronic type B aortic dissection can be safely repaired on bypass through a left thoracotomy with no blood transfusion if the preoperative Hb value is >10.0 g/dL., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Advances in vascular surgery are increasingly technology-driven, and the relationships between surgeons and the medical device industry can be complex. This study reviewed conflict of interest (COI) disclosure in the vascular surgery journals regarding several selected technology-driven topics, including endovascular stent grafts (EV), carotid artery stenting (CAS), and peripheral arterial interventions (PI), to suggest further directions., Methods: Authors' COI disclosures were reviewed from all clinical papers published in 2008 and 2009 in each of six vascular surgery journals, and pertaining to three selected topics (EV, CAS, and PI). Rate of COI disclosure was evaluated as a function of journal, topic, article type (randomized trial, case series, case report, review, or meta-analysis), and authors' region of origin. Secondarily, consistency of authors' disclosure was evaluated by reviewing papers by the same author and of the same topic., Results: Six hundred thirty-five papers were reviewed from the six journals. A COI was declared in 125 (19.7%) of these papers. This rate differed between journals (range, 3.2%-34.1%; P < .0001). Rate of disclosure did not differ between topics (range, 12.8%-21.2%; P = .12), article type (range, 14.7%-30%; P = .28), or region of origin (range, 0%-33.3%; P = .09). There were 116 instances of the same author writing papers describing the same general topic. COI disclosure was consistent in the majority of these instances (72.4%), but inconsistent in 32 cases (27.6%). The most common (P = .006) inconsistencies involved the same type of article in different journals (46.9%), or in the same journal (25%)., Conclusions: Rates of disclosure of COI, and inconsistencies in disclosure in the vascular surgery literature are at least partially due to differences in journals' reporting policies, while a smaller proportion of these inconsistencies are due to individual author behavior. Journals should adopt a consistent requirement for a separate COI declaration where all relevant financial arrangements are disclosed., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Specialty medical societies such as Society for Vascular Surgery (SVS) are instrumental in the development and dissemination of medical knowledge through scientific presentations, publication of rigorously peer-reviewed writings, awarding competitive research and training grants, and the provision of high-quality continuing medical education (CME). It is vital that in these roles the SVS remain in fact and in perception completely free of all influence and bias from industry. While independence from bias has always been necessary, the increasing focus by governmental agencies, industry organizations, and society has made it important for the SVS to address this issue in a formal way. In June 2010, the SVS Board of Directors approved a set of guidelines specifically designed to address management of conflict of interest among its members and its leaders. These guidelines, included in this article, were based on currently available information and policies put forth by legislative bodies, academic medical centers, industry groups, and other professional medical societies, and were designed to safeguard against abuse while maintaining valuable collaboration between vascular surgeons and their industry partners. The guidelines are included in this article., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

This article assesses the current mandates on conflict of interest issues as they affect the practice of community-based vascular surgery and the pharmaceutical and medical technology industries and expresses the views of a private practice vascular surgeon. Scenarios where conflict of interest may occur are presented with assessments on how these scenarios will play out if such mandates are enforced., (Copyright © 2011. Published by Mosby, Inc.)

Relationships between physicians and their industry partners have ranged from spectacular collaborations that produce extraordinary advances in patient care, such as endovascular aneurysm repair, to humiliating scandals such as extravagant trips and bogus "consulting" agreements resulting in legal actions. It is the latter which have led many to call for the end of all physician-industry relationships, and the former which mandate their preservation. While these two examples are representative of extremes at each end of the spectrum of this issue, in reality the majority of physician-industry relationships are far more complex, and the line between appropriate and inappropriate, and ethical and unethical, is hard to draw. The benefits of our relationships with industry are many: partnering to develop new therapies and technologies, educating and training physicians around new therapies and technologies, support of continuing medical education (CME), fellowship training, and patient education. The pitfall and danger of this relationship is that support from industry, be it a meal, a pen, an educational grant, or flattery, may unduly and inappropriately influence physician decision making around a specific company's product. While it is clear that free trips are not within the realm of proper interaction, what about unrestricted educational grants to institutions, or support of CME activities, professional society meetings, and new device training? As a result of the intense scrutiny of relationships between physicians and industry recently, multiple diverse entities (Association of American Medical Colleges, American Medical Association, Accreditation Council for Continuing Medical Education, professional medical associations, academic medical centers, industry, and government) have generated guidelines and policies with very different perspectives, reflective of their different missions. These policies range from vague and lenient, with only basic limitation of the physician-industry relationship, to extremely rigid and strict, with only minimal interaction and mission support permitted. Given the many changes in oversight and expectations for the relationship between physicians and industry, it is important for vascular surgeons to be aware of the background behind these modifications, the evidence that they are needed, and the positions of the diverse organizations and institutions that have already defined their policies on this issue., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

If it were not for the ongoing collaboration between vascular surgeons and the medical technology industry, many of these advanced treatments used every day in vascular interventional surgery would not exist. The flip side of this coin is that these vital relationships create multiple roles for surgeons and must be appropriately managed. The dynamic process of innovation, along with factors such as product delivery technique refinement, education, testing and clinical trials, and product support, all make it necessary for ongoing and close collaboration between surgeons and the device industry. This unique relationship sometimes leads to the perception of conflicts of interest for physicians, in part because the competing pressures from the multiple, overlapping roles as clinician/caregiver/investigator/innovator/customer are significant. To address this issue, the Advanced Medical Technology Association (AdvaMed), the nation's largest medical technology association representing medical device and diagnostics companies, developed a Code of Ethics to guide medical technology companies in their interactions with health care professionals. First introduced in 1993, the AdvaMed Code strongly encourages both industry and physicians to commit to openness and high ethical standards in the conduct of their business interactions. The AdvaMed Code addresses many of the types of interactions that can occur between companies and health care professionals, including training, consulting agreements, the provision of demonstration and evaluation units, and charitable donations. By following the Code, companies send a strong message that treatment decisions must always be based on the best interest of the patient., (Copyright © 2011. Published by Mosby, Inc.)

Current health care trends include movements toward general health care reform and rapidly evolving changes affecting treatment of vascular disease. Government-sponsored programs and private coalitions increasingly influence practice management and patient care. Emerging organizational influences derive from public perceptions, policies, laws, and regulations intended to make health care safe, effective, patient centered, timely, efficient, and equitable. These trends energized methods of quality assessment, cost containment, and practice protocols over individual judgments and seek to exert increasing direction over clinical practice. Some evolving measures are good, some controversial, and some, without deliberate intent, may be harmful. This review considers evolving initiatives in the context of ethics of practice and practicalities of managing patients with vascular disease. Key issues include compliance with purely process-based measures, pay for performance, and assessment of quality outcomes. Strengths, weaknesses, opportunities, and potential threats to vascular practice are outlined., (Copyright © 2011. Published by Mosby, Inc.)

Mr M.O. Gul returned for his postoperative visit today after you successfully repaired a leaking abdominal aortic aneurysm. Mr Gul owns most of the cable networks in the state, making him a billionaire. He realizes that he met the bearded reaper and walked away because of your skills. He is pioneering a new technology that will make current Wi-Fi obsolete. Unexpectedly, he offers you the opportunity to invest with the expectation of huge returns. M.O. personally guarantees you will not lose money. What should you do? A Invest. No questions asked. B Do not invest. It is unprofessional. C Do not invest without consulting with your attorney. D Do not invest. You have already been paid for services rendered. E Invest provided you forego future medical relationships with M.O. as the attending physician., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

We present the case of a 101-year-old female who was successfully operated for an open elective repair of a symptomatic 9 cm abdominal aortic aneurysm. This is the oldest case reported in the literature for elective open abdominal aortic aneurysm repair with successful outcome. This case raises an important ethical issue of human life expectancy and the appropriateness of high-risk surgery on a centenarian., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Vascular surgeons are often called emergently to help treat bleeding patients. These cases may involve unexpected intraoperative bleeding, bleeding in the pregnant patient, or bleeding in patients in the emergency room. In many instances, the vascular surgeon is not "on call" and therefore has no legal duty to assist in the care of these patients. Unfortunately, because many of these types of cases result in litigation, some vascular surgeons refuse to respond to a call for help. Simply, it is important that vascular surgeons "do the right thing" and answer these requests for assistance. The legal system recognizes the need to protect physicians who appropriately respond and, therefore, Good Samaritan statutes were adopted., (Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Many physicians refuse to provide an expert review of a medical malpractice case for a plaintiff's attorney. They consider it to be "sleeping with the enemy". However, one method of avoiding frivolous suits is for reputable vascular surgeons to provide an honest and thorough review of the care provided to a patient by another vascular surgeon. This article discusses the importance and some guidelines for providing these reviews.

An elderly patient who underwent a complex emergency abdominal aneurysmectomy two weeks ago is in coma, ventilator dependent, and in severe multisystem organ failure with a deteriorating prognostic index score. The family has become increasingly hostile towards Dr S. Cold, the consultants, the ICU nurses, and the janitorial staff. An estranged wife has called once to defer decision-making to the children. Three children intermittently visit and are openly critical of the medical care. One child is an ICU nurse supervisor at a small local suburban hospital. Dr Cold spoke to the family yesterday about instituting DNR orders and discontinuing some supportive therapy that was not working. The family first required another consultation and then demanded that Dr Cold transfer the patient to the hospital where the daughter works. The hospital does not provide tertiary care. A physician there is willing to assume responsibility. How should Dr Cold respond? A. Do as they request. B. Refuse outright. C. Call the accepting physician and explain why the case is futile. D. Take the matter to the ethics committee to prevent transfer. E. Call the wife and children to schedule an exploratory family conference and insist they come to a decision.

Objective: To evaluate the association between compassionate attitudes and seniority in vascular surgeons facing clinical ethical dilemmas (CED)., Subjects and Methods: (1) DESIGN: Cross-sectional. (2) SUBJECTS: Vascular surgeons (residents included) from the 28 vascular teaching departments of one European country. (3) MEASUREMENTS: Multidisciplinary team-designed, structured and self-administered questionnaire consisting of five clinical ethical dilemmas, of which four had conflict between compassion towards a 'small' or 'very costly' beneficial action vs. a reasonable but more 'pragmatic' allocation of health resources. Participants stated their degree of agreement with eight answers representing the two attitudes on a continuous scale. (4) STATISTICS: Cluster analysis and logistic regression model adjusted by confounding factors., Results: Two hundred and fifty three vascular surgeons (median age 37 years, 74% male) from the 26 participating teaching vascular departments (public hospitals) completed the questionnaire (88% surgeons/department). Cluster analysis identified two groups of surgeons according to their pattern of answers: Group I (n=63) were mainly compassionate whereas Group II (n=180) were mainly pragmatic. The multivariate analysis disclosed, after adjusting for additional private practice, on call services and career status, a significant V-shaped relationship between the compassionate behaviour and seniority. Surgeons with 8-15 years experience were the least compassionate., Conclusions: The youngest and the most senior vascular surgeons were more prone to favour compassionate attitudes when facing clinical ethical dilemmas. Although both compassionate and pragmatic attitudes may be legitimate ethically, physicians not favouring compassion may be at risk of leaving the patient without an advocate within the health care system.