Intraprocedural ergonomics of vascular surgeons

OBJECTIVE

The objective of this study was to estimate the ergonomic postural risk (EPR) for musculoskeletal posture of vascular surgeons performing open and endovascular procedure types and with various adjunctive equipment using wearable inertial measurement unit (IMU) sensors. The hypothesis was that EPR will increase with increased physical and mental demand as well as with procedural complexity.

METHODS

A prospective, observational study was conducted at a large, quaternary academic hospital located at two sites. Sixteen vascular surgeons (13 male) participated in the study. Participants completed a presurgery and postsurgery survey consisting of a body part discomfort scale and a modified NASA-Task Load Index. Participants wore IMU sensors on the head and upper body to measure EPR during open and endovascular procedures.

RESULTS

Vascular surgeons have increased EPR scores of the neck as measured by the IMUs and increased lower back pain when performing open surgery compared with non-open surgery (P < .05). Open procedures were rated as more physically demanding. The use of loupes resulted in increased EPR scores for the neck and torso (P < .05), and they were significantly associated with higher levels of lower back pain during procedures (P < .05) as well as with higher levels of physical demand (P < .05). The use of headlights also resulted in increased subjectively measured levels of physical demand and lower back pain. In comparing survey responses with IMU data, surveyed physical demand was strongly and significantly correlated with the neck (r = 0.61; P < .0001) and torso (r = 0.59; P < .0001) EPR scores. The use of lead aprons did not affect EPR or most surveyed measures of workload but resulted in significantly higher levels of distraction (P < .01). The data presented highlight the potential of using wearable sensors to measure the EPR of surgeons during vascular surgical procedures.

CONCLUSIONS

Vascular surgeons should be aware of EPR during the performance of their duties. Procedure type and surgical adjuncts can alter EPR significantly.

Impact of Procedure Type, Case Duration, and Adjunctive Equipment on Surgeon Intraoperative Musculoskeletal Discomfort

BACKGROUND

Surgeons are at high risk of developing musculoskeletal disorders.

STUDY DESIGN

This study was designed to identify risk factors and assess intraoperative physical stressors using subjective and objective measures, including type of procedure and equipment used. Wearable sensors and pre- and postoperation surveys were analyzed.

RESULTS

Data from 116 cases (34 male and 19 female surgeons) were collected across surgical specialties. Surgeons reported increased pain in the neck, upper, and lower back both during and after operations. High-stress intraoperative postures were also revealed by the real-time measurement in the neck and back. Surgical duration also impacted physical pain and fatigue. Open procedures had more stressful physical postures than laparoscopic procedures. Loupe usage negatively impacted neck postures.

CONCLUSIONS

This study highlights the fact that musculoskeletal disorders are common in surgeons and characterizes surgeons' intraoperative posture as well as surgeon pain and fatigue across specialties. Defining intraoperative ergonomic risk factors is of paramount importance to protect the well-being of the surgical workforce.

Meta-analysis and systematic review of interventional therapy versus anticoagulation for isolated femoropopliteal deep venous thrombosis

OBJECTIVE

Percutaneous endovenous intervention (PEVI) is gaining acceptance for select patients with symptomatic proximal lower extremity deep venous thrombosis (DVT), but the benefits are uncertain in patients with isolated femoropopliteal DVTs. We performed a systematic review and meta-analysis of the literature to assess the safety and effectiveness of PEVI vs systemic anticoagulation for patients with isolated femoropopliteal DVT.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library from inception to March 2018. All studies comparing clinical outcomes between PEVI and systemic anticoagulation were included. The main end points were post-thrombotic syndrome and bleeding complications. Secondary outcomes included femoropopliteal patency rate, venous obstruction, and recurrent DVT.

RESULTS

No studies directly comparing PEVI with systemic anticoagulation in isolated femoropopliteal DVTs were identified by the systematic review. A traditional literature review identified one randomized controlled trial comparing the two, which found no difference in rates of post-thrombotic syndrome in PEVI vs systemic anticoagulation (risk ratio, 0.96; 95% confidence interval, 0.82-1.11; P = .56). We additionally identified five retrospective case series containing patients with isolated femoropopliteal DVTs, of which two reported on patency rates (46%-100% at 2 years).

CONCLUSIONS

More data are required to definitively state that PEVI should be the preferred intervention for patients with isolated femoropopliteal DVTs, although the initial evidence is promising.

Transradial interventions in contemporary vascular surgery practice

OBJECTIVES

Upper extremity arterial access is often required for endovascular procedures, especially for antegrade access to the visceral aortic branches. Radial arterial access has been shown previously to have low complication rates, and patients tolerate the procedure well and are able to recover quickly. However, transradial access remains relatively uncommon amongst vascular surgeons.

METHODS

The radial artery was evaluated by ultrasound to evaluate for adequate caliber, and to identify any aberrant anatomy or arterial loops. A modified Barbeau test was performed to ensure sufficient collateral circulation. A cocktail of nitroglycerin, verapamil and heparin was administered intra-arterially to combat vasospasm. Sheaths up to 6 French were utilized for interventions. On completion of the procedure, a compression band was used for hemostasis in all cases.

RESULTS

Twenty-five interventions were performed in 24 patients. The left radial artery was used in 23/25 cases (92.0%). Procedures included visceral and renal artery interventions; stent graft repair of a renal artery aneurysm; embolization of splenic, pancreaticoduodenal and internal mammary aneurysms; embolization of bilateral hypogastric arteries following blunt pelvic trauma; interventions for peripheral arterial disease; delivery of a renal snorkel graft during endovascular aortic aneurysm repair, and access for diagnostic catheters during thoracic endovascular aortic aneurysm repair. Technical success was 92.0%. There was one post-operative radial artery occlusion (4.3%) which led to paresthesias but resolved with anticoagulation. There were no instances of arterial rupture, hematoma, or hand ischemia requiring intervention.

CONCLUSIONS

Using the transradial approach, we have demonstrated a high technical success rate over a range of clinical contexts with minimal morbidity and no significant complications such as bleeding or hand ischemia. The safety profile compares favorably to historical complication rates from brachial access. Radial access is a safe and useful skill for vascular surgeons to master.

Totally Percutaneous Fenestration via the "Cheese-Wire" Technique to Facilitate Endovascular Aneurysm Repair in Chronic Aortic Dissection

Here, we describe a totally percutaneous technique for longitudinal fenestration of a chronic dissection flap in the setting of endovascular aneurysm repair (EVAR), where the septum would otherwise preclude proper endograft sealing. This technique is demonstrated in a 65-year-old man with a history of open surgical repair of a Stanford type A aortic dissection, with a type B component that was managed nonoperatively. The patient developed aneurysmal degeneration of the infrarenal aorta during follow-up, and his anatomy was well suited for EVAR with the exception of a chronic dissection flap dividing the proximal seal zone. Using bilateral percutaneous access, a wire was passed through an existing fenestration in the septum from true to false lumen and snared from the contralateral side. Downward traction on this through-wire was then used as a "cheese-wire" to divide the septum longitudinally and clear it from the proximal fixation site. Removal of the septum provided an adequate proximal seal zone for the endograft, and standard infrarenal EVAR was then performed with a good technical result. Longitudinal fenestration using this technique is a useful adjunctive maneuver to facilitate EVAR in the setting of chronic aortic dissection and is safely achievable via a totally percutaneous approach.

Prophylactic Inferior Vena Cava Filter Utilization and Risk Factors for Nonretrieval

PURPOSE

Inferior vena cava filters (IVCFs) are often placed for prophylactic indications. We sought to better define the range of practice indications for placement of prophylactic IVCFs, as well as the specific retrieval rate and risk factors for nonretrieval.

METHODS

A retrospective, single-institution review of patients undergoing IVCF placement over a 2-year period was performed. Patients undergoing prophylactic IVCF placement were selected from a prospectively collected database. Risk factors for nonretrieval were identified using a multivariate logistic regression model.

RESULTS

Of 615 IVCFs placed, 256 were retrievable filters placed for prophylactic indications and comprised the study cohort. The most common indications were a history of venous thromboembolic disease (43.7%), malignancy (35.1%), bleeding risk precluding anticoagulation (33.9%), and trauma (22.6%). One hundred sixty-three (63.6%) were placed preoperatively. Placement was performed in 70.3% by interventional radiology, 21.4% by vascular surgery, and 8.2% by cardiology. The most common requesting services were orthopedics (67%), general surgery (11%), neurosurgery (9%), and bariatric surgery (7%). Of all, 67.6% were placed in the inpatient setting and 32.4% in outpatients. Seventy-one (27.7%) of the 256 prophylactic filters were retrieved, with a mean indwelling time of 92 ± 74 days. Inpatients were significantly less likely to have their IVCF removed (32.4% vs 57.8%; P < .001), as were preoperative patients.

CONCLUSIONS

This study helps define current practice trends for the placement of prophylactic IVCFs. Importantly, the specific retrieval rate for prophylactic filters is low. This suggests that prophylactic IVCF usage is suboptimal and efforts should be taken to increase retrieval, especially among inpatients and perioperative patients.

Risk Factors for Suboptimal Utilization of Statins and Antiplatelet Therapy in Patients Undergoing Revascularization for Symptomatic Peripheral Arterial Disease

BACKGROUND

The objective of this study was to identify risk factors for suboptimal medical therapy (defined as reported antiplatelet and statin use) among patients undergoing lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) for symptomatic peripheral arterial disease (PAD).

METHODS

The Vascular Study Group of Greater New York (VSGGNY) database was used to identify all patients undergoing PVI or LEB for PAD (2011-2013). Bivariate analyses were performed to identify characteristics of patients who were not prescribed statins and/or antiplatelet agents before revascularization. Multivariate relative risk regression models were developed to identify patients at risk for suboptimal therapy, with regards to antiplatelet and statin therapy.

RESULTS

About 1,030 patients underwent endovascular therapy (n = 822; 80%) or surgical bypass (n = 208; 20%) for symptomatic PAD (57.2% claudication; 15% rest pain and 27.8% tissue loss). Overall, preoperative statin use was observed in 59%. Preoperative antiplatelet therapy was observed in 79% of patients. Bivariate analysis revealed comparatively reduced statin use among patients without other cardiovascular risk factors including hypertension (63% vs. 39.3%; P < 0.0001) and coronary artery disease (CAD) with or without prior cardiac revascularization (coronary artery bypass grafting [CABG]/percutaneous coronary intervention [PCI]; 75.2% vs. 47.4%; P < 0.0001). Multivariate relative risk regression confirmed higher rates of statin use among patients with other cardiovascular risk factors including hypertension (1.14 [1.02-1.27]; P = 0.02) and CAD with prior CABG/PCI (1.22 [1.13-1.31]; P < 0.0001). Reduced statin use was observed in patients over 80 years old. (0.92 [0.84-0.1.0]; P = 0.059). By multivariate regression, antiplatelet therapy use was associated with CAD and/or prior CABG/PCI (1.11 [1.04-1.17]; P = 0.0015) and prior peripheral revascularization (1.07 [1.01-1.13]; P = 0.03).

CONCLUSIONS

Patients with symptomatic PAD, but without an antecedent cardiovascular history, are less likely to be optimally managed with statins and antiplatelet therapy preoperatively. Given the established role of these medications in the optimal medical management of patients with PAD, this presents an opportunity for improvement in the overall vascular care of patients undergoing intervention for symptomatic PAD at VSGGNY centers.

Left-Sided Varicocele as a Rare Presentation of May-Thurner Syndrome

BACKGROUND

May-Thurner syndrome (MTS), the clinical sequelae of left iliac vein compression between the right iliac artery and the spine, is an accepted cause of lower extremity edema and venous thromboembolism. It is more prevalent in younger women and typically presents with left lower extremity symptoms. Atypical presentations such as right-sided symptoms, chronic pelvic pain, and even fatal venous rupture have been reported. Here, we describe iliac vein compression presenting as a chronic left-sided testicular varicocele.

METHODS

A 22-year-old man presented with left testicular varicocele, scrotal edema, and pain after failing multiple attempts at surgical repair. MRI revealed left iliac vein compression and marked cross-pelvic collaterals. Venography and intravascular ultrasound confirmed left common iliac vein compression and typical changes of MTS. There was no gonadal vein (GV) reflux. An iliac vein stent (WALLSTENT, Boston Scientific) was placed.

RESULTS

A good technical result was achieved, with elimination of internal iliac vein reflux and marked reduction in pelvic collateral flow (see image). The patient reported resolution of his symptoms.

CONCLUSIONS

Varicocele is a leading cause of testosterone insufficiency and infertility in young males. In the majority of cases, successful treatment can be achieved by addressing reflux in the internal spermatic vein (ISV) and/or GV by a variety of surgical or endovascular approaches. In unusual cases, the culprit pathology may be reflux in the vein of the vas deferens, which unlike the ISV and GV, drains into the internal iliac vein. In such cases, iliac vein compression usually associated with MTS may result in varicocele. To our knowledge, this is the first report of refractory varicocele secondary to iliac vein compression successfully treated with endovenous stenting.

Comparison of outcomes after endovascular and open repair of abdominal aortic aneurysms in low-risk patients

Background

In randomized trials endovascular aortic aneurysm repair (EVAR) has been shown to have superior perioperative outcomes compared with open aneurysm repair (OAR). However, outcomes in patients at low risk of complications are unclear and many surgeons still prefer OAR in this cohort. The objective was to analyse perioperative and longer-term outcomes of OAR and EVAR in this low-risk group of patients.

Methods

All elective infrarenal EVARs and OARs in the Vascular Study Group of New England database were reviewed from 2003 to 2014. The Medicare scoring system was used to identity patients at low risk of perioperative complications and death. Perioperative and longer-term outcomes were analysed in this cohort. A Kaplan–Meier plot was constructed for evaluation of longer-term survival. Further propensity matching and multivariable analysis were performed to analyse additional differences between the two groups.

Results

Some 1070 patients who underwent EVAR and 476 who had OAR were identified. Mean(s.d.) age was 67·3(5·7) and 65·1(6·3) years respectively (P &lt; 0·001). EVAR was associated with a lower overall perioperative complication rate (4·2 versus 26·5 per cent; P &lt; 0·001). There was no difference in 30-day mortality (0·4 versus 0·6 per cent; P = 0·446). Overall survival at 3 years was similar after EVAR and OAR (92·5 versus 92·1 per cent respectively; P = 0·592). In multivariable analyses there was no difference in freedom from reintervention (odds ratio 1·69, 95 per cent c.i. 0·73 to 3·90; P = 0·220) or survival (hazard ratio 0·85, 0·61 to 1·20; P = 0·353).

Conclusion

In patients predicted to be at low risk of perioperative death following aneurysm repair, EVAR resulted in fewer perioperative complications than OAR. However, perioperative mortality, reinterventions and survival rates in the longer term appeared similar between endovascular and open repair.