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Saldana-Ruiz N, Okunbor O, Dematteis MN, Quiroga E, Singh N, Dansey K, Smith M, Zettervall SL. Patterns in Complex Aortic Vascular Surgery Training and Early Career Practice. Ann Vasc Surg 2024; 98:26-33. [PMID: 37866677 DOI: 10.1016/j.avsg.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/27/2023] [Accepted: 08/12/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Recent literature has suggested a decreasing experience with open aortic surgery among recent vascular surgery graduates. While trainees have a wide exposure to endovascular aortic repair, experience with both endovascular and open management of thoracoabdominal aneurysms, as well as the early career surgeon comfort with these procedures, remains unknown. Thus, we sought to evaluate early practice patterns in the surgical treatment of complex aortic surgery among recent US vascular surgery graduates. METHODS An anonymous survey was distributed among all vascular surgeons who completed vascular surgery residency or fellowship in 2020. Self-reported data assessed the number and type of cases performed in training, surgeon experience in early practice, and surgeon desire for additional training in these areas. RESULTS A total of 62 surgeons completed the survey with a response rate of 35%. Seventy-nine percent of respondents completed fellowship training (as compared to integrated residency), and 87% self-described as training in an academic environment. Sixty-six percent performed less than 5 open thoracoabdominal aortic surgeries and 58% performed less than 5 4-vessel branched/fenestrated aortic repairs (F/BEVARs), including 56% who completed less than 5 physician modified endovascular grafts repairs. Only 11% of respondents felt adequately prepared to perform open thoracoabdominal operations following training. For both open and F/BEVAR procedures, more than 80% respondents plan to perform such procedures with a partner in their current practice, and the majority desired additional open (61%) and endovascular (59%) training for the treatment of thoracoabdominal aneurysms. CONCLUSIONS The reported infrequency in open thoracoabdominal and multivessel F/BEVAR training highlights a desire and utility for an advanced aortic training paradigm for surgeons wishing to focus on this area of vascular surgery. Further research is warranted to determine the optimal way to provide such training, whether through advanced fellowships, junior faculty apprenticeship models, or regionalization of this highly complex patient care. The creation of these programs may provide pivotal opportunity, as vascular surgery and the management of complex aortic pathology continues to evolve.
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Affiliation(s)
| | - Osarumen Okunbor
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | | | - Elina Quiroga
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Niten Singh
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Kirsten Dansey
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Matthew Smith
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Sara L Zettervall
- Division of Vascular Surgery, University of Washington, Seattle, WA.
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Hakeem A, Najem M. Impact of Vascular Service Centralization on the Carotid Endarterectomy Pathway: A Study at the Bedfordshire, Luton, and Milton Keynes Vascular Network. Cureus 2023; 15:e49726. [PMID: 38050531 PMCID: PMC10693671 DOI: 10.7759/cureus.49726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/06/2023] Open
Abstract
Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50% internal carotid artery (ICA) stenosis supplying index hemispheric territory. The recommended period for CEA is 14 days post-index event; this period carries a heightened risk for second ischemic events. However, implementation of this stringent timeline often encounters delays stemming from multifaceted factors. The centralization of vascular services, designed to enhance patient care, introduces a paradigm shift. Centralization's efficacy in improving patient outcomes, particularly in the CEA pathway, is a subject of ongoing investigation. Our study aims to discern the impact of centralized services on the timeliness of CEA for symptomatic carotid artery stenosis, shedding light on this complex interplay of factors. Methods This retrospective study analyzed CEA data at the Bedfordshire, Luton, and Milton Keynes Vascular Network between January 2021 and June 2023. Eligible patients exhibited symptomatic carotid artery stenosis, with asymptomatic cases; those unfit for surgery or receiving best medical therapy only were excluded. Patients were categorized by their primary referral location: Hub, Spoke-1, or Spoke-2. Demographic and referral data were collected, and timelines from symptom onset to surgery were recorded. Continuous variables were expressed as means and standard deviations, and categorical variables as counts and percentages. Box plots illustrated the relationship between referral origin and surgery timing, and the Classification and Regression Tree (CART) assessed second events. Statistical significance was determined using Fisher's exact and chi-square tests, with p<0.05 indicating significance. Results A total of 148 patients underwent CEA after implementing exclusion criteria. 35.5% (n=53) of patients were referred from the Hub, while 45.6% (n=67) and 18.8% (n=28) were from Spoke-1 and Spoke-2, respectively. 40% (n=59) received CEA within the recommended timeframe, and 15.4% (n=23) experienced a second ischemic event pre-surgery. Time from TIA clinic review to referral was 5.5±8 days and 16.4±20 days from vascular referral to surgery. Patterns of delays were observed, with Spoke-2 exhibiting the most significant delays. Notably, amaurosis fugax and embolic stroke correlated with recurrent ischemic events, emphasizing the importance of timely care in CEA. Conclusion Our study underscores the significant benefits and challenges of the Hub and Spoke model in vascular surgery. The growing referral delays from Spoke sites are concerning, emphasizing the need for a multi-disciplinary team approach within Spoke sites to ensure efficient and standardized care delivery.
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Affiliation(s)
- Abdul Hakeem
- Vascular Surgery, Bedfordshire-Milton Keynes Vascular Centre, Bedford, GBR
| | - Mojahid Najem
- Vascular Surgery, Bedfordshire-Milton Keynes Vascular Centre, Bedford, GBR
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Eiberg JP, Mejnert Jørgensen TM, Budtz-Lilly JW. Centralisation of Vascular Surgery: A Danish Perspective. Eur J Vasc Endovasc Surg 2023; 65:772-773. [PMID: 36921756 DOI: 10.1016/j.ejvs.2023.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Jonas Peter Eiberg
- Department of Vascular Surgery, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark.
| | | | - Jacob W Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
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Loftus IM, Boyle JR. A Decade of Centralisation of Vascular Services in the UK. Eur J Vasc Endovasc Surg 2023; 65:315-316. [PMID: 36681176 DOI: 10.1016/j.ejvs.2023.01.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Affiliation(s)
- Ian M Loftus
- St George's Vascular Institute, St George's Hospital, London, UK
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK.
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Kolh P, Verhagen HJM. The ESVS Guidelines Provide a Solid Scientific Basis to Treat Patients with an Abdominal Aorto-iliac Aneurysm in Europe and Beyond. Eur J Vasc Endovasc Surg 2021; 62:845-846. [PMID: 34736845 DOI: 10.1016/j.ejvs.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/11/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Philippe Kolh
- ESVS Guidelines Steering Committee Chairman, ESVS Deputy President Elect, Department of Biomedical and Preclinical Sciences, University of Liège, Belgium.
| | - Hence J M Verhagen
- ESVS President, Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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D'Oria M, Pitoulias GA, Torsello GF, Pitoulias AG, Fazzini S, Masciello F, Verzini F, Donas KP. Bilateral Use of Iliac Branch Devices for Aortoiliac Aneurysms Is Safe and Feasible, and Procedural Volume Does Not Seem to Affect Technical or Clinical Effectiveness: Early and Midterm Results From the pELVIS International Multicentric Registry. J Endovasc Ther 2021; 28:585-592. [PMID: 34060354 DOI: 10.1177/15266028211016439] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate early and follow-up outcomes following bilateral use of iliac branch devices (IBD) for aortoiliac endografting and assess the impact of center volume. We used data from the pELVIS international multicentric registry. METHODS For the purpose of this study, only those patients receiving concomitant bilateral IBD implantation were analyzed. To assess the impact that procedural volume of bilateral IBD implantation could have on early and follow-up outcomes, participating institutions were classified as Site(s) A if they had performed >10 and/or >20% concomitant bilateral IBD procedure, otherwise they were classified as Site(s) B. Endpoints of the analysis included early (ie, 30-day) mortality and morbidity, as well as all-cause and aneurysm-related mortality during follow-up. Additional endpoints that were evaluated included IBD-related reinterventions, IBD occlusion or stenosis requiring reintervention (ie, loss of primary patency), and IBD-related type I endoleak. RESULTS Overall, 96 patients received bilateral IBD implantation (out of 910 procedures collected in the whole pELVIS cohort), of whom 65 were treated at Site A (ie, Group A) and 31 were treated at Site(s) B (ie, Group B). In total, only 1 death occurred within 30 days from bilateral IBD implantation, and 9 patients experienced at least 1 major complication without any significant difference between subjects in Group A versus those in Group B (10.8% vs 6.5%, p=0.714). In the overall cohort, the 2-year freedom from IBD-related type I endoleaks and IBD primary patency were 96% and 92%, respectively; no significant differences were seen in those rates between Group A or Group B (95% vs 100%, p=0.335; 93% vs 88%, p=0.470). Freedom from any IBD-related reinterventions was 83% at 2 years, with similar rates between study groups (85% vs 83%, p=0.904). CONCLUSIONS Within the pELVIS registry, concomitant bilateral IBD implantation is a safe and feasible technique for management of aortoiliac aneurysms in patients with suitable anatomy. Despite increased technical complexity, effectiveness of the repair is satisfactory with low rates of IBD-related adverse events at mid-term follow-up. Procedural volume does not seem to affect technical or clinical outcomes after bilateral use of IBD, which remains a favorable treatment option in selected patients.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Surgical Medical and Health Sciences, University of Trieste Medical School, Trieste, Italy
| | - Georgios A Pitoulias
- Second Department of Surgery, Division of Vascular Surgery, School of Medicine Aristotle University of Thessaloniki, "G. Gennimatas" Hospital, Thessaloniki, Greece
- Department of Vascular Surgery, Research Vascular Centre, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | | | - Apostolos G Pitoulias
- Second Department of Surgery, Division of Vascular Surgery, School of Medicine Aristotle University of Thessaloniki, "G. Gennimatas" Hospital, Thessaloniki, Greece
- Department of Vascular Surgery, Research Vascular Centre, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | - Stefano Fazzini
- Department of Vascular Surgery, University of Tor Vergata, Rome, Italy
| | | | - Fabio Verzini
- Division of Vascular Surgery, Department of Surgical Sciences, University of Torino, A. O. U. Città della Salute e della Scienza, Molinette Hospital, Turin, Italy
| | - Konstantinos P Donas
- Department of Vascular Surgery, Research Vascular Centre, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
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Association between Hospital Volume and Failure to Rescue after Open or Endovascular Repair of Intact Abdominal Aortic Aneurysms in the VASCUNET and International Consortium of Vascular Registries. Ann Surg 2021; 274:e452-e459. [PMID: 34225297 DOI: 10.1097/sla.0000000000005044] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the association between hospital volume and failure to rescue (FtR), after open (OAR) and endovascular (EVAR) repair of intact abdominal aortic aneurysms (AAA) among centers participating in the VASCUNET and International Consortium of Vascular Registries (ICVR). SUMMARY BACKGROUND DATA FtR (i.e., in-hospital death following major complications) is a composite end-point representing the inability to treat complications effectively and prevent death. METHODS Using data from eight vascular registries, complication and mortality rates after intact AAA repair were examined (n = 60,273; EVAR-43,668; OAR-16,605). A restricted analysis using pooled data from four countries (Australia, Hungary, New Zealand, USA) reporting data on all postoperative complications (bleeding, stroke, cardiac, respiratory, renal, colonic ischemia) was performed to identify risk-adjusted association between hospital volume and FtR. RESULTS The most frequently reported complications were cardiac (EVAR-3.0%, OAR-8.9%) and respiratory (EVAR-1.0%, OAR-5.7%). In adjusted analysis, 4.3% of EVARs and 18.5% of OARs had at least one complication. The overall FtR rate was 10.3% after EVAR and 15.7% after OAR. Subjects treated in the highest volume centers(Q4) had 46% and 80% lower odds of FtR after EVAR (OR = 0.54; 95%CI = 0.34-0.87;p = 0.04) and OAR (OR = 0.22; 95%CI = 0.11-0.44;p < 0.001) when compared to lowest volume centers(Q1), respectively. Colonic ischemia had the highest risk of FtR for both procedures (adjusted predicted risks, EVAR: 27%, 95%CI 14%-45%; OAR: 30%, 95%CI 17%-46%). CONCLUSIONS In this multi-national dataset, FtR rate after intact AAA repair with EVAR and OAR is significantly associated with hospital volume. Hospitals in the top volume quartiles achieve the lowest mortality after a complication has occurred.
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Field ML, Kuduvalli M, Torella F, Lip GY. Aortovascular medicine: what is it? J R Soc Med 2021; 114:467-469. [PMID: 33945348 DOI: 10.1177/01410768211013436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mark L Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L69 7TX, UK.,Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Manoj Kuduvalli
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L69 7TX, UK.,Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Francesco Torella
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L69 7TX, UK.,Liverpool Vascular & Endovascular Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L69 7TX, UK.,Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
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Donas KP, Scali ST. "Primum non Nocere" But Ultimately the Goal is to "Curare": The Case for a More Pliable Approach to Abdominal Aortic Aneurysm Repair Centralisation. Eur J Vasc Endovasc Surg 2021; 61:706. [PMID: 33602548 DOI: 10.1016/j.ejvs.2020.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/22/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Research Vascular Centre, Asklepios Clinic Langen, University of Frankfurt, Germany.
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
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