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Mandigers TJ, Yadavalli SD, Rastogi V, Marcaccio CL, Wang SX, Zettervall SL, Starnes BW, Verhagen HJM, van Herwaarden JA, Trimarchi S, Schermerhorn ML. Surgeon volume and outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury. J Vasc Surg 2024; 80:53-63.e3. [PMID: 38431064 DOI: 10.1016/j.jvs.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/10/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) at high-volume hospitals has previously been associated with lower perioperative mortality, but the impact of annual surgeon volume on outcomes following TEVAR for BTAI remains unknown. METHODS We analyzed Vascular Quality Initiative (VQI) data from patients with BTAI that underwent TEVAR between 2013 and 2023. Annual surgeon volumes were computed as the number of TEVARs (for any pathology) performed over a 1-year period preceding each procedure and were further categorized into quintiles. Surgeons in the first volume quintile were categorized as low volume (LV), the highest quintile as high volume (HV), and the middle three quintiles as medium volume (MV). TEVAR procedures performed by surgeons with less than 1-year enrollment in the VQI were excluded. Using multilevel logistic regression models, we evaluated associations between surgeon volume and perioperative outcomes, accounting for annual center volumes and adjusting for potential confounders, including aortic injury grade and severity of coexisting injuries. Multilevel models accounted for the nested clustering of patients and surgeons within the same center. Sensitivity analysis excluding patients with grade IV BTAI was performed. RESULTS We studied 1321 patients who underwent TEVAR for BTAI (28% by LV surgeons [0-1 procedures per year], 52% by MV surgeons [2-8 procedures per year], 20% by HV surgeons [≥9 procedures per year]). With higher surgeon volume, TEVAR was delayed more (in <4 hours: LV: 68%, MV: 54%, HV: 46%; P < .001; elective (>24 hours): LV: 5.1%; MV: 8.9%: HV: 14%), heparin administered more (LV: 80%, MV: 81%, HV: 87%; P = .007), perioperative mortality appears lower (LV: 11%, MV: 7.3%, HV: 6.5%; P = .095), and ischemic/hemorrhagic stroke was lower (LV: 6.5%, MV: 3.6%, HV: 1.5%; P = .006). After adjustment, compared with LV surgeons, higher volume surgeons had lower odds of perioperative mortality (MV: 0.49; 95% confidence interval [CI], 0.25-0.97; P = .039; HV: 0.45; 95% CI, 0.16-1.22; P = .12; MV/HV: 0.50; 95% CI, 0.26-0.96; P = .038) and ischemic/hemorrhagic stroke (MV: 0.38; 95% CI, 0.18-0.81; P = .011; HV: 0.16; 95% CI, 0.04-0.61; P = .008). Sensitivity analysis found lower adjusted odds for perioperative mortality (although not significant) and ischemic/hemorrhagic stroke for higher volume surgeons. CONCLUSIONS In patients undergoing TEVAR for BTAI, higher surgeon volume is independently associated with lower perioperative mortality and postoperative stroke, regardless of hospital volume. Future studies could elucidate if TEVAR for non-ruptured BTAI might be delayed and allow stabilization, heparinization, and involvement of a higher TEVAR volume surgeon.
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Affiliation(s)
- Tim J Mandigers
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Cardio Thoracic Vascular Department, Section of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sophie X Wang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Santi Trimarchi
- Cardio Thoracic Vascular Department, Section of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Gilmore BF, Scali ST, D’Oria M, Neal D, Schermerhorn ML, Huber TS, Columbo JA, Stone DH. Temporal Trends and Outcomes of Abdominal Aortic Aneurysm Care in the United States. Circ Cardiovasc Qual Outcomes 2024; 17:e010374. [PMID: 38775052 PMCID: PMC11187661 DOI: 10.1161/circoutcomes.123.010374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/08/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has had a dynamic impact on abdominal aortic aneurysm (AAA) care, often supplanting open AAA repair (OAR). Accordingly, US AAA management is often highlighted by disparities in patient selection and guideline compliance. The purpose of this analysis was to define secular trends in AAA care. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for all EVARs and OARs (2011-2021). End points included procedure utilization, change in mortality, patient risk profile, Society for Vascular Surgery-endorsed diameter compliance, off-label EVAR use, cross-clamp location, blood loss, in-hospital complications, and post-EVAR surveillance missingness. Linear regression was used without risk adjustment for all end points except for mortality and complications, for which logistic regression with risk adjustment was used. RESULTS In all, 66 609 EVARs (elective, 85% [n=55 805] and nonelective, 15% [n=9976]) and 13 818 OARs (elective, 70% [n=9706] and nonelective, 30% [n=4081]) were analyzed. Elective EVAR:OAR ratios were increased (0.2 per year [95% CI, 0.01-0.32]), while nonelective ratios were unchanged. Elective diameter threshold noncompliance decreased for OAR (24%→17%; P=0.01) but not EVAR (mean, 37%). Low-risk patients increasingly underwent elective repairs (EVAR, +0.4%per year [95% CI, 0.2-0.6]; OAR, +0.6 points per year [95% CI, 0.2-1.0]). Off-label EVAR frequency was unchanged (mean, 39%) but intraoperative complications decreased (0.5% per year [95% CI, 0.2-0.9]). OAR complexity increased reflecting greater suprarenal cross-clamp rates (0.4% per year [95% CI, 0.1-0.8]) and blood loss (33 mL/y [95% CI, 19-47]). In-hospital complications decreased for elective (0.7% per year [95% CI, 0.4-0.9]) and nonelective EVAR (1.7% per year [95% CI, 1.1-2.3]) but not OAR (mean, 42%). A 30-day mortality was unchanged for both elective OAR (mean, 4%) and EVAR (mean, 1%). Among nonelective OARs, an increase in both 30-day (0.8% per year [95% CI, 0.1-1.5]) and 1-year mortality (0.8% per year [95% CI, 0.3-1.6]) was observed. Postoperative EVAR surveillance acquisition decreased (67%→49%), while 1-year mortality among patients without imaging was 4-fold greater (9.2% versus imaging, 2.0%; odds ratio, 4.1 [95% CI, 3.8-4.3]; P<0.0001). CONCLUSIONS There has been an increase in EVAR and a corresponding reduction in OAR across the United States, despite established concerns surrounding guideline adherence, reintervention, follow-up, and cost. Although EVAR morbidity has declined, OAR complication rates remain unchanged and unexpectedly high. Opportunities remain for improving AAA care delivery, patient and procedure selection, guideline compliance, and surveillance.
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Affiliation(s)
- Brian F. Gilmore
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Salvatore T. Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas S. Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Jesse A. Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - David H. Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Abdul-Malak OM, Semaan DB, Madigan MC, Sridharan ND, Chaer RA, Siracuse JJ, Eslami MH. Midterm Outcomes and Predictors of Failure of Lower Extremity Bypass to Para-Malleolar and Pedal Targets. Ann Vasc Surg 2024; 106:227-237. [PMID: 38815913 DOI: 10.1016/j.avsg.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The frequency of distal lower extremity bypass (LEB) for infrapopliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets. METHODS We queried the Vascular Quality Initiative infrainguinal database from 2003 to 2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular reintervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized. RESULTS We identified 2331 LEB procedures (1,265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003-3.51% in 2021 (P < 0.001). The majority of cases presented with tissue loss (81.25. Common postoperative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Postoperative mortality at 1 year was 10%. On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56% ± 3.6%, MALE was 63.49% ± 3.27%, and amputation-free survival was 71.71% ± 0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than great saphenous vein (P < 0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (P = 0.015), and lower MALE (P = 0.021) at 2 years. CONCLUSIONS Despite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize reinterventions.
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Affiliation(s)
- Othman M Abdul-Malak
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA; MedStar Heart and Vascular Institute, Baltimore, MD.
| | - Dana B Semaan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Michael C Madigan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Natalie D Sridharan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Charleston Area Medical Center, Charleston, WV
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Sarikonda A, Leibold A, Sami A, Mansoor Ali D, Tecce E, August A, O'Leary M, Thalheimer S, Heller J, Prasad S, Sharan A, Jallo J, Harrop J, Vaccaro AR, Sivaganesan A. Do Busier Surgeons Have Lower Intraoperative Costs? An Analysis of Anterior Cervical Discectomy and Fusion Using Time-Driven Activity-Based Costing. Clin Spine Surg 2024:01933606-990000000-00294. [PMID: 38637916 DOI: 10.1097/bsd.0000000000001628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/28/2024] [Indexed: 04/20/2024]
Abstract
STUDY DESIGN The present study is a single-center, retrospective cohort study of patients undergoing neurosurgical anterior cervical discectomy and fusion (ACDF). OBJECTIVE Our objective was to use time-driven activity-based costing (TDABC) methodology to determine whether surgeons' case volume influenced the true intraoperative costs of ACDFs performed at our institution. SUMMARY OF BACKGROUND DATA Successful participation in emerging reimbursement models, such as bundled payments, requires an understanding of true intraoperative costs, as well as the modifiable drivers of those costs. Certain surgeons may have cost profiles that are favorable for these "at-risk" reimbursement models, while other surgeons may not. METHODS Total cost was divided into direct and indirect costs. Individual costs were obtained by direct observation, electronic medical records, and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented. All surgeons performing ACDFs at our primary and affiliated hospital sites from 2017 to 2022 were divided into four volume-based cohorts: 1-9 cases (n=10 surgeons, 38 cases), 10-29 cases (n=7 surgeons, 126 cases), 30-100 cases (n=3 surgeons, 234 cases), and > 100 cases (n=2 surgeons, 561 cases). RESULTS The average total intraoperative cost per case was $7,116 +/- $2,945. The major cost contributors were supply cost ($4,444, 62.5%) and personnel cost ($2,417, 34.0%). A generalized linear mixed model utilizing Poisson distribution was performed with the surgeon as a random effect. Surgeons performing 1-9 total cases, 10-29 cases, and 30-100 cases had increased total cost of surgery (P < 0.001; P < 0.001; and P<0.001, respectively) compared to high-volume surgeons (> 100 cases). Among all volume cohorts, high-volume surgeons also had the lowest mean supply cost, personnel cost, and operative times, while the opposite was true for the lowest-volume surgeons (1-9 cases). CONCLUSION It is becoming increasingly important for hospitals to identify modifiable sources of variation in cost. We demonstrate a novel use of TDABC for this purpose. LEVEL OF EVIDENCE Level-III.
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Affiliation(s)
- Advith Sarikonda
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Adam Leibold
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Ashmal Sami
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Daniyal Mansoor Ali
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Eric Tecce
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Ari August
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Matthew O'Leary
- Department of Medicine, Drexel University College of Medicine
| | - Sara Thalheimer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Joshua Heller
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Srinivas Prasad
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Jack Jallo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | | | - Ahilan Sivaganesan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
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Rafaqat W, Lagazzi E, Jehanzeb H, Abiad M, Hwabejire JO, Parks JJ, Kaafarani HM, DeWane MP. Which Volume Matters More? Systematic Review and Meta-Analysis of Hospital vs Surgeon Volume in Intra-Abdominal Emergency Surgery. J Am Coll Surg 2024; 238:332-346. [PMID: 37991251 DOI: 10.1097/xcs.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Wardah Rafaqat
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Emanuele Lagazzi
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Hamzah Jehanzeb
- Medical College, Aga Khan University, Karachi, Pakistan (Jehanzeb)
| | - May Abiad
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - John O Hwabejire
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Jonathan J Parks
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Haytham M Kaafarani
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Michael P DeWane
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
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Courtney A, Clymo J, Dorudi Y, Moonesinghe SR, Dorudi S. Scoping review: The terminology used to describe major abdominal surgical procedures. World J Surg 2024; 48:574-584. [PMID: 38342951 DOI: 10.1002/wjs.12084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/06/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Major abdominal surgery (MAS) can have a profound impact on the patient but there is currently no consensus as to which surgical procedures constitute MAS. The main objective of this work is to ascertain the terminology used to describe MAS procedures and to apply these findings in order to propose a definition of MAS. METHODS The following databases were searched: Ovid MEDLINE (R) ALL, Embase Classic and Embase (via OvidSP), Global Health (via OvidSP), Health Management Information Consortium (via OvidSP), APA PsycInfo (via OvidSP), PubMed and Web of Science. Original research articles, published between 1980 and April 26, 2022 that contained a description of MAS procedure were included in this study. Article screening and data extraction was undertaken independently by 3 authors. Content analysis was performed to identify key terminology used to describe MAS. RESULTS Five thousand six hundred and sixty three articles were identified, of which 767 underwent full-text review and 312 were included in the scoping review. Content analysis resulted in 4 main categories: (1) pre-operative factors, (2) intraoperative factors, (3) operation-related factors, (4) post-operative factors. Operation-related factors was the predominant category (1137 references coded). The gastrointestinal resection made the vast majority of the references coded (591). CONCLUSIONS Based on these results, the term "major abdominal surgery" should be defined as an intra-peritoneal operation with no primary involvement of the thorax, involving either luminal resection and/or resection of a solid organ associated with the gastrointestinal tract. However, further work is required to verify this definition using real world data.
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Affiliation(s)
- Alona Courtney
- Department of Targeted Intervention, Division of Surgery & Interventional Sciences, University College London, London, UK
- The Princess Grace Hospital, HCA Healthcare UK, London, UK
| | - Jonathon Clymo
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | | | - Suneetha Ramani Moonesinghe
- Department of Targeted Intervention, Division of Surgery & Interventional Sciences, University College London, London, UK
| | - Sina Dorudi
- Department of Targeted Intervention, Division of Surgery & Interventional Sciences, University College London, London, UK
- The Princess Grace Hospital, HCA Healthcare UK, London, UK
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Gruber M, Sotir A, Klopf J, Lakowitsch S, Domenig C, Wanhainen A, Neumayer C, Busch A, Eilenberg W. Operation time and clinical outcomes for open infrarenal abdominal aortic aneurysms to remain stable in the endovascular era. Front Cardiovasc Med 2023; 10:1213401. [PMID: 38034380 PMCID: PMC10682774 DOI: 10.3389/fcvm.2023.1213401] [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] [Received: 04/27/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Objective Endovascular aortic repair (EVAR) has become a routine procedure worldwide. Ultimately, the increasing number of EVAR cases entails changing conditions for open surgical repair (OSR) regarding patient selection, complexity, and surgical volume. This study aimed to assess the time trends of open abdominal aortic aneurysm (AAA) repair in a high-volume single center in Austria over a period of 20 years, focusing on the operation time and clinical outcomes. Materials and methods A retrospective analysis of all patients treated for infrarenal AAAs with OSR or EVAR between January 2000 and December 2019 was performed. Infrarenal AAA was defined as the presence of a >10-mm aortic neck. Cases with ruptured or juxtarenal AAAs were excluded from the analysis. Two cohorts of patients treated with OSR at different time periods, namely, 2000-2009 and 2010-2019, were assessed regarding demographical and procedure details and clinical outcomes. The time periods were defined based on the increasing single-center trend toward the EVAR approach from 2010 onward. Results A total of 743 OSR and 766 EVAR procedures were performed. Of OSR cases, 589 were infrarenal AAAs. Over time, the EVAR to OSR ratio was stable at around 50:50 (p = 0.488). After 2010, history of coronary arterial bypass (13.4% vs. 7.2%, p = 0.027), coronary artery disease (38.1% vs. 25.1%, p = 0.004), peripheral vascular disease (35.1% vs. 21.3%, p = 0.001), and smoking (61.6% vs. 34.3%, p < 0.001) decreased significantly. Age decreased from 68 to 66 years (p = 0.023). The operation time for OSR remained stable (215 vs. 225 min, first vs. second time period, respectively, p = 0.354). The intraoperative (5.8% vs. 7.2%, p = 0.502) and postoperative (18.3% vs. 20.8%, p = 0.479) complication rates also remained stable. The 30-day mortality rate did not change over both time periods (3.0% vs. 2.4%, p = 0.666). Conclusion Balanced EVAR to OSR ratio, similar complexity of cases, and volume over the two decades in OSR showed stable OSR time without compromise in clinical outcomes.
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Affiliation(s)
- M. Gruber
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
| | - A. Sotir
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - J. Klopf
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - S. Lakowitsch
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - C. Domenig
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - A. Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - C. Neumayer
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - A. Busch
- Department of Visceral, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technical University Dresden, Dresden, Germany
| | - W. Eilenberg
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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Mehta A, Patel P, Elmously A, Iannuzzi J, Garg K, Siracuse J, Takayama H, Schermerhorn ML, O'Donnell TFX, Patel VI. Low-volume surgeons can have better outcomes at certain hospital settings for open abdominal aortic repairs. J Vasc Surg 2023; 78:638-646. [PMID: 37172621 DOI: 10.1016/j.jvs.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 03/28/2023] [Accepted: 04/09/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The volume-outcomes relationship is cross-cutting among open abdominal aortic operations, where higher-volume surgeons have better perioperative outcomes. However, there has been minimal focus on low-volume surgeons and how to improve their outcomes. This study sought to identify if there are any differences in outcomes among low-volume surgeons for open abdominal aortic surgeries by different hospital settings. METHODS We used the 2012-2019 Vascular Quality Initiative registry to identify all patients who underwent open abdominal aortic surgery for aneurysmal or aorto-iliac occlusive disease by a low-volume surgeon (<7 operations annually). We categorized high-volume hospitals using three distinct definitions: those that performed ≥10 operations annually, those with at least one high-volume surgeon, and by the number of surgeons (1-2 surgeons, 3-4 surgeons, 5-7 surgeons, and 8+ surgeons). Outcomes included 30-day perioperative mortality, overall complications, and failure-to-rescue. We compared outcomes among low-volume surgeons using univariable and multivariable logistic regressions across each of these three hospital categorizations. RESULTS Among 14,110 patients who underwent open abdominal aortic surgery, 10,252 (7 3%) were performed by 1155 low-volume surgeons. Two-thirds of these patients (66%) underwent their surgery at a high-volume hospital, fewer than one-third (30%) at a hospital that had at least one high-volume surgeon, and one-half (49%) at hospitals with at least five surgeons. Among all patients operated on by low-volume surgeons, rates of 30-day mortality were 3.8%, perioperative complications were 35.3%, and failure-to-rescue were 9.9%. Low-volume surgeons operating at high-volume hospitals for aneurysmal disease had lower rates of perioperative death (adjusted odds ratio [aOR], 0.66; 95% confidence interval [CI], 0.48-0.90) and failure-to-rescue (aOR, 0.70; 95% CI, 0.50-0.98), but similar rates of complications (aOR, 1.06; 95% CI, 0.89-1.27). Similarly, patients undergoing their operation at hospitals that had at least one high-volume surgeon had lower rates of death (aOR, 0.71; 95% CI, 0.50-0.99) for aneurysmal disease. Patient outcomes among low-volume surgeons for aorto-iliac occlusive disease did not vary by hospital setting. CONCLUSIONS The majority of patients undergoing open abdominal aortic surgery have a low-volume surgeon, where outcomes are slightly better for those taking place at a high-volume hospital. Focused and incentivized interventions may be needed to improve outcomes among low-volume surgeons across all practice settings.
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Affiliation(s)
- Ambar Mehta
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Priya Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY; Division of General Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Adham Elmously
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - James Iannuzzi
- Division of Vascular and Endovascular Surgery, UCSF, San Francisco, CA
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Jeffrey Siracuse
- Division of Vascular and Endovascular Surgery, Boston University, Boston, MA
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Thomas F X O'Donnell
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY.
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10
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Kim TH, Oh J, Lee H, Kim MS, Sim SA, Min S, Song SW, Kim JJ. The impact of circulatory arrest with selective antegrade cerebral perfusion on brain functional connectivity and postoperative cognitive function. Sci Rep 2023; 13:13803. [PMID: 37612347 PMCID: PMC10447502 DOI: 10.1038/s41598-023-40726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/16/2023] [Indexed: 08/25/2023] Open
Abstract
Aortic surgery is one of the most challenging types of surgeries, which is possibly related to cognitive sequelae. We aimed to investigate the changes in resting-state functional connectivity (rsFC) associated with intraoperative circulatory arrest (CA) in aortic surgery, exploring the relationship between the altered connectivity and postoperative cognitive functions. Thirty-eight patients participated in this study (14 with CA, 24 without). Functional magnetic resonance imaging was scanned on the fifth day after surgery or after the resolution of delirium if it was developed. We assessed the differences in the development of postoperative cognitive changes and rsFC between patients with and without CA. The occurrence of postoperative delirium and postoperative cognitive dysfunction was not significantly different between the patients with and without the application of CA. However, patients with CA showed increased in posterior cingulate cortex-based connectivity with the right superior temporal gyrus, right precuneus, and right hippocampus, and medial prefrontal cortex-based connectivity with the dorsolateral prefrontal cortex. The application of moderate hypothermic CA with unilateral antegrade cerebral perfusion is unlikely to affect aspects of postoperative cognitive changes, whereas it may lead to increased rsFC of the default mode network at a subclinical level following acute brain insults.
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Affiliation(s)
- Tae-Hoon Kim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jooyoung Oh
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ha Lee
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
| | - Myeong Su Kim
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
| | - Seo-A Sim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sarang Min
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea.
| | - Jae-Jin Kim
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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11
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Xu R, Nair SK, Materi J, Raj D, Park G, Medikonda R, Alomari S, Kim T, Xia Y, Huang J, Lim M, Bettegowda C. Safety and Cost Savings Associated with Reduced Inpatient Hospitalization for Microvascular Decompression. World Neurosurg 2022; 166:e504-e510. [PMID: 35842175 DOI: 10.1016/j.wneu.2022.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Microvascular decompression (MVD) has grown as a first-line surgical intervention for severe facial pain from trigeminal neuralgia and/or hemifacial spasm. We sought to examine the safety and cost-benefits of discharging patients with MVD within 1 day of admission. METHODS We retrospectively reviewed patients undergoing MVD at our institution from 2008 to 2020. Patients were sorted by 1 day, 2 days, or >2 days until discharge and by year from 2008 to 2013, 2014 to 2018, or 2019 to 2020. Patient presenting characteristics, intraoperative measures, and complications were documented. Statistical differences were calculated by one-way analysis of variance and χ2 analyses. RESULTS Our cohort included 976 patients undergoing MVD, with 231 (23.6%) between 2008 and 2013, 517 (52.9%) between 2014 and 2018, and 228 (23.3%) between 2019 and 2020. Over time, postoperative admission rates to the critical care unit, total inpatient hospital admission times, and Barrow Neurological Institute scores at first follow-up decreased. Postoperative complications, including cerebrospinal fluid leak, decreased significantly. In addition, patients discharged within 1 day of admission incurred a total hospital cost of $26,689, which was $3588 lower than patients discharged within more than 1 day of admission, P < 0.0001. Discharging carefully selected patients who are appropriate for discharge within 1 day of admission could translate to a potential cost-savings of $255,346 per year in our clinical practice. CONCLUSIONS In our experience, MVDs are a safe, elective intervention. Our findings suggest that postoperative day 1 discharge in patients with an uncomplicated postoperative course may be safe while improving hospital resource use.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Divyaansh Raj
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Giho Park
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ravi Medikonda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Timothy Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuanxuan Xia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Titarenko V, Beer A, Schonefeld-Siepmann E, Muschal F, Beyer JK. Giant Symptomatic Unruptured Juxtarenal Abdominal Aortic Aneurysm. Vasc Specialist Int 2022; 38:23. [PMID: 36097707 PMCID: PMC9468660 DOI: 10.5758/vsi.220019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/30/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022] Open
Abstract
Herein, we present the case of an 84-year-old male with a 13-cm, symptomatic, unruptured juxtarenal abdominal aortic aneurysm. This aneurysm was successfully treated with open surgical repair, which was deemed satisfactory at the 3-year follow-up. Despite a paradigm shift towards endovascular techniques in aortic repair, postgraduate training with a focused exposure to open aortic surgery at high-volume centers is essential for future vascular surgeons to safely perform complex aortic repairs with acceptable mortality and morbidity rates.
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Affiliation(s)
- Valentin Titarenko
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Anita Beer
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Eva Schonefeld-Siepmann
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Felix Muschal
- Departments of Interventional, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Jochen Karsten Beyer
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
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George EL, Arya S, Ho VT, Stern JR, Sgroi MD, Chandra V, Lee JT. Trends in annual open abdominal aortic surgical volumes for vascular trainees compared to annual national volumes in the endovascular era. J Vasc Surg 2022; 76:1079-1086. [PMID: 35598821 DOI: 10.1016/j.jvs.2022.03.887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Prior analysis predicted a shortfall in open abdominal aortic repair (OAR) experience for vascular trainees resulting from the rapid adoption of and increased anatomic suitability of endovascular aortic repair (EVAR) technology. We explored how EVAR has transformed contemporary open aortic surgical education for vascular trainees. METHODS We examined ACGME case volumes of open abdominal aortic aneurysm (AAA) repair and reconstruction for aorto-iliac occlusive disease (AIOD) via aorto-iliac/femoral bypass (AFB) from integrated vascular surgery residents (VSR) and fellows (VSF) graduating 2006-2017 and compared them to national estimates of total OAR (open AAA repair + AFB) in the Agency for Healthcare Research and Quality National Inpatient Sample based on ICD-9 and ICD-10 procedural codes. Changes over time were assessed using Chi-square test, Student's t-test, and linear regression. RESULTS During the twelve-year study period, the national annual total OAR and open AAA repair estimates decreased: total OAR by 72.5% (2006: estimate (standard error) 24,255 (1185) vs. 2017: 6,690 (274); p<0.001) and open AAA repair by 84.7% (2006: 18,619 (924) vs. 2017: 2,850 (168); p<0.001); AFB estimates decreased by 33.0% (p<0.001). The percentage of total OAR, open AAA repair, and AFB performed at teaching hospitals significantly increased from ∼55 to 80% (all p<0.001). There was a 40.9% decrease in open AAA repairs logged by graduating VSF (mean 18.6 vs. 11) but only a 6.9% decrease in total OAR cases (mean 27.6 vs. 25.7) due to increasing AFB volumes (mean 9.0 vs. 14.7). VSR graduates consistently logged an average of ∼10 open AAA repairs and there was a 31.0% increase in total OAR (mean 23.2 vs. 30.4), again secondary to rising AFB volumes (mean 11.4 vs 17.5). Although there was an absolute decrease in open aortic experience for VSF, the rate of decline for total OAR case volumes was not significantly different after VSR programs were established (p=0.40). CONCLUSIONS As incidence decreases nationally, OAR is shifting towards teaching hospitals. While open AAA procedures for trainees are declining due to EVAR, open aortic reconstruction for AIOD is rising and plays an important role in ensuring that vascular trainees continue to have satisfactory OAR experience sufficient for meeting minimum graduation requirements. Strategies to maintain and maximize the education and experience from these cases should be top priority for vascular surgery program directors.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California; Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California; Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California; Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Vy T Ho
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Jordan R Stern
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael D Sgroi
- Division of Vascular Surgery, Santa Clara Valley Medical Center, Santa Clara, California
| | - Venita Chandra
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
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14
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OUP accepted manuscript. Br J Surg 2022; 109:340-345. [DOI: 10.1093/bjs/znab465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/10/2021] [Accepted: 12/17/2021] [Indexed: 11/14/2022]
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15
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Letter to the Editor Regarding "Effect of Surgeon Experience on Surgical Outcome of 80-Year-Old or Older Intracranial Meningioma Patients". World Neurosurg 2021; 151:318. [PMID: 34243653 DOI: 10.1016/j.wneu.2021.02.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 11/24/2022]
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16
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Jacobs CR, Scali ST, Khan T, Cadavid F, Staton KM, Feezor RJ, Back MR, Upchruch GR, Huber TS. EVAR Conversion is an Increasingly Common Indication for Open AAA Repair. J Vasc Surg 2021; 75:144-152.e1. [PMID: 34314833 DOI: 10.1016/j.jvs.2021.07.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/15/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Although EVAR re-intervention is common, conversion to open repair(EVAR-c) occurs less frequently but can be associated with significant technical complexity and perioperative risk. There is a paucity of data highlighting the evolution of peri-procedural results surrounding EVAR-c and change in practice patterns, especially for referral centers that increasingly manage EVAR failures. The purpose of this analysis was to perform a temporal analysis of our EVAR-c experience and describe changes in patient selection, operative details and outcomes. METHODS A retrospective single center review of all open AAA repairs was performed(2002-2019) and EVAR-c procedures were subsequently analyzed. EVAR-c patients(n=184) were categorized into two different eras(2002-2009, n=21; 2010-2019, n=163) for comparison. Logistic regression and Cox proportional hazards modeling were used for risk-adjusted comparisons. RESULTS A significant increase in EVAR-c as an indication for any type of open aneurysm repair was detected(9%→27%;p<.001). Among EVAR-c patients, no change in age or individual comorbidities was evident[mean age: 71±9 years]; however, the proportion of female subjects(p=.01) and ASA classification >3 declined(p=.05). There was no difference in prevalence[50% vs. 43%;p=.6] or number[median-1.5(0, 5)] of pre-admission EVAR re-interventions; however, time to re-intervention decreased(median: 23[6,34] vs. 0[0,22] months;p=.005). In contrast, time to EVAR-c significantly increased(median: 16[9,39]vs. 48[20,83]-months;p=.008). No difference in frequency of non-elective presentation[mean-52%;p=.9] or indication was identified but a trend toward increasing mycotic EVAR-c was observed(5% vs. 15%;p=.09). Use of retroperitoneal exposure(14% vs. 77%;p<.0001), suprarenal cross-clamp application[6286%;p=.04] and visceral-ischemia time(median: 0[0,11] vs. 5[0,20]min;p=.05) all increased. In contrast, estimated blood loss(P-trend=.03) and procedure-time(p=.008) decreased. The unadjusted elective 30-day mortality rate improved but did not reach statistical significance[elective: 10% vs. 5%;p=.5] with no change for non-elective operations[18% vs. 16%;p=.9]. However, a significantly decreased risk of complications was evident(OR 0.88, 95%CI .8-.9;p=.01). One and 3-year survival was similar over time. CONCLUSION EVAR-c is now a common indication for open AAA repair. Patients frequently present non-electively and at increasingly later intervals after their index EVAR. Despite increasing technical complexity, decreased complication risk and comparable survival can be anticipated when patients are managed at a high-volume aortic referral center.
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Affiliation(s)
- Christopher R Jacobs
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville.
| | - Tabassum Khan
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Felipe Cadavid
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Kyle M Staton
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Gilbert R Upchruch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
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Lawrence PF. Journal of Vascular Surgery – April 2021 Audiovisual Summary. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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