Surgeon experience versus volume differentially affects lower extremity bypass outcomes in contemporary practice

Prospective Comparison of Wound Complication Rates after Elective Open Peripheral Vascular Surgery - Endovascular Versus Open Vascular Surgeons

BACKGROUND

Skill and experience of surgeons are likely to influence the incidence of surgical wound complications (SWC) after open lower limb revascularization. Differences in SWC between surgeons with predominantly endovascular or open vascular surgical profiles could be expected. The aim of this study was to compare SWC rates after elective open vascular surgery between primarily endovascular and primarily open vascular surgeons.

METHODS

Prospective data from patients undergoing elective surgery for peripheral artery disease (PAD) was collected between 2013 and 2019. Senior surgeons were assigned to the open-surgeon or the endo-surgeon group based on the percentage of their open surgical case load during the 6 year study period. SWC was measured by their clinical impact scale (grade 1-outpatient treatment to grade 6-death). Surgical site infection was defined by Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay (ASEPSIS) criteria. Propensity score adjusted analysis (PSAA) was used to account for differences in baseline and perioperative characteristics and expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The proportion of chronic limb-threatening ischemia (P = 0.001), ipsilateral foot wound (P = 0.012) and femoro-popliteal bypass procedures (P < 0.001) were higher in the open-surgeon group. A lower incidence of SWC according to ASEPSIS criteria (25.6% vs. 38.6%, respectively, P = 0.042) and SWC grade ≥1 (33.7% vs. 51.0%, respectively, P = 0.010) was found in the endo-surgeon group (n = 86) compared to the open-surgeon group (n = 153). These differences disappeared after PSAA (OR 0.63, 95% CI 0.27-1.44, and OR 0.60, 95% CI 0.27-1.33, respectively).

CONCLUSIONS

Patients operated by endo-surgeons had less advanced PAD and lower incidence of SWC compared to those treated by open-surgeons. No difference in SWC remained after PSAA.

Feasibility of robotic cholecystectomy at an academic center with a young robotic surgery program: a retrospective cohort study with umbrella review

Laparoscopic cholecystectomy (LC) has been standard of care for surgical treatment of benign gallbladder pathology for decades. With the advent of robotic surgical technology, robotic cholecystectomy (RC) has gained attention as an alternative to conventional laparoscopy. This study introduces a single-surgeon experience with laparoscopic versus robotic cholecystectomy and an umbrella systematic review of the outcomes of both approaches. A retrospective chart review was performed at a single institution on a prospectively maintained database of patients undergoing laparoscopic or robotic cholecystectomy for benign gallbladder pathology. An umbrella systematic review was conducted using PRISMA methodology. A total of 103 patients were identified; 61 patients underwent LC and 42 underwent RC. In the RC cohort, 17 cases were completed using a four-port technique while 25 were completed using a three-port technique. Patients undergoing RC were older compared to the LC group (44.78 vs 57.02 years old; p < 0.001) and exhibited lower body mass index (29.37 vs 32.37 kg/m2, p = 0.040). No statistically significant difference in operative time or need for postoperative ERCP was noted. Neither this series nor the umbrella systematic review revealed significant differences in conversion to open surgery or readmissions between the LC and RC cohorts. Three-port RC was associated with reduced operative time compared to four-port RC (101.28 vs 150.76 min; p < 0.001). Robotic cholecystectomy is feasible and safe at a young robotic surgery program in an academic center setting and comparable to laparoscopic cholecystectomy clinical outcomes.

Trends in Utilization of Completion Imaging after Lower Extremity Bypass and Its Association with Major Adverse Limb Events and Loss of Primary Patency

BACKGROUND

Failure following lower extremity bypasses (LEBs) isoften secondary to technical defects. Despite traditional teachings, routine use of completion imaging (CI) in LEB has been debated. This study assesses national trends of CI following LEBs and the association of routine CI with 1-year major adverse limb events (MALE) and 1-year loss of primary patency (LPP).

METHODS

The Vascular Quality Initiative (VQI) LEB dataset from 2003-2020 was queried for patients who underwent elective bypass for occlusive disease. The cohort was divided based on surgeons' CI strategy at time of LEB, categorized as routine (≥80% of cases/year), selective (<80% of cases/year), or never. The cohort was further stratified by surgeon volume category [low (<25th percentile), medium (25th-75th percentile), or high (>75th percentile)]. The primary outcomes were 1-year MALE-free survival and 1-year loss of primary patency (LPP)-free survival. Our secondary outcomes were temporal trends in CI use and temporal trends in 1-year MALE rates. Standard statistical methods were utilized.

RESULTS

We identified 37,919 LEBs; 7,143 in routine CI strategy cohort, 22,157 selective CI and 8,619 in never CI. Patients in the 3 cohorts had comparable baseline demographics and indications for bypass. There was a significant decrease in CI utilization from 77.2% in 2003 to 32.0% in 2020 (P < 0.001). Similar trends in CI use were observed in patients who underwent bypass to tibial outflows (86.0% in 2003 vs. 36.9% in 2020; P < 0.001). While the use of CI has decreased over time, 1-year MALE rates have increased from 44.4% in 2003 to 50.4% in 2020 (P < 0.001). On multivariate COX regression, however, no significant associations between CI use or CI strategy and risk of 1-year MALE or LPP was found. Procedures performed by high-volume surgeons carried a lower risk of 1-year MALE (HR: 0.84; 95% CI [0.75-0.95]; P = 0.006) and LPP (HR:0.83; 95% CI [0.71-0.97]; P < 0.001) compared to low-volume surgeons. Repeat adjusted analyses showed no association between CI (use or strategy) and our primary outcomes when the subgroups with tibial outflows were analyzed. Similarly, no associations were found between CI (use or strategy) and our primary outcomes when the subgroups based on surgeons' CI volume were evaluated.

CONCLUSIONS

The use of CI, for both proximal and distal target bypasses, has decreased over time while 1-year MALE rates have increased. Adjusted analyses indicate no association between CI use and improved MALE or LPP survival at 1 year and all CI strategies were found to have equivalent outcomes.

The Relationship Between Hospital Procedure Volume and Outcomes After Endovascular or Open Surgical Revascularisation for Peripheral Arterial Disease: An Analysis of Health Insurance Claims Data

OBJECTIVE

There is a paucity of data on the relationship between hospital procedure volume and outcomes after inpatient treatment of symptomatic peripheral arterial disease (PAD). This study aimed to generate meaningful hypotheses to support the ongoing discussion.

METHODS

Data derived from BARMER, Germany's second largest insurance provider, were linked with nationwide hospital procedure volumes from mandatory hospital quality reports. All endovascular (EVR) and open surgical revascularisations (OSR) provided to patients (≥ 40 years) with symptomatic PAD between 1 January 2013 and 31 December 2018 were included. Hospital volume was defined as the number of procedures performed by a hospital in the previous calendar year (in quartiles). Freedom from re-intervention, amputation, and overall mortality rate within 12 months after discharge were analysed using multivariable Cox proportional hazards models. In hospital mortality was determined by generalised estimating equations logistic regression models.

RESULTS

There were 88 187 revascularisations (72.4% EVR; EVR: 72.7 years and 45.2% females; OSR: 71.9 years and 41.9% females) registered by 668 hospitals. No statistically significant association was found between 12 month freedom from re-intervention and hospital volume (EVR: 4; quartile HR 1.05; 95% CI 0.94 - 1.16. OSR: 4; quartile HR 1.05; 95% CI 0.92 - 1.21). Patients with OSR had a decreased hazard of 12 month mortality in a high volume hospital compared with a low volume hospital (HR 0.85; 95% CI 0.73 - 0.98), but not with EVR (HR 1.03; 95% CI 0.91 - 1.16). Patients who were treated in hospitals with highest volumes showed decreased hazards of 12 month freedom from amputation when compared with low volume hospitals (EVR: HR 0.72; 95% CI 0.52 - 0.99. OSR: HR 0.61; 95% CI 0.44 - 0.85).

CONCLUSION

This large retrospective analysis of insurance claims suggests that higher procedure volume is associated with lower major amputation rates, although there is a need for standardisation of the definition of volume stratification. Future studies should address the impact of subsequent outpatient care and surveillance to further examine the complex interaction between treatment and outcomes.

Non-reversed bifurcated vein graft improves time to healing in ischemic patients undergoing lower limb distal bypass

BACKGROUND

Bifurcated vein grafts have been described in reconstructive microsurgery. No comparative studies have been published in lower limb arterial revascularization. The aim of this study was to compare non-reversed bifurcated vs. single vein graft in patients with critical limb-threatening ischemia (CLTI) undergoing lower limb distal bypass.

METHODS

Between January 2015 and December 2021 193 CLTI patients have been treated at our center with vein bypass, and distal anastomosis on infrapopliteal vessels; 137 patients (71%) received a single graft (Group SIN), and 56 patients (29%) had a bifurcated bypass (Group BIF). Primary outcomes measures were time to healing, primary patency, primary assisted patency, secondary patency, and limb salvage. Two-year outcomes according to Kaplan-Meier curves were evaluated and compared.

RESULTS

Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation except for an elderly age in Group BIF (77.5 vs. 71.5 years; P<0.001). Intraoperative technical success was achieved in all patients. Overall median duration of follow-up was 19 months (interquartile range 9-36). Wound healing did not differ between the two groups (77.4% Group SIN vs. 73.2% Group BIF; P=0.33). Mean time to healing was faster in Group BIF (2.4 vs. 6.8 months; P<0.001). At 2-year follow-up there were no differences between the two groups in terms of primary patency (71.4% Group SIN vs. 54% Group BIF; P=0.10), primary assisted patency (81.7% Group SIN vs. 76.4% Group BIF; P=0.53), secondary patency (85.1% Group SIN vs. 80.9% Group BIF; P=0.79), and limb salvage (92.3% Group SIN vs. 87.2% Group BIF; P=0.64).

CONCLUSIONS

Bifurcated graft improved time to healing in CLTI patients undergoing infrapopliteal non-reversed vein bypass. Two-year overall patencies and limb salvage did not differ accordingly to vein graft configuration (single vs. bifurcated).

Higher Surgeon Volume is Associated with Lower Odds of Complication Following TEVAR for Aortic Dissections

OBJECTIVE

This study aimed to understand the impact of surgeon volume on outcomes of thoracic endovascular aortic repair (TEVAR) in patients being treated for aortic dissection.

METHODS

Patients undergoing TEVAR from January 2014 - March 2021 in the Vascular Quality Initiative (VQI) database were analyzed. Patients with aortic dissection who underwent TEVAR were divided into quartiles based on the annual TEVAR volume of their vascular surgeon. The highest quartile, middle two quartiles, and lowest quartile were deemed high volume (HV), moderate volume (MV), and low volume (LV), respectively. Multivariable logistic regressions were performed to compare cohort outcomes in terms any postoperative complication, stroke, spinal cord ischemia, reintervention, and 30-day mortality. A Cox proportional hazard model was used to assess the hazard of overall postoperative mortality.

RESULTS

Amongst 1,217 patients undergoing TEVAR, 321, 621, and 275 were performed by HV, MV, and LV surgeons, respectively. HV performed >19 annual TEVARs, MV surgeons between 5 and 18, and LV surgeons ≤4. Adjusted odds of any postoperative complication revealed that HV and MV surgeons had lower odds of overall postoperative complications [(OR 0.58, (95% CI 0.30 - 0.85), p = 0.011) and (OR 0.60, (95% CI 0.38 - 0.87), p = 0.008)], respectively when compared to LV patients. HV had lower odds of respiratory complications than LV surgeons complications [(OR 0.42, (95% CI 0.17 - 0.93), p = 0.039)]. Adjusted analysis of outcomes including spinal cord ischemia, stroke, myocardial infarction, 30-day mortality, and overall mortality did not reveal statistically significant differences between cohorts.

CONCLUSION

Surgeon volume does not to impact 30-day mortality or long-term mortality after TEVAR for aortic dissection, but the odds of overall postoperative complications were lower for HV and MV surgeons when compared to LV surgeons.