Trust but Verify? Utility of Intraoperative Angiography After Revascularization for Vascular Trauma

BACKGROUND

Trauma surgical dogma teaches that patients should have intraoperative angiography (IA) if the surgeon cannot identify a pulse in the injured extremity following a vascular repair. This study was undertaken to assess the utility of IA in trauma patients who underwent open brachial or femoral artery revascularization.

METHODS

Retrospective analysis of the Prospective Observational Vascular Injury Trial (PROOVIT) database from 2013 to 2021 evaluated patients >15 years with penetrating or blunt injuries requiring operative intervention of the brachial, superficial femoral, or common femoral arteries. Prospective Observational Vascular Injury Trial data evaluated included documented pulse in the injured extremity at revascularization completion, adjunctive IA, immediate revision, and vascular reintervention during the hospitalization.

RESULTS

Of the 5057 patients with vascular injury, 185 patients met our inclusion criteria. The majority were male (86.5%) with a median age, injury severity score, and systolic blood pressure of 29, 12, and 117, respectively. Of the study patients, 39% underwent IA, 14% had immediate revision, and 8% required vascular reoperation during their admission. Patients who underwent IA and with no documented palpable pulse after repair were significantly more likely to require immediate revision before leaving the operating room (22% vs 9%, P = .013) and were not more likely to require reoperation, than those who did not undergo IA (7% vs 9%, P = .613).

CONCLUSIONS

Intraoperative angiography is a valuable tool for surgeons for vascular extremity trauma and is associated with a greater rate of immediate revision. Familiarity with angiographic technique is essential for vascular trauma and should be a focal point of training.

Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis

BACKGROUND

Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation.

METHODS

Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE.

RESULTS

A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation.

CONCLUSION

Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.

Accreditation Council for Graduate Medical Education Milestone Training Ratings and Surgeons' Early Outcomes

Importance

National data on the development of competence during training have been reported using the Accreditation Council for Graduate Medical Education (ACGME) Milestones system. It is now possible to consider longitudinal analyses that link Milestone ratings during training to patient outcomes data of recent graduates.

Objective

To evaluate the association of in-training ACGME Milestone ratings in a surgical specialty with subsequent complication rates following a commonly performed operation, endovascular aortic aneurysm repair (EVAR).

Design, Setting, and Participants

This study of patient outcomes followed EVAR in the Vascular Quality Initiative (VQI) registry (4213 admissions from 208 hospitals treated by 327 surgeons). All surgeons included in this study graduated from ACGME-accredited training programs from 2015 through 2019 and had Milestone ratings 6 months prior to graduation. Data were analyzed from December 1, 2021, through September 15, 2023. Because Milestone ratings can vary with program, they were corrected for program effect using a deviation score from the program mean.

Exposure

Milestone ratings assigned to individual trainees 6 months prior to graduation, based on judgments of surgical competence.

Main Outcomes and Measures

Surgical complications following EVAR for patients treated by recent graduates during the index hospitalization, obtained using the nationwide Society for Vascular Surgery Patient Safety Organization's VQI registry, which includes 929 participating centers in 49 US states.

Results

The study included outcomes for 4213 patients (mean [SD] age, 73.25 [8.74] years; 3379 male participants [80.2%]). Postoperative complications included 9.5% major (400 of 4213 cases) and 30.2% minor (1274 of 4213 cases) complications. After adjusting for patient risk factors and site of training, a significant association was identified between individual Milestone ratings of surgical trainees and major complications in early surgical practice in programs with lower mean Milestone ratings (odds ratio, 0.50; 95% CI; 0.27-0.95).

Conclusions and Relevance

In this study, Milestone assessments of surgical trainees were associated with subsequent clinical outcomes in their early career. Although these findings represent one surgical specialty, they suggest Milestone ratings can be used in any specialty to identify trainees at risk for future adverse patient outcomes when applying the same theory and methodology. Milestones data should inform data-driven educational interventions and trainee remediation to optimize future patient outcomes.

Management of Traumatic Radial and Ulnar Artery Injuries and Risk Factors for Amputation

INTRODUCTION

Traumatic injuries to the radial and/or ulnar arteries represent a subset of arterial injuries. In the absence of injury to both forearm arteries, treatment was historically ligation if perfusion was maintained to the hand via the uninjured vessels or adequate collateral vessels. We sought to determine management of traumatic forearm arterial injuries in 2019 and to identify risk factors for major upper extremity amputation.

METHODS

The American College of Surgeons Trauma Quality Improvement Program database was queried by International Classification of Diseases 10 code for patients with traumatic radial and/or ulnar artery injuries within the year 2019. Patient demographics, Injury Severity Score, time to operating room, type of repair, outcomes, and mortality were collected. Multivariable logistic regression was used to identify risk factors for major upper extremity amputation.

RESULTS

A total of 4048 patients with traumatic radial and/or ulnar artery injuries were identified. A total of 1907 radial artery operations were performed including repair (59%), ligation (29%), and interposition bypass (12%). A total of 1637 ulnar artery operations were completed including repair (67%), ligation (21%), and interposition bypass (12%). Major upper extremity amputation occurred in 0.6%. Older age (adjusted odds ratio [AOR]: 1.014, 95% confidence interval [CI]: 1.004-1.024, P = 0.0048), blunt mechanism (AOR: 2.457, 95% CI: 1.730-3.497, P < 0.0.0001), and ipsilateral radial and ulnar artery injury (AOR: 2.148, 95% CI: 1.298-3.553, P = 0.0029) were associated with major amputation. Surgical revascularization, time to operating room, fasciotomy, and compartment syndrome were not associated with major amputation, but this may be secondary to Type II error.

CONCLUSIONS

In the operating room, radial and ulnar artery injuries were managed more often with restoration of flow versus ligation. Older age, blunt mechanism, and ipsilateral radial and ulnar artery injury were associated with major amputation. Amputation rate was low at 3% overall and 0.6% for amputation of the hand or a more proximal level. Upper extremity fracture, upper extremity nerve injury, and ipsilateral radial and ulnar artery injury were associated with need for revision operation.

The Use of Learning Analytics to Enable Detection of Underperforming Trainees: An Analysis of National Vascular Surgery Trainee ACGME Milestones Assessment Data

OBJECTIVE

This study aims to investigate at-risk scores of semiannual Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings for vascular surgical trainees' final achievement of competency targets.

SUMMARY BACKGROUND DATA

ACGME Milestones assessments have been collected since 2015 for Vascular Surgery. It is unclear whether milestone ratings throughout training predict achievement of recommended performance targets upon graduation.

METHODS

National ACGME Milestones data were utilized for analyses. All trainees completing 2-year vascular surgery fellowships in June 2018 and 5-year integrated vascular surgery residencies in June 2019 were included. A generalized estimating equations model was used to obtain at-risk scores for each of the 31 subcompetencies by semiannual review periods, to estimate the probability of trainees achieving the recommended graduation target based on their previous ratings.

RESULTS

A total of 122 vascular surgery fellows (VSFs) (95.3%) and 52 integrated vascular surgery residents (IVSRs) (100%) were included. VSFs and IVSRs did not achieve level 4.0 competency targets at a rate of 1.6% to 25.4% across subcompetencies, which was not significantly different between the 2 groups for any of the subcompetencies ( P = 0.161-0.999). Trainees were found to be at greater risk of not achieving competency targets when lower milestone ratings were assigned, and at later time-points in training. At a milestone rating of 2.5, with 1 year remaining before graduation, the at-risk score for not achieving the target level 4.0 milestone ranged from 2.9% to 77.9% for VSFs and 33.3% to 75.0% for IVSRs.

CONCLUSION

The ACGME Milestones provide early diagnostic and predictive information for vascular surgery trainees' achievement of competence at completion of training.

Predicting Performance at Graduation From Early ACGME Milestone Ratings: Longitudinal Learning Analytics in Professionalism and Communication in Vascular Surgery

OBJECTIVE

Program directors in surgical disciplines need more tools from the ACGME to help them use Milestone ratings to improve trainees' performance. This is especially true in competencies that are notoriously difficult to measure, such as professionalism (PROF) and interpersonal and communication skills (ICS). It is now widely understood that skills in these two areas have direct impact on patient care outcomes. This study investigated the potential for generating early predictors of final Milestone ratings within the PROF and ICS competency categories.

DESIGN

This retrospective cohort study utilized Milestone ratings from all ACGME-accredited vascular surgery training programs, covering residents and fellows who completed training in June 2019. The outcome measure studied was the rate of achieving the recommended graduation target of Milestone Level 4 (possible range: 1-5), while the predictors were the Milestone ratings attained at earlier stages of training. Predictive probability values (PPVs) were calculated for each of the 3 PROF and two ICS sub-competencies to estimate the probability of trainees not reaching the recommended graduation target based on their previous Milestone ratings.

SETTING

All ACGME-accredited vascular surgery training programs within the United States.

PARTICIPANTS

All trainees completing a 2 year vascular surgery fellowship (VSF) in June 2019 (n = 119) or a 5 year integrated vascular surgery residency (IVSR) in June 2019 (n = 52) were included in the analyses.

RESULTS

The overall rate of failing to achieve the recommended graduation target across all PROF and ICS sub-competencies ranged from 7.7% to 21.8% of all trainees. For trainees with a Milestone rating at ≤ 2.5 with 1 year remaining in their training program, the predictive probability of not achieving the recommended graduation target ranged from 37.0% to 71.5% across sub-competencies, with the highest risks observed under PROF for "Administrative Tasks" (71.5%) and under ICS for "Communication with the Healthcare Team" (56.7%).

CONCLUSIONS

As many as 1 in 4 vascular surgery trainees did not achieve the ACGME vascular surgery Milestones targets for graduation in at least one of the PROF and ICS sub-competencies. Biannual ACGME Milestone assessment ratings of PROF and ICS during early training can be used to predict achievement of competency targets at time of graduation. Early clues to problems in PROF and ICS enable programs to address potential deficits early in training to ensure competency in these essential non-technical skills prior to entering unsupervised practice.

Society for Vascular Surgery best practice recommendations for use of social media

The use of social media (SoMe) in medicine has demonstrated the ability to advance networking among clinicians and other healthcare staff, disseminate research, increase access to up-to-date information, and inform and engage medical trainees and the public at-large. With increasing SoMe use by vascular surgeons and other vascular specialists, it is important to uphold core tenets of our commitment to our patients by protecting their privacy, encouraging appropriate consent and use of any patient-related imagery, and disclosing relevant conflicts of interest. Additionally, we recognize the potential for negative interactions online regarding differing opinions on optimal treatment options for patients. The Society for Vascular Surgery (SVS) is committed to supporting appropriate and effective use of SoMe content that is honest, well-informed, and accurate. The Young Surgeons Committee of the SVS convened a diverse writing group of SVS members to help guide novice as well as veteran SoMe users on best practices for advancing medical knowledge-sharing in an online environment. These recommendations are presented here with the goal of elevating patient privacy and physician transparency, while also offering support and resources for infrequent SoMe users to increase their engagement with each other in new, virtual formats.

Ensuring equity, diversity, and inclusion in the Society for Vascular Surgery: A report of the Society for Vascular Surgery Task Force on Equity, Diversity, and Inclusion

Diversity, equity, and inclusion represent interconnected goals meant to ensure that all individuals, regardless of their innate identity characteristics, feel welcomed and valued among their peers. Equity is achieved when all individuals have equal access to leadership and career advancement opportunities as well as fair compensation for their work. It is well-known that the unique backgrounds and perspectives contributed by a diverse workforce strengthen and improve medical organizations overall. The Society for Vascular Surgery (SVS) is committed to supporting the highest quality leadership, patient care, surgical education, and societal recommendations through promoting diversity, equity, and inclusion within the SVS. The overarching goal of this document is to provide specific context and guidance for enhancing diversity, equity, and inclusion within the SVS as well as setting the tone for conduct and processes beyond the SVS, within other national and regional vascular surgery organizations and practice settings.

Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit

OBJECTIVE

Vascular surgeons may be consulted to evaluate hospitalized patients with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in intensive care unit (ICU) patients.

METHODS

All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger photoplethysmography. The patients' demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were also recorded. ICU patients were compared with concurrently evaluated non-ICU inpatients with finger ischemia.

RESULTS

There were 98 ICU patients (55 male, 43 female) identified. The mean age was 57.1 ± 16.8 years. Of these patients, 42 (43%) were in the surgical ICU and 56 (57%) in the medical ICU. Seventy (72%) had abnormal findings on finger photoplethysmography, 40 (69%) unilateral and 30 (31%) bilateral. Thirty-six (37%) had ischemia associated with an arterial line. Twelve (13%) had concomitant toe ischemia. Eighty (82%) were receiving vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (31%), epinephrine (26%), and vasopressin (24%). Treatment was with anticoagulation in 88 (90%; therapeutic, 48%; prophylactic, 42%) and antiplatelet agents in 59 (60%; aspirin, 51%; clopidogrel, 15%). Other frequently associated conditions included mechanical ventilation at time of diagnosis (37%), diabetes (34%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 3-year survival was 84%, 69%, and 59%. By Cox proportional hazards modeling, cancer (hazard ratio, 2.4; 95% confidence interval, 1.1-5.6; P = .035) was an independent predictor of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P = .05) and hyperlipidemia (42% vs 24%; P = .03) and to undergo finger amputations (16% vs 5%; P = .03).

CONCLUSIONS

Finger ischemia in the ICU is frequently associated with the presence of arterial lines and the use of vasopressor medications, of which phenylephrine and norepinephrine are most frequent. Anticoagulation or antiplatelet therapy is appropriate treatment. Whereas progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.

Characterization of profunda femoris vein thrombosis

OBJECTIVE

The incidence of and risk factors for profunda femoris vein (PFV) thrombosis are poorly characterized. We prospectively identified patients with PFV deep venous thrombosis (DVT) to characterize the demographics and anatomic distribution of proximal DVT in patients with PFV DVT.

METHODS

A prospective study was conducted of patients at a tertiary care university hospital with DVT diagnosed by venous duplex ultrasound scanning between June 2014 and June 2015. DVT patients were categorized as having PFV involvement (yes or no), and the anatomic distribution of other sites of ipsilateral venous thrombi was further stratified to determine whether there was external iliac vein (EIV), common femoral vein (CFV), or femoropopliteal vein (FPV) DVT. Demographic characteristics of the patients were compared between groups, PFV DVT vs proximal DVT without PFV DVT.

RESULTS

Of 4584 lower extremity venous duplex ultrasound studies performed, 398 (8.7%) scans were positive for proximal DVT from 260 patients; 23.1% of patients with DVT (60/260) had DVT involving the PFV. Of 112 patients who had CFV DVT, 55 (49.1%) also had ipsilateral involvement of the PFV. Of 60 patients with PFV DVT, 55 (91.7%) had involvement of the ipsilateral CFV. Patients in the PFV DVT group were more likely to have a history of a hypercoagulable disorder (26.7% vs 14.5%; P = .029) and a history of immobility (58.3% vs 42%; P = .026) compared with those with proximal DVT without PFV DVT. There were no differences in smoking, recent surgery, personal or family history of DVT, other medical comorbidities, inpatient status, or survival. There was no difference in laterality of DVT between the PFV DVT and proximal DVT without PFV DVT groups (35% vs 41.5% left, 35% vs 33.5% right, 30% vs 25% bilateral; P = .619). There was a higher proportion of PFV DVT with EIV involvement (21.7% vs 2.5%; P < .00001) and a higher proportion of PFV DVT with CFV + FPV involvement (65.0% vs 19%; P < .00001) compared with proximal DVT without PFV DVT. There was no difference in survival between the PFV DVT and proximal DVT without PFV DVT groups.

CONCLUSIONS

Patients with PFV thrombosis tend to have more thrombus burden with more frequent concurrent DVT in the EIV and FPV. Patients with PFV DVT are also more likely to have a history of hypercoagulable disorder and immobility. Ultrasound protocols for assessment of DVT should include routine examination of the PFV as a potential marker of a more virulent prothrombotic state.

Nonatherosclerotic vascular causes of acute abdominal pain

BACKGROUND

To examine the epidemiology, treatments, and outcomes of acute symptomatic non-atherosclerotic mesenteric vascular disease.

METHODS

Subjects were reviewed over a six year period. Categories included embolism (EM), dissection (DI), and aneurysm (AN). Presentation, demographics, treatment and outcomes were compared.

RESULTS

46 patients were identified (EM:20, AN:15, DI:11). Age at presentation differed (EM: 66.3, AN 62.4, DI 54.6, p < .05). EM more likely affected the superior mesenteric artery (EM80%, AN20%, DI45%, p = .002), DI hepatic artery (EM20%, AN13%, DI55%, p < .05), and AN mesenteric branches (EM5%, AN47%, DI0%; p = .001). EM more likely had history of arrhythmia (EM40%, AN7%, DI0%, p,0.05) and diarrhea (EM30%, AN7%, DI0%, p < .05). Treatment was most often surgical in EM (EM85%, AN33%, DI9%, p < .001), endovascular in AN (EM5%, AN40%, DI 9%, p < .02), and conservative in DI (EM15%, AN 33%, DI82%, p < .05). In hospital mortality was infrequent (EM10%, AN7%, DI0%, p = ns). Mean hospital length of stay differed by mechanism (EM13.6days, AN9.2, DI2.3, p = .005). Median follow up was 61 months. Survival at 1, 3 and 5 years for emboli was 75%, 70% and 59%, for aneurysms 93%, 86%, and 77%, and for dissections 100% at all time points (p = .043 log rank).

CONCLUSIONS

Patients with EM, AN, and DI differ in age, anatomic distribution and method of treatment. The etiology significantly affects long term survival.

Interhospital vascular surgery transfers to a tertiary care hospital

OBJECTIVE

Interhospital transfers (IHTs) to tertiary care centers are linked to lower operative mortality in vascular surgery patients. However, IHT incurs great health care costs, and some transfers may be unnecessary or futile. In this study, we characterize the patterns of IHT at a tertiary care center to examine appropriateness of transfer for vascular surgery care.

METHODS

A retrospective review was performed of all IHT requests made to our institution from July 2014 to October 2015. Interhospital physician communication and reasons for not accepting transfers were reviewed. Diagnosis, intervention, referring hospital size, and mortality were examined. Follow-up for all patients was reviewed.

RESULTS

We reviewed 235 IHT requests for vascular surgical care involving 210 patients during 15 months; 33% of requested transfers did not occur, most commonly after communication with the physician resulting in reassurance (35%), clinic referral (30%), or further local workup obviating need for transfer (11%); 67% of requests were accepted. Accepted transfers generally carried life- or limb-threatening diagnoses (70%). Next most common transfer reasons were infection or nonhealing wounds (7%) and nonurgent postoperative complications (7%). Of accepted transfers, 72% resulted in operative or endovascular intervention; 20% were performed <8 hours of arrival, 12% <24 hours of arrival, and 68% during hospital admission (average of 3 days); 28% of accepted patients received no intervention. Small hospitals (<100 beds) were more likely than large hospitals (>300 beds) to transfer patients not requiring intervention (47% vs 18%; P = .005) and for infection or nonhealing wounds (30% vs 10%; P = .013). Based on referring hospital size, there was no difference in IHTs requiring emergent, urgent, or nonurgent operations. There was also no difference in transport time, time from consultation to arrival, or death of patients according to hospital size. Overall patient mortality was 12%.

CONCLUSIONS

Expectedly, most vascular surgery IHTs are for life- or limb-threatening diagnoses, and most of these patients receive an operation. Transfer efficiency and surgical case urgency are similar across hospital sizes. Nonoperative IHTs are sent more often by small hospitals and may represent a resource disparity that would benefit from regionalizing nonurgent vascular care.

Effect of a hospital-associated urinary tract infection reduction policy on general surgery patients

BACKGROUND

Hospital-associated UTI rates in surgery patients have not improved despite recommendations for reducing indwelling catheter days.

METHODS

We performed a retrospective review of institutional NSQIP general surgery patient data, 2006-2015. During this time, a UTI-reduction policy was implemented. Demographics, HA-UTI incidence, CA-UTI incidence, indwelling catheter days, straight catheterization rates, and mortality were examined.

RESULTS

Females had significantly higher risk of HA-UTI. There was no significant change in HA-UTI (X12 = 0.02, p = .878) or indwelling catheter days (5.18 ± 1.12 days v 3.73 ± 0.39 days, p = .23). Straight catheterizations among those with HA-UTI increased (0.04 ± 0.04 v 0.32 ± 0.12, p = .029). There was no change in CA-UTI (1.38 v 1.11 CAUTI/1000 patient hospital-days P = .555) or in initial indwelling catheter days of patients with CA-UTI (7.2 SD 8.89 v 47.0 SD 7.04 days P = .961) after policy implementation.

CONCLUSIONS

The reduction policy increased the number of straight catheterizations for patients developing HA-UTI, but did not reduce the number of initial indwelling catheter days, HA-UTI rates, or CA-UTI rates.

Imaging features of myeloproliferative neoplasms

Myeloproliferative neoplasms (MPNs) are a heterogeneous group of haematological disorders including polycythaemia vera (PV), essential thrombocythaemia (ET), primary myelofibrosis (PMF), and chronic myeloid leukaemia (CML). These disorders show large overlap in genetic and clinical presentations, and can have many different imaging manifestations. Unusual thromboses, embolic events throughout the systemic or pulmonary vasculature, or osseous findings can often be clues to the underlying disease. There is limited literature about the imaging features of these disorders, and this may result in under-diagnosis. Multiple treatments are available for symptom control, and the development of multiple new pharmacological inhibitors has significantly improved morbidity and prognosis. Knowledge of these conditions may enable the radiologist to suggest an MPN as a possible underlying cause for certain imaging findings, particularly unexplained splanchnic venous thrombosis, i.e. in the absence of chronic liver disease or pancreatitis. The aim of the present review is to outline using examples the different categories of MPN and illustrate the variety of radiological findings associated with these diseases.

Reduced Intestinal Motility, Mucosal Barrier Function, and Inflammation in Aged Monkeys

OBJECTIVE

We aimed to examine the general health and intestinal physiology of young and old non-human primates with comparable life histories and dietary environments.

DESIGN

Vervet monkeys (Chlorcebus aethiops sabaeus) in stable and comparable social and nutritional environments were selected for evaluation. Health phenotype, circulating cytokines and biomarkers of microbial translocation (MT) were measured (n=26-44). Subsets of monkeys additionally had their intestinal motility, intestinal permeability, and fecal microbiomes characterized. These outcomes document age-related intestinal changes present in the absence of nutritional stressors, which are all known to affect gastrointestinal motility, microbiome, and MT.

RESULTS

We found that old monkeys have greater systemic inflammation and poor intestinal barrier function as compared to young monkeys. Old monkeys have dramatically reduced intestinal motility, and all changes in motility and MT are present without large differences in fecal microbiomes.

CONCLUSION

We conclude that deteriorating intestinal function is a feature of normal aging and could represent the source of inflammatory burden yet to be explained by disease or diet in normal aging human primate populations. Intestinal changes were seen independent of dietary influences and aging within a consistent environment appears to avoid major microbiome shifts. Our data suggests interventions to promote intestinal motility and mucosal barrier function have the potential to support better health with aging.

Demographic and echocardiographic predictors of anatomic site and outcomes of surgical interventions for cardiogenic limb emboli

We sought to determine if symptomatic cardiogenic limb emboli have a random distribution or if there are demographic or echocardiographic factors that predict site of embolization, limb salvage and mortality. Upper (UE) and lower extremity (LE) emboli were evaluated over a 16-year period (1996-2012). Demographic (age, gender, smoking, medical comorbidities) and echocardiographic data were analyzed to determine predictors of embolic site. All symptomatic patients underwent surgical revascularization. Limb salvage and mortality were compared with Kaplan-Meier analysis. A total of 161 patients with symptomatic cardiogenic emboli were identified: 56 UE and 105 LE. The female-to-male ratio for UE emboli (70%:30%) was significantly higher than for LE emboli (47%:53%, p=0.008). No other demographic factors were statistically different. Upper extremity patients were more likely to have atrial fibrillation (50% vs 29.8%, p=0.028), while LE patients had a higher percentage of aortic or mitral valvular disease or intracardiac thrombus (71.4% vs 52.5%, p=0.038). The 30-day limb salvage was higher for UE compared to LE (100% vs 88%, p=0.008). There was a trend toward higher 30-day mortality in the LE group (14% vs 5%, p=0.11). Survival at 1, 3, and 5 years were similar (UE: 62.2%, 44.2%, 35.3%; LE: 69.1%, 47.5%, 30.3%; p=ns). Upper extremity emboli are more frequent in women and patients with atrial fibrillation. Lower extremity emboli are more frequent in the presence of valvular disease or intracardiac thrombus, and are associated with increased 30-day limb loss and mortality. These findings suggest gender- and cardiac-specific differences in patterns of blood flow leading to preferential sites of peripheral embolization.

0 + 5 Vascular Surgery Residents' Operative Experience in General Surgery: An Analysis of Operative Logs from 12 Integrated Programs

OBJECTIVE

Integrated (0 + 5) vascular surgery (VS) residency programs must include 24 months of training in core general surgery. The Accreditation Council for Graduate Medical Education currently does not require specific case numbers in general surgery for 0 + 5 trainees; however, program directors have structured this time to optimize operative experience. The aim of this study is to determine the case volume and type of cases that VS residents are exposed to during their core surgery training.

DESIGN

Accreditation council for graduate medical education operative logs for current 0 + 5 VS residents were obtained and retrospectively reviewed to determine general surgery case volume and distribution between open and laparoscopic cases performed. Standard statistical methods were applied.

SETTING

A total of 12 integrated VS residency programs provided operative case logs for current residents.

PARTICIPANTS

A total of 41 integrated VS residents in clinical years 2 through 5.

RESULTS

During the postgraduate year-1 training year, residents participated in significantly more open than laparoscopic general surgery cases (p < 0.0001). This difference was consistent over the first 3 years of training. The most frequently logged open general surgery cases are hernia repair (20%), skin and soft tissue (7.4%), and breast (6.3%). Residents in programs with core surgery over 3 years participated in significantly more general surgery operations compared with residents in programs with core surgery spread out over 4 years (p = 0.035).

CONCLUSIONS

0 + 5 VS residents perform significantly more open operations than laparoscopic operations during their core surgery training. The majority of these operations are minor, nonabdominal procedures. The 0 + 5 VS residency program general surgery operative training requirements should be reevaluated and case minimums defined. The general surgery training component of 0 + 5 VS residencies may need to be restructured to meet the needs of current and future trainees.

The Natural History of Indeterminate Blunt Cerebrovascular Injury

IMPORTANCE

The Denver criteria grade blunt cerebrovascular injuries (BCVIs) but fail to capture many patients with indeterminate findings on initial imaging.

OBJECTIVE

To evaluate outcomes and clinical significance of indeterminate BCVIs (iBCVIs).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of all patients treated for BCVIs at our institution from January 1, 2007, through July 31, 2014, was completed. Patients were divided into 2 groups: those with true BCVIs as defined by the Denver criteria and those with iBCVIs, which was any initial imaging suggestive of a cerebrovascular arterial injury not classifiable by the Denver criteria.

MAIN OUTCOMES AND MEASURES

Primary outcomes were rate of resolution of iBCVIs, freedom from cerebrovascular accident (CVA) or transient ischemic attack (TIA), and 30-day mortality.

RESULTS

We identified 100 patients with 138 BCVIs: 79 with true BCVIs and 59 with iBCVIs. With serial imaging, 23 iBCVIs (39.0%) resolved and 21 (35.6%) remained indeterminate, whereas 15 (25.4%) progressed to true BCVI. The rate of CVA or TIA in the iBCVI group was 5.1% compared with 15.2% in the true BCVI group (P = .06). Of the 15 total CVAs or TIAs, 11 (73.3%) resulted from carotid injury and 4 (26.7%) from vertebral artery occlusion (P = .03). By Kaplan-Meier analysis, there was no difference in freedom from CVA or TIA for the 2 groups (P = .07). Median clinical follow-up was 91 days. Overall and 30-day mortality for the entire series were 17.4% and 15.2%, respectively. There was no difference in long-term or 30-day mortality between true BCVI and iBCVI groups.

CONCLUSIONS AND RELEVANCE

Detection of iBCVI has become a common clinical conundrum with improved and routine imaging. Indeterminate BCVI is not completely benign, with 25.4% demonstrating anatomical progression to true BCVI and 5.1% developing cerebrovascular symptoms. We therefore recommend serial imaging and antiplatelet therapy for iBCVI.

Genetics, Pregnancy, and Aortic Degeneration

We present a case of familial thoracic aortic aneurysm and dissection (FTAAD) in a pregnant female. FTAAD is an inherited, nonsyndromic aortopathy resulting from several genetic mutations critical to aortic wall integrity have been identified. One such mutation is the myosin heavy chain gene (MYH11) which is responsible for 1-2% of all FTAAD cases. This mutation results in aortic medial degeneration, loss of elastin, and reticulin fiber fragmentation predisposing to TAAD. Aortic disease is more aggressive during pregnancy as a result of increased wall stress from hyperdynamic cardiovascular changes and estrogen-induced aortic media degeneration. Our patient was a 29-year-old G2P1 woman at 26 weeks gestation presenting with abdominal and back pain. Work-up revealed a 6.4-cm ascending aortic aneurysm with a type A dissection extending into all arch vessels, aortic coarctation at the isthmus, and a separate focal type B aortic dissection with visceral involvement. Surgical management included concomitant cesarean section with delivery of a live premature infant, tubal ligation, ascending aortic replacement with reconstruction of the arch vessels, and aortic valve resuspension. The type B dissection was managed medically without complication. This is the first reported case of aortic dissection in a patient with FTAAD/MYH11 mutation and pregnancy. This case highlights that FTAAD and pregnancy cause aortic degeneration via distinct mechanisms and that hyperdynamics of pregnancy increase aortic wall stress. Management of pregnancy associated with aortopathy requires early transfer to a tertiary center, careful investigation to identify familial aortopathy, fetal monitoring, and a multidisciplinary team approach.

Nasal methicillin-resistant Staphylococcus aureus colonization is associated with increased wound occurrence after major lower extremity amputation

OBJECTIVE

Wound occurrence (WO) after major lower extremity amputation (MLEA) can be due to wound infection or sterile dehiscence. We sought to determine the association of nasal methicillin-resistant Staphylococcus aureus (MRSA) colonization and other patient factors with overall WO, WO due to wound infection, and WO due to sterile dehiscence.

METHODS

The medical records of all patients undergoing MLEA from August 1, 2011, to November 1, 2013, were reviewed. Demographic data, hemoglobin A1c level, albumin concentration, dialysis dependence, peripheral vascular disease (PVD), nasal MRSA colonization, and diabetes mellitus (DM) were examined as variables. The overall WO rate was determined, and the cause of WO was categorized as either a sterile dehiscence or a wound infection.

RESULTS

Eighty-three patients underwent 96 MLEAs during a 27-month period. The rates of overall WO, WO due to infection, and WO due to sterile dehiscence were 39%, 19%, and 19%, respectively (1% developed a traumatic wound). On univariate analysis, PVD, MRSA colonization, DM, and dialysis dependence were all associated with higher rates of overall WO (P < .05). On multivariate analysis, MRSA colonization was associated with higher rates of overall WO (P = .03) and WO due to wound infection (11% vs 45%; P < .01). DM and PVD were associated with higher rates of overall WO and WO due to sterile dehiscence on both univariate and multivariate analysis (P < .05).

CONCLUSIONS

Nasal MRSA colonization is associated with higher rates of overall WO and WO due to wound infection. DM and PVD are associated with higher rates of overall WO and WO due to sterile dehiscence but are not associated with WO due to wound infection. Further studies addressing the effect of nasal MRSA eradication on postoperative wound outcomes after MLEA are warranted.

Objective measurement of lower extremity function and quality of life after surgical revascularization for critical lower extremity ischemia

BACKGROUND

Outcomes of revascularization for critical limb ischemia (CLI) have historically been patency, limb salvage, and survival. Functional status and quality of life have not been well described. This study used functional and quality of life assessments to measure patient-centered outcomes after revascularization for CLI.

METHODS

The study observed 18 patients (age, 65 ± 11 years) prospectively before and after lower extremity bypass for CLI. Patients completed the Short Physical Performance Battery, which measures walking speed, leg strength, and balance, as well as performed a 6-minute walk, and calorie expenditure was measured by an accelerometer. Isometric muscle strength was assessed with the Muscle Function Evaluation chair (Metitur, Helsinki, Finland). Quality of life instruments included the 36-Item Short Form Health Survey and the Vascular Quality of Life questionnaire. Patients' preoperative status was compared with 4-month postoperative status.

RESULTS

Muscle Function Evaluation chair measurements of ipsilateral leg strength demonstrated a significant increase in knee flexion from 64 ± 62 N to 135 ± 133 N (P = .038) and nearly significant increase in knee extension from 120 ± 110 N to 186 ± 85 N (P = .062) and ankle plantar flexion from 178 ± 126 N to 267 ± 252 N (P = .078). In the contralateral leg, knee flexion increased from 71 ± 96 N to 149 ± 162 N (P = .028) and knee extension from 162 ± 112 N to 239 ± 158 N (P = .036). Absolute improvements were noted in 6-minute walk distance, daily calorie expenditure, and individual domains and overall Short Physical Performance Battery scores, and upper extremity strength decreased, although none were significant. The Vascular Quality of Life questionnaire captured significant improvement in all individual domains and overall score (P < .015). Significant improvement was noted only for bodily pain (P = .011) on the 36-Item Short Form Health Survey.

CONCLUSIONS

Despite lack of statistical improvement in most functional test results, revascularization for CLI results in improved patient-perceived leg function. Significant improvements in isometric muscle strength may explain the measured improvement in quality of life after revascularization for CLI.

A systematic review of assessment of skill acquisition and operative competency in vascular surgical training

OBJECTIVE

The aim of this systematic review is to describe the literature and assessment tools evaluating vascular surgical operative performance that could potentially be used for the assessment of educational outcomes applicable to the Milestone Project and the Next Accreditation System.

METHODS

A systematic review of PubMed/MEDLINE, EMBASE, PsycINFO, and key journals from 1985 to 2013 was performed to identify English-language articles describing assessment of vascular surgical skills and competence. Qualifying studies were abstracted for data concerning study aims, study and assessment setting, skills measured, and metrics used to determine competency. Strengths, weaknesses, and psychometric robustness of the assessment tools were determined.

RESULTS

The literature search identified 617 citations. After title and abstract review, 65 articles were retrieved for full-text assessment and 48 articles were included in the final review. Twenty-nine articles assessed open vascular skills; 19, endovascular skills; six, nontechnical skills; and one, teamwork skills. The majority (84%) of studies were performed in a simulated environment, four (8%) were performed in the operating room, and the remaining three were performed in both a simulated environment and an operating room. Strengths and weaknesses of assessment tools were study and assessor dependent, with none applicable to all study scenarios or procedures.

CONCLUSIONS

The literature describing assessment tools pertinent to vascular surgery is diverse. Existing assessment tools may be relevant to individual technical skill acquisition assessment; however, an operative assessment tool relevant to vascular/endovascular surgery and generalizable to the wide spectrum of technical and nontechnical skills pertinent to vascular surgery needs to be developed, validated, and implemented to allow the practical assessment of resident readiness to operate in an unsupervised setting.