Perception of shared learning environment differs between vascular surgery and general surgery residents

BACKGROUND

An enriching learning environment is integral to resident wellness and education. Integrated vascular (VS) and general surgery (GS) residents share 18 months of core GS rotations during the postgraduate years 1-3 (PGY1-3); differences in their experiences may help identify practical levers for change.

METHODS

We used a convergent mixed-methods design. Cross-sectional surveys were administered after the 2020 American Board of Surgery In-Training Examination and Vascular Surgery In-Training Examination, assessing eight domains of the learning environment and resident wellness. Multivariable logistic regression models identified factors associated with thoughts of attrition between categorical PGY1-3 residents at 57 institutions with both GS and VS programs. Resident focus groups were conducted during the 2022 Vascular Annual Meeting to elicit more granular details about the experience of the learning environment. Transcripts were analyzed using inductive and deductive logics until thematic saturation was achieved.

RESULTS

Surveys were completed by 205 VS and 1198 GS PGY1-3 residents (response rates 76.8% for VS and 82.5% for GS). After adjusting for resident demographics, PGY level, and program type, GS residents were more likely than their VS peers to consider leaving their programs (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.37-4.99). This finding did not persist after adjusting for differences in perceptions of the learning environment, specifically: GS residents had higher odds of mistreatment (OR: 1.99, 95% CI: 1.36-2.90), poorer work-life integration (OR: 2.88, 95% CI: 1.41-5.87), less resident camaraderie (OR: 3.51, 95% CI: 2.26-5.45), and decreased meaning in work (OR: 2.94, 95% CI: 1.80-4.83). Qualitative data provided insight into how the shared learning environment was perceived differently: (1) vascular trainees expressed that early specialization and a smaller, more invested faculty allow for an apprenticeship model with early operative exposure, hands-on guidance, frequent feedback, and thus early skill acquisition (meaning in work); (2) a smaller program is conducive to closer relationships with co-residents and faculty, increasing familiarity (camaraderie and work-life integration); and (3) due to increased familiarity with program leadership, vascular trainees feel more comfortable reporting mistreatment, allowing for prompt responses (mistreatment).

CONCLUSIONS

Despite sharing a learning environment, VS and GS residents experience training differently, contributing to differential thoughts of attrition. These differences may be attributable to intrinsic features of the integrated training paradigm that are not easily replicated by GS programs, such as smaller program size and higher faculty investment due to early specialization. Alternative strategies to compensate for these inherent differences should be considered (eg, structured operative entrustment programs and faculty incentivization).

Reported pain at work is a risk factor for vascular surgery trainee burnout

BACKGROUND

Work-related pain is a known risk factor for vascular surgeon burnout. It risks early attrition from our workforce and is a recognized threat to the specialty. Our study aimed to understand whether work-related pain similarly contributed to vascular surgery trainee well-being.

METHODS

A confidential, voluntary survey was administered after the 2022 Vascular Surgery In-Service Examination to trainees in all Accreditation Council for Graduate Medical Education-accredited vascular surgery programs. Burnout was measured by a modified, abbreviated Maslach Burnout Inventory; pain after a full day of work was measured using a 10-point Likert scale and then dichotomized as "no to mild pain" (0-2) vs "moderate to severe pain" (3-9). Univariable analyses and multivariable regression assessed associations of pain with well-being indicators (eg, burnout, thoughts of attrition, and thoughts of career change). Pain management strategies were included as additional covariables in our study.

RESULTS

We included 527 trainees who completed the survey (82.2% response rate); 38% reported moderate to severe pain after a full day of work, of whom 73.6% reported using ergonomic adjustments and 67.0% used over-the-counter medications. Significantly more women reported moderate to severe pain than men (44.3% vs 34.5%; P < .01). After adjusting for gender, training level, race/ethnicity, mistreatment, and dissatisfaction with operative autonomy, moderate-to-severe pain (odds ratio, 2.52; 95% confidence interval, 1.48-4.26) and using physiotherapy as pain management (odds ratio, 3.06; 95% confidence interval, 1.02-9.14) were risk factors for burnout. Moderate to severe pain was not a risk factor for thoughts of attrition or career change after adjustment.

CONCLUSIONS

Physical pain is prevalent among vascular surgery trainees and represents a risk factor for trainee burnout. Programs should consider mitigating this occupational hazard by offering ergonomic education and adjuncts, such as posture awareness and microbreaks during surgery, early and throughout training.

The Diversity of Surgical Trainees Index identifies racial and ethnic disparities among surgical specialties

OBJECTIVE

Racial and ethnic disparities have been well-described among surgical specialties; however, variations in underrepresented in medicine (URiM) representation between these specialties have not previously been quantified.

METHODS

Data collected from Accreditation Council for Graduate Medical Education (ACGME) annual reports were used to derive the Diversity of Surgical Trainee Index (DoSTI) metric, which was calculated as the proportion of URiM residents and fellow physicians within a given surgical specialty, relative to the overall proportion of URiM trainees within all surgical and non-surgical ACGME-accredited programs in the same academic year.

RESULTS

From 2013 to 2022, a total of 108,193 ACGME-accredited residency programs trained 1,296,204 residents and fellows in the United States. Of these, 14.1% (n = 182,680) of trainees self-identified as URiM over the study period. The mean DoSTI among all surgical specialties was 0.80 (standard error, 0.01) compared with all ACGME-accredited programs. High DoSTI specialties incorporated significantly higher proportions of Hispanic (8.7% vs 6.3%) and Black (5.2% vs 2.5%) trainees compared with low DoSTI specialties (P < .0001 each). General surgery (1.06 ± 0.01), plastic surgery (traditional) (1.12 ± 0.06), vascular surgery (integrated) (0.96 ± 0.03), and vascular surgery (traditional) (0.94 ± 0.06) had the highest DoSTI indices (P < .05 each vs composite). On linear regression analysis, only ophthalmology (+0.01/year; R2 = 0.41; P = .019), orthopedic surgery (+0.01/year; R2 = 0.33; P = .047), otolaryngology (+0.02/year; R2 = 0.86; P < .001), and pediatric surgery (+0.06/year; R2 = 0.33; P = .048) demonstrated an annual increase in DoSTI.

CONCLUSIONS

The DoSTI is a novel metric used to quantify the degree of URiM representation among surgical specialties. DoSTI has revealed specialty-specific variations in racial/ethnic minority representation among surgical training programs. This metric may be used to improve provider awareness, identify high performing DoSTI specialties to highlight their best practices, and ultimately, recruit a more diverse surgical workforce.

Natural history of visceral branch artery dissections and the influence of concurrent aortic dissection on overall and intervention-free survival

OBJECTIVE

Visceral branch artery dissection (VBAD) is uncommon and may occur with or without an associated aortic dissection (AD). We hypothesized that isolated VBAD would have a more benign clinical course than those with concurrent AD and compared survival outcomes stratified based on aortic involvement.

METHODS

VBAD over a 5-year period were identified using International Classification of Diseases codes. Data related to patient demographics, comorbid conditions, clinical presentation, management (including procedural interventions), and survival were obtained from medical records. Anatomic imaging studies were reviewed to characterize anatomy, including the presence or absence of concurrent AD. Overall survival and intervention-free survival were evaluated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

A total of 299 VBAD were identified, 174 of which were isolated VBAD and 125 were associated with concurrent AD. Seventy-one percent of patients were men, 77% were White, and 85% were non-Hispanic. The mean age was 61.1 ± 14.4 years. The mean follow-up was 53.2 ± 50.0 months. The estimated overall survival was 88.2% and the estimated overall intervention-free survival was 55.6% at 12 months. Isolated VBAD had better overall survival than those with concurrent AD (69.2% vs 32.4%; P < .001). Concurrent AD was also associated with inferior intervention-free survival (57.5% vs 7.3%; P < .001). Acute presentation was associated with decreased intervention-free survival (86.1% vs 13.4%; P < .001). Acute presentation was also associated with decreased overall survival in patients with isolated VBAD (60.8% vs 80.0% at 180 months; P < .001) and inferior intervention-free survival (48.4% vs 69.5% at 180 months; P < .001) in the subgroup of patients with isolated VBAD. Multivariable Cox models identified that age (hazard ratio [HR]: 1.05, standard deviation [SD]: 0.02; P = .001) was associated with inferior survival and renal dissections (HR: 3.08, SD: 0.99; P = .001) or mesenteric and renal dissections (HR: 3.39, SD: 1.44; P = .004) were associated with inferior intervention-free survival.

CONCLUSIONS

Isolated VBAD has superior overall and intervention-free survival to those associated with concurrent AD. The absence vs presence of aortic involvement is useful for risk stratification and may support tailored approaches to the frequency of imaging surveillance.

Concerning Trends in Vascular Surgery Trainee Operative Experience in Venous Disease

BACKGROUND

Comprehensive vascular care includes both arterial and venous disease management. However, operative training in venous disease is often significantly overshadowed by arterial procedures, despite the public health burden of acute and chronic venous disease. The purpose of this study is to evaluate the case-mix and volume of venous procedures performed by graduating integrated vascular surgery residents and fellows in the United States.

METHODS

Accreditation Council for Graduate Medical Education national operative log reports were compiled for graduating integrated VSR (vascular surgery residency) and traditional vascular surgery fellowship (VSF) trainees from academic years 2013 to 2022. Only cases categorized as "surgeon fellow", "surgeon chief", or "surgeon junior" were included. Linear regression analysis was utilized to evaluate trends in case-mix and volume.

RESULTS

Over the 10-year study period, total vascular cases increased for both VSR (mean 870.5 ± 9.3 cases, annual change +9.5 cases/year, R2 = 0.77, P < 0.001) and VSF (mean 682.1 ± 6.9 cases, annual change +6.7 cases/year, R2 = 0.85, P < 0.001) trainees. Concurrently, the proportion of venous cases in the VSR group decreased from 12.5% to 7.3% (annual change -3.7 cases/year, R2 = 0.72, P < 0.001). VSR trainees experienced an annual decrease in 4 of the top 5 venous case types performed, including venous angioplasty/stenting (-1.6 cases/year, P = 0.002), vena cava filter placement (-0.9 cases/year, P = 0.002), endoluminal ablation (-0.2 cases/year, P = 0.47), diagnostic venography (-1.7 cases/year, P < 0.001), and varicose vein treatment (-1.0 cases/year, P < 0.001). Venous cases proportions also decreased in the VSF group from 8.4% to 6.2% (annual change -2.2 cases/year, R2 = 0.54, P = 0.002). VSF trainees experienced an annual decrease in 4 of the top 5 venous case types, including venous angioplasty/stenting (-1.5 cases/year, P = 0.003), diagnostic venography (-1.2 cases/year, P < 0.001), vena cava filter placement (-0.2 cases/year, P = 0.44), endoluminal ablation (-0.6 cases/year, P < 0.001), and varicose vein treatment (-0.1 cases/year, P = 0.04). Both VSR and VSF trainee groups graduated with fewer than 5 cases for each of the following venous procedures-percutaneous mechanical thrombectomy, venous thrombolysis, open venous reconstruction, sclerotherapy, venous embolectomy, portal-systemic shunting, venous ulceration treatment, and arteriovenous malformation treatment.

CONCLUSIONS

Current vascular residents and fellows have limited exposure to venous procedures, in part due to a proportional decline in venous cases. More robust venous operative experience is needed during surgical training. Further studies are needed to understand whether this discrepancy in venous and arterial training impacts career progression and patient outcomes.

Comparative evaluation of transcutaneous oxygen tension vs ankle-brachial index as predictors of reoperation following below-knee amputation

OBJECTIVE

Decision-making regarding level of lower extremity amputation is sometimes challenging. Selecting an appropriate anatomic level for major amputation requires consideration of tradeoffs between postoperative function and risk of wound complications that may require additional operations, including debridement and/or conversion to above-knee amputation (AKA). We evaluated the utility of common, non-invasive diagnostic tests used in clinical practice to predict the need for reoperations among patients undergoing primary, elective below knee-amputations (BKAs) by vascular surgeons.

METHODS

Patients undergoing elective BKA over a 5-year period were identified using Current Procedural Terminology codes. Medical records were reviewed to characterize demographics, pre-amputation testing transcutaneous oxygen tension (TcPO2), and ankle-brachial index (ABI). The need for ipsilateral post-BKA reoperation (including BKA revision and/or conversion to AKA) regardless of indication was the primary outcome. Associations were evaluated using univariable and multivariable logistic regression models. Cutpoints for TcPO2 values associated with amputation reoperation were evaluated using receiver operating characteristic curves.

RESULTS

We identified 175 BKAs, of which 46 (26.3%) required ipsilateral reoperation (18.9% BKA revisions and 14.3% conversions to AKA). The mean age was 63.3 ± 14.8 years. Most patients were male (65.1%) and White (72.0%). Mean pre-amputation calf TcPO2 was 40.0 ± 20.5 mmHg, and mean ABI was 0.64 ± 0.45. In univariable models, post-BKA reoperation was associated with calf TcPO2 (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.94-0.99; P = .013) but not ABI (OR, 0.53; 95% CI, 0.19-1.46; P = .217). Univariable associations with reoperation were also identified for age (OR, 0.97; 95% CI, 0.94-0.990; P = .003) and diabetes (OR, 0.43; 95% CI, 0.21-0.87; P = .019). No associations with amputation revision were identified for gender, race, end-stage renal disease, or preoperative antibiotics. Calf TcPO2 remained associated with post-BKA reoperation in a multivariable model (OR, 0.97; 95% CI, 0.94-0.99; P = .022) adjusted for age (OR, 0.98; 95% CI, 0.94-1.01; P = .222) and diabetes (OR, 0.98; 95% CI, 0.94-1.01; P = .559). Receiver operating characteristic analysis suggested a TcPO2 ≥38 mmHg as an appropriate cut-point for assessing risk for BKA revision (area under the curve = 0.682; negative predictive value, 0.91).

CONCLUSIONS

Reoperation after BKA is common, and reoperation risk was associated with pre-amputation TcPO2. For patients undergoing elective BKA, higher risk of reoperation should be discussed with patients with an ipsilateral TcPO2 <38 mmHg.

A national analysis of vascular surgery resident operative experience in peripheral artery disease

BACKGROUND

Endovascular and hybrid interventions have played an increasingly prominent role in the treatment of peripheral arterial disease (PAD) in the past decade. This shift has prompted concerns about the adequacy of open surgical training for current surgical residents. Moreover, the recent Best Surgical Therapy in Patients With Critical Limb Ischemia trial has further emphasized the importance of open surgical techniques in the treatment of peripheral arterial disease. The purpose of this study was to examine national temporal trends in peripheral operative volume among integrated vascular surgery residents.

METHODS

Data was obtained from the Accreditation Council for Graduate Medical Education national data reports for integrated vascular surgery residents. Case volumes for surgeon chief or surgeon junior cases were collected from academic years 2012 to 2013 and 2021 to 2022. Trends in case-mix and volume were evaluated using linear regression analysis.

RESULTS

The mean total vascular operative volume increased from 851.2 to 914.3 cases among graduating chief residents, with an annual growth of 8.5 ± 1.7 cases/year (R2 = 0.77; P < .0001). Major vascular case volume also increased at a rate of 5.7 ± 1.2 cases/year (R2 = 0.74; P < .001). Among operative categories, peripheral cases were the most frequent (n = 232.2 [26.6%]) and demonstrated the greatest annual growth (+8.0 ± 0.8 cases/year, R2 = 0.93; P < .001). No changes were seen in volume of open peripheral cases, including suprainguinal bypass (+0.1 ± 0.2 cases/year; R2 = 0.08; P = .40) or femoropopliteal bypass procedures (-0.1 ± 0.2 cases/year; R2 = 0.17; P = .20). Infrapopliteal bypass (+0.4 ± 0.1 cases/year; R2 = 0.48; P = .006), iliac/femoral endarterectomy (+1.3 ± 0.2 cases/year; R2 = 0.82; P < .001), and leg thromboembolectomy (+0.4 ± 0.1 cases/year; R2 = 0.64; P < .001) all demonstrated annual growth. For endovascular peripheral cases, aortoiliac revascularization (+3.4 ± 0.3 cases/year; R2 = 0.94; P < .001), femoropopliteal revascularization (+5.4 ± 0.2 cases/year; R2 = 0.98; P < .001), and tibioperoneal revascularization (+2.0 ± 0.2 cases/year; R2 = 0.92; P < .001) all increased in volume. Lower extremity amputations, including above-knee amputation (+0.6 ± 0.2 cases/year; R2 = 0.65; P < .001) and below-knee amputation (+0.9 ± 0.2 cases/year; R2 = 0.72; P < .001) also demonstrated an increase in volume.

CONCLUSIONS

Current graduating residents have higher open and endovascular case volumes for peripheral artery disease on a national level, despite the increasing popularity of endovascular techniques. Further studies are needed to identify how these trends may impact current vascular surgery milestones. These trends may also influence the rising interest in competency-based training programs.

Genome-wide association meta-analysis identifies risk loci for abdominal aortic aneurysm and highlights PCSK9 as a therapeutic target

Abdominal aortic aneurysm (AAA) is a common disease with substantial heritability. In this study, we performed a genome-wide association meta-analysis from 14 discovery cohorts and uncovered 141 independent associations, including 97 previously unreported loci. A polygenic risk score derived from meta-analysis explained AAA risk beyond clinical risk factors. Genes at AAA risk loci indicate involvement of lipid metabolism, vascular development and remodeling, extracellular matrix dysregulation and inflammation as key mechanisms in AAA pathogenesis. These genes also indicate overlap between the development of AAA and other monogenic aortopathies, particularly via transforming growth factor β signaling. Motivated by the strong evidence for the role of lipid metabolism in AAA, we used Mendelian randomization to establish the central role of nonhigh-density lipoprotein cholesterol in AAA and identified the opportunity for repurposing of proprotein convertase, subtilisin/kexin-type 9 (PCSK9) inhibitors. This was supported by a study demonstrating that PCSK9 loss of function prevented the development of AAA in a preclinical mouse model.

International Multi-Institutional Experience with Presentation and Management of Aortic Arch Laterality in Aberrant Subclavian Artery and Kommerell's Diverticulum

BACKGROUND

Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch.

METHODS

Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions.

RESULTS

288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change.

CONCLUSIONS

In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality.

Defining sources and ramifications of mistreatment among female vascular surgery trainees

OBJECTIVE

Mistreatment among vascular surgery trainees is a known risk factor for physician burnout. This study aims to characterize forms of and identify sources of mistreatment.

METHODS

This is a cross-sectional study of United States vascular surgery trainees who voluntarily participated in an anonymous survey administered after the 2021 Vascular Surgery In-Training Examination. The primary outcome measures were self-reported mistreatment and sources of mistreatment between genders. Logistic regression was used for multivariable analysis.

RESULTS

Representing all 125 vascular surgery training programs, 510 trainees (66.9% male) participated in the survey (83.6% response rate). Mistreatment was reported by 54.8% of trainees, with twice as many women reporting as men (82.3% vs 41.0%; P < .001). Women reported higher rates of being shouted at (44.1% vs 21.1%; P < .001); repeatedly reminded of errors (24.3% vs 16.1%; P = .04); ignored/treated hostilely (28.9% vs 10.5%; P < .001); subjected to crude/sexually demeaning remarks, stories, jokes (19.2% vs 2.1%; P < .001); evaluated by different standards (29.3% vs 2.1%; P < .001); and mistaken for a non-physician (75.2% vs 3.5%; P < .001). Among trainees reporting bullying, attendings were the most common source (68.5%). Patients and their families were the most common source of sexual harassment (66.7%), gender discrimination (90.4%), and racial discrimination (74.4%). Compared with men, women identified more patients and families as the source of bullying (50.0% vs 29.7%; P = .005), gender discrimination (97.2% vs 50.0%; P < .001), and sexual harassment (78.4% vs 27.3%; P = .003). Compared with men, women more frequently felt unprepared to respond to the behavior in the moment (10.4% vs 4.6%; P = .002), did not know how to report mistreatment at their institution (7.6% vs 3.2%; P = .04), and did not believe that their institution would take their mistreatment report seriously (9.0% vs 3.9%; P = .002). On multivariable analysis, female gender was an independent risk factor for both gender discrimination (odds ratio, 56.62; 95% confidence interval, 27.89-115) and sexual harassment (odds ratio, 26.2; 95% confidence interval, 3.34-14.8) when adjusting for children, training year, relationship status, and training program location.

CONCLUSIONS

A majority of vascular surgery trainees experience mistreatment during training. Sources and forms of abuse are varied. Understanding the sources of mistreatment is critical to guide intervention strategies such as faculty remediation and/or sanctions; allyship training for staff, residents, and faculty; and institutional procedures for patient-initiated abuse.

Early findings and strategies for successful implementation of SIMPL workplace-based assessments within vascular surgery residency and fellowship programs

OBJECTIVE

As medical education systems increasingly move toward competency-based training, it is important to understand the tools available to assess competency and how these tools are utilized. The Society for Improving Medical Professional Learning (SIMPL) offers a smart phone-based assessment system that supports workplace-based assessment of residents' and fellows' operative autonomy, performance, and case complexity. The purpose of this study was to characterize implementation of the SIMPL app within vascular surgery integrated residency (0+5) and fellowship (5+2) training programs.

METHODS

SIMPL operative ratings recorded between 2018 and 2022 were collected from all participating vascular surgery training institutions (n = 9 institutions with 5+2 and 0+5 programs; n = 4 institutions with 5+2 program only). The characteristics of programs, trainees, faculty, and SIMPL operative assessments were evaluated using descriptive statistics.

RESULTS

Operative assessments were completed for 2457 cases by 85 attendings and 86 trainees, totaling 4615 unique operative assessment ratings. Attendings included dictated feedback in 52% of assessments. Senior-level residents received more assessments than junior-level residents (postgraduate year [PGY]1-3, n = 439; PGY4-5, n = 551). Performance ratings demonstrated increases from junior to senior trainees for both resident and fellow cohorts with "performance-ready" or "exceptional performance" ratings increasing by nearly two-fold for PGY1 to PGY5 residents (28.1% vs 40.6%), and from first- to second-year fellows (PGY6, 46.7%; PGY7, 60.3%). Similar gains in autonomy were demonstrated as trainees progressed through training. Senior residents were more frequently granted autonomy with "supervision only" than junior residents (PGY1, 8.7%; PGY5, 21.6%). "Supervision only" autonomy ratings were granted to 21.8% of graduating fellows. Assessment data included a greater proportion of complex cases for senior compared with junior fellows (PGY6, 20.9% vs PGY7, 26.5%). Program Directors felt that faculty and trainee buy-in were the main barriers to implementation of the SIMPL assessment app.

CONCLUSIONS

This is the first description of the SIMPL app as an operative assessment tool within vascular surgery that has been successfully implemented in both residency and fellowship programs. The assessment data demonstrates expected progressive gains in trainees' autonomy and performance, as well as increasing case complexity, across PGY years. Given the selection of SIMPL as the assessment platform for required American Board of Surgery and Vascular Surgery Board Entrustable Professional Activities assessments, understanding facilitators and barriers to implementation of workplace-based assessments using this app is imperative, particularly as we move toward competency-based medical education.

Thromboembolic outcomes are decreased with the use of a standardized venous thromboembolism risk assessment and prophylaxis protocol for patients undergoing superficial venous procedures

OBJECTIVE

Patients with venous insufficiency can be treated with ablation or phlebectomy, or both. Patients undergoing superficial venous procedures have an elevated risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). At our institution, we initiated a standardized protocol in which patients with a Caprini score (2005 version) of ≥8 are treated with 1 week of prophylactic anticoagulation after the procedure. Duplex ultrasound was performed at 1 week and then within 90 days after the procedure. This aim of the present study was to determine the thrombotic and clinical outcomes after superficial vein procedures using a standardized protocol for DVT/PE risk assessment and prophylaxis.

METHODS

We performed a retrospective analysis of prospectively collected data of superficial vein procedures from 2015 to 2021 at a single center. The patient demographics, CEAP (Clinical-Etiology-Anatomy-Pathophysiology) clinical class, venous clinical severity score, patient-reported outcomes, treatment type, Caprini scores, pre- and postoperative anticoagulation use, and outcomes were collected. Descriptive statistics were used for the patient demographics, procedure details, and unadjusted surgical outcomes. Multivariable logistic regression was used to evaluate the relationship between procedure type and DVT and PE after adjusting for patient characteristics, disease severity, periprocedural anticoagulation, and Caprini score.

RESULTS

A total of 1738 limbs were treated with ablation (n = 820), phlebectomy (n = 181), or ablation and phlebectomy (n = 737). More patients were women (67.1%) and White (90.9%). The overall incidence of DVT/PE was 1.4%. Patients undergoing ablation with phlebectomy had higher rates of DVT/PE (2.7%) than those undergoing ablation (0.2%) or phlebectomy alone (1.7%; P < .01). However, only 30% of DVTs were above the knee. On multivariate analysis, only the procedure type predicted for DVT/PE. However, patients undergoing ablation and phlebectomy achieved better patient-reported outcomes (Caprini score, 5.9) compared with those undergoing ablation (Caprini score, 7.2) or phlebectomy (Caprini score, 7.9) alone (P < .01). The best improvement in the venous clinical severity score was seen with phlebectomy alone.

CONCLUSIONS

The expected difference in the DVT/PE rates between high- and low-risk groups did not materialize in our patients, perhaps secondary to the additional chemoprophylaxis prescribed for the high-risk cohort (Caprini score, ≥8). These results call for a randomized trial to assess the efficacy of a standardized protocol in the reduction of DVT/PE after superficial vein procedures.

Nonatherosclerotic Renovascular Hypertension

Renovascular hypertension (RVH) is a secondary form of high blood pressure resulting from impaired blood flow to the kidneys with subsequent activation of the renin-angiotensin-aldosterone system. Often, this occurs due to abnormally small, narrowed, or blocked blood vessels supplying one or both kidneys (ie: renal artery occlusive disease) and is correctable. Juxtaglomerular cells release renin in response to decreased pressure, which in turn catalyzes the cleavage of circulating angiotensinogen synthesized by the liver to the decapeptide angiotensin I. Angiotensin-converting enzyme then cleaves angiotensin I to form the octapeptide angiotensin II, a potent vasopressor and the primary effector of renin-induced hypertension. The effects of angiotensin II are mediated by signaling downstream of its receptors. Angiotensin receptor type 1 is a G-protein-coupled receptor that activates vasoconstrictor and mitogenic signaling pathways resulting in peripheral arteriolar vasoconstriction and increased renal tubular reabsorption of sodium and water which promotes intravascular volume expansion. Angiotensin II stimulates the adrenal cortical release of aldosterone, which promotes renal tubular sodium reabsorption, resulting in volume expansion. Angiotensin II acts on glial cells and regions of the brain responsible for blood pressure regulation increasing renal sympathetic activation. Angiotensin II simulates the release of vasopressin from the pituitary which stimulates thirst and water reabsorption from the kidney to expand the intravascular volume and cause peripheral vasoconstriction (increased sympathetic tone). All of these mechanisms coalesce to increase arterial pressure by way of arteriolar constriction, enhanced cardiac output, and the retention of sodium and water.

Persistent racial discrimination among vascular surgery trainees threatens wellness

OBJECTIVE

Racial/ethnic discrimination is one form of mistreatment and a known risk factor for physician burnout. In the present study, we aimed to characterize the forms and identify the sources of racial/ethnic discrimination among vascular surgery trainees.

METHODS

We performed a cross-sectional study of U.S. vascular surgery trainees who had voluntarily participated in an anonymous survey administered after the 2021 Vascular Surgery In-Training Examination. The primary outcome measures were self-reported mistreatment and sources of mistreatment between race and ethnicity groups. We used χ² tests and logistic regression for bivariate and multivariable analyses, respectively.

RESULTS

Representing all 123 vascular surgery training programs, 510 trainees (66.9% men) participated in the survey (83.6% response rate). Most of the trainees had self-identified as White (53.1%), followed by Asian (24.4%), Hispanic/Latinx (7.6%), Black (4.2%), and other/prefer not to say (10.8%). No significant differences were found in the self-reported duty hour violations among the groups. Black (56.3%) and Asian (36.3%) trainees reported higher rates of racial/ethnic discrimination compared with the White, Hispanic/Latinx, and other/prefer not to say groups (P < .001). Patients and their families were reported as the most common source (74.7%). Other reported sources of discrimination included nurses or staff (60%), attendings (37.4%), co-residents (31.3%), and administration (16.9%). Regarding specific forms of racial discrimination, Black and Asian trainees reported the highest rates of different standards of evaluation (20% and 5.9%, respectively), being mistaken for a nonphysician (50.0% and 5.9%, respectively), slurs and/or hurtful comments (13.3% and 5.9%, respectively), social isolation (13.0% and 1.0%, respectively), and being mistaken for another trainee of the same race/ethnicity (60.0% and 33.7%, respectively). Only 62.5% of Black trainees reported their program/institution would take their mistreatment report seriously compared with the White (88.9%), Hispanic/Latinx (88.2%), Asian (83.2%), and other/prefer not to say (71.4%) trainees (P = .01). On multivariable analysis, female gender (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.44-4.33), Asian race (OR, 6.9; 95% CI, 3.53-13.3), Black race (OR, 13.6; 95% CI, 4.25-43.4), and training in the Southeastern United States (OR, 3.8; 95% CI, 1.17-12.80) were risk factors for racial/ethnic discrimination.

CONCLUSIONS

The results from the survey revealed that racial/ethnic discrimination persists in surgical training programs, with Asian and Black trainees reporting higher rates than other racial and ethnic groups. Overall, patients and family members were the most common source of racial/ethnic discrimination. However, faculty, staff, and co-trainees also contributed to racial/ethnic discrimination. Further interventions that optimize diversity, equity, and inclusion strategies and policies to address all forms of racial/ethnic discrimination with faculty, staff, and patients within the hospital are critically needed.

Fibromuscular Dysplasia and Abdominal Aortic Aneurysms Are Dimorphic Sex-Specific Diseases With Shared Complex Genetic Architecture

BACKGROUND

The risk of arterial diseases may be elevated among family members of individuals having multifocal fibromuscular dysplasia (FMD). We sought to investigate the risk of arterial diseases in families of individuals with FMD.

METHODS

Family histories for 73 probands with FMD were obtained, which included an analysis of 463 total first-degree relatives focusing on FMD and related arterial disorders. A polygenic risk score for FMD (PRSFMD) was constructed from prior genome-wide association findings of 584 FMD cases and 7139 controls and evaluated for association with an abdominal aortic aneurysm (AAA) in a cohort of 9693 AAA cases and 294 049 controls. A previously published PRSAAA was also assessed among the FMD cases and controls.

RESULTS

Of all first degree relatives of probands, 9.3% were diagnosed with FMD, aneurysms, and dissections. Aneurysmal disease occurred in 60.5% of affected relatives and 5.6% of all relatives. Among 227 female first-degree relatives of probands, 4.8% (11) had FMD, representing a relative risk (RR)FMD of 1.5 ([95% CI, 0.75-2.8]; P=0.19) compared with the estimated population prevalence of 3.3%, though not of statistical significance. Of all fathers of FMD probands, 11% had AAAs resulting in a RRAAA of 2.3 ([95% CI, 1.12-4.6]; P=0.014) compared with population estimates. The PRSFMD was found to be associated with an AAA (odds ratio, 1.03 [95% CI, 1.01-1.05]; P=2.6×10-3), and the PRSAAA was found to be associated with FMD (odds ratio, 1.53 [95% CI, 1.2-1.9]; P=9.0×10-5) as well.

CONCLUSIONS

FMD and AAAs seem to be sex-dimorphic manifestations of a heritable arterial disease with a partially shared complex genetic architecture. Excess risk of having an AAA according to a family history of FMD may justify screening in family members of individuals having FMD.

Physician Wellness in Academic Cardiovascular Medicine: A Scientific Statement From the American Heart Association

Academic medicine as a practice model provides unique benefits to society. Clinical care remains an important part of the academic mission; however, equally important are the educational and research missions. More specifically, the sustainability of health care in the United States relies on an educated and expertly trained physician workforce directly provided by academic medicine models. Similarly, the research charge to deliver innovation and discovery to improve health care and to cure disease is key to academic missions. Therefore, to support and promote the growth and sustainability of academic medicine, attracting and engaging top talent from fellows in training and early career faculty is of vital importance. However, as the health care needs of the nation have risen, clinicians have experienced unprecedented demand, and individual wellness and burnout have been examined more closely. Here, we provide a close look at the unique drivers of burnout in academic cardiovascular medicine and propose system-level and personal interventions to support individual wellness in this model.

In-situ Bypass Is Associated with Superior Infection-free Survival Compared to Extra-Anatomic Bypass for the Management of Secondary Aortic Graft Infections Without Enteric Involvement

OBJECTIVE

The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI.

METHODS

A retrospective, multi-institutional study of AGI from 2002-2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed.

RESULTS

241 patients at 34 institutions from 7 countries presented with AGI during the study period (median age 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%) and 66 endografts (27%) and 3 unknown (2%). 172 (71%) of the patients underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (NAIS) (24%), and cryopreserved allograft (41%). 69 patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier (KM) estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB versus EAB, there was a significant difference in KM estimated infection-free survival (2910 days, IQR 391, 3771 versus 180 days, IQR 27, 3750 days; p<0.001). There were otherwise no significant differences in presentation, comorbidities, nor perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (HR 2.4, 95% CI 1.6-3.6; p<0.001), polymicrobial infection (HR 2.2, 95% CI 1.4-3.5; p=0.001), MRSA infection (HR 1.7, 95% CI 1.1-2.7; p=0.02), as well as the protective effect of omental/muscle flap coverage (HR 0.59, 95% CI 0.37-0.92; p=0.02).

CONCLUSIONS

After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two-and-half fold higher re-infection/mortality compared to ISB. Omental and/or muscle flap coverage of the repair appear protective.

Overcoming COVID-19: Strategies to Mitigate the Perpetuated Gender Achievement Gap

Sex inequity in academic achievement was well documented before the COVID-19 pandemic, and evolving data suggest that women in academic surgery are disproportionately disadvantaged by the pandemic. This perspective piece reviews currently accepted solutions to the sex achievement gap, with their associated shortcomings. We also propose innovative strategies to overcoming barriers to sex equity in academic medicine that broadly fall into three categories: strategies to mitigate inequitable caregiving responsibilities, strategies to reduce cognitive load, and strategies to value uncompensated, impactful work. These approaches address inequities at the system-level, as opposed to the individual-level, lifting the burden of changing the system from women.

Prevalence and risk factors for burnout in U.S. vascular surgery trainees

OBJECTIVE

Burnout and suicidality are known risks for vascular surgeons above other surgical subspecialties, with surgical trainees at risk for exposure to factors that increase burnout. This study aimed to inform initiatives to improve wellness by assessing the prevalence of hazards in vascular training (mistreatment, duty-hour violations) and the rates of wellness outcomes (burnout, thoughts of attrition/specialty change/suicide). We hypothesized that mistreatment and duty-hour violations would predispose trainees to increased burnout.

METHODS

We performed a cross-sectional study of residents and fellows enrolled in accredited United States vascular surgery training programs using a voluntary, confidential survey administered during the 2020 Vascular Surgery In-Training Examination. The primary outcome assessed was burnout symptoms reported on a weekly basis or more frequently. The rates of wellness outcomes were measured. The association of mistreatment and duty hours with the primary outcome was modeled with multivariable logistic regression.

RESULTS

A total of 475 residents and fellows who were enrolled in one of 120 vascular surgery training programs completed the survey (84.2% response rate). Of 408 trainees completing burnout survey items, 182 (44.6%) reported symptoms of burnout. Fewer trainees reported thoughts of attrition (n = 42 [10.0%], specialty change (n = 35 [8.4%]), or suicide (n = 22 [4.9%]). Mistreatment was reported by 191 vascular trainees (47.3%) and was more common in female trainees (n = 63 [48.5%] reporting monthly or more frequently) compared with male trainees (n = 51 [18.6%]; P < .001). Duty-hour violations were also more commonly reported by female trainees (n = 31 [21.4%] reporting 3+ months in violation) compared with male trainees (n = 50 [16.2%]; P = .002). After controlling for race/ethnicity, postgraduate year, program type, and geography, female trainees were less likely to report burnout (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28-0.86). Trainees experiencing mistreatment monthly or more were three times more likely to report burnout (OR, 3.09; 95% CI, 1.78-5.39). Frequency of duty-hour violations also increased the odds of reporting burnout (1-2 months in violation: OR, 2.09; 95% CI, 1.17-3.73; 3+ months in violation: OR, 3.95; 95% CI, 2.24-6.97).

CONCLUSIONS

Nearly one-half of vascular surgery trainees reported symptoms of burnout, which was associated with frequency of mistreatment and duty-hour violations. Interventions to improve well-being in vascular surgery must be tailored to the local training environment to address trainee experiences that contribute to burnout.

Trainee Reliance on Public Service Loan Forgiveness

OBJECTIVE

The Public Service Loan Forgiveness (PSLF) program is an option to trainees to help alleviate federal education debt. The prevalence of PSLF utilization and how this may impact career decisions of trainees is unknown. The purpose of this study was to understand the prevalence, impact, and understanding of PSLF participation on trainees.

DESIGN

IRB-approved anonymous survey asking study subjects to report demographics, financial status, and reliance on PSLF. In addition, study subjects were asked to report their participation in PSLF, the possible impact of PSLF participation on career decisions, and to identify the qualifications needed to complete PSLF.

SETTING

Online anonymous survey.

PARTICIPANTS

The survey was offered to all physician trainees in all specialties at the University of Texas, Southwestern, University of Wisconsin, Madison, and University of Michigan, Ann Arbor.

RESULTS

There were 934 respondents, yielding a 37.6% response rate. A total of 416/934 (44.5%) respondents were actively or planning on participating in the PSLF program with 175/934 (18.7%) belonging to a surgical specialty. Those belonging to a surgical specialty were more likely to be PSLF participants compared to medical specialties (53.1% versus 42.6%, p = 0.01). For those participating in PSLF, 82/416 (19.7%) stated this participation impacted career decisions. A total of 275/934 (29.4%) respondents obtained and 437/934 (46.8%) wanted to receive formal training/lectures in regards to the PSLF program. Of those actively or planning on participating in the PSLF program, only 58/416 (13.9%) were able to correctly identify all of the qualifications/criteria to complete the program.

CONCLUSIONS

A large proportion of trainees rely on the PSLF program for education loan forgiveness with approximately 20% reporting participation impacted career decisions. Additionally, the majority may not fully understand PSLF criteria. Programs should strongly consider providing a formal education regarding PSLF to their trainees.

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.

Genetic investigation of fibromuscular dysplasia identifies risk loci and shared genetics with common cardiovascular diseases

Fibromuscular dysplasia (FMD) is an arteriopathy associated with hypertension, stroke and myocardial infarction, affecting mostly women. We report results from the first genome-wide association meta-analysis of six studies including 1556 FMD cases and 7100 controls. We find an estimate of SNP-based heritability compatible with FMD having a polygenic basis, and report four robustly associated loci (PHACTR1, LRP1, ATP2B1, and LIMA1). Transcriptome-wide association analysis in arteries identifies one additional locus (SLC24A3). We characterize open chromatin in arterial primary cells and find that FMD associated variants are located in arterial-specific regulatory elements. Target genes are broadly involved in mechanisms related to actin cytoskeleton and intracellular calcium homeostasis, central to vascular contraction. We find significant genetic overlap between FMD and more common cardiovascular diseases and traits including blood pressure, migraine, intracranial aneurysm, and coronary artery disease.

Molecular genetic evaluation of Pediatric Renovascular hypertension due to renal artery stenosis and abdominal aortic Coarctation in Neurofibromatosis type 1

The etiology of renal artery stenosis (RAS) and abdominal aortic coarctation (AAC) causing the midaortic syndrome (MAS), often resulting in renovascular hypertension (RVH), remains ill-defined. Neurofibromatosis type 1 (NF-1) is frequently observed in children with RVH. Consecutive pediatric patients (N = 102) presenting with RVH secondary to RAS with and without concurrent AAC were prospectively enrolled in a clinical data base, and blood, saliva, and operative tissue when available, were collected. Among the 102 children were 13 having a concurrent clinical diagnosis of NF-1 (12.5%). Whole exome sequencing was performed for germline variant detection and RNASeq analysis of NF1, MAPK pathway genes, and MCP1 levels were undertaken in five NF-1 stenotic renal arteries, as well as control renal and mesenteric arteries from children with no known vasculopathy or NF-1. In 11 unrelated children with sequencing data, 11 NF1 genetic variants were identified, of which 10 had not been reported in gnomAD. Histologic analysis of NF-1 RAS specimens consistently revealed intimal thickening, disruption of the internal elastic lamina, and medial thinning. Analysis of transcript expression in arterial lesions documented an approximately 5-fold reduction in NF1 expression, confirming heterozygosity, MAPK pathway activation, and increased MCP1 expression. In summary, NF-1 related RVH in children is rare but often severe and progressive and as such, important to recognize. It is associated with histologic and molecular features consistent with an aggressive adverse vascular remodeling process. Further research is necessary to define the mechanisms underlying these findings.

Malpractice Allegations Against Vascular Surgeons:Prevalence, Risk Factors, and Impact on Surgeon Wellness

OBJECTIVES

The contemporary medicolegal environment has been linked to procedure overuse, healthcare variation, and higher costs. For physicians accused of malpractice, there is also a personal toll. The objective of this study was to evaluate the prevalence of and risk factors for involvement in medical malpractice lawsuits among US vascular surgeons, and to examine the association between these allegations with surgeon wellness.

METHODS

In 2018, the Society of Vascular Surgery (SVS) Wellness Task Force conducted a confidential survey of active members using a validated burnout assessment (Maslach Burnout Index) embedded into a questionnaire. This survey included questions related to medical errors and malpractice litigation. De-identified demographic, personal, and practice-related characteristics were assessed in respondents who reported malpractice allegations in the preceding two years, then compared to those without recent medicolegal litigation. Risk factors for malpractice allegations were identified (chi-square, Kruskal-Wallis tests), and the association between malpractice allegations with wellness was examined. Multivariate logistic regression models were developed to identify independent risk factors for malpractice accusations.

RESULTS

Of 2905 active SVS members, 871 responses from practicing vascular surgeons were analyzed. 161 (18.5%) were named in a malpractice lawsuit within two years. Malpractice allegations were significantly associated with surgeon burnout [OR 1.47 (1.01, 2.15), p=0.041], but not with self-reported depression or suicidal ideation. The nature of malpractice claims included procedural errors (23.1%), failure to treat (18.8%) and error/delay in diagnosis (16.9%). 20% of claims were settled prior to trial and 19% were dismissed. Defendant vascular surgeons reported a "fair" resolution in 26.4% of closed cases. By unadjusted analysis, factors significantly associated with recent malpractice claims included mean age (51.7+/-10.0 vs. 49.3+/-11.2; p=0.0044) and mean years in practice (18.0+/-10.7 vs. 15.2+/-11.8; p=0.0007). Multivariate analysis revealed independent variables associated with malpractice allegations, including on-call frequency (p=0.0178), recent medical errors (p=0.0189), and male surgeons (p=0.045).

CONCLUSIONS

Malpractice allegations are common for vascular surgeons and are significantly associated with surgeon burnout. Nearly 20% of survey respondents reported being named in a lawsuit within the preceding two years. Our findings underscore the need for SVS initiatives to provide counseling and peer support for vascular surgeons facing litigation.

Interview Experience, Post-interview Communication and Gender-based Differences in the Integrated Vascular Surgery Residency Match

OBJECTIVE

Integrated vascular surgery residency (IVSR) applicant perspective about the Match process has been rarely studied, yet has important implications on trainee recruitment. We sought to better understand the nature of the interview process, and post-interview communication and its impact on students' ranking choices.

METHODS

A voluntary and anonymous survey was sent to students who matched to IVSR in 2020, inquiring about interviews, post-interview communications and factors influencing students' rank-lists.

RESULTS

70 of the 73 matched students completed the survey (96% response rate; 23 female and 47 male). Applicants reported they were asked questions about other programs of interest (81.4%), top choice programs (65.7%), marital-status (32.9%), family-planning (7.1%) and religion (1.4%) during interviews. Female applicants were more frequently asked questions about family-planning (17.4% vs 2.1%; P<.01) and marital-status (52.5% vs 23.4%; P <.01) compared to male applicants. After interviews, 92.9% of applicants notified their top choice program of their ranking preference. 61.4% of applicants received post-interview communication with regards to ranking from at least one program, initiated by program directors in 81.3% of instances. Among these applicants, 58.1% reported that the post-interview communication had an impact on their rank-list and 46.5% matched at a program by which they were contacted. 5.7% of applicants were asked by a program to reveal their ranking of the program and 11.4% were promised by a program to be ranked first if the applicant reciprocally ranked them first. Female and male applicants weighed program culture, operative volume, mentorship and prestige equally in making their rank-list. Male applicants weighed the sub-internship experience more significantly; however, female applicants weighed the sub-internship experience, personal relationships in certain cities, dedicated professional development years and large female representation in the program more heavily (P<.02).

CONCLUSIONS

This study provides insight into the interview experience and impactful factors for the vascular surgery match. Both female and male applicants were asked a high number of questions about personal matters unrelated to medical school performance. Female applicants, however, experienced a higher proportion of these instances, particularly regarding family-planning. These findings demonstrate the factors that are important to applicants in the match process and raises awareness of potential challenges in the interview and recruitment process.

Factors influencing medical student choices in the integrated vascular surgery match: Implications for future post-pandemic residency matches

OBJECTIVE

Integrated vascular surgery residency is among the most competitive specialties, but little is known about the applicant perspective. The coronavirus disease 2019 outbreak impacted the 2021 integrated vascular surgery residency match because of travel restrictions. We sought to better understand pre-pandemic applicant recruitment strategies, logistics of away rotations, and the residency interview process to identify areas for improvement in the application process.

METHODS

An anonymous survey was sent to matched students in 2020, inquiring about motivations for pursuing vascular surgery (VS), logistic of away rotations and interviews, and factors influencing students' rank lists.

RESULTS

Seventy of the 73 matched students completed the survey (95.9% response rate). The median age was 27 (range, 25-41); 32.9% were female, 91.4% were U.S. medical students, and 77.1% were from institutions with a VS training program. Factors most strongly influencing the decision to choose VS as a career were interest in open vascular procedures, endovascular procedures, perceived job satisfaction, emerging technologies, and influence of a mentor. The prospect of the job market, future salary, and competitiveness of the application process had the least impact. Of the matched students, 82.9% completed an away rotation (median, 2; range, 1-4), with 51.7% of students paying a total cost of more than $2500. Fifty percent of students matched either at their home institution or where they had performed an away rotation. Students reported application submissions to a median of 50 programs (range, 1-70) and interviewed at 17 (range, 1-28), with 40% of students paying a total of more than $4000 for interview costs. The most significant factors affecting students' rank lists included program culture, open aortic surgical volume, geography, and complex endovascular procedure volume. Tours of facilities, resident salary, and male/female distribution had the least importance.

CONCLUSIONS

Successfully matched applicants in 2020 prioritized operative case volume and program collegiality when ranking programs. Despite their high cost, away rotations played an important role in the Match, suggesting that time spent at potential institutions allowed ideal assessment of factors for students. The high average number of away rotations and in-person interviews performed in 2019-2020 was limited for the 2021 Match due to coronavirus disease 2019 restrictions. Programs will have to continue developing creative alternatives or additions to away rotations and the application processes to assure continued success in future post-pandemic Match cycles.

Trainee Wellness and Safety in the Context of COVID-19: The Experience of One Institution

The COVID-19 pandemic has had significant ramifications for provider well-being. During these unprecedented and challenging times, one institution's Department of Surgery put in place several important initiatives for promoting the well-being of trainees as they were redeployed to provide care to COVID-19 patients. In this article, the authors describe these initiatives, which fall into 3 broad categories: redeploying faculty and trainees, ensuring provider safety, and promoting trainee wellness. The redeployment initiatives are the following: reframing the team mindset, creating a culture of grace and forgiveness, establishing a multidisciplinary wellness committee, promoting centralized leadership, providing clear communication, coordinating between departments and programs, implementing phased restructuring of the department's services, establishing scheduling flexibility and redundancy, adhering to training regulations, designating a trainee ombudsperson, assessing physical health risks for high-risk individuals, and planning for structured deimplementation. Initiatives specific to promoting provider safety are appointing a trainee safety advocate, guaranteeing personal protective equipment and relevant information about these materials, providing guidance regarding safe practices at home, and offering alternative housing options when necessary. Finally, the initiatives put in place to directly promote trainee wellness are establishing an environment of psychological safety, providing mental health resources, maintaining the educational missions, solidifying a sense of community by showing appreciation, being attentive to childcare, and using social media to promote community morale. The initiatives to carry out the department's strategy presented in this article, which were well received by both faculty and trainee members of the authors' community, may be employed in other departments and even outside the context of COVID-19. The authors hope that colleagues at other institutions and departments, independent of specialty, will find the initiatives described here helpful during, and perhaps after, the pandemic as they develop their own institution-specific strategies to promote trainee wellness.

The impact of the COVID-19 pandemic on vascular surgery practice in the United States

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has led to widespread postponement and cancelation of elective surgeries in the United States. We designed and administered a global survey to examine the impact of COVID-19 on vascular surgeons. We describe the impact of the pandemic on the practices of vascular surgeons in the United States.

METHODS

The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons is an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force disseminated April 14 to 24, 2020. This analysis focuses on pattern changes in vascular surgery practices in the United States including the inpatient setting, ambulatory, and vascular laboratory setting. Specific questions regarding occupational exposure to COVID-19, adequacy of personal protective equipment, elective surgical practice, changes in call schedule, and redeployment to nonvascular surgery duties were also included in the survey. Regional variation was assessed. The survey data were collected using REDCap and analyzed using descriptive statistics.

RESULTS

A total of 535 vascular surgeons responded to the survey from 45 states. Most of the respondents were male (73.1%), white (70.7%), practiced in urban settings (81.7%), and in teaching hospitals (66.8%). Almost one-half were in hospitals with more than 400 beds (46.4%). There was no regional variation in the presence of preoperative COVID-19 testing, COVID-19 OR protocols, adherence to national surgical standards, or the availability of personal protective equipment. The overwhelming majority of respondents (91.7%) noted elective surgery cancellation, with the Northeast and Southeast regions having the most case cancellations 94.2% and 95.8%, respectively. The Northeast region reported the highest percentage of operations or procedures on patients with COVID-19, which was either identified at the time of the surgery or later in the hospital course (82.7%). Ambulatory visits were performed via telehealth (81.3%), with 71.1% having restricted hours. More than one-half of office-based laboratories (OBLs) were closed, although there was regional variation with more than 80% in the Midwest being closed. Cases performed in OBLs focused on critical limb ischemia (42.9%) and dialysis access maintenance (39.9%). Call schedules modifications were common, although the number of call days remained the same (45.8%).

CONCLUSIONS

Vascular surgeons in the United States report substantial impact on their practices during the COVID-19 pandemic, and regional variations are demonstrated, particularly in OBL use, intensive care bed availability, and COVID-19 exposure at work.

Global vascular surgeons' experience, stressors, and coping during the coronavirus disease 2019 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges for health care systems globally. We designed and administered a global survey to examine the effects of COVID-19 on vascular surgeons and explore the COVID-19-related stressors faced, coping strategies used, and support structures available.

METHODS

The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons was an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force. The survey analysis evaluated the effects of COVID-19-related stressors on vascular surgeons measured using the Generalized Anxiety Disorder 7-item scale. The 28-item Brief Coping Orientation to Problems Experienced inventory was used to assess the active and avoidant coping strategies. Survey data were collected using REDCap (Research Electronic Data Capture) from April 14, 2020 to April 24, 2020 inclusive. Additional qualitative data were collected using open-ended questions. Univariable and multivariable analyses of the factors associated with the anxiety levels and qualitative analysis were performed.

RESULTS

A total of 1609 survey responses (70.5% male; 82.5% vascular surgeons in practice) from 58 countries (43.4% from United States; 43.4% from Brazil) were eligible for analysis. Some degree of anxiety was reported by 54.5% of the respondents, and 23.3% reported moderate or severe anxiety. Most respondents (∼60%) reported using active coping strategies and the avoidant coping strategy of "self-distraction," and 20% used other avoidant coping strategies. Multivariable analysis identified the following factors as significantly associated with increased self-reported anxiety levels: staying in a separate room at home or staying at the hospital or a hotel after work (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.08-1.79), donning and doffing personal protective equipment (OR, 1.81; 95% CI, 1.41-2.33), worry about potential adverse patient outcomes due to care delay (OR, 1.47; 95% CI, 1.16-1.87), and financial concerns (OR, 1.90; 95% CI, 1.49-2.42). The factors significantly associated with decreased self-reported anxiety levels were hospital support (OR, 0.83; 95% CI, 0.76-0.91) and the use of positive reframing as an active coping strategy (OR, 0.88; 95% CI, 0.81-0.95).

CONCLUSIONS

Vascular surgeons globally have been experiencing multiple COVID-19-related stressors during this devastating crisis. These findings have highlighted the continued need for hospital systems to support their vascular surgeons and the importance of national societies to continue to invest in peer-support programs as paramount to promoting the well-being of vascular surgeons during and after the COVID-19 pandemic.

The initial experience and response of vascular surgeons in Michigan during the COVID-19 pandemic

BACKGROUND/OBJECTIVE

The unprecedented pandemic spread of the novel coronavirus has severely impacted the delivery of healthcare services in the United States and around the world, and has exposed a variety of inefficiencies in healthcare infrastructure. Some states have been disproportionately affected such as New York and Michigan. In fact, Detroit and its surrounding areas have been named as the initial Midwest epicenter where over 106,000 cases have been confirmed in April 2020.Method, Results and Conclusions: Facilities in Southeast Michigan have served as the frontline of the pandemic in the Midwest and in order to cope with the surge, rapid, and in some cases, complete restructuring of care was mandatory to effect change and attempt to deal with the emerging crisis. We describe the initial experience and response of 4 large vascular surgery health systems in Michigan to COVID-19.

Vascular surgeon wellness and burnout: A report from the Society for Vascular Surgery Wellness Task Force

INTRODUCTION

Physician burnout has been linked to medical errors, decreased patient satisfaction, and decreased career longevity. In light of the increasing prevalence of cardiovascular disease, vascular surgeon burnout presents a legitimate public health concern owing to the impact on the adequacy of the vascular surgery workforce. The aims of this study were to define the prevalence of burnout among practicing vascular surgeons and identify factors that contribute to burnout to facilitate future Society for Vascular Surgery (SVS) initiatives to mitigate this crisis.

METHODS

In 2018, active SVS members were surveyed electronically and confidentially using the Maslach Burnout Inventory. The survey was tailored to explore specialty-specific issues, and to capture demographic and practice-related characteristics. Emotional exhaustion (EE) and depersonalization (DP) were analyzed as dimensions of burnout. Consistent with convention, surgeons with a high score on the DP and/or EE subscales of the Maslach Burnout Inventory were considered to have at least one manifestation of professional burnout. Risk factors associated with symptoms of burnout were identified using bivariate analyses (χ², Kruskal-Wallis). Multivariate logistic regression models were developed to identify independent risk factors for burnout.

RESULTS

Of 2905 active SVS members, 960 responded to the survey (34% participation rate). After excluding retired surgeons and incomplete submissions, responses from 872 practicing vascular surgeons were analyzed. The mean age was 49.7 ± 11.0 years; the majority of respondents (81%) were male. Primary practice settings were academic (40%), community practice (41%), veteran's hospital (3.3%), active military practice (1.5%), or other. Years in practice averaged 15.7 ± 11.7. Overall, 41% of respondents had at least one symptoms of burnout (ie, high EE and/or high DP), 37% endorsed symptoms of depression in the past month, and 8% indicated they had considered suicide in the last 12 months. In unadjusted analysis, factors significantly associated with burnout (P < .05) included clinical work hours, on-call frequency, electronic medical record and documentation requirements, work-home conflict, and work-related physical pain. On multivariate analysis, age, work-related physical pain and work-home conflict were independent predictors for burnout.

CONCLUSIONS

Symptoms of burnout and depression are common among vascular surgeons. Advancing age, work-related physical pain, and work-home conflict are independent predictors for burnout among vascular surgeons. Efforts to promote vascular surgeon well-being must address specialty-specific challenges, including the high prevalence of work-home conflict and occupational factors that contribute to work-related pain.

The Impact of the COVID-19 Pandemic on Vascular Surgery Trainees in the United States

BACKGROUND

The impact of the coronavirus disease 19 (COVID-19) pandemic on health care workers has been substantial. However, the impact on vascular surgery (VS) trainees has not yet been determined. The goals of our study were to gauge the impact of COVID-19 on VS trainees' personal and professional life and to assess stressors, coping, and support structures involved in these trainees' response to the COVID-19 pandemic.

METHODS

This was an anonymous online survey administered in April 12-24, 2020 during the surge phase of the global COVID-19 pandemic. It is a subset analysis of the cross-sectional Society for Vascular Surgery Wellness Committee Pandemic Practice, Anxiety, Coping, and Support Survey. The cohort surveyed was VS trainees, integrated residents and fellows, in the United States of America. Assessment of the personal impact of the pandemic on VS trainees and the coping strategies used by them was based on the validated Generalized Anxiety Disorder 7-item (GAD-7) scale and the validated 28-time Brief Coping Orientation to Problems Experienced inventory.

RESULTS

A total of 145 VS trainees responded to the survey, with a 23% response rate (145/638). Significant changes were made to the clinical responsibilities of VS trainees, with 111 (91%) reporting cancellation of elective procedures, 101 (82%) with call schedule changes, 34 (24%) with duties other than related to VS, and 29 (24%) participation in outpatient care delivery. Over one-third (52/144) reported they had performed a procedure on a patient with confirmed COVID-19; 37 (25.7%) reported they were unaware of the COVID-19 status at the time. The majority continued to work after exposure (29/34, 78%). Major stressors included concerns about professional development, infection risk to family/friends, and impact of care delay on patients. The median score for GAD-7 was 4 (interquartile range 1-8), which corresponds to no or low self-reported anxiety levels. VS trainees employed mostly active coping and rarely avoidant coping mechanisms, and the majority were aware and used social media and online support systems. No significant difference was observed between integrated residents and fellows, or by gender.

CONCLUSIONS

The pandemic has had significant impact on VS trainees. Trainees reported significant changes to clinical responsibilities, exposure to COVID-19, and pandemic-related stressors but demonstrated healthy coping mechanisms with low self-reported anxiety levels. The VS community should maintain awareness of the impact of the pandemic on the professional and personal development of surgeons in training. We recommend adaptive evolution in training to accommodate the changing learning environment for trainees.

A Novel Recurrent COL5A1 Genetic Variant Is Associated With a Dysplasia-Associated Arterial Disease Exhibiting Dissections and Fibromuscular Dysplasia

OBJECTIVE

While rare variants in the COL5A1 gene have been associated with classical Ehlers-Danlos syndrome and rarely with arterial dissections, recurrent variants in COL5A1 underlying a systemic arteriopathy have not been described. Monogenic forms of multifocal fibromuscular dysplasia (mFMD) have not been previously defined. Approach and Results: We studied 4 independent probands with the COL5A1 pathogenic variant c.1540G>A, p.(Gly514Ser) who presented with arterial aneurysms, dissections, tortuosity, and mFMD affecting multiple arteries. Arterial medial fibroplasia and smooth muscle cell disorganization were confirmed histologically. The COL5A1 c.1540G>A variant is predicted to be pathogenic in silico and absent in gnomAD. The c.1540G>A variant is on a shared 160.1 kb haplotype with 0.4% frequency in Europeans. Furthermore, exome sequencing data from a cohort of 264 individuals with mFMD were examined for COL5A1 variants. In this mFMD cohort, COL5A1 c.1540G>A and 6 additional relatively rare COL5A1 variants predicted to be deleterious in silico were identified and were associated with arterial dissections (P=0.005).

CONCLUSIONS

COL5A1 c.1540G>A is the first recurring variant recognized to be associated with arterial dissections and mFMD. This variant presents with a phenotype reminiscent of vascular Ehlers-Danlos syndrome. A shared haplotype among probands supports the existence of a common founder. Relatively rare COL5A1 genetic variants predicted to be deleterious by in silico analysis were identified in ≈2.7% of mFMD cases, and as they were enriched in patients with arterial dissections, may act as disease modifiers. Molecular testing for COL5A1 should be considered in patients with a phenotype overlapping with vascular Ehlers-Danlos syndrome and mFMD.

Brazilian vascular surgeons experience during the coronavirus (COVID-19) pandemic

Background

The COVID-19 pandemic has made a significant impact on all spheres of society. The objective of this study was to examine the impact of COVID-19 on the practices, finances, and social aspects of Brazilian vascular surgeons’ lives.

Methods

This is a descriptive analysis of the responses from Brazilian vascular surgeons to the cross-sectional anonymous Society for Vascular Surgery Wellness Task Force Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons disseminated 14–24 April 2020. Survey dissemination in Brazil occurred mainly via the Brazilian Society of Angiology and Vascular Surgery (SBACV) and social media. The survey evaluated the impact of the COVID-19 pandemic on vascular surgeons’ lives by assessing COVID-19-related stressors, anxiety using theGeneral Anxiety Disorder (GAD)-7 scale, and coping strategies using the Brief Coping Orientation to Problems Experienced (Brief-COPE) inventory.

Results

A total of 452 responses were recorded from Brazil, with 335 (74%) respondents completing the entire survey. The majority of respondents were males (N = 301, 67%) and practiced in an urban hospitals. The majority of respondents considered themselves at high risk to be infected with COVID-19 (N = 251, 55.8%), and just over half the respondents noted that they had adequate PPE at their primary hospital (N = 171, 54%). One hundred and nine (35%) surgeons confirmed that their hospitals followed professional surgical society guidelines for prioritizing surgeries during the pandemic. At the time of the survey, only 33 (10%) surgeons stated they have pre-operative testing of patients for COVID-19 available at their hospital. Academic vascular surgeons reported being redeployed more often to help with other non-vascular duties compared to community-based or solo practitioners (43% vs. 30% vs. 21% respectively, P = .01). Severe anxiety due to pandemic-related financial concerns was similar in those surgeons practicing solo compared to those in community- or academic-based/group practice (46% vs. 38% vs. 22%; P = .54). The respondents reported their anxiety levels as mild based on the stressors investigated instead of moderate-severe (54% vs. 46%; P = .04). Social media was utilized heavily during the pandemic, with video gatherings being the most commonly used tool (76%). Self-distraction (60%) and situational acceptance (81%) were the most frequently reported coping mechanisms used among Brazilian vascular surgeons.

Conclusion

The COVID pandemic has greatly affected healthcare providers around the world. At the time of this survey, Brazilian vascular surgeons are reporting low anxiety levels during this time and are using mostly active coping mechanisms.

Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355520953759] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.06.008]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/)

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT.

One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed.

Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

Closed plication is a safe and effective method for treating popliteal vein aneurysm

BACKGROUND

Popliteal vein aneurysms are a rare vascular anomaly first reported in the 1980s. Degeneration of elastic fibers and smooth muscle cell reduction, possibly secondary to inflammation, are implicated as integral steps in the development of these aneurysms. Given the rarity of this clinical entity, significant controversy exists regarding ideal treatment strategies, including the role of observation, medical management with anticoagulation, and surgical intervention. Retrospective reviews have demonstrated a failure rate of >40% with anticoagulation alone, with patients often presenting with pulmonary embolism. This has prompted our institutional preference for surgical management once the aneurysm is identified. Surgical management involves tangential repair with lateral venorrhaphy most commonly, followed in prevalence by aneurysm resection and end-to-end anastomosis either primarily or with vein interposition. Herein, we report our results with venous plications, through both closed and open techniques.

METHODS

We performed a retrospective review of prospectively collected data for 10 patients undergoing popliteal vein plication for treatment of popliteal vein aneurysms. Patient-level characteristics and operative details were examined from periprocedural and follow-up records.

RESULTS

We identified 10 patients undergoing popliteal vein plication, including 9 closed plications and 1 open plication. The average aneurysm size at presentation was 2.35 ± 0.69 cm for closed plication and 4.74 cm for the one open plication. After treatment, the average popliteal vein size was significantly reduced to 1.12 ± 0.45 cm for the closed plications (P < .001 from preprocedural size) and 1.13 cm for the open plication with 100% primary patency. Average follow-up for patients treated with closed plication was 35.0 ± 25.2 months, during which seven (78%) patients had a stable, normal popliteal vein size. One patient with recurrence was diagnosed with Klippel-Trénaunay syndrome. The other had degeneration of the popliteal vein cranial to the previous repair at 39 months after the original operation that required additional plication. The open plication patient experienced a hematoma requiring washout and resulting in a transient peroneal mononeuropathy. There was one case of cellulitis after closed plication but no hematomas within this group.

CONCLUSIONS

Closed plication demonstrated favorable primary patency rates and low recurrence rates, avoiding technical issues or need for early institution of systemic anticoagulation associated with tangential repair and venorrhaphy or resection methods. Closed plication represents an attractive option in patients without luminal thrombus to limit the risk of these postoperative complications and obviates the need for bypass conduit and postoperative anticoagulation.

Histologic and morphologic character of pediatric renal artery occlusive disease

OBJECTIVE

The pathologic nature of pediatric renal artery occlusive lesions causing renovascular hypertension has been the subject of numerous anecdotal reports. This study was undertaken to define the character of childhood renal artery stenoses. A better understanding of this disease is particularly germane, given its unknown etiology and the limited success of certain contemporary treatment options.

METHODS

Renal artery specimens obtained during open operations in children being treated for renovascular hypertension from 2004 to 2016 were studied. Excluded from study were arteries subjected to earlier open or endovascular operations. Histologic preparations employing hematoxylin-eosin, Movat, Masson trichrome, and Verhoeff-van Gieson stains allowed characterization of the intima, media, and adventitial tissues. External and luminal diameters were measured. Microscopic data were correlated with preoperative arteriographic images. The histologic and morphologic findings were assessed in regard to coexistent nonrenal arterial and aortic lesions as well as known syndromic diseases.

RESULTS

Thirty-three stenotic renal arteries from 28 children were subjected to examination. Stenoses involved the proximal-ostial renal arteries (24), central renal arteries (7), and distal segmental renal arteries (2). Ostial stenoses commonly exhibited preocclusive concentric hyperplasia of intimal tissues, frequent internal elastic lamina disruptions, and diminutive and discontinuous media. Central and distal renal stenoses most often exhibited lesser intimal cellular hyperplasia and more noticeable fibrodysplasia of the media and adventitia. The mean external and luminal diameters of the renal arteries having ostial stenoses were smaller than the expected renal artery size for a given age. Abdominal aortic coarctation or hypoplastic aortas occurred in 14 children. Neurofibromatosis type 1 affected four children with ostial renal artery disease and one child with midrenal artery disease, but there were no distinguishing features unique to their stenoses.

CONCLUSIONS

Pediatric renal artery stenotic disease affects exceedingly small arteries. Ostial lesions frequently exhibit extensive luminal encroachments characterized by cellular hyperplasia of intimal tissues and scant medial smooth muscle. Central and distal renal arterial stenoses were characterized most often by extensive fibrodysplasia of the media and adventitia. The early success and durability of catheter-based angioplasty may be compromised by the cellular abnormalities of pediatric renal artery occlusive disease observed in this investigation.

Surgical management of pediatric renin-mediated hypertension secondary to renal artery occlusive disease and abdominal aortic coarctation

BACKGROUND

Renovascular hypertension (RVH) associated with renal artery and abdominal aortic narrowings is the third most common cause of pediatric hypertension. Untreated children may experience major cardiopulmonary complications, stroke, renal failure, and death. The impetus of this study was to describe the increasingly complex surgical practice for such patients with an emphasis on anatomic phenotype and contemporary outcomes after surgical management as a means of identifying those factors responsible for persistent or recurrent hypertension necessitating reoperation.

METHODS

A retrospective analysis was performed of consecutive pediatric patients with RVH undergoing open surgical procedures at the University of Michigan from 1991 to 2017. Anatomic phenotype and patient risk factors were analyzed to predict outcomes of blood pressure control and the need for secondary operations using ordered and binomial logistic multinomial regression models, respectively.

RESULTS

There were 169 children (76 girls, 93 boys) who underwent primary index operations at a median age of 8.3 years; 31 children (18%) had neurofibromatosis type 1, 76 (45%) had abdominal aortic coarctations, and 28 (17%) had a single functioning kidney. Before treatment at the University of Michigan, 51 children experienced failed previous open operations (15) or endovascular interventions (36) for RVH at other institutions. Primary surgical interventions (342) included main renal artery (136) and segmental renal artery (10) aortic reimplantation, renal artery bypass (55), segmental renal artery embolization (10), renal artery patch angioplasty (8), resection with reanastomosis (4), and partial or total nephrectomy (25). Non-renal artery procedures included patch aortoplasty (32), aortoaortic bypass (32), and splanchnic arterial revascularization (30). Nine patients required reoperation in the early postoperative period. During a mean follow-up of 49 months, secondary interventions were required in 35 children (21%), including both open surgical (37) and endovascular (14) interventions. Remedial intervention to preserve primary renal artery patency or a nephrectomy if such was impossible was required in 22 children (13%). The remaining secondary procedures were performed to treat previously untreated disease that became clinically evident during follow-up. Age at operation and abdominal aortic coarctation were independent predictors for reoperation. The overall experience revealed hypertension to be cured in 74 children (44%), improved in 78 (46%), and unchanged in 17 (10%). Children undergoing remedial operations were less likely (33%) to be cured of hypertension. There was no perioperative death or renal insufficiency requiring dialysis after either primary or secondary interventions.

CONCLUSIONS

Contemporary surgical treatment of pediatric RVH provides a sustainable overall benefit to 90% of children. Interventions in the very young (<3 years) and concurrent abdominal aortic coarctation increase the likelihood of reoperation. Patients undergoing remedial surgery after earlier operative failures are less likely to be cured of hypertension. Judicious postoperative surveillance is imperative in children surgically treated for RVH.

Computational analysis of renal artery flow characteristics by modeling aortoplasty and aortic bypass interventions for abdominal aortic coarctation

OBJECTIVE

Suprarenal abdominal aortic coarctation (SAAC) alters flow and pressure patterns to the kidneys and is often associated with severe angiotensin-mediated hypertension refractory to drug therapy. SAAC is most often treated by a thoracoabdominal bypass (TAB) or patch aortoplasty (PA). It is currently unclear what effect these interventions have on renal flow and pressure waveforms. This study, using retrospective data from a patient with SAAC subjected to a TAB, undertook computational modeling to analyze aortorenal blood flow preoperatively as well as postoperatively after a variety of TAB and PA interventions.

METHODS

Patient-specific anatomic models were constructed from preoperative computed tomography angiograms of a 9-year-old child with an isolated SAAC. Fluid-structure interaction (FSI) simulations of hemodynamics were performed to analyze preoperative renal flow and pressure waveforms. A parametric study was then performed to examine the hemodynamic impact of different bypass diameters and patch oversizing.

RESULTS

Preoperative FSI results documented diastole-dominated renal perfusion with considerable high-frequency disturbances in blood flow and pressure. The postoperative TAB right and left kidney volumes increased by 58% and 79%, respectively, reflecting the increased renal artery blood flows calculated by the FSI analysis. Postoperative increases in systolic flow accompanied decreases in high-frequency disturbances, aortic pressure, and collateral flow after all surgical interventions. In general, lesser degrees of high-frequency disturbances followed PA interventions. High-frequency disturbances were eliminated with the 0% PA in contrast to the 30% and 50% PA oversizing and TAB interventions, in which these flow disturbances remained.

CONCLUSIONS

Both TAB and PA dramatically improved renal artery flow and pressure waveforms, although disturbed renal waveforms remained in many of the surgical scenarios. Importantly, only the 0% PA oversizing scenario eliminated all high-frequency disturbances, resulting in nearly normal aortorenal blood flow. The study also establishes the relevance of patient-specific computational modeling in planning interventions for the midaortic syndrome.