Complications Following Ulnar Artery Catheterization for Coronary Angiography

BACKGROUND

Use of radial and ulnar access has increased due to its perceived benefits over femoral access. Ulnar artery catheterization can place patients at risk of significant complications, including pseudoaneurysm, expanding hematoma, compartment syndrome, ulnar nerve injury, and critical hand ischemia. The purpose of this study was to describe complications specific to ulnar artery catheterization.

METHODS

After obtaining institutional review board approval, a retrospective review was performed on all patients who underwent ulnar artery catheterization at our institution between 2019 and 2021. Complications were assessed, and complication rates were compared with previously published studies on ulnar artery catheterization for coronary angiography (percutaneous coronary intervention).

RESULTS

A total of 41 patients were available for review with a mean age of 59 years. Of these, 17 patients (41%) sustained complications in the immediate postprocedural period. These complications included hematoma (12 patients, 29%), pseudoaneurysm (1 patient, 2%), ulnar artery thrombosis (1 patient, 2%), ulnar neuropathy (3 patients, 7%), arterial damage requiring repair (2 patients, 5%), transient ischemia (3 patients, 7%), and compartment syndrome (2 patients, 5%). Three of these patients (7%) required operative intervention, and several were admitted to the hospital for an additional period of observation.

CONCLUSIONS

This series highlights the significant risks associated with ulnar artery catheterization for percutaneous procedures. Complications include pseudoaneurysm, expanding hematoma, compartment syndrome, ulnar nerve damage, and critical hand ischemia. Several of these patients required urgent or emergent surgical intervention, with some patients experiencing ongoing ulnar nerve symptoms.

Diagnosis of mental illness does not affect postoperative outcomes in patients undergoing endovascular aortic aneurysm repair in the VA healthcare system

OBJECTIVE

Mental illness can be a debilitating chronic disease associated with a higher likelihood of preexisting medical comorbidities and postoperative morbidity and mortality. Given the relative prevalence of mental health disorders among the veteran population, we sought to examine postoperative outcomes in patients undergoing endovascular aortic aneurysm repair (EVAR).

METHODS

Retrospective review of a single institution Veterans Administration Hospital operative database was used to identify patients who underwent EVAR from January 2010 to December 2021. Patients' demographics, comorbidities, medications, and intraoperative variables were collected. In addition, mental illness status was evaluated to stratify patients based on preexisting anxiety, depression, posttraumatic stress disorder, substance abuse disorder, or major psychiatric illness. The study's primary outcomes were postoperative complications, mortality, and follow-up rates. Secondary outcomes included hospital length of stay, readmission rates, and intervention rates.

RESULTS

A total of 241 patients underwent infrarenal EVARs at our institution. One hundred forty patients (58.1%) were diagnosed with mental illness, whereas 101 (41.9%) had no prior diagnosis of mental illness. Of the 241 patients, 65.7% had a history of substance abuse disorder, 38.6% depression, 29.3% post-traumatic stress disorder, 19.3% anxiety, and 3.6% major psychiatric illness. There was no statistical difference in the number of medical comorbidities, race, smoking status, or medications compared with patients without mental illness. We found no statistical difference in access type, wound infection rates, hypogastric coiling, estimated blood loss, and operating time. χ2 analysis demonstrated a statistically significant lower overall postoperative complication rate (28.6% vs 32.7%; P = .05) and decreased loss to follow-up (8.6% vs 15.8%; P = .05) among patients with a preexisting mental illness diagnosis. There were no statistically significant differences in readmission rate, length of stay, or 30-day mortality. When stratified by type of mental illness, binary logistic regression demonstrated no statistically significant differences in primary outcomes of postoperative complications, readmission rates, loss to follow-up, and 1-year mortality. Cox proportional hazards modeling demonstrated no significant difference in cumulative survival in patients diagnosed with a mental illness (0.56; 95% confidence interval, 0.29-0.107; P = .08).

CONCLUSIONS

There was no association between the presence of a prior mental health diagnosis and adverse outcomes following EVAR. Preceding mental illness did not correlate with an increased rate of complications, readmission, length of stay, or 30-day mortality in a veteran population. Lower loss to follow-up rates in patients with mental illness may reflect overall Veterans Health Administration expansion in resources and surveillance of these at-risk individuals. Further research is needed to assess the association between postoperative outcomes and mental illness.

Carotid artery dissections from transcarotid artery revascularization as reported by the Food and Drug Administration

OBJECTIVES

Transcarotid artery revascularization (TCAR) is a hybrid procedure that allows reversal of blood flow away from the brain while placing a stent through direct surgical access of the common carotid artery. It has been shown to have a lower risk of perioperative stroke compared with any prospective trial of transfemoral carotid artery stenting. However, intraoperative injuries related to the procedure and its management are not well characterized. One of the intraoperative complications seen in TCAR is iatrogenic carotid artery dissection (CD). We aim to add qualitative insight in further characterizing CDs and its management in this emerging technology.

METHODS

The Food and Drug Administration (FDA) maintains the Manufacturer and User Facility Device Experience (MAUDE) database for surveillance of all medical devices approved for use. This database was queried for all cases associated with Silk Road Medical's ENROUTE Transcarotid Neuroprotection System from September 2016 to October 2020. Case narratives related to CD were individually analyzed to determine time of injury (intraoperative, recovery, and post-discharge follow-up). CD reporting was further analyzed for the associated procedural event at the time of injury, number of access attempts to CD repair, and type of CD repair. Reports associated with CD repair were further categorized into endovascular repair and open surgical repair.

RESULTS

Of the 115 unique adverse events in the database, there were 58 CDs. Most were identified intraoperatively (n = 55), while three were incidentally found postoperatively. Overall, sheath placement was the most common procedural event attributed to CD (N = 34). There was adequate narrative information about CD repair in 54 patients. Intraoperative repair was performed in 52 cases and two were repaired after post-discharge follow-up imaging was performed.Among CDs that did not require additional access to engage the true lumen, the proportion of endovascular repair (62.5%) was significantly higher (p = .044) compared to the proportion of open surgical repair (37.5%). However, the proportion of open surgical repair (75%) was significantly higher than the proportion of endovascular repair (25%) in CDs with persistent failure to engage the true lumen despite ≥2 access attempts (p = .039).

CONCLUSION

CD is the most common injury related to TCAR as reported on MAUDE. The most commonly reported procedural event associated with CD was sheath placement. The rate of intraoperative endovascular and open surgical CD repair was associated with whether the access to the true lumen of the carotid artery required additional access attempts or not. This should add qualitative insight among the vascular surgery community regarding intraoperative management of CDs from a TCAR procedure.

Trends in Resident Supervision and Patient Outcomes of Laparoscopic Cholecystectomies Within the Veterans Affairs Healthcare System

OBJECTIVE

We sought to use the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database to determine if there is an increase in morbidity or mortality when resident physicians independently perform laparoscopic cholecystectomy compared to when an attending surgeon is scrubbed.

DESIGN

We performed a retrospective review of 54,144 cases of laparoscopic cholecystectomy performed within the Veterans Affairs (VA) Healthcare system from 2000 to 2020. Cases were divided into groups based on if the attending was scrubbed or not scrubbed. We then performed 1:1 case matching without replacement based on sex, race, and major comorbidities.

PARTICIPANTS

Veterans over age 18 undergoing laparoscopic cholecystectomy within the VA healthcare system between 2000 and 2020. Cases were excluded if a resident was not involved in the surgery or if the level of autonomy was not defined.

RESULTS

Significantly more operative cases were performed without the attending scrubbed before 2003 than after (14.6% vs 1.60%, p < 0.01). After matching, in 1464 (48.6%) cases the attending physician was scrubbed, and in 1549 (51.4%) the attending physician was not scrubbed. Patients were statistically similar in all measured comorbidities between the groups. Operative time was noted to be slightly longer when the attending was scrubbed (1.86 hours ± 0.79 vs 1.72 ± 0.67, p < 0.01) as well as increased complication rates (9.0% vs 6.1%, p < 0.01). No differences existed for 30-day mortality (0.8% vs 0.5%, p = 0.416), postoperative length of stay (2.7 days vs 2.96 days, p = 0.43), or superficial infection (1.9% vs 1.7%, p = 0.73).

CONCLUSIONS

Our analysis of the VASQIP database indicates that decreased resident supervision during laparoscopic cholecystectomy has minimal impact on patient outcomes. Rates of resident independent operating have declined 10-fold since the early 2000's. Further research is required to better define the changes in resident surgical education and their impact on patient outcomes.

Assessing Resident Impact on Surgical Outcomes in Below-the-Knee Amputations Based on Operative Autonomy

BACKGROUND

Gradual increases in resident autonomy with attending physician oversight is crucial to developing safe and competent surgeons¹. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows surgical outcomes within the VA. We set forth to examine the VASQIP database to compare outcomes between resident independent cases and nonindependent cases during below-the-knee amputations (BKA).

METHODS

All VASQIP records for BKA from 2000 to 2020 were examined and categorized based on whether the attending was scrubbed during the case. Case matching was performed based on preoperative comorbidities; 30-day postoperative outcomes, including a return to the operating room, wound infection, and mortality, were assessed in addition to operative time, hospital length of stay, and transfusion requirements. Student's t-test and Fisher's Exact Test were utilized.

RESULTS

A total of 13,208 BKA VASQIP records were obtained. After case control matching, 2,688 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n = 1,344), or not scrubbed (n = 1,344). Patients were similar in comorbidities across both groups. No statistically significant difference in operative time (1.52 hr ± 0.78 vs. 1.47 hr ± 0.75, P = 0.08), 30-day mortality (3.3% vs. 4.8%, P = 0.05), or complication rate (19.5% vs. 21.3%, P = 0.25). Resident independent cases were noted to have slightly longer postop length of stay (12.47 days ± 12.69 vs. 15.33 days ± 20.56, P < 0.01) and operative bleeding requiring more than 4 units transfused (0.3% vs. 1.3%, P ≤ 0.01).

CONCLUSIONS

Resident independent operating during below-the-knee amputation at VA hospitals is associated with an increased length of stay and blood transfusion. There was no statistically significant increase in operative time, 30-day mortality, or total complication rate. Further research is required to assess the risks associated with surgical training, resident supervision, and resident preparedness for independent practice.

Establishing 3D Printing at the Point of Care: Basic Principles and Tools for Success

As the medical applications of three-dimensional (3D) printing increase, so does the number of health care organizations in which adoption or expansion of 3D printing facilities is under consideration. With recent advancements in 3D printing technology, medical practitioners have embraced this powerful tool to help them to deliver high-quality patient care, with a focus on sustainability. The use of 3D printing in the hospital or clinic at the point of care (POC) has profound potential, but its adoption is not without unanticipated challenges and considerations. The authors provide the basic principles and considerations for building the infrastructure to support 3D printing inside the hospital. This process includes building a business case; determining the requirements for facilities, space, and staff; designing a digital workflow; and considering how electronic health records may have a role in the future. The authors also discuss the supported applications and benefits of medical 3D printing and briefly highlight quality and regulatory considerations. The information presented is meant to be a practical guide to assist radiology departments in exploring the possibilities of POC 3D printing and expanding it from a niche application to a fixture of clinical care. An invited commentary by Ballard is available online. ^©RSNA, 2022.

Using the risk analysis index to assess frailty in a veteran cohort undergoing endovascular aortic aneurysm repair

OBJECTIVE

Surgical frailty is strongly associated with increased perioperative morbidity and mortality. The risk analysis index (RAI) is a validated frailty score system, which has been shown to predict for short-term outcomes and long-term mortality in various surgical subspecialties. In the present study, we applied the frailty score to a veteran aneurysm population who had undergone nonemergent endovascular aortic aneurysm repair (EVAR).

METHODS

After obtaining institutional review board approval, the Veteran Affairs Surgical Quality Improvement Program data were queried for endovascular repair of infrarenal abdominal aortic aneurysm or dissection using the Current Procedural Terminology codes 34,800, 34,803, and 34,805 from 2001 to 2018. The preoperative variables were used to calculate the RAI score. The patients were placed into six cohorts according to the RAI score (≤20, 21-25, 26-30, 31-35, 35-40, and ≥41). The χ² test and analysis of variance test were used compare the cohorts. Forward logistic regression modeling was used to determine the risks of each cohort.

RESULTS

From 2001 to 2018, 5568 patients had undergone EVAR. Of the 5568 patients, 99.6% were male, with a mean age of 71 ± 8 years. Of these patients, 4.5%, 43.8%, 33.9%, 11.7%, 4.2%, and 1.8% were included in the following RAI groups: ≤20, 21 to 25, 26 to 30, 31 to 35, 35 to 40, and ≥41, respectively. Frailty was associated with increased rates of overall complications, death, and an increased length of stay. When risk adjusted, frailty at the highest vs lowest level was associated with 2.7 times the odds of any complication developing and 4.4 times the odds of mortality ≤30 days.

CONCLUSIONS

Frailty, as determined by the RAI, was associated with postoperative outcomes in a dose-dependent manner. Frailty was associated with higher rates of major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean from ventilation, reintubation), renal (renal failure), overall complications, length of stay, and death. We recommend the use of this frailty index as a screening tool to guide discussions with patients scheduled to undergo EVAR.

Modern Lower Extremity Bypass Outcomes by Anesthesia Type in the Veteran Population

BACKGROUND

Lower extremity bypass (LEB) revascularization can be performed under general (GA) or neuraxial anesthesia (NA). Studies show that the use of NA may decrease morbidity, 30-day mortality, and hospital length-of-stay (LOS). The goal of our analysis is to examine the differences in postsurgical outcomes following LEB between patients who undergo GA compared to NA in the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database.

METHODS

After IRB approval, the VASQIP database was assessed for patients who underwent LEB between 1998-2018. Only infrainguinal bypass procedures and anesthesia type classified as "general," "epidural," or "spinal" were included. The neuraxial cohort includes both spinal and epidural anesthesia patients. The Risk Analysis Index (RAI), a validated measure of frailty, was additionally calculated for each patient. Chi squared, paired t-test, and binary logistic regression were used to compare the cohorts.

RESULTS

During this period, 22,960 veterans underwent LEB recorded in VASQIP. Compared to those who underwent surgery under GA, patients with procedures performed using NA were older (66.4 ± 9.6 years vs. 65.3 ± 9 years respectively; P <0.001) and more frail (average RAI score 25.7 ± 7.0 vs. 24.9 ± 6.7; P < 0.001). Operative time was shorter in the NA group (4.1 ± 1.7 hrs vs. 4.7 ± 3.0 hrs; P < 0.001) and fewer cases were emergent (1.55% vs. 4.13%; P <0.001). Patients in the GA group had higher rates of postoperative prolonged ileus (0.31% vs. 0.00%; P = 0.03), pneumonia (1.60% vs. 1.06%; P = 0.025), deep wound infection (2.67% vs. 2.61%; P = 0.01), sepsis (1.68% vs. 0.79%; P < 0.001), reintubation (1.80% vs. 1.30%) (P = 0.04),and number of packed red blood cell (pRBC) transfused intraoperatively (0.39 ± 1.21 units vs. 0.22 ± 0.79 units; P <0.001). There was no significant difference in rate of graft failure, return to the OR, myocardial infarction, death, or LOS. In regression analysis, those undergoing NA were less likely to require pRBC transfusion intraoperatively (OR: 0.43; 95% CI: 0.31-0.61; P < 0.001), however no other outcomes reached statistical significance.

CONCLUSION

Although younger and less frail, veteran patients undergoing GA for lower extremity revascularization had higher rates of postoperative ileus, pneumonia, deep wound infection, sepsis, and need for transfusion as compared to those undergoing NA. There was no significant difference in the rate of other major complications, myocardial infarction, death or LOS. After adjustment, only intraoperative transfusion remained statistically significant, likely reflecting longer and more complex cases for those that undergo general anesthesia rather than the effect of anesthetic choice itself.

Gender Trends of Authors Presenting at a Regional Vascular Surgery Meeting

OBJECTIVE

We hypothesized a potential gender disparity within a regional society like the Southern Association of Vascular Surgery (SAVS) when compared to vascular surgery demographics in the region. To assess this, we analyzed meeting and membership participation at SAVS compared to regional data from the Society of Vascular Surgery (SVS) as well as Board certification in Vascular Surgery published by the American Board of Surgery (ABS).

METHODS

The published programs from the SAVS Annual Meeting from 2012 to 2019 were analyzed for membership, presenter gender, type, topic, discussant gender, moderator gender, post graduate course presenter gender, as well as manuscript publication demographics. The ABS was petitioned and yearly Vascular Surgery diplomate (ABS-VS) gender from member states of the SAVS was examined for the same period. Fisher's Exact students t-test and Analysis of Covariance were utilized.

RESULTS

There were 257 total presentations (184 podium, 71.6%; 73 poster, 28.4%). 61.4% (n=43) of presentations by females were podium presentations, compared to 75.4% (n=141) for males (p=0.03). Females were less likely to be published when compared to their male counterparts (41.8% vs. 58.7%, p=0.02). Percentage of female gendered presenters statistically increased over the time period examined compared to a decrease in male presenters (R² = 0.61, m=1.27 vs. R² = 0.08, m=-0.35, p=0.02). Females presenters had a female discussant 10.5% of the time compared to male presenters who had a male discussant 95.1% of the time (p<0.0001). Females comprised 3.8 ± 1.1% of SAVS yearly membership compared to 12.0 ± 4.6% ABS-VS diplomates among SAVS member states (p<0.0001). SAVS female membership significantly lagged behind the increase in ABS-VS female diplomate rate (p=0.001). Only 39.1% of SAVS members were cross listed in SVS membership rolls, with a total of 464 potential SAVS members, 11.2% or 52 of which are female.

CONCLUSIONS

We found that female presenters at the SAVS annual meeting were less likely to be podium presenters, interface with other female discussants and publish manuscripts when compared to their male counterparts. Statistically, female members were underrepresented within the SAVS membership rolls when compared to known boarded female vascular surgeons among southern member states. This gender gap highlights a unique opportunity to enhance and potentially increase mentorship opportunities for female trainees who are presenting and/or attending this regional vascular surgery meeting.

Analysis of Twitter Activity and Engagement From Annual Meetings of the Society for Vascular Surgery and the Society of Interventional Radiology

BACKGROUND

Medical societies such as the Society for Vascular Surgery (SVS) and the Society of Interventional Radiology (SIR) have been encouraging the use of social media at annual meetings by establishing unique meeting hashtags (eg. #VAM19, #SIR19ATX). These two specialties have similar number of active physicians and share procedural interests. We set forth to understand differences in Twitter activity and engagement by analyzing Twitter outputs from the vascular annual meeting (VAM) and the interventional radiology annual meeting (IRAM) in 2019.

METHODS

Tweets with "#VAM19" and "#SIR19ATX" from 30 days before and 30 days after respective meetings were collected. Proportion of distinct Twitter users relative to total number of meeting attendees, number of posts per user, number of hashtags per post, and number of engagement metrics (likes, replies, and retweets) were collected for comparison. As for the top 100 most liked tweets, specialty-related hashtags were categorized into identity, diversity, education, procedure, and medical care, and the authors of these tweets were also identified for comparison. Student's t-test* and Fisher's Exact^⁎⁎ were utilized for analysis.

RESULTS

A total of 362 and 1944 tweets were collected from the VAM and IRAM in 2019. There was no difference in proportion of active Twitter users relative to total number of meeting attendees between the VAM (7.5%) and IRAM (7.7%). Average number of posts per user from the VAM and IRAM showed no significant difference. However, tweets related to IRAM had significantly higher number of hashtags per post (2.67±1.96) than ones related to VAM (1.78±1.26) (P < 0.0001*). Additionally, these tweets on average received significantly higher number of likes (P < 0.0001*), retweets (P < 0.0001*), and replies (P < 0.0001*) than ones related to the VAM. Specialty-related hashtags from the 100 most liked tweets showed significantly greater proportion of hashtags associated with specialty identity (4% vs 28.6%, P < 0.0001**), diversity (2.9% vs 8.0%, p=0.0268**), and education (1.1% vs 9.1%, p=0.0004**) in tweets related to the IRAM whereas the proportion of hashtags associated with procedure and medical care was similar between the two meetings. Lastly, the 100 most liked tweets were authored by trainees (p=0.005*) and official societies (p=0.003*) in significantly greater proportion in IRAM whereas academic institutions/training hospitals authored in significantly greater proportion (p=0.004*) from the VAM. Contributions from attending physician users to the 100 most liked tweets were similar between the two meetings.

CONCLUSION

Analysis of Twitter activity centered around #VAM19 and #SIR19ATX indicates that there was no significant difference in proportion of Twitter users relative to meeting attendees and average number of posts per user. However, tweets with #SIR19ATX had significantly higher number of hashtags per post and had greater level of engagement than ones with #VAM19. The top 100 most liked tweets from the two meetings differed in proportion of hashtags related to specialty identity, diversity, and education, as well as proportion of contributing authors identified as trainees, official societies, and academic institutions/training hospitals. These data should help the SVS and its members to establish a more directed social media effort to facilitate its use during national gatherings.

Frailty Index associated with postoperative complications and mortality after lower extremity amputation in a national veteran cohort

OBJECTIVE

Surgical frailty and its assessment have become essential considerations in perioperative management for the modern aging surgical population. The risk analysis index is a validated frailty score that has been proven to predict short-term outcomes and long-term mortality in several surgical subspecialties and high-risk procedures. We examined the association of risk analysis index scores with postoperative outcomes in a retrospective nationwide database of patients who underwent lower extremity amputation in the Veterans Health Administration Health Care System.

METHODS

The Veteran Affairs Surgical Quality Improvement Program data was queried across the Veteran Affairs Health Care System with institutional review board approval for lower extremity amputations. Records of above and below knee amputation, Current Procedural Terminology codes 27590, 27591, 27592, 27594, 27596 and 27880, 27881, 27882, 27884, and 27886, respectively, from 1999 to 2018 were obtained. Incomplete and traumatic entries were removed. Risk Analysis Index score was calculated from preoperative variables and patients were separated into five score cohorts (≤15, 16-25, 26-35, 36-45, ≥46). The χ² test and analysis of variance were used to compare the cohorts. Forward binary logistic regression modeling was used to determine covariate-adjusted odds ratios for outcomes in each cohort (SPSS software; version 25, IBM Corp).

RESULTS

A total of 47,197 patients (98.9% male) with an average age of 66.4 ± 10.6 years underwent nontraumatic lower extremity amputation, including 27,098 below knee and 20,099 above knee amputations, during the study period. Frailty was associated with increased rates of deep vein thrombosis, sepsis, cardiac arrest, myocardial infarction, pneumonia, intubation for more than 48 hours, pulmonary embolism, reintubation, acute kidney injury, renal failure, increased length of stay, overall complications, and death. Increases in the frailty score were associated with up to three times the likelihood for the occurrence of a postoperative complication and up to 32 times likelihood to perish within 30 days than those with low frailty scores.

CONCLUSIONS

Risk analysis index assessment of frailty was found to be associated with several postoperative outcomes in a dose-dependent manner in patients undergoing lower extremity amputation in the Veterans Health Care System, with higher scores associated with higher rates of death and major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean vent, reintubation), and renal (renal insufficiency, renal failure) complications. We recommend the use of risk analysis index score as a frailty screening tool for patients undergoing lower extremity amputation to enable providers to adequately inform and counsel patients regarding potential significant risks.

The COMET framework: A novel approach to design an escape room workshop for interprofessional objectives

While recreational escape rooms have gained momentum across education and team training in multiple professions, few published escape room designs have been truly interprofessional. A major obstacle faced by educators and team leaders alike is the lack of any practical design framework for escape room development that is specific to meeting learning objectives. The COMET Framework (Context, Objectives, Materials, Execution, and Team Dynamics) was developed as a step-by-step approach to escape room design using general terminology and piloted in a one-hour workshop at a regional interprofessional conference. Surveys completed by participants suggest that application of the COMET framework increased understanding and confidence regarding escape room design regardless of prior experience with the format. The generality of the COMET framework may allow it to be utilized for team exercise design more broadly in the contexts of interprofessional training and faculty development.

Statins Protect against Thrombosis of Cannulated Radiocephalic Fistulas in Diabetic Patients

BACKGROUND

Radiocephalic arteriovenous fistula (RCAVF) creation is the preferred first line hemodialysis access procedure. Analysis of diabetic rat arteriovenous fistula model indicates improved vascular function with HMG-CoA-Reductase Inhibitor (statin) use. We predict similar outcomes in diabetic patients undergoing primary RCAVF placement.

METHODS

A Veterans Administration Hospital dialysis access database over a 15-year period was queried identifying all RCAVF placements in diabetic patients. Patients were stratified into statin medication usage or not at RCAVF creation. Outcomes examined include rate of successful cannulation, functional patency duration, interventions per access, and rates of access thrombosis. Thrombosis-free survival of cannulated RCAVFs were compared using Kaplan-Meier method with log-rank analysis followed by univariate, stepwise logistic regression and ROC curve analysis.

RESULTS

Total number of 123 RCAVF cases were performed in 122 diabetic male patients. At the time of RCAVF placement, 92 cases were performed on patients that were taking statin medication and 31 cases were performed on patients that were not taking statin medication. There was no difference in terms of rate of successful cannulation, functional patency duration, and number of interventions per access between the statin and non-statin groups. However, rate of RCAVF thrombosis once accessed was significantly lower in the statin group compared to the non-statin group (P = 0.0005). Kaplan-Meier survival curve for each group were compared using log-rank test to reveal that diabetic patients who were on statin therapy at the time of operation had significantly higher access survival over time against thrombosis once it was cannulated for dialysis treatment compared to those who were not on statin therapy (P = 0.0003). Univariate, stepwise logistic regression model indicated statin use as the only significant factor associated with lack of thrombosis (P = 0.05).

CONCLUSIONS

Statins appear to have protective effects against RCAVF thrombosis as predicted in animal models for diabetic patients undergoing primary RCAVF placements. There were similar functional outcomes in terms of rate of successful cannulation, functional patency duration, and number of interventions per access. These data should encourage further investigation of statins and their role in hemodialysis access.

Optimizing Peripandemic Care for Veteran Major Non-Traumatic Lower Extremity Amputees: A Proposal Informed by a National Retrospective Descriptive Analysis of COVID-19 Risk Factor Prevalence

INTRODUCTION

In response to the Coronavirus 2019 (COVID-19) pandemic, vascular surgeons in the Veteran Affairs Health Care System have been undertaking only essential cases, such as advanced critical limb ischemia. Surgical risk assessment in these patients is often complex, considers all factors known to impact short- and long-term outcomes, and the additional risk that COVID-19 infection could convey in this patient population is unknown. The European Centre for Disease Prevention and Control (ECDC) published risk factors (ECDC-RF) implicated in increased COVID-19 hospitalization and case-fatality which have been further evidenced by initial reports from the United States Centers for Disease Control and Prevention. CDC reports additionally indicate that African American (AA) patients have incurred disparate infection outcomes in the United States. We set forth to survey the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database over a nearly 20 year span to inform ongoing risk assessment with an estimation of the prevalence of ECDC-RF in our veteran critical limb ischemia population and investigate whether an increased COVID-19 comorbidity burden exists for AA veterans presenting for major non-traumatic amputation.

MATERIALS AND METHODS

The VASQIP database was queried for all above knee amputation (AKA) and below knee amputation (BKA) completed 1999-2018 after IRB approval (MIRB:#02507). Patient race and ECDC-RF including male gender, age > 60 years, smoking status, hypertension, diabetes, chronic obstructive pulmonary disease, cancer, and cardiovascular disease were recorded from preoperative patient history. AKA and BKA cohorts were compared via χ2-test with Yates correction or unpaired t-test and a subgroup analysis was conducted between AA and all other race patients for COVID-19 comorbidities in each cohort.

RESULTS

VASQIP query returned 50,083 total entries. Average age was 65.1 ± 10.4 years and 68.2 ± 10.5 years for BKA and AKA cohorts, respectively, (P < .0001) and nearly all patients were male (99%). At least one ECDC-RF comorbidity was present in 25,526 (88.7%) of BKA and 17,558 (82.4%) of AKA patients (P < .0001). AA BKA patients were significantly more likely than non-AA BKA patients to present with at least one ECDC-RF comorbidity (P = .01).

CONCLUSIONS

According to a large national Veterans Affairs database, there are high rates of ECDC-RF in veteran amputees. During the present crisis, management of these patients should incorporate telehealth, expedient discharge, and ongoing COVID-19 transmission precautions.

Anatomic suitability for commercially available percutaneous arteriovenous fistula creation systems

OBJECTIVE

The Food and Drug Administration recently approved two percutaneous arteriovenous fistula creation systems: the Ellipsys vascular access (EL) system and WavelinQ EndoAVF (WQ) system. Although the initial clinical trials of each system have demonstrated a high success rate, little detail on anatomic suitability was provided. We sought to determine the real-world applicability of the EL and WQ systems by studying them in a single representative cohort.

METHODS

All patients receiving a first-time arteriovenous access consultation at a single Veterans Affairs institution underwent extensive vein mapping of the bilateral upper extremities. Anatomic suitability was assessed in accordance with the manufacturer's instructions for use (IFU), and clinical usability was determined using additional published anatomic guidelines. The suitability for radiocephalic fistula (RCF) creation was also assessed. To estimate how often these systems would be used in practice, a clinical algorithm was created, with a preference for RCF creation, followed by percutaneous arteriovenous fistula (pAVF) creation, surgical fistula creation at the elbow, and, finally, graft placement.

RESULTS

During the study period, 116 upper extremities were measured in 58 male patients. Per the IFU, the rate of extremity suitability was 93% and 52% for the WQ and EL systems, respectively (P < .0001). In the same population, 32% of the extremities had acceptable anatomy for RCF creation. The overall clinical usability of these systems using more recent published guidelines was 55% for the WQ system and 44% for the EL system (P = .09). The usability of both pAVF systems was most limited by the size of the deep perforating cubital vein. The proximity of the antecubital perforator vein and proximal radial artery additionally limited EL usability. Based on the clinical algorithm, initial access creation would have been RCF creation for 31% of the cohort, followed by the WQ (32%), the EL (23%), surgical fistula creation at the elbow (18%), and graft placement (17%).

CONCLUSIONS

Anatomic suitability was greater for WQ than for EL when considering only the IFU. Once the full requirements for pAVF creation were considered, we found no significant differences in usability between the two systems. Anatomic analysis showed that pAVF creation can constitute a substantial part of a hemodialysis access practice.

Talking About Ethical Issues in Surgery-Results of a Novel Online Pilot Curriculum

OBJECTIVES

Surgical ethics has been suggested as a distinct field of study apart from clinical ethics due to a unique practice type and treatment dynamic. At our institution, most if not all teaching of clinical ethics is undertaken by nonsurgical faculty. We introduced a novel online Surgical Ethics Program (SEO) in a pilot form (SEO-P) for initial presentation to learners in our environment. The overall goal of our educational intervention was to enhance knowledge, understanding and appreciation for surgical ethics in medical students and to evaluate our curriculum.

SETTING

SEO-P was undertaken over a 4-week period in 2018 with 9 fourth-year medical students enrolled in a surgery elective at our institution. These learners all had career plans in general surgery or a surgical subspecialty. There was 3 weeks of content: (1) background in clinical ethics as it applies to surgical practice, (2) surgical consents and autonomy, and (3) the impaired physician. All pilot learners were evaluated with: (1) postprogram final exam assessment (compared to preprogram knowledge base test), (2) self-reflection essay of ethical practice in surgery, (3) evaluation of 2 case studies, and (4) an assessment of participation in online discussion forums. Postprogram survey of the learners was also undertaken in an anonymous fashion.

RESULTS

Four of 9 or 44.4% of students scored greater than or equal to 80% on the postprogram knowledge assessment test. A preprogram knowledge-based examination of all learners yielded a mean and standard deviation of 57.1 ± 6.0%. Postprogram knowledge-based test with mean and standard deviation was 78.8 ± 15%. This was a statistically significant increase in scores (p = 0.004; t test). All 9 passed the course with a mean final summative course grade of 95.2 ± 3.2%. From the postprogram evaluation survey, all 7 students who responded felt that the SEO-P would help them become an "ethical" practitioner. Surprisingly, only half of the learners (57.1%) thought "technology used to support the SEO Course (i.e., the chosen curriculum management system) was effective in conducting the course."

CONCLUSIONS

We set forth to use "web-based" technology to enhance exposure of medical students in our institution to surgical ethics. Hence, we designed our pilot curriculum to be a completely online offering. We feel that the utilization of the surgical voice, that is a surgical ethics curriculum developed by surgeons to explore surgically related clinical ethical issues, is an essential theme and goal of our program. Future challenges will be to present this voice in an effective manner with either an improved curriculum delivery system or by potentially utilizing a blended approach.

Common Femoral Artery Access on YouTube: What Practices are Being Shown and Who is Delivering the Message?

OBJECTIVES

Novice learners are increasingly turning to YouTube as a learning resource for surgical procedures. One example of such a procedure is common femoral artery puncture and sheath placement. Practitioners in several specialties perform this procedure to access the arterial system for angiography and intervention. We set forth to compare the techniques demonstrated on YouTube by the various specialists, as well as compare each specialty׳s prevalence on this website.

METHODS

YouTube (www.youtube.com) was accessed in December 2015 at multiple time points with a cleared-cache web browser for the keyword search categories: "femoral artery access," "femoral access," and "angiography access." The top 500 videos from each of these keyword searches were analyzed. Videos were categorized by practitioner specialty, technique, duration of video, age of video, and total views. Videos with clear demonstration of femoral artery access were included in the analysis. All industry videos were excluded from the analysis. Categorical variables were compared using Fisher׳s exact test, and continuous variables were compared with the Student׳s t-test.

RESULTS

A total of 2460, 4680 and 1800 videos were found for each keyword search, respectively. Of these, 33 videos clearly demonstrated femoral artery access technique. Vascular specialists, compared to interventional cardiology and radiology, had fewer videos (n = 4 vs. 14) and older videos (3.5 ± 2.1y vs. 2.25 ± 0.5y, p < 0.05). The vascular specialists demonstrated ultrasound-guided access, while interventional cardiology predominantly demonstrated landmark-guided access (p < 0.05).

CONCLUSIONS

Although YouTube and other online resources are being used by novice learners, vascular specialists are underrepresented for femoral artery access, a foundational vascular procedure. Other practitioners demonstrate videos with landmark-guided access and rarely demonstrate ultrasound use. As recognized vascular experts, vascular surgeons should improve their visibility in online learning resources.