Prophylactic Transversely Hemisected Sartorius Flap for High-Risk Groin Dissections in Vascular Surgery-A Case Series.

Groin wound dehiscence and infection are a common complication of femoral artery exposure. In patients with prosthetic conduits placed in the groin, these complications can lead to graft infection or anastomotic dehiscence with hemorrhage. Sartorius flaps can be useful in preventing graft infections or anastomotic breakdown in the setting of wound infections. Prophylactic sartorius flaps have been suggested to be a useful adjunct in patients who are at high risk for groin complications. Standard sartorius flaps can be difficult to perform and increase the operative time. We present our experience with a modified sartorius flap, a Transversely Hemisected Sartorius (THT), which avoids dissection to the anterior superior iliac spine. Patients who received femoral artery exposure and a modified prophylactic sartorius flap were included in this case series. The Penn Groin Assessment Scale (PGAS) was calculated for each patient and our primary outcome was the rate of deep space wound infections. Fifteen patients received a THT muscle flap. The average age of the cohort was 67.5 (35-86) years. Eight (50%) were male. The mean PGAS was 2.5 (0-6). Eight (50%) groins had a prosthetic conduit underlying the flap. Four (25%) patients had infrainguinal bypass, 3 (18.8%) for femoral-femoral bypass, and 1 (6.3%) patient received aortic-bifemoral bypass. Eight (50%) patients received sartorius flap after femoral artery exposure for thromboembolectomy, endarterectomy, or access complications. Six (37.5%) patients developed superficial surgical site infections however no deep space infections or prosthetic graft excisions resulted. This procedure was effective in preventing graft infections in all patients with high-risk features for groin infection in our retrospective case series. The segmental blood supply is maintained while providing good coverage of the femoral vessels with this rotational flap.

A toolkit for individualizing interventions to mitigate second-victim syndrome in a diverse surgery community.

Adverse outcomes are an inevitable consequence of surgical care. The term "second victim" was introduced by Wu to describe the emotional trauma experienced by a clinician who feels responsibility for an adverse clinical outcome. Second victims may feel shame, guilt, sadness, and a crisis of confidence. Surgeons rarely seek professional support following an adverse event but are more likely to confide in colleagues. Surgeons who represent groups traditionally underrepresented in medicine may be less likely to seek assistance following an adverse clinical outcome. There is a need for surgeons to have sufficient training to provide peer-to-peer support for wounded colleagues. The PEARLS Toolkit provides a blueprint toward this end.

Endovascular treatment of an isolated iliac artery aneurysm associated with segmental arterial mediolysis.

Segmental arterial mediolysis is a noninflammatory nonatherosclerotic vasculopathy of uncertain etiology characterized by dissection and/or aneurysm formation. It affects medium-to-large arteries, primarily the celiac, superior mesenteric, and renal arteries. Iliac involvement is rare, and its specific treatment has not been described. We detail a patient who presented with intrabdominal hemorrhage from a ruptured right colic artery aneurysm. He underwent transcatheter arterial embolization followed by right hemicolectomy. Histopathology confirmed the diagnosis of segmental arterial mediolysis. Endovascular treatment of a 3-cm iliac artery aneurysm was performed 18 months later. There was successful exclusion of the aneurysm demonstrated on computed tomography angiography at 10 years.

Rapid progression of finger gangrene in a hemodialysis patient: A case report.

Severe hemodialysis access-induced distal ischemia is an uncommon complication after arteriovenous fistula creation. Finger amputation is rare and generally does not involve the entirety of the digit. The distal revascularization interval ligation procedure has become less commonly used for hemodialysis access-induced distal ischemia over the past decade. The procedure typically requires general anesthesia, greater saphenous vein harvest, and brachial artery ligation. We describe a 64-year-old female with hypertension, diabetes mellitus, and end-stage renal disease on hemodialysis via a well-functioning brachiocephalic arteriovenous fistula who developed rapid progression of finger gangrene. She underwent the distal revascularization interval ligation procedure, followed by finger amputations. The finger amputations healed within 6 months of the distal revascularization interval ligation procedure and the fistula was preserved at 2-year follow-up.

Trends in Preoperative Imaging Prior to Elective Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative.

BACKGROUND: Duplex ultrasound (DUS) has been an important imaging modality for carotid bifurcation disease due to its low cost and noninvasive nature. Over the past decade, computed tomography angiography (CTA) has replaced conventional angiography (CA) due to safety and availability. There are significant differences in cost and patient exposures between CTA and DUS. The objective of this study is to analyze the trends in preoperative imaging modalities in the Southern California region for elective carotid endarterectomies (CEA). METHODS: A retrospective review of the Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe) was performed. All elective CEA procedures were identified from January 2011 through May 2020. Data included all preoperative imaging modalities used. An analysis was performed of the types and numbers of studies obtained. The trends in the usage of single and multiple preoperative studies and the trends in use of DUS versus CTA were analyzed. RESULTS: From January 2011 to May 2020, 2,519 elective CEAs were entered into the regional database. Of the 2,336 eligible cases (183 excluded due to incomplete data), 38% were for symptomatic (Sx) and 62% for asymptomatic (ASx) carotid disease. Preoperative imaging studies ordered included 56% DUS, 28% CTA, 6% magnetic resonance angiography, and 10% CA. Single imaging studies were used in 56.3% of cases, 2 studies in 40.4%, and >2 studies in 3.3%. A majority of both Sx and ASx patients undergoing elective CEA had only a single preoperative imaging study. ASx patients were more likely to have a single study than Sx patients (P = 0.0054). DUS was the most frequent single study ordered in both Sx and ASx patients, 37.4% and 41.4%, respectively. The trend over time shows a decreasing use of DUS and an increasing use of CTA for both Sx and ASx patients. In 2020, CTA overtook duplex as the most frequently ordered study for Sx patients. The average number of imaging studies per procedure per year for both Sx and ASx patients has not changed substantially at approximately 1.5 studies. In addition, the overall trend shows that although a single preoperative study was more common than 2 or more studies for elective CEA, single studies were more common for ASx patients, whereas the use of 2 or more studies was more common for Sx patients. The overall trend among three different time periods, 2011-2013, 2014-2016, and 2017-2020 shows that for both Sx and ASx patients, the use of single DUS studies has decreased over time (P < 0.001), whereas the use of single CTA studies has increased over time (P < 0.001). The use of CTA varied widely by a study center ranging from 12-53% for Sx and 10.5-75% for ASx patients. CONCLUSIONS: Over the past decade, most patients undergoing elective CEA in the SoCal VOICe had only a single preoperative imaging study with DUS as the most frequent sole study in both Sx and ASx patients. However, as a single study, CTA is becoming more frequently used than DUS. Further investigation into the variation in practice may help standardize imaging prior to CEA and control healthcare costs.

A gender-based analysis of predictors and sequelae of burnout among practicing American vascular surgeons.

OBJECTIVE: Surgeons report higher burnout and suicidal ideation (SI) rates than the general population. This study sought to identify the prevalence and gender-specific risk factors for burnout and SI among men and women vascular surgeons to guide future interventions. METHODS: In 2018, active Society for Vascular Surgery members were surveyed confidentially using the Maslach Burnout Index embedded in a questionnaire that captured demographic and practice-related characteristics. Results were stratified by gender. Univariate and multivariate logistic regression models were developed to identify predictors for the end points of burnout and SI. RESULTS: Overall survey response rate was 34.3% (N = 878) of practicing vascular surgeons. A higher percentage of women responded (19%) than compose membership in the Society for Vascular Surgery (13.7%). Women respondents were significantly younger, with fewer years in practice, and were less likely to be in private practice than the men who responded. Women were also less likely to be married/partnered, or to have children. The prevalence of burnout was similar for women and men (42.3% and 40.9%; P = nonsignificant); however, the prevalence of SI was significantly higher in women (12.9% vs 6.6%; P < .007). Whereas there was no difference in mean hours worked or call taken, women were more likely to have had a recent conflict between work and home responsibilities and to have resolved this conflict in favor of work. Although men and women had the same incidence of reported recent medical errors, women were less likely to self-report a recent malpractice suit or to think that a fair resolution was reached. There was no gender difference in reported work-related pain. Multivariable analysis revealed that not enough family time and work-related pain were predictors for burnout in both men and women. Additional factors were associated with burnout in men, such as malpractice and electronic medical record dissatisfaction. Multivariable analysis revealed that work-related pain was an independent predictor for SI for the entire cohort. CONCLUSIONS: The prevalence of burnout among vascular surgeons is high. Women vascular surgeons have double the rates of SI compared with male vascular surgeons. Taken together, this study demonstrated that many of the same factors are associated with burnout in women and men, which include not enough family time, conflict between work and personal life, and work-related pain. Additional factors in men included conflict between work and family, work-related pain, and electronic medical record dissatisfaction.

Surgical and Endovascular Management of Extracranial Carotid Artery Aneurysms, Outcomes From the American College of Surgeons, National Surgical Quality Improvement Program.

OBJECTIVES: Extracranial carotid artery aneurysms (ECAA) are rare and consequentially understudied; yet multiple management strategies for ECAA have been pursued. The goal of this study was to compare rates of stroke and cardiac events following surgical or endovascular management of ECAA utilizing the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: The ACS-NSQIP database was queried for patients with both selected procedure codes and diagnostic codes specific for ECAA. 139 patients, 0.2% of carotid procedures, were located within ACS-NSQIP from 2013-2017. RESULTS: The endovascular group (n = 19) had a higher proportion of emergency procedures than the open surgical group (n = 120). Post-operative strokes in the endovascular group (n = 3, 15.8%) were not significantly higher than the open surgical group (n = 5, 4.2%; P = 0.078). One cardiac event (0.7%) in the cohort occurred in the surgical group. DISCUSSION: This study provides insight into trends in national management of ECAA. Post-operative stroke rates trended higher with endovascular approaches, perhaps due to traumatic presentation as this group had a higher proportion of emergency procedures. Additionally, this study suggests patients with ECAA may have less cardiac burden than their peers with carotid stenosis.

Factors Affecting One-Year Outcomes After Major Lower Extremity Amputation in the Vascular Quality Initiative Amputation Registry.

INTRODUCTION: Major lower extremity amputation (LEA) results in significant morbidity and mortality. This study identifies factors contributing to adverse long-term outcomes after major LEA. STUDY DESIGN: Amputations in the Vascular Quality Initiative (VQI) long-term follow-up database from 2012 to 2017 were included. Multivariable logistic regression determined which significant patient factors were associated with 1-year mortality, long-term functional status, and progression to higher level amputation within 1 year. RESULTS: 3440 major LEAs were performed and a mortality rate of 19.9% was seen at 1 year. Logistic regression demonstrated that 1-year mortality was associated with post-op myocardial infarction (MI) (odds ratio (OR) 1.7, CI 1.02-2.97, P = .04), congestive heart failure (CHF) (OR 1.9, confidence interval (CI) 1.56-2.38, P < .001), hypertension (HTN) (OR 1.31, CI 1.00-1.72, P = .05), chronic obstructive pulmonary disease (COPD) (OR 1.36, CI 1.13-1.63, P < .001), and dependent functional status (OR 2.01, CI 1.67-2.41, P < .001). A decline in ambulatory status was associated with COPD (OR 1.36, CI 1.09-1.68, P = .006). Dependent functional status was protective against revision to higher level amputation (OR .18, CI .07-.45, P < .001). CONCLUSION: In the VQI, 1-year mortality after major LEA is nearly 20% and associated with HTN, CHF, COPD, dependent functional status, and post-op MI. Decreased functional status at 1 year was associated with COPD, and progression to higher level amputation was less likely in patients with dependent functional status.

5-Item Modified Frailty Index Predicts Outcomes After Below-Knee Amputation in the Vascular Quality Initiative Amputation Registry.

Patient frailty indices are increasingly being utilized to anticipate post-operative complications. This study explores whether a 5-factor modified frailty index (mFI-5) is associated with outcomes following below-knee amputation (BKA). All BKAs in the vascular quality initiative (VQI) amputation registry from 2012-2017 were reviewed. Preoperative frailty status was determined with the mFI-5 which assigns one point each for history of diabetes, chronic obstructive pulmonary disease or active pneumonia, congestive heart failure, hypertension, and nonindependent functional status. Outcomes included 30-day mortality, unplanned return to odds ratio (OR), post-op myocardial infarction (MI), post-op SSI, all-cause complication, revision to higher level amputation, disposition status, and prosthetic use. 2040 BKAs were performed. Logistic regression showed an increasing mFI-5 score that was associated with higher risk of combined complications (OR 1.22, confidence interval [CI] 1.07-1.38, P < .05), 30-day mortality (OR 1.60, CI 1.19-2.16, P < .05), post-op MI (OR 1.79, CI 1.30-2.45, P < .05), and failure of long-term prosthetic use (OR 1.17, CI 1.03-1.32, P < .05). In the VQI, every one-point increase in mFI-5 is associated with an increased risk of 22% for combined complications, 60% for 30-day mortality, nearly 80% for post-op MI, and 17% for failure of prosthetic use in BKA patients. The mFI-5 frailty index should be incorporated into preoperative planning and risk stratification.

Immediate Carotid Endarterectomy Is Associated with Higher Risk in Symptomatic Patients.

BACKGROUND: Guidelines recommend that patients with carotid artery stenosis ≥50% (Sx-CAS) undergo carotid endarterectomy (CEA) within 14 days of symptoms. However, perioperative risks, especially stroke, may be increased when CEA is performed within 48 hours. This study seeks to more fully evaluate the effect of timing of surgery on outcomes for Sx-CAS. METHODS: All CEAs in the Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe) from 2012 to 18 were reviewed. Ipsilateral cortical or visual symptoms within 6 months defined Sx-CAS. Timing from symptom occurrence to CEA was classified as immediate (0-2 days), early (3-14 days), or delayed (>14 days). Perioperative stroke, myocardial infarction (MI), and 30-day mortality rates were compared by time to surgery. RESULTS: Of 2203 CEAs, 436 (20%) were for Sx-CAS (52% stroke, 48% transient ischemic attack). Mean time from symptoms to CEA was 28.3 days (range, 0-172; median, 14 days). Sixty-one cases (14%) were immediate, 166 (38%) early, and 209 (48%) delayed. Perioperative stroke occurred in 2.8% and stroke/MI/30-day mortality in 5.7%. Stroke rate was significantly higher in the immediate group (vs. early and delayed): 8.2%, versus 3.0%, and 0.96%, respectively (P = 0.009). Stroke/MI/30-day mortality was also higher in the immediate group: 13.1%, versus 6.0%, and 3.3%, respectively (P = 0.001). Immediate surgery was associated with greater postoperative events (P = 0.009), and logistic regression confirmed decreased risk of postoperative stroke and stroke/MI/30-day mortality in delayed surgery using immediate surgery as a reference. Wide variability existed among centers in the timing of CEA (immediate-range, 0-50%; delayed-range, 41-83%; P = 0.01). CONCLUSIONS: In the SoCal VOICe, 52% of patients undergo CEA within 2 weeks of symptoms. Increased stroke rates occur when CEA is performed within 2 days, whereas stroke and death rates are decreased at 3-14 days and beyond. These data support avoidance of immediate CEA. Opportunity exists to standardize timing of CEA for Sx-CAS among SoCal VOICe participants. Further study is required to define the role of immediate CEA.

Association between Preoperative Indications and Outcomes after Major Lower Extremity Amputation.

Despite aggressive limb salvage techniques, lower extremity amputation (LEA) is frequently performed. Major indications for LEA include ischemia and uncontrolled infection (UI). A review of the national Vascular Quality Initiative amputation registry was performed to analyze the influence of indication on outcomes after LEA. Retrospective review of the Vascular Quality Initiative LEA registry (2012-2017) identified all above- and below-knee amputations. Outcome measures included 30-day mortality, return to operating room (OR), postoperative myocardial infarctions, and postoperative SSI. Indications for surgery included ischemic rest pain, ischemic tissue loss (TL), acute limb ischemia (ALI), UI, and neuropathic TL. A total of 6701 patients met the inclusion criteria. The indications for surgery included TL (49.0%), UI (31.7%), ALI (8.0%), rest pain (6.6%), and neuropathic TL (2.3%). Patients with ALI had the highest 30-day mortality (12.0%) compared with TL (6.6%) and UI (6.4%) [P < 0.001]. The highest rate of return to OR occurred in the UI group (12.6%) [P < 0.001]. Multivariate analysis demonstrated that patients with UI have significantly higher rates of return to OR, whereas those with ALI have a 30-day mortality twice as high as other indications (both P < 0.001). These data can inform expectations after LEA based on the indications for surgery.

Adventitial cystic disease of the popliteal artery.

Adventitial cystic disease (ACD) is a vascular disorder most commonly affecting the popliteal artery. ACD is an uncommon and often misdiagnosed cause of lower extremity intermittent claudication that is usually acute in onset and of longer duration than claudication associated with atherosclerosis. We present two cases of ACD affecting the popliteal artery.

Rotational vertebral artery occlusion secondary to completely extraosseous vertebral artery.

Rotational vertebral artery (VA) occlusion is a possible cause of reduced blood flow through the posterior circulation of the brain due to compression of the VA on head turning when blood flow from the contralateral VA is compromised. When compression occurs in the V2 segment of the VA, it is usually due to compression from the longus colli muscle or cervical osteophytes. We present a unique case of a patient with a completely extraosseous course of the V2 segment of her dominant right VA that resulted in symptomatic rotational VA occlusion.

Dialysis Access Surgery: Does Anesthesia Type Affect Maturation and Complication Rates?

BACKGROUND: Creation of an arteriovenous fistula (AVF) is the preferred method of establishing long-term dialysis access. There are multiple anesthetic techniques used for patients undergoing this surgery including general endotracheal intubation, laryngeal mask airway, regional anesthesia with nerve blocks, and monitored anesthesia care with local infiltration. It is unclear what effect the method of anesthesia has on AVF creation success rate. It is our objective to determine if anesthesia type affects success of these surgeries defined by complication and maturation rates. METHODS: A retrospective review was performed in a single institution, single surgeon study of 253 patients who underwent AVF creation between January 2003 and December 2010. Patients were cross analyzed between 3 anesthesia types (General Endotracheal Intubation, Laryngeal Mask Airway and Local Infiltration with Monitored Anesthesia Care) and AVF creation surgeries (radiocephalic, brachiocephalic, and basilic vein transposition). No patients had regional anesthesia performed. Demographic data including comorbidities and risk factors were stratified among all categories. Analysis of variance, chi-squared testing, and Fisher's exact P testing was performed across all anesthesia types and specific operations and measured according to success of fistula maturation and complication rates (including death within 30 days, myocardial infarction within 30 days, respiratory insufficiency, venous hypertension, wound infections, neuropathy, and vascular steal syndrome). RESULTS: There were no significant differences in maturation rate in terms of all 3 anesthesia types for radiocephalic (P = 0.191), brachiocephalic (P = 0.191), and basilic vein transposition surgeries (P = 0.305). In addition, there were no differences in complication rates between the surgeries and the 3 types of anesthesia (P = 0.557). CONCLUSIONS: Our study shows that despite anesthesia type, outcomes in terms of maturation and complication rate are not statistically different in AVF creation surgeries. The use of monitored anesthesia care with local anesthesia may improve operative efficiency in terms of time in the operating room and in the recovery unit and therefore may be the preferred method of anesthesia. This recommendation may also parallel the preference to avoid general anesthesia in a patient population with more medical comorbidities. It is our conclusion that dialysis access surgery should therefore be performed under local anesthesia with monitored anesthesia care.

Necrotizing enterocolitis is associated with neonatal intestinal injury.

PURPOSE: We hypothesized that a subset of premature newborns has subclinical, intestinal mucosal compromise that predisposes to the development of necrotizing enterocolitis (NEC) days or weeks later. METHODS: Fifty-five newborns of 23 to 36 weeks' gestational age were identified, and urine was collected over the first 90 hours of life. The urinary concentration of intestinal fatty acid binding protein (iFABP(u)), a sensitive marker for intestinal injury, was determined. The diagnosis of NEC was based upon clinical condition, pathology, and/or imaging findings. RESULTS: Neonatal iFABP(u) exceeded 800 pg/mL in 27 subjects, including 9 of 9 who subsequently developed stage 2 or 3 NEC. This degree of iFABP(u) elevation, but not asphyxia, was significantly associated with the development of NEC (P < .01). CONCLUSION: In this population of premature newborns, there was a substantial incidence of intestinal mucosal compromise. All infants who subsequently developed stage 2 or 3 NEC had an elevated iFABP(u). This finding suggests a model for the pathogenesis of some cases of NEC, whereby perinatal mucosal injury predisposes to further damage when feedings are initiated. In addition, neonatal iFABP(u) assessment may represent a tool to identify infants at the highest risk for NEC and allow for the institution of focused, preventive measures.