Timing of thoracic endovascular aortic repair for uncomplicated acute type B aortic dissection and the association with complications.

OBJECTIVE: Previous publications have clearly established a correlation between timing of thoracic endovascular aortic repair (TEVAR) and complications after treatment of complicated acute type B aortic dissection (ATBAD). However, the temporal association of TEVAR with morbidity after uncomplicated presentations is poorly understood and has not previously been examined using real-world national data. Therefore, the objective of this analysis was to determine whether TEVAR timing of uncomplicated ATBAD (UATBAD) is associated with postoperative complications. METHODS: The Vascular Quality Initiative TEVAR and complex endovascular aneurysm repair registry was analyzed from 2010 to 2019. Procedures performed for non-dissection-related disease as well as for ATBAD with malperfusion or rupture were excluded. Because of inherent differences between timing cohorts, propensity score matching was performed to ensure like comparisons. Univariate and multivariable analysis after matching was used to determine differences between timing groups (symptom onset to TEVAR: acute, 1-14 days; subacute, 15-90 days) for postoperative mortality, in-hospital complications, and reintervention. RESULTS: A total of 688 cases meeting inclusion criteria were identified. After matching 187 patients in each of the 1- to 14-day and 15- to 90-day treatment groups, there were no statistically significant differences between groups. On univariate analysis, the 1- to 14-day treatment group had a higher proportion of cases requiring reintervention within 30 days (15.3%) compared with UATBAD patients undergoing TEVAR within 15 to 90 days (5.2%; P = .02). There was also a difference (P = .007) at 1 year, with 33.8% of the 1- to 14-day UATBAD patients undergoing reintervention compared with 14.5% for the 15- to 90-day group. There were no statistically significant differences on multivariable analysis for long-term survival, complications, or long-term reintervention. There was a trend toward significance (P = .08) with the 1- to 14-day group having 2.3 times the odds of requiring an in-hospital reintervention compared with the 15- to 90-day group. CONCLUSIONS: Timing of TEVAR for UATBAD does not appear to predict mortality or postoperative complications. However, there is a strong association between repair within 1 to 14 days and higher risk of reintervention. This may in part be related to the 1- to 14-day group's representing an inherently higher anatomic or physiologic risk population that cannot be entirely accounted for with propensity analysis. The role of optimal timing to intervention should be incorporated into future study design of TEVAR trials for UATBAD.

Milestones: The Road to Faculty Development.

PURPOSE: Milestones for the assessment of residents in graduate medical education mark a change in our evaluation paradigms. The Accreditation Council for Graduate Medical Education has created milestones and defined them as significant points in development of a resident based on the 6 competencies. We propose that a similar approach be taken for resident assessment of teaching faculty. We believe this will establish parity and objectivity for faculty evaluation, provide improved data about attending surgeons' teaching, and standardize faculty evaluations by residents. METHODS: A small group of advanced surgery educators determined appropriate educational characteristics, resulting in creation of 11 milestones (Fig. 2) that were reviewed by faculty and residents. The residents have historically answered 16 questions, developed by our surgical education committee (Fig. 3), on a 5-point Likert score (never to very often). Three weeks after completing this Likert-type evaluation, the residents were asked to again evaluate attending faculty using the Faculty Milestones evaluation. The residents then completed a survey of 7 questions (scale of 1-9-disagree to strongly agree, neutral = 5), assessing the new milestones and compared with the previous Likert evaluation system. RESULTS: Of 32 surgery residents, 13 completed the Likert evaluations (3760 data points) and 13 completed the milestones evaluations (1800 data points). The number completing both or neither is not known, as the responses are anonymous when used for faculty feedback. The Faculty Milestones attending physicians' scores have far fewer top of range scores (21% vs 42%) and have a wider spread of data giving better indication of areas for improvement in teaching skills. The residents completed 17 surveys (116 responses) to evaluate the new milestones system. Surveys indicated that milestones were easier to use (average rating 6.13 ± 0.42 Standard Error (SE)), effective (6.82 ± 0.39) and efficient (6.11 ± 0.53), and more objective (6.69 ± 0.39/6.75 ± 0.38) than the Likert evaluations are. Average response was 6.47 ± 0.46 for overall satisfaction with the Faculty Milestones evaluation. More surveys were completed than evaluations, as all residents had an opportunity to review both evaluation systems. CONCLUSIONS: Faculty Milestones are more objective in evaluating surgical faculty and mirror the new paradigm in resident evaluations. Residents found this was an easier, more effective, efficient, and objective evaluation of our faculty. Although our Faculty Milestones are designed for surgical educators, they are likely to be applicable with appropriate modifications to other medical educators as well.

Age does not predict need for reintervention in patients with critical limb ischemia.

OBJECTIVE: Conventional wisdom holds that patients with a need for intervention for femoropopliteal occlusive disease at a younger age have more aggressive disease, although there is a paucity of support in the literature. The purpose of this study was to evaluate this assumption. METHODS: A retrospective cohort of patients undergoing endovascular or open revascularization for femoropopliteal occlusive disease for critical limb ischemia during a 4-year period was assembled. Demographic information, comorbidities, disease characteristics, and time to last follow-up, repeat intervention, amputation, or death was recorded. The patients were stratified by age into a young (≤55 years) group, middle (56-77 years) group, and elderly (≥78 years) group. Univariate and multivariate statistical methods were used to evaluate the primary outcome. RESULTS: The study included 124 patients with a mean age of 64.4 ± 0.8 years. Progression to reintervention or amputation occurred in 50% of the patients during the follow-up period, with 18% dying before having an outcome. Kaplan-Meier analysis showed a trend toward significance (P = .06) in time to reintervention, amputation, or death among the three groups, with time to event of 253, 1083, and 504 days for the young, middle, and elderly groups, respectively. However, differences based on age were not significant (P = .57) in Cox regression analysis. CONCLUSIONS: There does not appear to be an association between time to reintervention and patient age.

Examining Hemodialysis Reliable Outflow catheter performance and cost in hemodialysis access.

BACKGROUND: The Hemodialysis Reliable Outflow (HeRO) vascular access device is a hybrid polytetrafluoroethylene graft-stent construct designed to address central venous occlusive disease. Although initial experience has demonstrated excellent mid-term patency rates, subsequent studies have led to external validity questions. The purpose of this study was to examine a single center experience with this vascular access device in challenging access cases with associated costs. METHODS: A retrospective study representing the authors' cumulative HeRO vascular access device experience was undertaken. The primary endpoint was graft failure or death, with secondary endpoints including secondary intervention rates and cost. RESULTS: Forty-one patients with 15,579 HeRO days and a mean of 12.7 ± 1.5 mo with the vascular access device were available for analysis. Secondary patency was 81.6% at 6 mo and 53.7% at 12 mo. The reintervention rate was 2.84 procedures per HeRO vascular access device year. Associated HeRO costs related to subsequent procedures were estimated at $34,713.63 per patient/y. CONCLUSIONS: These data on the patency and primary outcome data diverge significantly from initial multicenter studies and represent a real-world application of this technology. It is costly to maintain patency. Use of HeRO vascular access devices should be judicious with outcome expectations reduced.

Impact of psychological factors on objective ambulatory measures in patients with intermittent claudication.

OBJECTIVE: The purpose of this study was to evaluate the difference in objective measures of ambulation and psychosocial factors in patients with intermittent claudication (IC) stratified by type D personality, which incorporates elements of social inhibition and negative affectivity. METHODS: During a 1-year period, routine history and physical examination, ankle-brachial index, and pulse volume recording were performed on IC patients. Questionnaires assessing type D personality and psychosocial factors were also collected. The 6-minute walk test (6MWT) was performed, assessing symptoms and distance walked. Univariate and multivariate methods were used to assess the association between ambulation and type D personality. RESULTS: Seventy-one patients were enrolled (mean age, 62.5 ± 1.1 years; mean ankle-brachial index, 0.55 ± 0.03). Mean distance to symptoms and total distance walked were 83.7 ± 80.1 m and 206.5 ± 126.3 m, respectively. Type D personality was present in 29.6% of the population (n = 21). On 6MWT, 83.1% of all patients developed symptoms, and 57.4% quit because of symptoms. Univariate analysis of objective measures of ambulation demonstrated lower distance to symptoms in the type D group and trends toward lower total distance walked and quitting the 6MWT. Multivariate models showed increased odds of quitting the 6MWT (odds ratio, 7.71; P = .01) and less total distance walked by an average of 33.2 ± 13.3 m (P = .02) for the type D group. CONCLUSIONS: Despite equivalent demographic, medical, and psychosocial factors, the type D group was limited in ambulation, suggesting that type D personality is a strong predictor of disease impact in patients with IC.