Intraoperative Pedal Pressure Changes Offers Another Quantitative Assessment for Revascularization.

BACKGROUND: Lower extremity angiography is one of the most prevalent vascular procedures performed, generally via the contralateral common femoral artery. The use of retrograde pedal artery access to perform angiography has long been reserved as a "bail-out" technique to help cross chronic total occlusions that were not amenable from an antegrade approach. Recently, there have been reports and discussions involving increased utilization of pedal access for primary revascularization. The purpose of this study is to describe the outcomes of pedal access as a primary approach and to propose a novel evaluation of distal perfusion changes associated with interventions using direct pressure measurements. METHODS: A retrospective observational study evaluating all patients who underwent lower extremity angiography via retrograde pedal access between December 1, 2020, and June 30, 2021, within a single health-care system spanning 3 hospitals was performed. Demographics, comorbidities, procedural indications, and details were all recorded. Hemodynamic measurements were obtained and recorded upon initial pedal access and post intervention with a pressure transducer connected directly to the access sheath. Outcomes were analyzed with paired t-test. RESULTS: Twenty-eight angiograms using primary pedal access for endovascular intervention were performed during the study period. Most patients were African American (75%) females (57.1%) with hypertension (89.3%), hyperlipidemia (78.6%), diabetes (85.7%), coronary artery disease (64.3%), and current tobacco users (57.1%). The most prevalent indication for angiography was nonhealing wounds (67.9%). Pedal access was mostly achieved via the anterior tibial artery (79%). Sixty-three vessels were treated during the 28 angiograms (averaging 2.3 vessels per angiogram), most commonly the superficial femoral (27%), anterior tibial (25%), and popliteal (22%) arteries. Balloon angioplasty with or without stenting (98.5%) was predominately performed with an overall technical success rate of 94%. The mean preintervention and postintervention pressures were 36.5 mm Hg (standard deviation [SD] 25.7) and 83.4 mm Hg (SD 19.5), respectively. The mean change in pressure after intervention was 46.9 mm Hg (SD 23.3) (Table 3). There was a statistically significant difference detected between preintervention and postintervention pressure (P < 0.001) (Figure 1). There were no major amputations or adverse cardiovascular events at a mean first follow-up duration of 89 days. Six of the total 28 patients (21.4%) underwent repeat endovascular intervention on the ipsilateral extremity within a median of 45 (interquartile range 22.5-62.3) days. CONCLUSIONS: Primary pedal access is a viable option for performing lower extremity angiographic interventions. A significant increase in pedal artery pressure can be observed after angiographic intervention from retrograde pedal artery access. Further studies are necessary to define the clinical prognostic importance of these findings in relation to wound healing rates.

Evaluating the Ergonomics of Surgical Residents During Laparoscopic Simulation: A Novel Computerized Approach.

BACKGROUND: Assessment of residents' body positioning during laparoscopy has not been adequately investigated. This study presents a novel computer vision technique to automate ergonomic evaluation and demonstrates this approach through simulated laparoscopy. METHODS: Surgical residents at a single academic institution were video recorded performing tasks from the Fundamentals of Laparoscopic Surgery (FLS). Ergonomics were assessed by 2 raters using the Rapid Upper Limb Assessment (RULA) tool. Additionally, a novel computer software program was used to measure ergonomics from the video recordings. All participants completed a survey on musculoskeletal complaints, which was graded by severity. RESULTS: Ten residents participated; all performed FLS in postures that exceeded acceptable ergonomic risks as determined by both the human and computerized RULA scores (P < .001). Lower-level residents scored worse than upper-level residents on the human-graded RULA assessment (P = .04). There was no difference in computer-graded RULA scores by resident level (P = .39) and computer-graded scores did not correlate with human scores (P = .75). Shoulder and wrist position were the greatest contributors to higher computer-graded scores (P < .001). Self-reported musculoskeletal complaints did not differ at resident level (P = .74); however, all residents reported having at least 1 form of musculoskeletal complaint occurring "often." CONCLUSIONS: Surgery residents demonstrated suboptimal ergonomics while performing simulated laparoscopic tasks. A novel computer program to measure ergonomics did not agree with the scores generated by the human raters, although it concluded that resident ergonomics remain a concern, especially regarding shoulder and wrist positioning.

Reinvigorating an Academy of Medical Educators Using Ecological Systems Theory.

The educational framework of communities of practice postulates that early learners join medical communities as social networks that provide a common identity, role modeling and mentorship, and experiential learning. While being elected into a medical society is an honor, member engagement in these groups can falter if the society membership is seen as an honorific rather than one requiring continuing participation. As an example, Academies of Medical Educators have been established by many academic medical centers to encourage collaboration, skill development, professional identity formation, and scholarship. The University of North Carolina established the Academy of Educators in 2006 to create a diverse community of educators to promote the scholarship, teaching skills, and professional identity of educators. Despite rapid growth to over 500 members, we had less than 30 participants at events over the 2017-2018 academic year. To increase member engagement and participation, our academy leadership team used Bronfenbrenner's Ecological Systems Theory to design interventions at each layer of environmental influence, specifically at the microsystem, mesosystem, exosystem, macrosystem, and chronosystem levels. In this paper, we describe the multipronged approach used to increase the University of North Carolina Academy of Medical Educators event attendance from 30 to 1,000 faculty participants over the course of one academic year (2018-2019). This paper provides a model as to how medical societies can use ecological systems theory as a natural and comprehensive approach to plan and improve their member engagement and experience.

The Society for Vascular Surgery Objective Performance Goals for Critical Limb Ischemia are attainable in select patients with ischemic wounds managed with wound care alone.

BACKGROUND: To set therapeutic benchmarks, in 2009 the Society for Vascular Surgery defined objective performance goals (OPG) for treatment of patients with chronic limb threatening ischemia (CLTI) with either open surgical bypass or endovascular intervention. The goal of these OPGs are to set standards of care from a revascularization standpoint and to provide performance benchmarks for 1 year patency rates for new endovascular therapies. While OPGs are useful in this regard, a critical decision point in the treatment of patients with CLTI is determining when revascularization is necessary. There is little guidance in the comprehensive treatment of this patient population, especially in the nonoperative cohort. Guidelines are needed for the CLTI patient population as a whole and not just those revascularized, and our aim was to assess whether CLTI OPGs could be attained with nonoperative management alone. METHODS: Our cohort included patients with an incident diagnosis of CLTI (by hemodynamic and symptomatic criteria) at our institution from 2013-2017. The primary outcome measured was mortality. Secondary outcomes were limb loss and failure of amputation-free survival. Descriptive statistics were used to define the 2 groups - patients undergoing primary revascularization and patients undergoing primary wound management. The risk difference in outcomes between the 2 groups was estimated using collaborative-targeted maximum likelihood estimation. RESULTS: Our cohort included 349 incident CLTI patients; 60% male, 51% white, mean age 63 +/- 13 years, 20% Rutherford 4, and 80% Rutherford 5. Most patients (277, 79%) underwent primary revascularization, and 72 (21%) were treated with wound care alone. Demographics and presenting characteristics were similar between groups. Although the revascularized patients were more likely to have femoropopliteal disease (72% vs. 36%), both groups had a high rate of infrapopliteal disease (62% vs. 57%). Not surprisingly, the patients in the revascularization group were less likely to have congestive heart failure (34% vs. 42%), complicated diabetes (52% vs. 79%), obesity (19% vs. 33%), and end stage renal disease (14% vs. 28%). In the wound care group, 2-year outcomes were 65% survival, 51% amputation free survival, 19% major limb amputation, and 17% major adverse cardiac event. The wound care cohort had a 13% greater risk of death at 2 years; however, the risk of limb loss at 2 years was 12% less in the wound care cohort. CONCLUSIONS: A comprehensive set treatment goals and expected amputation free survival outcomes can guide revascularization, but also assure that appropriate outcomes are achieved for patients treated without revascularization. The 2-year outcomes achieved in this cohort provide an estimate of outcomes for nonrevascularized CLTI patients. Although multi-center or prospective studies are needed, we demonstrate that equal, even improved, limb salvage rates are possible.

Performance of Viabahn balloon-expandable stent compared with self-expandable covered stents for branched endovascular aortic repair.

OBJECTIVE: The objective of this study was to compare the performance between the Viabahn balloon-expandable stent (VBX; Viabahn [W. L. Gore & Associates, Flagstaff, Ariz]) and a covered self-expandable stent (SES; Fluency [Bard Peripheral Vascular, Tempe, Ariz]) used as bridging stents for directional branches during fenestrated or branched endovascular aneurysm repair of complex aortic aneurysms. METHODS: Patients with thoracoabdominal aortic aneurysms (type I-IV) or pararenal aortic aneurysms either at high risk for open repair or unsuitable for endovascular repair with commercially available devices were prospectively enrolled in a physician-sponsored investigational device exemption trial. Descriptive statistics of the cohort included demographics, risk factors, and anatomic and device characteristics. Individual branches were grouped as either VBX or SES and had data analyzed for primary patency, branch-related type I or type III endoleaks, branch instability, branch-related secondary intervention, and branch-related aortic rupture or death. Categorical variables were expressed as total and percentage, and continuous variables were expressed as median (interquartile range). Kaplan-Meier curves were used to estimate long-term results. Groups were compared with the log-rank test. P value <.05 was considered statistically significant. RESULTS: During the period from July 2012 through June 2019, there were 263 patients treated for complex aortic aneurysm (thoracoabdominal aortic aneurysm) with fenestrated or branched endografts. The devices used were either custom-manufactured devices or off-the-shelf p-Branch or t-Branch (Cook Medical, Bloomington, Ind) devices. The median age was 71 years (interquartile range, 66-79 years); 70% were male, and 81% were white. The most common cardiac risk factors were smoking (92%), hypertension (91%), hyperlipidemia (78%), and chronic obstructive pulmonary disease (52%). The total number of vessels incorporated into the repair was 977, with branches representing 18.4% (179 branches). Among these 179 branches, the celiac artery, superior mesenteric artery, right renal artery, and left renal artery received 54 (30%), 56 (31%), 38 (21%), and 31 (18%) branches, respectively. VBX and SES groups represented 96 (54%) and 81 (46%) of the branches implanted. The celiac artery, superior mesenteric artery, right renal artery, and left renal artery received VBX as a bridging stent in 40%, 46.7%, 33.8%, and 32.2% respectively. The overall cohort survival rate was 78.5% at 24 months. There was no branch-related rupture or mortality. Primary patency at 24 months (VBX, 98.1%; SES, 98.6%; log-rank, P = .95), freedom from endoleak (VBX, 95.6%; SES, 98.6%; log-rank, P = .66), freedom from secondary intervention (VBX, 94.7%; SES, 98.1%; log-rank, P = .33), and freedom from branch instability (VBX, 95.6%; SES, 97.2%; log-rank, P = .77) were similar between groups. CONCLUSIONS: This initial experience with VBX stents demonstrated excellent primary patency and similarly low rates of branch-related complications and endoleaks, with no branch-related aortic rupture or death. Our results demonstrate that in a high-volume, experienced aortic center, the VBX stent is a safe and effective bridging stent option during branched endovascular aortic repair. Multicenter studies with a larger cohort and longer follow-up are necessary to validate these findings.

Peak Performance: A Communications-Based Leadership and Teamwork Simulation for Fourth-Year Medical Students.

BACKGROUND: Medical education has traditionally been rooted in the teaching of health and disease processes, with little attention to the development of teamwork and leadership competencies. OBJECTIVE: In an era of value-based health care provided by high-functioning teams, new approaches are needed to develop communication, leadership, and teamwork skills for medical students. DESIGN: We designed and piloted a simulation-based educational activity called Peak Performance that linked a workbook, which focused on self-reflection on communication and leadership skills, with professional coaching. The simulation scenario placed students in the role of an upper-level resident on an inpatient service, followed by a small group debrief with students, a clinical faculty member, and a professional executive coach. After the debriefing session, students were invited to complete a self-reflection workbook within 1 week of the initial simulation. The final element of the curriculum was an individualized session with an executive coach. Peak Performance was offered to all fourth-year medical students enrolled in the Social and Health Systems Science required course at the University of North Carolina School of Medicine. RESULTS: Pre-/post-self-assessments of leadership competencies were completed by students. Pre-simulation self-assessment scores ranged from 3.72 to 4.33 on a 5-point scale. The lowest scores were in "Managing Conflict" and "Managing Others." The highest score was in "Self-Awareness." The post-simulation scores decreased in every competency, with "Managing Others" dropping significantly from 3.72 pre-simulation to 3.36 post-simulation (0.31, P < .05). Satisfaction with the curriculum was high, as reflected by a Net Promoter Score of 91% ("excellent" > 50%). CONCLUSIONS: A novel simulation-based educational activity linked to professional coaching is a feasible and impactful strategy to develop leadership, communication, and teamwork skills in medical students. Student insight and self-awareness increased as evidenced by a decrease in competency self-assessment after guided reflection and individualized coaching.

Poor glycemic control is associated with significant increase in major limb amputation and adverse events in the 30-day postoperative period after infrainguinal bypass.

OBJECTIVE: Understanding modifiable risk factors to improve surgical outcomes is increasingly important in value-based health care. There is an established association between peripheral artery disease (PAD), diabetes, and limb loss, but less is known about expected outcomes after revascularization relative to the degree of glycemic control. The purpose of this study was to determine the association between hemoglobin A1c (HbA1c) management in diabetics and surgical outcomes after open infrainguinal bypass. METHODS: The Vascular Quality Initiative infrainguinal bypass module was used to identify adult patients (≥18 years) with a history of diabetes who underwent bypass for PAD between 2011 and 2018. Exclusion criteria included missing or illogical HbA1c values and if the indication for the limb treated was not PAD. Patients were categorized by preoperative HbA1c levels as low severity/controlled (<7.0%), high severity (7.0%-10.0%), and very high severity (>10.0%). Primary outcomes were 30-day incidence of major adverse cardiac events (MACEs), major adverse limb events (MALEs), ipsilateral amputation, and 1-year all-cause mortality. Thirty-day outcomes were calculated using multivariable regression to compute odds ratios; hazard ratios were calculated for all-cause mortality. All analyses were adjusted for demographics, comorbidities, and clinical characteristics. RESULTS: The final sample included 30,813 operations (27,988 unique patients): 17,517 (57%) nondiabetic patients, 5194 patients with low-severity/controlled diabetes, and 8102 (26%) patients with poorly controlled diabetes, including 5531 (70%) treated with insulin. There were 6439 (21%) patients with high-severity HbA1c values and 1663 (5%) patients with very-high-severity HbA1c values. Those with a very high HbA1c level were more likely to be nonwhite, insulin dependent, and active smokers. Compared with nondiabetics, patients with very-high-severity HbA1c had an 81% increase in MACEs and 31% increase in MALEs, whereas patients with high-severity HbA1c only had a 49% increase in MACEs and a 12% increase in MALEs. Each one-step increase in severity category (eg, low to high to very high) was associated with an average 29% increase in the odds of MACEs and an 8% increase in the odds of MALEs. CONCLUSIONS: Uncontrolled diabetes with an HbA1c value >10.0% was associated with significantly worse 30-day surgical outcomes. Patients with incrementally better glycemic control (HbA1c level of 7.0%-10.0%) did not suffer the same rate of complications, suggesting that preoperative attempts at improving diabetes management even slightly could lead to improved surgical outcomes in open infrainguinal bypass patients.

Aberrant Right Subclavian Artery to Esophageal Fistula: A Rare Case and Its Management.

A 29-year-old woman underwent esophageal stent placement after developing esophageal stenosis in the setting of tracheoesophageal fistula repair in childhood. The patient developed hemoptysis from an esophageal to aberrant right subclavian artery fistula; this was managed with several staged procedures involving arterial stent placement, carotid-to-subclavian bypass, and aberrant subclavian artery ligation. The patient then underwent pericardial patch repair of her perforated esophagus. This case illustrates the importance of understanding congenital anatomy and frequent associations, such as tracheoesophageal fistula and aberrant right subclavian artery; furthermore, it demonstrates the importance of multidisciplinary care for complex cases.

Operative strategies for inferior vena cava repair in oncologic surgery.

OBJECTIVE: Tumor involvement of the inferior vena cava (IVC) can result from primary caval leiomyosarcoma, local invasion by retroperitoneal malignant neoplasm, or metastases. Whereas ligation of the IVC may be well tolerated if collateral circulation can be adequately preserved, collaterals must often be ligated during oncologic resection. Reconstruction of the IVC may be performed by primary repair, patch angioplasty, or interposition graft. The purpose of our study was to describe different strategies of IVC reconstruction and to measure outcomes associated with IVC reconstruction among patients with retroperitoneal malignant disease. METHODS: All patients undergoing IVC reconstruction at our quaternary care hospital between November 2004 and February 2018 were identified using billing data (Current Procedural Terminology code 34502). Patients who underwent resection of the IVC for tumor involvement were enrolled in our study; data were collected on demographics, operative intervention, type of reconstruction, postoperative course, and 1-year outcomes. Patency rates were assessed by reviewing postoperative imaging including computed tomography, magnetic resonance imaging, ultrasound, and venography. Two-year mortality and patency were calculated using Kaplan-Meier analysis methods. RESULTS: We identified 52 (46% female) patients who underwent IVC reconstruction for retroperitoneal malignant disease. The mean age was 53.6 years (range, 23-80 years). Procedures performed included primary repair (n = 17 [33%]), patch angioplasty (n = 18 [35%]), and interposition grafting (n = 17 [33%]). The mean length of stay was 16 days and did not vary significantly by group. Patients undergoing interposition graft were discharged on aspirin 81 mg daily. The 30-day survival rate was 96.2% (95% confidence interval [CI], 90.9-100), 1-year survival rate was 75.1% (95% CI, 62.8-87.4), and 2-year survival rate was 64.7% (95% CI, 50.5-78.9). There were no intraoperative deaths. The 30-day primary patency rate was 96% (95% CI, 90.7-100.0), 1-year primary patency rate was 88.8% (95% CI, 79.4-98.2), and 2-year primary patency rate was 77.5% (95% CI, 63.0-92.0). Seven patients (14%) developed nonocclusive thrombus within the IVC, and 16 patients (30%) developed postoperative symptoms of venous obstruction. CONCLUSIONS: IVC reconstruction is a safe option for patients requiring IVC resection during oncologic surgery as evidenced by 1-year survival of 75% and 1-year primary patency approaching 90%. The overall rate of postoperative thrombus development was low and similar across all groups. In the management of primary and secondary retroperitoneal malignant disease with IVC infiltration, IVC reconstruction should be considered to achieve appropriate oncologic resection while minimizing possible complications from caval interruption.

Renal volumes and estimated glomerular filtration rate changes after fenestrated-branched endovascular aortic repair.

OBJECTIVE: To describe changes in renal volumes (RV) and renal function after fenestrated-branched endovascular repair (F-BEVAR) for complex aortic aneurysms. METHODS: The data from patients enrolled in a physician-sponsored investigational device exemption clinical trial for endovascular treatment of complex aortic aneurysms from July 2012 to April 2017 were retrospectively analyzed. Descriptive statistics were calculated using the mean ± standard deviation. The mean estimated glomerular filtration rate (eGFR) and RV were calculated at baseline and 6, 12, and 18 months after F-BEVAR. Variable distributions were evaluated for skewness, and all models required log-transformation. Linear models using generalized estimating equations were used to assess the association between the RV and eGFR over time after adjustment for relevant covariates. We used Kaplan-Meier life-table analysis to calculate survival and branch patency. RESULTS: A total of 139 patients were followed up for 18 months or until death. The mean age was 71 ± 8 years (70% male). The most common risk factor was hypertension (92%). Chronic kidney disease (CKD; eGFR <60 mL/min) was present in 56 patients (40%). Thirty-one patients (22%) had ≥1 accessory renal artery. Of these 31 accessory arteries, 27 (87%) were embolized or covered. On average, the eGFR had decreased over time compared with baseline, with a median change of -4.4 mL/min (interquartile range [IQR], -11.4 to 4.9 mL/min), -2.6 mL/min (IQR, -11.9 to 6.5 mL/min), and -3.4 mL/min (IQR, -11.9 to 5.5 mL/min) at 6, 12, and 18 months postoperatively, respectively. Similarly, the RV had decreased from baseline by 8% ± 17%, 10% ± 17%, and 11% ± 22% at 6, 12, and 18 months, respectively. An increase in the baseline patient age of 5 years was estimated to be associated with a 3% (95% confidence interval [CI], 0.2%-6.0%) decrease in the mean eGFR during the follow-up period, collapsing over time. This change is similar to the natural history of renal deterioration with age. We estimated that an increase in the log-RV of 1 U would be associated with an estimated 26% (95% CI, 3%-52%) increase in the mean eGFR. Preexisting CKD did not affect the average change in RV. Of the 56 patients with previous CKD, 9 (16.1%) showed improvement in the eGFR to >60 mL/min. The median follow-up period was 17.9 months (IQR, 6.3-24.8). The Kaplan-Meier survival rate at 1 and 2 years was 84.7% (95% CI, 78.3%-91.1%) and 78.8% (95% CI, 71.0%- 86.6%), respectively. CONCLUSIONS: The RV and eGFR decreased in patients undergoing repair at the rates expected for patients with complex aortic disease. The eGFR correlated with the RV. Most of the decline in renal function occurred within the first 6 months postoperatively, after which, the renal function had stabilized.