Fundamental Technical Skills of Endovascular Surgery: A Preliminary Study on Its Impact on Skills and Stress during Procedures.

BACKGROUND: Our objective is twofold: determining if simulation allows residents to reach proficient surgeons' performance concerning fundamental technical skills of endovascular surgery (FEVS) while investigating effects of the program on surgeons' stress. METHODS: Using a FEVS training simulator, 8 endovascular FEVS were performed by vascular surgery residents (simulator-naive or simulator-experienced residents [SER]) and seniors. Total time needed to complete the 8 tasks, called total completion time (TCT), was the main evaluation criterion. Analgesia Nociception Index (ANI) was monitored during simulation. Likert scale questionnaire was filled out after each simulation. RESULTS: For each task, TCT was significantly lower for SER and seniors than simulator-naive residents (P = 0.0163). After only 5 simulations, SER were able to reach and even exceed the seniors' level in terms of TCT, with a median time of 10.8 min for SER and 11.9 min for seniors, and wire's movements with a median distance during cannulation of 4.44 m for SER and 4.17 m for seniors. Seniors remained better than SER in terms of precise wire manipulation (wire movement after cannulation), 4.17 m against 4.44 m (3.72-5.96), respectively. Based on the Likert scale stress analysis, seniors felt less stressed than both residents' groups (P = 0.0618). Seniors' initial ANI and mean ANI over the session were significantly lower than those of the residents, P = 0.0358 and P = 0.0250, respectively. CONCLUSIONS: We showed that 5 simulation sessions allowed residents to reach experienced surgeons' capacities on FEVS concerning TCT. Subjectively, seniors felt less stressed than residents, contrary to the results of our objective measures of stress.

Objective Evaluation of Clock Face Suture Using the Objective Structured Assessment of Technical Skill (OSATS) Checklist.

Objective: Assessment of the quality of the final product (QFP) is critical in simulation training, such as the clock face suture (CFS) exercise that is used to assess trainees' needle handling and suturing accuracy. Objective Structured Assessment of Technical Skill (OSATS) scores are the gold standard for the evaluation of trainees. The aim was to investigate variability in the use of OSATS checklists and to evaluate a semi-automatic method of suture analysis vs. OSATS scores. Methods: Details of 287 CFSs performed by trainees during Fundamentals in Vascular Surgery examinations were collected. All were rated according to a seven item OSATS checklist, including QFP score and an overall score by one or two expert surgeons immediately after completion. Interassessor variability was assessed for the CFS that were assessed by two assessors.In order to assess intra- and interassessor variability, 50 CFS pictures were chosen randomly and submitted to three expert surgeons to rate the QFP twice and to carry out a semi-automatic image analysis of each CFS and the estimated cumulative error (CE; mm) recorded. It was hypothesised that the CE correlates to OSATS checklist items or overall score. Variables were compared for correlation with OSATS results using a linear regression. A Pearson's test was used to confirm the proposed hypothesis. Results: Mean ± standard deviation overall score for the OSATS checklist was 20.61 ± 6.33. Inter- and intra-assessor correlation were statistically significant regarding OSATS checklist items. Both correlations presented a low coefficient of determination, indicating variability. The mean CE was 16.07 ± 4.84 mm, and the correlation between the QFP and CE was statistically significant, proving that CE is an objective metric by which to assess the QFP. Conclusion: OSATS score demonstrated intra- and interassessor variability, although there was a significant correlation between scores. CE is an objective metric that is not subject to assessor subjectivity or interassessor variability and is correlated with the gold standard of evaluation.

Xray Exposure Time in Dedicated Academic Simulation Programs Is Realistic of Patient Procedures.

OBJECTIVE: To ascertain whether simulated endovascular procedures are comparable to real life operating room (OR) procedures, particularly with regard to irradiation time. METHODS: This was a retrospective study comparing simulation with clinical data. Fluoroscopy time and overall operation time were compared between simulated abdominal aortic endovascular repair (EVAR) and iliac procedures that were performed, respectively, from 2016 to 2019 and from 2015 to 2019, and clinical EVAR and iliac procedures performed in the OR between January 2018 and November 2021. RESULTS: Within the defined periods, 171 simulated procedures (91 EVAR, 80 iliac) and 199 clinical procedures (111 EVAR, 88 iliac) were performed. For both EVAR and iliac procedures, median total procedure time was much longer during real surgery (p < .001). However, median total fluoroscopy time remained the same, whether the procedure was real surgery or performed on the simulator, for iliac procedures (8.47 minutes in the OR, 8.35 minutes on the simulator, p = .61) and for EVAR procedures (14.80 minutes in the OR, 15.00 minutes on the simulator p = .474). CONCLUSION: Simulated endovascular procedures are comparable with real life OR procedures, particularly with regard to irradiation time when integrated in a dedicated curriculum.

Temporary Vascular Debranching to Facilitate Retroperitoneal Tumour en bloc Resection.

BACKGROUND: Oncovascular teams are known to be a cornerstone in planning and facilitating en bloc resection of large retroperitoneal masses. Vascular surgeons can help with dissection close to major vessels by vascular reconstruction when necessary, and also in performing specific procedures that can facilitate safe and optimal tumour mass resection. Two cases are reported where temporary vascular debranching of major arteries allowed safe tumour harvesting. CASE REPORTS: A 68 year old man with a necrotic retroperitoneal carcinoma underwent en bloc resection with temporary debranching of the coeliac trunk, superior mesenteric artery, and right renal artery using a multibranched bypass from the axillary artery. The post-operative course included septic shock related to pulmonary infection requiring a 10 day stay in the intensive care unit (ICU). Renal function was normalised on day two. The patient was discharged on day 18. However, he died 78 months post-operatively from pulmonary metastases after anti-angiogenic treatment.A 34 year old man with a retroperitoneal mature teratoma underwent en bloc resection with temporary debranching of the coeliac trunk, superior mesenteric artery, left and right renal arteries, and left and right common iliac arteries, with a multibranched bypass from the axillary artery. Post-operatively he required a five day stay in the ICU. Acute kidney injury (AKI) was noted, but it resolved without dialysis. The patient was discharged on day 16. After 78 months follow up he presented with chronic renal failure requiring dialysis. Follow up computed tomography angiography showed pulmonary metastases; although the metastases were manageable with surgical treatment, the patient refused further care. CONCLUSIONS: Temporary extra-anatomical bypass from the axillary artery to the visceral arteries could be considered as an option to provide adequate perfusion and to prevent visceral ischaemia during en bloc resection of large retroperitoneal masses.

Computed-tomography-based predictive scores of surgical complications to help decision-making in enrolling obese patients in kidney transplantation list.

This study aimed at developing scores predicting surgical complications in obese transplant recipients, based on preoperative computed tomography (CT) parameters. All consecutive patients with a body mass index (BMI) ≥ 30 kg/m2 who underwent kidney transplantation between 2012 and 2019 were included. The preoperative CT parameters were assessed: total fatty surface (TFS), subcutaneous fatty surface (SFS), iliac vessel to skin distance (VSD), and abdominal perimeter (AP). Per- and postoperative complications (vascular, urinary, parietal, and digestive complications) within 30 days were listed. Predictive models of surgical complications were generated based on the results of the logistic regression. Among the 163 patients included, 53 (32.5%) experienced surgical complications. The AP was a risk factor for complications in multivariate analysis (OR: 1.050; 95% CI: 1.016-1.087; p = 0.03). Two predictive models of complications were created based on the statistical analysis: a one-variable model based on AP (sensitivity 86.8%, specificity 41.8%, area under the curve (AUC) 65.3, with a cutoff value of 107 cm) and a five-variable model based on BMI, TFS, SFS, VSD, and AP (sensitivity 73.6%, specificity 57.3%, AUC 66.2). These models, based on patient morphometric measurements, could allow predicting the occurrence of surgical complications in obese candidates for kidney transplantation.

Volume Change after Endovascular Treatment of Common Iliac Arteries ≥ 17 mm Diameter: Assessment of Type 1b Endoleak Risk Factors.

OBJECTIVE: The aim of this study was to assess the post-operative volumetric evolution of common iliac arteries (CIA) ≥ 17 mm diameter with respect to the type of endovascular technique performed and to assess type 1b endoleak risk factors. METHODS: All consecutive patients presenting with aneurysmal disease with CIA ≥17 mm treated endovascularly from 2008 to 2016 were included. Patients were divided into two groups dependent upon the type of endovascular technique performed: bell bottom technique (BBT group), vs. other techniques (non-BBT group). Volumetric evolution of the CIA was assessed for each patient by computed tomography angiographic reconstructions performed pre-operatively, at six months, one year, and two years. Multivariable analysis was performed to identify risk factors for type 1b endoleak. RESULTS: From 2008 to 2016, 74 patients with 110 CIA ≥17 mm were treated (BBT group: n = 58; non-BBT group: n = 52). Mean follow up was 48.1 months (median 39.0, IQR 38.1). Mean volumetric evolution significantly differed in the BBT group +14.2% (median 19.9%, IQR 24.6) compared with the non-BBT group: -20.9% (median -20.1%, IQR -26.0), p < .001. The five year type 1b endoleak related re-intervention rate was 16.1% and 7.7% in the BBT and non-BBT groups, respectively (p = .04), mean time to type 1b endoleak was 24.8 months and 54.3 months, respectively. The BBT appeared as a risk factor for type 1b endoleak (OR: 7.13; 95% CI: 1.58-3.04; p < .001). CONCLUSION: The BBT is associated with an increase in CIA volume post-operatively and consequently can be considered a risk factor for type 1b endoleak. It might be avoided if an iliac branched endograft is possible.

A Popliteal Cyst Responsible for Acute Lower Limb Ischemia.

We report the case of a 68-year-old man complaining of sudden intermittent claudication of the left limb. The patient was rapidly diagnosed with duplex ultrasound (DUS), computed tomography angiography, and magnetic resonance angiography as having a popliteal cyst (PC) compressing the popliteal artery, responsible for intermittent claudication. The patient underwent DUS-guided PC aspiration allowing symptoms resolution. However, he presented 3 recurrent ischemic syndromes from brutal claudication to more severe ischemia in a 3-month period, with increasing severity of the symptoms, treated with 3 DUS-guided PC aspirations. An extensive work-up excluded an atherosclerotic etiology. Consequently, due to increasing severity and quick recurrence of the symptoms and given the underlying knee osteoarthritis, the patient underwent radical treatment and got a total knee prosthetic replacement. One year later, follow-up was uneventful.

Late Peroneal Neuropathy after Open Surgical Treatment of Popliteal Artery Aneurysm.

We report the case of a 71-year-old man complaining of swollen left limb and progressively worsening pain. He underwent surgery 12 years ago for popliteal artery aneurysm with proximal and distal ligation and venous bypass grafting. The patient was diagnosed as having left peroneal neuropathy caused by a 10.5 cm expanded aneurysmal sac compressing the peroneal nerve in the popliteal fossa. The patient underwent open repair with opening of the aneurysmal sac, removal of the thrombus, and sewing of the left genicular artery responsible for back-bleeding. Postoperative range of motion exercises and physical therapy allowed resolving foot drop 1 year after surgery.