Letter of recommendation characteristics associated with interview offer to a vascular surgery residency program.

BACKGROUND: Letters of recommendation (LORs) are considered by program directors (PDs) to be an integral part of the residency application. With the conversion of USMLE Step 1 to a binary pass/fail outcome, LORs will likely have higher important in the application process moving forward. However, their utility in securing an interview for a particular applicant remains undetermined. This study aims to identify the applicant and LOR characteristics associated with an interview invitation. METHODS: Letter writer (n=977) characteristics were abstracted from applications (n=264) to an individual integrated vascular surgery residency program over 2 application cycles. A validated text analysis program, Linguistic Inquiry and Word Count, was used to characterize LOR content. Applicant, letter writer, and LOR characteristics associated with an interview invitation was determined using multivariable analysis. RESULTS: Letter writers were 70.9% vascular surgeons (VS), 23.7% PDs, and 45.4% professors. Applicants offered an interview were more likely to come from a top 50 medical school (35.2% vs 25.8%, p=0.013) and an institution with a home vascular program (45.5% vs 34.1%, p=0.006). Alpha Omega Alpha membership was significantly associated with interview offer (28.4%, p<0.001). A greater proportion of letters from VS was associated with an interview offer (p <0.001) compared with letter writers of other specialties. One or more PD letters was significantly associated with an interview offer (79.55% vs 20.45%, p=0.008), whereas number of letters from APDs was not significantly associated with interview offer. Letters written by away institution faculty were significantly associated with interview offer (75%, p<0.001), whereas nonclinical letters were not. Presence of one or more letters from a chair (57.95% vs 42.05%, p=0.015) or chief (67.05% vs 32.95%, p=0.028) was significantly associated with interview offer. Letters for applicants offered an interview had more references to research and teaching, which were more common in letters written by VS. Letters written by PDs were more likely to use assertive, advertising language in favor of applicants. There were no significant applicant, letter writer, or LOR characteristics associated with a top 20 rank. CONCLUSION: Successful applicants were more likely to have LORs written by VS, PDs, and those of higher academic rank with references to research and teaching.

Patient experience of the process to diagnosis of chronic limb-threatening ischaemia: A qualitative study.

INTRODUCTION: Delays exist at each stage of the chronic limb-threatening ischaemia (CLTI) care pathway, but there is little known about patient factors influencing delay to diagnosis of CLTI. This study explores the experiences and perceptions of patients recently diagnosed with CLTI. METHODS: A qualitative interview study was conducted. Sixteen participants underwent semi-structured interviews. Reflexive thematic analysis was performed on the data, aiming to understand factors which can influence delay in the CLTI care pathway. RESULTS: Five interrelated themes were developed: CLTI is a devastating condition; Reluctance to ask for help; When we are empowered we get better care; Luck plays a role in the process to diagnosis; and Vascular units can do better, comprising sub-themes of information transfer-consider communication and arterial versus non-arterial centres-proximity isn't everything. CONCLUSIONS: The five themes generated from the interview data describe factors relevant to delay given meaning by participants who have lived experience of CLTI. Theme content should be noted by clinicians, commissioners and providers looking to improve care pathways for patients with CLTI. The importance of awareness for the public, patients and clinicians linked ideas in some themes and interventions to raise awareness should be considered.

Carotid stenosis in logistic restraints Optimizing treatment of significant carotid artery stenosis in times of logistic restraints as a result of COVID-19 pandemic.

BACKGROUND: COVID-19 confronted medical care with many challenges. During the pandemic, several resources were limited resulting in renouncing or postponing medical care like carotid endarterectomy (CEA) for patients with significant carotid artery stenosis. Although according to international guidelines CEA is the first choice, carotid artery stenting (CAS) could potentially be a reasonable alternative especially during logistical restraints. PURPOSE: To evaluate outcomes of CAS versus CEA before, during and after the COVID-19 pandemic. Our hypothesis was that a CAS first approach yielded comparable outcomes compared to a CEA first approach. METHODS: Retrospective analysis of consecutive patients with significant carotid artery stenosis treated with CEA or CAS between September 2018 and March 2023. Each consecutive period of 1.5 year marked a new (treatment) period: pre-COVID (CEA first strategy), during COVID (CAS first strategy) and post COVID (patient tailored approach). Primary outcome was the composite endpoint of stroke, TIA or death within 30 days. Secondary outcome consisted of the rate of technical success, cerebral hyperperfusion syndrome, myocardial infarction or other cardiac complications needing intervention, bleeding of the surgical site needing intervention, nerve palsy, unintended IC admission, pseudoaneurysm, restenosis or occlusion. RESULTS: A total of 318 patients were included. Out of 137 patients treated with CEA, 55, 36 and 46 were treated pre-COVID, during COVID and post-COVID, respectively. Out of 181 CAS procedures, 38, 59 and 84, respectively, were performed in each time period. Primary outcome occurred in 5.5%, 0% and 2.2% in the CEA group and 0%, 1.7% and 3.6% in the CAS group (p = .27; p = 1.00; p = 1.00, respectively). Overall technical success was 100% for CEA and 99.4% for CAS (p = 1.00). Rate of restenosis was the only secondary outcome measure which was significantly better after CAS compared to CEA in the pre- and post-COVID period (CEA vs CAS, 12.7% vs 7.9% and 23.9% vs 4.8% with a p-value of .03 and .03, respectively). Hospital presentation to treatment interval did not differ significantly during the pandemic. CONCLUSION: Outcomes were comparable between CAS versus CEA in patients with significant carotid artery stenosis before, during and after the COVID-19 pandemic. CAS showed better results in terms of other complications (i.e., restenosis rate) in the pre- and post-COVID period compared to CEA. Our results may support a CAS first approach when no relevant contra-indications exist without exposing the patient to complications associated with an open surgical approach. Discussion in a multidisciplinary team is advised.

Mycotic Aortic Aneurysm, a very sudden development for a preexisting Aortic Aneurysm: Case report.

INTRODUCTION: An Infectious Aortic Aneurysm (IAA), also known as a Mycotic Aortic Aneurysm (MAA), is a rare lesion of the aorta resulting from an infection of its wall. PRESENTATION: A male patient in his 70s presented to our emergency department with fever, intense abdominal pain, and a pulsatile mass in the middle of the abdomen. A Computed Tomography (CT) angiography scan was done two weeks earlier and it showed a 6.6 cm subrenal aortic aneurysm. A new CT angiography scan revealed a 3.4 cm growth (10*10*9.3) with periaortic fluids. The diagnosis of MAA was considered, and emergency surgery was performed. DISCUSSION: MAA is a rare disease characterized by a high risk of rupture and a high mortality rate, up to 43 %, despite the advances in treatment techniques. Adjacent infection is a rare cause for MAA especially on a preexisting aneurysm. The two main surgical approaches are Open Surgical Repair (OSR) and Endo-Vascular Repair (EVR). We opted for OSR with careful debridement because EVR was not available at our center and the huge size of the aneurysm posed high rupture risk. CONCLUSION: This case demonstrates the importance of close monitoring and early intervention for aneurysms, particularly in cases with adjacent infection. Moreover, the rapid growth rate and rupture risk demands more urgent intervention if the MAA is suspected.

Residual Popliteal Aneurysm Perfusion Leading to Embolic Complications: A Case Report.

Introduction: Surgical management of popliteal artery aneurysms has been described for half a century. Long term development of the excluded aneurysm sac in the popliteal segment however remains widely unknown, with only a few small series describing outcomes. Residual aneurysm perfusion has the potential to lead to serious complications. Report: A 63 year old man presents with skin and soft tissue necrosis of the right calf two years after proximal and distal aneurysm ligation and great saphenous vein bypass for a popliteal artery aneurysm. Computed tomography and magnetic resonance angiography show perfusion of the excluded aneurysm as well as extensive necrosis of the gastrocnemius muscle. Direct angiography of the aneurysm demonstrated retrograde aneurysm perfusion due to insufficient distal ligation with recurrent micro-embolisation to the calf via geniculate arteries. Coiling of the geniculate arteries was performed, plugging the connection to the tibiofibular trunk and embolisation of the aneurysm sac. After the intervention, no flow was seen in the aneurysm sac and the patient made full recovery. Discussion: Residual aneurysm sac perfusion can lead to complications long after successful aneurysm exclusion. Follow-up after surgery of popliteal aneurysms should include observation of the excluded aneurysm sac with control of residual blood flow. For persistent sac perfusion, aneurysm enlargement or symptoms, further treatment should be considered. Surgical aspects such as complete transection of the artery after aneurysm ligation or end to end anastomosis of the bypass may be considered, to prevent such complications.

Hybrid Repair of Left Subclavian Artery Pseudoaneurysm With Vertebral Artery Revascularisation: A Solution for a Complex Case.

Introduction: Pseudoaneurysms of the subclavian artery are a rare complication. Surgical treatment is necessary to prevent potentially lethal complications. This needs adequate planning in cases that require vertebral artery revascularisation. Report: A 56 year old man with multiple systemic comorbidities underwent endovascular treatment using a balloon expandable bare metal stent for symptomatic subclavian Steal syndrome. During follow up, computed tomography angiography (CTA) revealed a pseudoaneurysm in the proximal segment of the left subclavian artery. The patient had criteria warranting left vertebral artery revascularisation. The patient underwent scheduled hybrid surgical treatment involving transposition of the vertebral artery to the common carotid artery, endarterectomy of the internal carotid artery, and endovascular therapy for pseudoaneurysm exclusion; all were performed on the left side. The post-operative period was without incident. After 12 months the patient remains asymptomatic, with adequate exclusion of the pseudoaneurysm, and patency of the procedures. Discussion: Hybrid surgery could offer a secure, feasible, and less invasive option for treating subclavian artery pseudoaneurysms that require vertebral artery revascularisation.

Staged endovascular and open surgical approach for treatment of a giant left upper back arteriovenous malformation.

We present a case of a symptomatic, giant, left upper back arteriovenous malformation that was treated through a staged endovascular and open approach. Through a series of embolizations, followed by resection, we were able to preserve the limb and upper back neurovascular supply, demonstrating an approach to preserve sensation and function and improving quality of life.

Congenital right subclavian artery aneurysm resection in a 30-year-old woman.

Right-sided subclavian artery aneurysms (SAAs) are exceedingly rare. The most common cause of intrathoracic SAAs is atherosclerosis; however, causes can also include infection, trauma, cystic medial degeneration, Marfan syndrome, and Takayasu arteritis. Symptoms present most commonly with compression of surrounding structures, although adverse events, including rupture, thrombosis, and embolization, can also occur. We present a case of a 30-year-old woman with an asymptomatic, 15-mm, right-sided SAA, which was successfully resected with subsequent end-to-end primary anastomosis.

Paget-Schroetter Syndrome: A Case of a Young Weightlifter.

Venous thoracic outlet syndrome is a rare type of thoracic outlet disorder that is often overlooked. When an upper extremity deep vein thrombosis (UEDVT) occurs due to thoracic outlet compression, it is commonly referred to as Paget-Schroetter syndrome (PSS). The space between the first rib and the clavicle where the subclavian vein passes through is highly vulnerable to compression and injury. This space often undergoes repetitive trauma due to extrinsic compression which ultimately results in scarring and clot formation. This case report reviews the case of a 26-year-old white male who presented with the chief complaint of right arm swelling and soreness after strenuous bench pressing. He went to urgent care and the initial diagnosis was a strained muscle. An ultrasound was ordered, revealing multiple UEDVTs. At this time, the patient was referred to vascular surgery for further management. Recommended management for PSS is to initiate anticoagulation or thrombolytic therapy depending on the timing between the onset of symptoms and diagnosis. Although there is some disagreement on the next steps after thrombolysis, most physicians agree that decompression of the thoracic outlet with first rib resection is the logical next step to prevent clot recurrence. The patient received the above-mentioned therapy and is progressing well with recovery. Recognizing the thoracic outlet as a potential location for pathology and keeping in mind those who have a presentation similar to this case study is extremely important.

Management of renal artery aneurysms: A retrospective study.

BACKGROUND: Although renal artery aneurysms (RAAs) are rare and often asymptomatic with slow growth, their natural progression and optimal management are not well understood. Treatment recommendations for RAAs do exist; however, they are supported by limited data. METHODS: A retrospective cohort study was conducted to explore the management of patients diagnosed with an RAA at our institution from January 1st, 2013, to December 31st, 2020. Patients were identified through a search of our radiological database, followed by a comprehensive chart review for further assessment. Data collection encompassed patient and aneurysm characteristics, the rationale for initial imaging, treatment, surveillance, and all-cause mortality. RESULTS: One hundred eighty-five patients were diagnosed with or treated for RAAs at our center during this timeframe, with most aneurysms having been discovered incidentally. Average aneurysm size was 1.40 cm (±0.05). Of those treated, the mean size was 2.38 cm (±0.24). Among aneurysms larger than 3 cm in size, comprising 3.24% of the total cases, 83.3% underwent treatment procedures. Only 20% of women of childbearing age received treatment for their aneurysms. There was one instance of aneurysm rupture, with no associated mortality or significant morbidity. CONCLUSIONS: Our institution's management of RAAs over the period of the study generally aligned with guidelines. One potential area of improvement is more proactive intervention for women of childbearing age.

Uncharted Territories: Dynamic Hip Screw Migration Into the Pelvis Requiring Laparotomy.

Hip fractures are common in patients with poor bone quality and are seen to affect the elderly and frail population. We report a case of implant failure after fixing an unstable intertrochanteric fracture with a dynamic hip screw (DHS). The patient presented with a DHS that had migrated into the pelvis approximately six months after surgery. Plain radiographs showed migration of the DHS through the acetabulum and into the pelvis. Migration of DHS into the pelvis is an extremely rare complication and has only been reported a few times. A 71-year-old man presented with a fall and confusion. The patient reported having a fall but could not recall the exact events. Past medical history included Alzheimer's dementia, osteoporosis, left total hip replacement, right DHS, peripheral neuropathy, and recurrent falls. He had undergone reduction and fixation of a right intertrochanteric fracture with DHS implant via direct lateral approach six months before hospital admission. On examination, he had right-sided hip pain and was unable to straighten leg raise. His abdomen was soft and non-tender, with no distension or palpable masses. Neurovascular status was normal, and no signs of infection were detected. On the anteroposterior radiograph, the implant seemed to have migrated through the acetabulum and into the abdomen. A CT of the abdomen and pelvis was performed to identify any visceral injuries (negative) and for surgical planning. The patient underwent a midline laparotomy to remove the implant. Although the exact reason for the implant failure is unknown, the migration of an unbroken hip screw into the abdomen and pelvis requiring laparotomy has not been reported in literature.

Jejunal ischaemia following inferior mesenteric artery angioembolisation for type 2 endoleak.

We present a rare case of short-segment jejunal infarction following inferior mesenteric artery embolisation for type 2 endoleak in a patient who previously underwent endovascular repair of abdominal aortic aneurysm. Potential causes for the event might include thromboembolism or traumatic thrombosis of a jejunal branch of the superior mesenteric artery (SMA) caused by a buddy guide wire used to maintain the position of the long vascular sheath in the SMA hiatus. The condition was recognised on CT and treated with resection of the infarcted segment of the small bowel followed by primary anastomosis.

Aortic aneurysm sac filling with AneuFix injectable polymer during endovascular aneurysm repair: feasibility and safety trial study protocol.

INTRODUCTION: Type II endoleaks (T2ELs) following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) can lead to aneurysm growth, compromising the stent graft seal and risking rupture. Preventing these endoleaks during EVAR involves filling the AAA sac around the stent graft to exclude the aneurysm and block any arteries causing the endoleak. This study investigates the feasibility and safety of using AneuFix, a biocompatible injectable polymer developed by TripleMed (Geleen, the Netherlands), for aneurysmal sac filling during EVAR in high-risk T2EL patients. METHODS AND ANALYSIS: A feasibility, single-arm, single-centre clinical trial will initially include five patients with infrarenal AAA, eligible for EVAR, and at high risk for T2EL based on the number of patent lumbar arteries and the cross-sectional area of the aortic lumen at the level of the inferior mesenteric artery. Postevaluation by the Data Safety and Monitoring Board, the study cohort will extend to 25 patients. During EVAR and after stent graft deployment, the aneurysm sac is filled with AneuFix polymer using a filling sheath positioned parallel to the contralateral limb with the tip inside the aneurysm sac. Primary outcome is technical success (successful AAA sac filling). The secondary outcomes include clinical success at 6 and 12 months (occurrence of T2ELs and AAA growth assessed with CT angiography), intraoperative and perioperative complications, all endoleaks, adverse events, re-interventions, aneurysm rupture and patient survival. ETHICS AND DISSEMINATION: This trial was approved by the Dutch Authorities (Central Committee on Research Involving Human Subjects, IGJ), Amsterdam University Medical Centre Ethical Commission, and adheres to the Declaration of Helsinki and European Medical Device Regulation. Results will be shared at (inter)national conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04307992.

Simulation training in vascular and endovascular surgery: A nationwide survey among surgeon educators and trainees in France.

OBJECTIVES: Vascular surgical training is evolving towards simulation-based methods to enhance skill development, ensure patient safety, and adapt to changing regulations. This study aims to investigate the utilization of simulation training among vascular surgeons in France, amidst ongoing shifts in teaching approaches and educational reforms. METHODS: A national survey assessed the experiences and perceptions of vascular surgery professionals regarding simulation training. Participation was open to self-reported health professionals specialized (or specializing) in vascular surgery, including interns or fellows. Participants were recruited through various channels, and data were collected via a questionnaire covering participant characteristics, simulation experiences, and perceptions. RESULTS: Seventy-six participants, predominantly male (74%) took part in the survey. While 58% reported access to simulation laboratories, only 17% had organized simulation sessions 1 to 3 times a year, and 5% had sessions more than 10 times annually. High fidelity simulators were available in 57% of institutions, while low fidelity simulators were available in 50%. Regarding funding, 20% received financial assistance for training, predominantly from industry (18%). One third of the participants experienced 9 or more sessions (34%), lasting between 1 to 2 hours (34%), 30% expressed satisfaction with access to simulation, while 33% were dissatisfied with communication of simulation training opportunities. CONCLUSION: Despite recognizing the benefits of simulation training, its integration into vascular surgery education in France remains incomplete. Challenges such as limited access and communication barriers hinder widespread adoption. Collaborative efforts are needed to ensure uniformity and enhance the effectiveness of simulation training in vascular surgery education.

A Comprehensive Analysis of Leadership Attributes, Discrepancies, and Implications for Gender Equity in Vascular Surgery.

OBJECTIVE: Well-developed leadership skills have been associated with a better understanding of healthcare context, increased team performance, and improved patient outcomes. Surgeons, in particular, stand to benefit from leadership development. While studies have focused on investigating knowledge gaps and needs of surgeons in leadership roles, there is a noticeable gap in the literature concerning leadership in Vascular Surgery. The goal of this study was to characterize current leadership attributes of vascular surgeons and understand demographic influences on leadership patterns. METHODS: This retrospective cohort study was a descriptive analysis of vascular surgeons and their observers who took the leadership practice inventory (LPI) from 2020 to 2023. The LPI is a 30 question inventory that measures the frequency of specific leadership behaviors across five practices of leadership. RESULTS: A total of 110 vascular surgeons completed the LPI. The majority of participants were white (56%) and identified as male (60%). Vascular surgeons most frequently observed the "enabling others to act" leadership practice style (8.90 ± 0.74) by all evaluators. Vascular surgeons were most frequently above the 70th percentile in the "challenge the process" leadership practice style (49%) compared to the average of other leaders world-wide. Observers rated vascular surgeons as displaying significantly more frequent leadership behaviors than vascular surgeons rated themselves in every leadership practice style (P-value < 0.01). The only demographic variable associated with a significantly increased occurrence of achieving 70th percentile across all five leadership practice styles was the male gender: a multivariable model adjusting for objective experience showed men were at least 3.5 times more likely to be rated above the 70th percentile than women. CONCLUSIONS: Vascular surgeons under report the frequency at which they practice leadership skills across all five leadership practice styles and should recognize their strengths of enabling others to act and challenging the process. Men are recognized as exhibiting all five leadership practices more frequently than women, regardless of current position or experience level. This observation may reflect the limited leadership positions available for women, thereby restricting their opportunities to demonstrate leadership practices as frequently or recognizably as their male counterparts.

Staged bilateral release of the popliteus muscle using a posterior surgical approach to the popliteal fossa to treat type 4 popliteal artery entrapment.

Popliteal artery entrapment syndrome (PAES) is a rare cause of intermittent claudication in the young. Aberrant embryological development results in entrapment of the popliteal artery by myofascial structures of the popliteal fossa. Type 4 PAES is due to aberrant development of the popliteus muscle superficial to the popliteal artery. We present a case of bilateral type 4 PAES, along with intraoperative photography highlighting the anatomical cause for this pathology. Both limbs in this patient were treated successfully with surgical release of the entrapping popliteus muscle via a posterior surgical approach to the popliteal fossa. This report emphasises the importance of determining popliteal artery integrity and entrapment subtype to guide the management of this condition.

Pseudoaneurysm of the superolateral genicular artery following ACL outside-in reconstruction.

A female underwent arthroscopic anterior cruciate ligament reconstruction (ACLR) via an outside-in drilling technique. At 4 weeks after surgery, she presented with a pulsatile painful mass on the lateral femoral condyle. Imaging confirmed a superolateral genicular artery pseudoaneurysm. Thrombin injections were administered twice, resulting in reduced size and minimal pain. This case emphasises the rare occurrence of pseudoaneurysms post-ACLR and highlights the importance of early detection and intervention for vascular complications. Although debated, we suggest tourniquet deflation before closure to facilitate identification and management of vascular issues. This report contributes valuable insights into managing pseudoaneurysms following ACLR.

The state of vascular surgery education in the United States.

With the growing proportion of elderly population in the US and a relatively fixed supply of well-trained vascular surgeons, there is a serious concern that we will be facing a shortage of vascular surgery workforce in the near future. One of the main reasons why there is a shortage of vascular surgeons in the US is due to the fact that many students don't get exposed to this field throughout their student lives and a recent survey of medical students from a non-urban tertiary care academic institution showed that early exposure of the medical students to the surgical careers is correlated with an increased interest in the surgical field. This review of the state of vascular surgery education in the US at the undergraduate level describes in detail the importance of an early introduction to vascular surgery in the education curricula, the current state of the education, potential avenues to improve the exposure of students to the field of vascular surgery and the importance of this effort in matching the increasing need for vascular surgeons for an aging population which is likely to require dedicated care by vascular surgeons of the future. At the present time, the two pathways by the Accreditation Council for Graduate Medical Education (ACGME) to obtain dedicated vascular surgery training in the US include either enrolling in a two year clinical fellowship after completion of general surgery training or to match in a five year vascular surgery integrated residency program after successful completion of medical degree.