Brigitte K. Smith

Surgical Management of Retroperitoneal Leiomyosarcoma Arising from the Inferior Vena Cava

Retroperitoneal leiomyosarcomas are uncommon tumors, with approximately 300 documented cases in the literature. Management necessitates complete surgical resection in order to offer patients a chance at long-term cure. Resection often presents a challenge as these tumors are often large, involving adjacent structures, and may require reconstruction of the inferior vena cava (IVC). In this article, we will present background information on retroperitoneal leiomyosarcomas and the technical aspects of surgical resection and vascular reconstructive options of the IVC.

0 + 5 Vascular Surgery Residents’ Operative Experience in General Surgery: An Analysis of Operative Logs from 12 Integrated Programs

OBJECTIVE Integrated (0 + 5) vascular surgery (VS) residency programs must include 24 months of training in core general surgery. The Accreditation Council for Graduate Medical Education currently does not require specific case numbers in general surgery for 0 + 5 trainees; however, program directors have structured this time to optimize operative experience. The aim of this study is to determine the case volume and type of cases that VS residents are exposed to during their core surgery training. DESIGN Accreditation council for graduate medical education operative logs for current 0 + 5 VS residents were obtained and retrospectively reviewed to determine general surgery case volume and distribution between open and laparoscopic cases performed. Standard statistical methods were applied. SETTING A total of 12 integrated VS residency programs provided operative case logs for current residents. PARTICIPANTS A total of 41 integrated VS residents in clinical years 2 through 5. RESULTS During the postgraduate year-1 training year, residents participated in significantly more open than laparoscopic general surgery cases (p < 0.0001). This difference was consistent over the first 3 years of training. The most frequently logged open general surgery cases are hernia repair (20%), skin and soft tissue (7.4%), and breast (6.3%). Residents in programs with core surgery over 3 years participated in significantly more general surgery operations compared with residents in programs with core surgery spread out over 4 years (p = 0.035). CONCLUSIONS 0 + 5 VS residents perform significantly more open operations than laparoscopic operations during their core surgery training. The majority of these operations are minor, nonabdominal procedures. The 0 + 5 VS residency program general surgery operative training requirements should be reevaluated and case minimums defined. The general surgery training component of 0 + 5 VS residencies may need to be restructured to meet the needs of current and future trainees.

Utilization of the Electronic Health Record to Improve Provision of Smoking Cessation Resources for Vascular Surgery Inpatients

BACKGROUND AND OBJECTIVES Identification of hospitalized patients who smoke has shown significant improvement in recent years, but provision of evidence-based tobacco cessation treatment remains a challenge. This study evaluated the utilization of an electronic health record (EHR) to facilitate implementation of evidence-based clinical practice guidelines for smoking cessation on a vascular surgery inpatient unit. METHODS A pre-and post-intervention cohort study was conducted over 6 months at a single academic medical center with a comprehensive EHR. All patients admitted to the vascular surgery service and documented as current smokers were included. A vascular surgery discharge order set with an evidence-based smoking cessation module was developed and implemented. The primary outcome was prescription of nicotine replacement therapy (NRT) at the time of discharge. The secondary outcome was referral for smoking cessation counseling at the time of discharge. RESULTS There were 52 and 42 smokers in the pre-and post-intervention cohorts, respectively. Over the 3 months following implementation of the EHR order set, prescription of NRT at the time of discharge did not change significantly (27% vs 19%, p=0.30). Referral for outpatient smoking cessation counseling increased in the post-intervention group, but did not reach significance (64% vs 72%, p=0.20). CONCLUSIONS Implementation of a brief tobacco dependence treatment order set in an existing EHR increased cessation counseling referrals on a vascular surgery inpatient unit. One potential limitation of the study was the modest sample size. Not being able to make smoking cessation treatment a mandatory component in discharge orders may also have contributed to the modest effect. Assessing the differential effect of EHR-based order implementation will be important in future research on this topic.

Foot claudication with plantar flexion as a result of dorsalis pedis artery impingement in an Irish dancer

Dorsalis pedis artery impingement is an extremely rare cause of foot claudication, with a single case reported in the literature. In this report, we describe the case of a 17-year-old female Irish dancer who presented with intermittent bilateral foot pain and discoloration during active plantar flexion.

Implementation of an academic half day in a vascular surgery residency program improves trainee and faculty satisfaction with surgical indications conference

Background: The Accreditation Council for Graduate Medical Education mandates scheduled didactics for residency programs but allows flexibility in implementation. Work‐hour restrictions, patient care duties, and operative schedules create barriers to attendance for surgical trainees. We explored vascular surgery trainees and faculty perceptions on trainees operative preparation and participation, and overall fund of knowledge after implementing an academic half day conference (AHD) schedule. Methods: The vascular surgery conference at a single academic institution was changed from three 1‐hour conferences weekly, to a single protected, 3‐hour conference once weekly. Faculty and trainees were surveyed before and 5 months after implementing the new AHD schedule. Results: Overall satisfaction improved after initiating the AHD (4 of 4 trainees, 3 of 4 faculty). All trainees (n = 4) and faculty (n = 4) believed the AHD conference format was worthwhile. Most trainees believed the AHD format improved their Vascular Surgery in Service Training Exam preparation (3 of 4), fund of knowledge (4 of 4), and operative preparation (3 of 4). More trainees than faculty tended to feel that the AHD interfered with operative participation (3 of 4 trainees vs 1 of 4 faculty). Neither group agreed that the conference was optimally scheduled. Conclusion: This single‐institution, pilot study suggests a positive association in the attitudes of most vascular surgery trainees and faculty regarding preparation for the Vascular Surgery In‐Training Exam and overall fund of knowledge after implementing a protected AHD schedule. Further research is needed to understand the impact of the AHD conference on operative experience and training exam scores.

PC092. Patient-Reported Outcomes in Patients With End-Stage Renal Disease: Is Quality of Life Affected When Catheters Are Used for Hemodialysis versus Arteriovenous Fistulas?

FA access was performed in three arteries because of prior common FA interposition grafts. There were 18 (6%) access site complications (8 bleeding, 9 thrombosis, 1 infection) leading to immediate (n 1⁄4 12) or delayed (n 1⁄4 5) conversion to cutdown. Factors independently associated with percutaneous access site complication were sheath outer diameter to FA diameter ratio (odds ratio [OR], 58.9; 95% confidence interval [CI], 3.5-985.8; P 1⁄4 .005), morbid obesity with a body mass index of >40 kg/ m (OR, 16.0; 95% CI, 3.0-84.5; P 1⁄4 .001), FA stenosis of >50% (OR, 52.1; 95% CI, 7.7-351.5; P # . 001), FA stenosis of >75% (OR, 271.5; 95% CI, 15.14888.6; P # .001), and postoperative anticoagulation (OR, 10.5; 95% CI, 2.0-54.0; P 1⁄4 .005). A risk prediction model based on these criteria produced a C statistic of .91, a Hosmer-Lemeshow goodness of fit of 0.99, and a Brier score of .03. A risk score of >6 of 15 corresponded with a >10% probability of groin access complication (Table). Conclusions: Percutaneous ultrasound-guided access can be safely performed in almost all patients undergoing endovascular aortic procedures; however, access site failures still occur. Application of this risk score can help identify patients at high risk for complications after initial FA ultrasound-guided percutaneous access.

Case Report of Percutaneous Retrograde Transcollateral Recanalization of the Superior Mesenteric Artery via the Celiac Artery for Acute Mesenteric Ischemia.

AbstractRevascularization for acute mesenteric ischemia (AMI) can be achieved through a bypass from the aorta or iliac arteries, embolectomy, open exposure of SMA and retrograde recanalization and stent, or percutaneous antegrade stenting. Flush occlusion of the SMA can make antegrade recanalization very challenging and is usually unsuccessful.We present a novel approach for recanalization of superior mesenteric artery (SMA) via the celiac artery for acute mesenteric ischemia. A 69-year-old lady with previous endarterectomy of SMA and extensive small bowel resection presented with severe abdominal pain, emesis, leukocytosis, and imaging finding of new SMA flush occlusion. She refused to consent for a laparotomy. Percutaneous retrograde transcollateral recanalization of SMA was performed via the celiac artery through the pancreaticoduodenal arcade, and the SMA then stented. This resulted in subsequent resolution of patients symptoms and discharge.SMA revascularization with retrograde transcollateral wiring technique is an important tool in the armamentarium of the vascular care specialist when antegrade percutaneous approach and open exposure via laparotomy are not an option.