Danielle R. Doucet

In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneurysms has a lower in-hospital mortality and morbidity than open repair

OBJECTIVE Previous studies have reported that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) has lower postoperative mortality than open repair (OR). However, comparisons involved heterogeneous populations that lacked adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR. METHODS In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England RAAA risk score into low-risk (score 0-1), medium-risk (score 2-3), and high-risk (score 4-6) groups. RESULTS Among 514 patients who underwent EVAR and 651 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (25% vs 33%, P = .001). In risk-stratified patients, EVAR trended toward a lower mortality in the low-risk group (n = 626; EVAR, 10% vs OR, 15%; P = .07), had a significantly lower mortality in the medium-risk group (n = 457; EVAR, 37% vs OR, 48%; P = .02), and no advantage in the high-risk group (n = 82; EVAR, 95% vs OR, 79%; P = .17). Across all risk groups, cardiac complications (EVAR, 29% vs OR, 38%; P = .001), respiratory complications (EVAR, 28% vs OR, 46%; P < .0001), renal insufficiency (EVAR, 24% vs OR, 38%; P < .0001), lower extremity ischemia (EVAR, 2.7% vs OR, 8.1%; P < .0001), and bowel ischemia (EVAR, 3.9% vs OR, 10%; P < .0001) were significantly lower after EVAR than after OR. Across all risk groups, median (interquartile range) intensive care unit length of stay (EVAR, 2 [1-5] days vs OR, 6 [3-13] days; P < .0001) and hospital length of stay (EVAR, 6 [4-12] days vs OR, 13 [8-22] days; P < .0001) were lower after EVAR. CONCLUSIONS This novel risk-stratified comparison using a national clinical database showed that EVAR of RAAA has a lower mortality and morbidity compared with OR in low-risk and medium-risk patients and that EVAR should be used to treat these patients when anatomically feasible. For RAAA patients at the highest preoperative risk, there is no benefit to using EVAR compared with OR.

Outcomes of Fenestrated and Branched Endovascular Repair of Complex Abdominal and Thoracoabdominal Aortic Aneurysms

Background: More than 80% of infrarenal aortic aneurysms are treated by endovascular repair. However, adoption of fenestrated and branched endovascular repair for complex aortic aneurysms has been limited, despite high morbidity and mortality associated with open repair. There are few published reports of consecutive outcomes, inclusive of all fenestrated and branched endovascular repairs, starting from the inception of a complex aortic aneurysm program. Therefore, we examined a single centers consecutive experience of fenestrated and branched endovascular repair of complex aortic aneurysms. Methods: This is a single‐center, prospective, observational cohort study evaluating 30‐day and 1‐year outcomes in all consecutive patients who underwent fenestrated and branched endovascular repair of complex aortic aneurysms (definition: requiring one or more fenestrations or branches). Data were collected prospectively through an Institutional Review Board‐approved registry and a physician‐sponsored investigational device exemption clinical trial (G130210). Results: We performed 100 consecutive complex endovascular aortic aneurysm repairs (November 2010 to March 2016) using 58 (58%) commercially manufactured custom‐made devices and 42 (42%) physician‐modified devices to treat 4 (4%) common iliac, 42 (42%) juxtarenal, 18 (18%) pararenal, and 36 (36%) thoracoabdominal aneurysms (type I, n = 1; type II, n = 4; type III, n = 12; type IV, n = 18; arch, n = 1). The repairs included 309 fenestrations, branches, and scallops (average of 3.1 branch arteries/case). All patients had 30‐day follow‐up for 30‐day event rates: three (3%) deaths; six (6%) target artery occlusions; five (5%) progressions to dialysis; eight (8%) access complications; one (1%) paraparesis; one (1%) bowel ischemia; and no instances of myocardial infarction, paralysis, or stroke. Of 10 type I or type III endoleaks, 8 resolved (7 with secondary intervention, 1 without intervention). Mean follow‐up time was 563 days (interquartile range, 156‐862), with three (3%) patients lost to follow‐up. On 1‐year Kaplan‐Meier analysis, survival was 87%, freedom from type I or type III endoleak was 97%, target vessel patency was 92%, and freedom from aortic rupture was 100%. Average lengths of intensive care unit stay and inpatient stay were 1.4 days (standard deviation, 3.3) and 3.6 days (standard deviation, 3.6), respectively. Conclusions: These results show that complex aortic aneurysms can now be treated with minimally invasive fenestrated and branched endovascular repair. Endovascular technologies will likely continue to play an increasingly important role in the management of patients with complex aortic aneurysm disease.

Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair

OBJECTIVE Endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) reduces in-hospital mortality compared with open repair (OR), but it is unknown whether EVAR reduces long-term mortality. We hypothesized that EVAR of RAAA would independently reduce long-term mortality compared with OR. METHODS The Vascular Quality Initiative database (2003-2013) was used to determine Kaplan-Meier 1-year and 5-year mortality after EVAR and OR of RAAA. Multivariate analysis was performed to identify patient and operative characteristics associated with mortality at 1 year and 5 years after RAAA repair. RESULTS Among 590 patients who underwent EVAR and 692 patients who underwent OR of RAAA, the lower mortality seen in the hospital after EVAR (EVAR 23% vs OR 35%; P < .001) persisted at 1 year (EVAR 34% vs OR 42%; P = .001) and 5 years (EVAR 50% vs OR 58%; P = .003) after repair. After adjusting for patient and operative characteristics, EVAR did not independently reduce mortality at 1 year (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.7-1.1) or 5 years (HR, 0.95; 95% CI, 0.77-1.2) compared with OR. Dialysis dependence (HR, 3.9; 95% CI, 1.8-8.6), home oxygen use (HR, 1.9; 95% CI, 1.3-2.7), cardiac ejection fraction <50% (HR, 1.5; 95% CI, 1.03-2.1), female gender (HR, 1.3; 95% CI, 1.04-1.6), and age (HR, 1.06; 95% CI, 1.05-1.08 per 5 years) as well as cardiac arrest (HR, 3.4; 95% CI, 2.5-4.5), loss of consciousness (HR, 1.7; 95% CI, 1.3-2.2), and preoperative systolic blood pressure <90 mm Hg (HR, 1.4; 95% CI, 1.1-1.8) on admission predicted mortality at 1 year and 5 years after RAAA repair. Type I endoleak (HR, 2.2; 95% CI, 1.2-3.8) also predicted mortality at 1 year. CONCLUSIONS EVAR does not independently reduce long-term mortality compared with OR. Patient comorbidities and indices of shock on admission are the primary independent determinants of long-term mortality. However, the lower early mortality observed in the Vascular Quality Initiative for patients selected to undergo EVAR of RAAA compared with patients selected for OR is sustained over time, suggesting that EVAR for RAAA is beneficial in appropriate candidates. Better elucidation of the key selection factors, including aneurysm anatomy, is needed to best select patients for EVAR and OR to reduce long-term mortality.

An intensive vascular surgical skills and simulation course for vascular trainees improves procedural knowledge and self-rated procedural competence

Background: Surgical skills and simulation courses are emerging to meet the demand for vascular simulation training for vascular surgical skills, but their educational effect has not yet been described. We sought to determine the effect of an intensive vascular surgical skills and simulation course on the procedural knowledge and self‐rated procedural competence of vascular trainees and to assess participant feedback regarding the course. Methods: Participants underwent a 1.5‐day course covering open and endovascular procedures on high‐fidelity simulators and cadavers. Before and after the course, participants completed a written test that assessed procedural knowledge concerning index open vascular and endovascular procedures. Participants also assessed their own procedural competence in open and endovascular procedures on a 5‐point Likert scale (1: no ability to perform, 5: performs independently). Scores before and after the course were compared among postgraduate year (PGY) 1–2 and PGY 3–7 trainees. Participants completed a survey to rate the relevance and realism of open and endovascular simulations. Results: Fifty‐eight vascular integrated residents and vascular fellows (PGY 1–7) completed the course and all assessments. After course participation, procedural knowledge scores were significantly improved among PGY 1–2 residents (50% correct before vs 59% after; P < .0001) and PGY 3–7 residents (52% correct before vs 63% after; P = .003). Self‐rated procedural competence was significantly improved among PGY 1–2 (2.2 ± 0.1 before vs 3.1 ± 0.1 after; P < .0001) and PGY 3–7 (3.0 ± 0.1 before vs 3.7 ± 0.1 after; P ≤ .0001). Self‐rated procedural competence significantly improved for both endovascular (2.4 ± 0.1 before vs 3.3 ± 0.1 after; P < .0001) and open procedures (2.7 ± 0.1 before vs 3.5 ± 0.1 after; P < .0001). More than 93% of participants reported they were “satisfied” or “very satisfied” with the relevance and realism of the open and endovascular simulations. All participants reported they would recommend the course to other trainees. Conclusions: This intensive vascular surgical skills and simulation course improved procedural knowledge concerning index open vascular and endovascular procedures among PGY 1–2 and PGY 3–7 trainees. The course also improved self‐rated procedural competence across all levels of training for open and endovascular procedures. Trainees rated the value of a surgical skills and simulation course highly. These results support strong consideration for the implementation of similar intensive simulation and surgical skills courses with ongoing objective assessment of their educational effect.

C10: Poster CompetitionPC094 Increasing the Number of Integrated Vascular Surgery Residency Positions Is Necessary to Address the Impending Shortage of Vascular Surgeons in the United States

three-dimensional (3D) printed aortic model connected to hemodynamic pump. Methods: The study was a prospective validation of EVAR simulation using a 3D printed photopolymer aortic model (Objet500 Connex3 printer; Stratasys, Eden Prairie, Minn) connected to BDC PD-0500 fluid pump (BDC Laboratories, Wheat Ridge, Colo). EVAR procedure metrics were benchmarked in two expert implanters and compared to 20 vascular surgical trainees with different levels of EVAR experience (<20 or >20 cases). All procedures were performed using commercially available stent grafts, fluoroscopic guidance, and high-fidelity simulation of procedural steps with guidewires, catheters, and contrast angiography (Fig). End points included ability to complete the procedure independently and time to deploy aortic component, cannulate the contralateral (CL) gate and complete the repair, total fluoroscopy time, and estimated distance from lowest renal artery. Results: Trainee experience with EVAR prior to the first simulation session was fewer than 5 in 7 trainees, 6 to 20 in 6 and 20 in 7. A total of 22 EVAR simulation procedures were performed by trainees with mean total procedure time of 37 6 12 minutes. Experienced trainees had significantly (P < .003) lower total procedural time (32 6 9 vs 44 6 6 minutes), fluoroscopic time (13 6 5 vs 23 6 8 minutes), and lag time between steps (5 6 2 vs 7 6 2 minutes). All experienced trainees completed the procedure independently in <45 minutes, compared to six (46%) of those with less EVAR experience (P 1⁄4 .016). Among less experienced trainees, only two (15%) completed the entire procedure independently (P < .001). Expert implanters performed significantly better than both trainee groups in nearly all EVAR metrics (Table). Conclusions: EVAR simulation with 3D printed aortic models and hemodynamic pump was feasible and simulated all procedural steps with high fidelity. This model may be applicable for assessment of technical competencies and standard endovascular skill acquisition within vascular surgery training curricula.

SS27 A Physician-Led Initiative to Improve Clinical Documentation Results in Improved Case-Mix Index and Increased Contribution Margin

mean of 167 days after stenting. Mean poststenting GFR and creatinine were 59 (range, 42-60) and 0.8 (range, 0.5-1.7). There was no difference betweenmean prestenting and poststenting GFR (P 1⁄4 .32) or creatinine (P 1⁄4 .41). Mean poststenting GFR and creatinine in the Wallstent, Z-stent, “renal gap,” and iliac vein only stents patients were: 60 and 0.9, 60 and 0.8, 60 and 0.7, and 59 and 0.8, respectively. There were no differences in poststenting mean GFR or creatinine between the Wallstent (P 1⁄4 .23; P 1⁄4 .27), Z-stent (P 1⁄4 .18; P 1⁄4 .32), and “renal gap” (P 1⁄4 .25; P 1⁄4 .15), and iliac vein only stent groups. One patient (1%) developed renal vein thrombosis treated with thrombolysis and stenting. Thirty patients (77%) with stents across the renal veins had follow-up imaging and all 30 (100%) had patent renal veins. Conclusions: Renal vein confluence stenting with small and large lattice stents does not compromise renal function or renal vein patency and may be performed when clinically indicated with few complications.

Increasing the number of integrated vascular surgery residency positions is important to address the impending shortage of vascular surgeons in the United States

Objective: The demand for vascular surgeons is expected to far exceed the current supply. In an attempt to decrease the training duration and to address the impending shortage, integrated vascular surgery residencies were approved and have expanded nationally. Meanwhile, vascular fellowships have continued to matriculate approximately 120 trainees annually. We sought to evaluate the supply and demand for integrated vascular residency positions as well as changes in the quality of applicants. Methods: We conducted a retrospective review of national data compiled by the Association of American Medical Colleges and the National Resident Matching Program regarding integrated vascular surgery residency programs (2008‐2015) and fellowships (2007‐2016). Variables reviewed included the total number of applicants, sex, U.S. vs international medical school enrollment, applications per program, and applicants per position. In addition, we conducted a retrospective review of applicants to the University of Massachusetts Medical School integrated vascular surgery residency program from 2008 to 2015 to examine these variables and United States Medical Licensing Examination Step 1 and Step 2 CK scores over time. Results: The number of vascular surgery integrated residency positions increased from 4 in 2008 to 56 in 2015. Concurrently, the number of integrated residency applicants grew from 112 in 2008 to 434 in 2015. This increase has been predominantly driven by a 575% increase in U.S. graduate applicants and a 170% increase in women applicants. The percentage of international medical graduates has decreased by 17% during the study period. The total number of applicants per residency position increased from 5.9 to 7.8. Meanwhile, the number of vascular surgery fellowship positions remained stable with an applicant to position ratio near 1:1. At the University of Massachusetts Medical School, the mean United States Medical Licensing Examination Step 1 (226 to 235) and Step 2 CK (237 to 243) scores among integrated residency applicants have improved annually and typically exceed the national average among U.S. applicants who have matched in their preferred specialty. Conclusions: Since the approval of a primary certificate in vascular surgery and the subsequent rollout of integrated vascular residency programs, the number of residency programs and the quality of residency applicants have continued to increase. Demand from medical school applicants vastly outweighs the current supply of training positions by eightfold. In contrast, demand from fellowship applicants matches the supply of fellowship positions. The matriculation of additional trainees must be met with continued expansion of the integrated vascular surgery residency pathway to manage future public health needs.