Francis J. Caputo

Relative value unit-based compensation incentivization in an academic vascular practice improves productivity with no early adverse impact on quality

Objective: Given the increased pressure from governmental programs to restructure reimbursements to reflect quality metrics achieved by physicians, review of current reimbursement schemes is necessary to ensure sustainability of the physicians performance while maintaining and ultimately improving patient outcomes. This study reviewed the impact of reimbursement incentives on evidence‐based care outcomes within a vascular surgical program at an academic tertiary care center. Methods: Data for patients with a confirmed 30‐day follow‐up for the vascular surgery subset of our institutions National Surgical Quality Improvement Program submission for the years 2013 and 2014 were reviewed. The outcomes reviewed included 30‐day mortality, readmission, unplanned returns to the operating room, and all major morbidities. A comparison of both total charges and work relative value units (RVUs) generated was performed before and after changes were made from a salary‐based to a productivity‐based compensation model. P value analysis was used to determine if there were any statistically significant differences in patient outcomes between the two study years. Results: No statistically significant difference in outcomes of the core measures studied was identified between the two periods. There was a trend toward a lower incidence of respiratory complications, largely driven by a lower incidence in pneumonia between 2013 and 2014. The vascular division had a net increase of 8.2% in total charges and 5.7% in work RVUs after the RVU‐based incentivization program was instituted. Conclusions: Revenue‐improving measures can improve sustainability of a vascular program without negatively affecting patient care as evidenced by the lack of difference in evidence‐based core outcome measures in our study period. Further studies are needed to elucidate the long‐term effects of incentivization programs on both patient care and program viability.

Descending thoracic aortic mural thrombus presentation and treatment strategies

Background: Thoracic aortic mural thrombus (TAMT) of the descending aorta is rare but can result in dramatic embolic events. Early treatment is therefore crucial; however, there is not a consensus on ideal initial treatment. Methods: A review of the literature using PubMed was conducted, and all relevant publications describing descending TAMT of the past 15 years were reviewed. Variables included for this analysis were presentation, initial treatment strategy employed, outcome measures of thrombus resolution or regression, recurrence of symptomatic emboli, and mortality. Results: Seventy‐four patients were included in this analysis. Women were significantly more likely to be described with descending TAMT. The majority (82.4%) of cases reported were diagnosed after an embolic event. Patients were equally likely to receive medical, open surgical, or endovascular therapy as the initial treatment modality. However, there is a trend within the past 5 years to report cases describing successful thoracic endovascular aortic repair for initial management. Of patients who initially underwent medical management, nine patients (34.6%) had persistent thrombus. Of the patients who initially underwent open surgical repair, six patients (31.6%) had persistent thrombus; of these patients, four underwent endovascular repair. Twenty‐nine patients (39.2%) with descending TAMT initially underwent thoracic endovascular aortic repair. Twenty‐seven (93.1%) had fully excluded thrombus at the time of the procedure, with no recurrence or evidence of repeated embolic phenomena at follow‐up. Conclusions: Whereas mural thrombus of the thoracic aorta is uncommon, it must be considered in the differential diagnosis of embolic events. Although endovascular therapy may be a useful first‐line option for TAMT with reports of positive outcomes in select literature, further study of this treatment option is required.

The endothelial cell secretome as a novel treatment to prime adipose-derived stem cells for improved wound healing in diabetes

Background: Chronic wounds are a common surgical problem exacerbated by diabetes and ischemia. Although adipose‐derived stem cells (ASCs) have shown promise as a wound healing therapy, their function and proliferation are hindered in diabetes. This study examines the ability of the human umbilical vein endothelial cell (HUVEC) secretome to reverse the deleterious effects of high glucose concentrations on ASCs through priming, thereby enhancing their ability to participate in angiogenesis and wound healing. Methods: Institutional review board‐approved human ASCs were cultured in M199 medium with or without glucose (30 mmol/L). HUVEC were grown in 30 mmol/L glucose‐containing M199 medium; the resulting conditioned medium (HUVEC‐CM) was collected every 3 days and used to prime ASCs. An aliquot of HUVEC‐CM was heated (85°C for 30 minutes) to produce thermal denaturation of protein. Viability, proliferation, and endothelial differentiation were measured by MTT assays, growth curves, and quantitative polymerase chain reaction, respectively. A Matrigel assay was used to assess the ability of primed ASCs to participate in capillary‐like tube formation. An Institutional Animal Care and Use Committee–approved in vivo murine model of diabetic and ischemic hindlimbs was used to evaluate the angiogenic potential of primed stem cells. Human ASCs were cultured with either control M199 or HUVEC‐CM. Mice were randomized to a control group, an unprimed ASC group, or a HUVEC‐primed ASC group. Cellular therapies were injected into the ischemic muscle. Thirty days later, slides were made. Microvessels were counted by three blinded observers. Results: MTT assays revealed that HUVEC‐priming induced a 1.5 times increase in cell viability over diabetic controls. This promoting effect was lost with heated HUVEC‐CM (P < .001), indicating that the active molecules are of protein origin. After 9 days, ASCs cultured in 30 mmol/L glucose solution showed a 14% reduction in growth from nondiabetic controls (P = .013) and exhibited atrophic morphology. Conversely, diabetic HUVEC‐primed stem cells demonstrated a nearly four‐fold increase in proliferation (P < .05) and took on a fusiform, endothelial‐like phenotype. Polymerase chain reaction demonstrated enhanced expression of CD31 messenger RNA by 4.7‐fold after 14 days in the HUVEC‐primed group, and endothelial nitric oxide synthase messenger RNA messenger RNA was increased 20.1‐fold from controls. Unlike unprimed controls, HUVEC‐primed ASCs readily formed capillary‐like tube networks on Matrigel. Diabetic mice that were injected with HUVEC‐primed ASCs demonstrated greater vessel density than both controls (2.1‐fold) and unprimed stem cell treatments (P < .001). Conclusions: HUVECs secrete protein factors that significantly increase proliferation and endothelial differentiation of ASCs under diabetic conditions. Injection of ischemic hindlimbs in diabetic mice with HUVEC‐primed ASCs leads to enhanced angiogenesis. Clinical Relevance: In the current climate of increasing diabetes rates, there exists a significant need for improved therapies for diabetic wounds. ASCs have exhibited improved wound healing in previous studies, but this benefit is known to be suppressed by hyperglycemia. Treating stem cells with the secreted protein cocktail of endothelial cells—secretomal priming—seems to overcome the inhibition of the diabetic state, making ASCs a viable treatment option for these wounds. Priming evidently induces endothelial differentiation of ASCs, thereby enhancing their involvement in angiogenesis. This study demonstrates the potential of these primed ASC‐based therapies in vitro and in vivo and proposes several approaches by which they could be used in the clinical setting.

Secondary Interventions after Endovascular Repair of Aortic Dissections

BACKGROUNDnReview the literature on secondary interventions performed for patients who underwent endovascular repair of their type B aortic dissection. Endovascular repair for type B aortic dissection (TBAD) has been proven to be both technically feasible and beneficial in some patients. However, the information regarding secondary interventions is not cohesive. To date, there are little data to help guide physicians on the indications and benefits of secondary interventions in the setting of previous endovascular repair for TBAD.nnnMETHODSnPubMed database was queried for publications using the following combination of keywords; aortic dissection, type B, secondary intervention, false lumen thrombosis, stent graft, aortic remodeling, and endovascular repair. Sixteen articles were selected and reviewed for secondary interventions, indications for procedure, and effects on false lumen thrombosis. Data were collected, and a composite database of patients was created.nnnRESULTSnLiterature review demonstrated 161 of 862 patients required secondary interventions for entry tears, retrograde type A dissection, false lumen degeneration with aortic expansion, graft malfunction, and various access complications. The complete false lumen thrombosis rate was 33%, and overall mortality was 18.2%.nnnCONCLUSIONSnSecondary interventions provide a useful adjunct to failing endovascular repair of aortic dissections. A variety of treatment options are available for aneurysmal degeneration after thoracic endovascular aneurysm repair. This review also shows that these secondary interventions, in combination with proper surveillance and optimal medical management, are feasible but carry a high all-cause mortality.

Treatment of Abdominal Aortic Pathology

Abdominal aortic pathology is a diverse topic, ranging through a broad span of possible pathologies. The treatment options are equally vast, particularly with the ever-expanding endovascular techniques. In this article, we discuss management strategies for abdominal aortic aneurysms and aortic occlusive disease, because they represent some of the most common pathologies encountered in clinical scenarios.

PC110. Trends in the 10-Year History of the Vascular Integrated Residency Match: More Work, Higher Cost, Same Result

occurred in four patients (9.3%), leading to graft explanation in two cases. During the follow-up period, eight patients (18.6%) died. Conclusions: In comparison with the expanded polytetrafluroethilene arteriovenous fistula data, the present results are favorable with respect to secondary patency. In comparison with published HeRO data, we had a low risk of graft infection This method may be a fair alternative to patients where catheter dialysis is the only option.

PC130 Development and Implementation of a Level One Vascular Emergency Program

and 2015. Prescription claims were examined for statin, ACEi/ARB, and AP medications. Linear regression analysis was performed to assess for trends. Results: During the study interval, we identified 237,324 patients (49% female) with a diagnosis of PAD with a mean age of 67.6 (12.4) years. The proportion of women increased from 47% to 50% of patients over the study interval (test for trend, P < .01). Overall, 73.2% patients had IC and 26.8% had a diagnosis of CLI. Patients were predominantly white and lived in the South. Over the study interval, 22.2%% of patients were on an AP agent, and 50.8% were on a statin. AP rates decreased 26% to 19% over the study interval; however, statin use increased from 50% to 54%. The rate of statin + ACEi/ARB use was 36.2% and also increased slightly from 33% to 37%. Use of AP + statin + ACEi/ARB was stable at 11.8% (11% to 13%, Fig). Conclusions: Although statin use has increased, overall patients within PAD remain undertreated for their cardiovascular disease with potentially only 12% receiving optimal medical therapy of statin, ACEi/ARB and antiplatelet medications. These patients remain at increased risk for cardiovascular events and administrative data may be used to identify these patients at high risk of under-treatment for future targeted interventions.

Use of an extracorporeal bypass for renal preservation to treat a rare case of a true mycotic aneurysm in a renal transplant patient

True mycotic aneurysms of the abdominal aorta are extremely rare after organ transplantation. We report a renal transplant recipient who presented with Pseudomonas aeruginosa bacteremia and a new saccular infrarenal aortic aneurysm. A temporary extracorporeal axillofemoral bypass was placed to maintain perfusion to the transplant kidney. A contained rupture was found, and excision and in-line reconstruction were performed using a cryopreserved human aortic allograft. At 3 years, the patient remained well, with normal renal function while on oral antibiotic suppressive therapy. Use of an extracorporeal bypass was a viable technique with minimal morbidity for renal transplant preservation during open aortic replacement.