Gregory S. Cherr

Results of a national survey of surgical resident interest in international experience, electives, and volunteerism.

BACKGROUND Data are emerging about the essential nature of sustainable global surgical care and interest among North American surgeons. Currently, there is no formal mechanism for US surgical residents to participate in international training opportunities. A small, single-institution survey found that general surgery residents at New York University are highly motivated to pursue international training. But little research has addressed the attitudes of North American residents about international training. The goal of this study was to acquire a broader understanding of surgical resident interest in international training. STUDY DESIGN A structured questionnaire was administered anonymously and voluntarily to all American College of Surgeons resident members. RESULTS Seven hundred twenty-four residents completed surveys. Ninety-four percent of respondents planned careers in general surgery. Ninety-two percent of respondents were interested in an international elective, and 82% would prioritize the experience over all or some other electives. Fifty-four percent and 73% of respondents would be willing to use vacation and participate even if cases were not counted for graduation requirements, respectively. Educational indebtedness was high among respondents (50% of respondents carried >or=

Management of early (<30 day) vascular groin infections using vacuum-assisted closure alone without muscle flap coverage in a consecutive patient series

100,000 debt). Despite debt, 85% of respondents plan to volunteer while in practice. The most frequent barriers identified by respondents were financial (61%) and logistic (66%). CONCLUSIONS American College of Surgeons resident members are highly motivated to acquire international training experience, with many planning to volunteer in the future. A consensus among stakeholders in North American surgical education is needed to further explore international training within surgical residency.

Total percutaneous endovascular repair of abdominal aortic aneurysms using Perclose ProGlide closure devices.

OBJECTIVE Vacuum-assisted closure (VAC) therapy without muscle flap coverage is our primary approach for graft preservation in early, deep groin infections with and without exposed grafts; however, concerns exist regarding its safety. We report our experience in a consecutive series of patients with early groin infections managed without muscle flap closure. METHODS All patients with early (<30 day), deep vascular groin infections without (Szilagyi II) or with (Szilagyi III) exposed vascular graft or suture line between January 2004 and December 2008 were reviewed. Graft preservation followed by local wound care with VAC was attempted in all with intact anastomoses, patent grafts, and absence of systemic sepsis. Szilagyi classification, microorganism cultured, duration of VAC use, time to healing, additional interventions, and follow-up data (limb salvage, survival) were analyzed. RESULTS Twenty-two patients (26 groins, mean age 69.1 +/- 9.5 years [range, 44-86 years]) presented with deep groin infections 16 +/- 5 days (range, 7-28 days) after the index procedure (bypass-polytetrafluoroethylene [n = 11], autologous vein [n = 3], endarterectomy/patch [n = 6], extra-anatomic bypass [n = 5], percutaneous closure device [n = 1]). Grafts were exposed in 12 groins (Szilagyi III, nine with suture lines). VAC was started one to six days (median, three) after operative debridement. All had positive wound cultures and received culture-directed antibiotic therapy for 47 +/- 45 days (range, 14-180 days). Length of stay was significantly more in Szilagyi III, whereas mean VAC use and time-to-healing were similar. Mean follow-up was 33.4 +/- 19.5 months (range, 2-72 months). All wounds healed (mean, 49 +/- 21 days). Two treatment failures occurred in the Szilagyi III group (17%). One patient had bleeding from the anastomotic heel eight days after debridement, had graft removal/in situ replacement and one presented with reinfection on day 117 and had partial graft removal/extra-anatomic bypass. There was no perioperative mortality or limb loss, but six late unrelated mortalities and one amputation at 46 months unrelated to the groin infection. CONCLUSIONS Management of early, deep groin wound infections with debridement, antibiotics, and VAC treatment is safe and enables graft preservation in the majority of patients with minimal morbidity, no perioperative limb loss, or mortality.

Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease

Purpose: To describe a technique for access site closure in percutaneous abdominal aortic aneurysm (AAA) repair using double Perclose ProGlide devices to overcome the problems associated with the bulky delivery system and braided suture of the antecedent (Prostar) device. Technique: After obtaining guidewire access, 2 Perclose ProGlide sutures are deployed at 90° to each other. The appropriate sheaths are placed over the stiff guidewires. After the stent-graft procedure is completed, an assistant holds pressure while the knots are tightened with the stiff guidewire still in the artery. Once the second knot is tightened with the knot pusher and after confirming adequate hemostasis, the wire is removed, pressure is applied, and heparin reversed. This method has been used in 17 consecutive patients (age range 65–85 years) undergoing endovascular AAA repair. One patient needed patch angioplasty and 2 required small incisions for additional suture placements (81% primary success rate for total percutaneous repair, 90% success rate for all sites). Conclusion: We have found the double Perclose ProGlide technique to be easy to use, safe, and feasible for total percutaneous AAA repair. More experience with longer follow-up is needed to assess its potential to replace the Perclose Prostar closure device for total percutaneous AAA repairs.

Superior limb salvage with endovascular therapy in octogenarians with critical limb ischemia

OBJECTIVE Hybrid reconstructions have been increasingly used for multilevel revascularization procedures as surgeons have embraced endovascular interventions. The goal of this study is to define the role of simple and complex hybrid techniques in patients who need multilevel revascularization. METHODS All patients undergoing arterial revascularization (endovascular [EV], open, hybrid) between June 2001 and May 2008 were included. Hybrid procedures were stratified as simple (sHYBRID group) when the endovascular-treated segment was TransAtlantic Society Consensus II (TASC) A/B, and complex (cHYBRID group), when TASC C/D. RESULTS Of the 654 patients, 770 limbs (67% critical limb ischemia), 226 (29%) had open, 436 (57%) had endovascular, and 108 (14%) had hybrid procedures (56 sHYBRID, 52 cHYBRID). The HYBRID group was more likely to have hypertension, chronic obstructive pulmonary disease, American Society of Anesthesia (ASA) 4, and aortoiliac reconstructions, with more ASA 4 in the cHYBRID than the sHYBRID group. Length of stay in the HYBRID group was significantly longer than the EV group, but less than open-treated groups. Endovascular intervention was performed for inflow in 85%, for runoff in 5%, and for both inflow and runoff in the remaining 10% of hybrid cases. Eleven (20%) sHYBRID cases were staged, while all cHYBRID cases were performed simultaneously. Femoral endarterectomy was more frequent in cHYBRID (75% vs 23% in sHYBRID), infrainguinal bypass (17% vs 55%) was more common in sHYBRID, the remainder being femoro-femoral bypasses (8% vs 21%). Endovascular procedures were primarily iliac interventions (91% in sHYBRID, 88% in cHYBRID). Thirty-day myocardial infarction/death rate was significantly higher in the HYBRID than the EV group, with no difference within the HYBRID group. The patency rates were similar in the sHYBRID and cHYBRID groups, and comparable to the endovascular and open treated patients with similar disease complexity. Limb salvage in patients who presented with critical limb ischemia was better in the cHYBRID group than other groups. Overall survival was similar in all groups. CONCLUSIONS Complex and simple hybrid procedures enable multilevel revascularizations in high-risk patients with comparable patency and limb salvage. Femoral endarterectomy plays a central role, especially in complex hybrid repairs. An increase in perioperative morbidity and mortality was observed in the hybrid group, likely due to attempting revascularization in higher risk patients.

Peroneal artery-only runoff following endovascular revascularizations is effective for limb salvage in patients with tissue loss

OBJECTIVE The goal of this study is to compare our results following open and endovascular infrainguinal revascularizations in patients >or=80 and <80 years old presenting with critical limb ischemia (CLI) and to determine if limb salvage (LS) attempt is justified in patients >or=80 with CLI, especially following endovascular interventions. METHODS A retrospective analysis of 344 consecutive patients (399 limbs) who presented with CLI and underwent infrainguinal open or endovascular (EV) revascularizations between June 2001 and December 2007 was performed. Patients >or=80 (89 patients, 101 limbs) and <80 years old (255 patients, 298 limbs) were compared for demographics, characteristics, patency, limb salvage, sustained clinical success (preservation of limb, freedom from target extremity revascularization (TER), and resolution of symptoms), secondary clinical success (preservation of limb and resolution of symptoms), overall improvement (preservation of limb, improvement of symptoms), and survival. RESULTS Patients >or=80 were more likely to be nonambulatory and have coronary artery disease, whereas those <80 were more likely to have hypertension, hyperlipidemia, dialysis-dependence, active tobacco abuse, and taking beta-blockers. Primary amputation rates were similar between two groups (<80 vs >or=80, 6.7% vs 8.1%, P = .530). Perioperative mortality was significantly worse in >or=80 group in the open-treated group (16.2% vs 2.9%, P = .009), whereas it was similar in EV-treated patients (3.1% vs 0.6%, P = .197). The patency rates were similar between groups, however, LS was significantly better in >or=80 EV-treated patients than <80 group, whereas it was similar between groups in open-treated patients. Sustained clinical success, secondary clinical success, and overall improvement rates were similar between age groups. Endovascular-treated patients in >or=80 had significantly better overall improvement than those who were treated by open revascularization (24-month overall improvement 83% +/- 5% vs 61% +/- 9%, P = .043). Multivariate analysis showed diabetes, infrapopliteal intervention, presence of gangrene, nonambulatory status, dialysis-dependence, and runoff status being associated with limb loss whereas age being >/= or <80 was not. Age, coronary artery disease, chronic obstructive pulmonary disease, nonambulatory status, and dialysis-dependence were found to be independently associated with decreased survival. CONCLUSIONS Our results suggest that revascularization in patients >/=80 with CLI is justified, especially when an endovascular intervention can be accomplished. Although limb salvage following endovascular interventions were better in the >/=80 group, sustained clinical success, and secondary clinical success rates were similar following open and endovascular interventions in both age groups. Open procedures carry a high perioperative mortality in the >/=80 age group and should be avoided if possible.

Stenting vs above knee polytetrafluoroethylene bypass for TransAtlantic Inter-Society Consensus-II C and D superficial femoral artery disease

OBJECTIVE Peroneal artery bypass is effective for limb salvage (LS), however, the efficacy of peroneal artery-only runoff (PAOR) following endovascular (EV) interventions is unknown. The goal of our article was to compare the efficacy of EV interventions with PAOR to those with other runoff vessels for LS in patients presenting with tissue loss. METHODS A retrospective review of 111 consecutive patients who underwent infrainguinal EV revascularizations for nonhealing ulcers/gangrene between June 2001 and December 2006 was performed. Patients with PAOR (n = 33) were compared with those with other vessel runoff (OTHER, n = 78). Fisher exact test and chi2 test were used for comparing variables, Kaplan-Meier analyses for patency, LS, and Cox regression multivariate analysis was used for identifying factors associated with limb loss. RESULTS The patients in PAOR were older, but other morbidities were similar between groups. The most distal level of intervention was infrapopliteal (tibioperoneal or peroneal artery) in 42% in PAOR group whereas this was 24% in OTHER group (P = .071). Preoperative ankle-brachial index (ABI) was similar (0.49 +/- 0.23 vs 0.50 +/- 0.23), however, postprocedure ABI was significantly less for patients with PAOR (0.76 +/- 0.21 vs 0.92 +/- 0.13, P = .001). The primary patency, assisted primary patency, secondary patency and LS were not significantly different between groups. There was also no difference in time-to healing between groups (PAOR vs OTHER, 2.9 +/- 2.1 mo vs 3.7 +/- 3.6 mo, P = .319). We found the presence of gangrene (odds ratio [OR]: 3.5, 95% confidence interval [CI], 1.1-10.8, P = .028) and dialysis-dependence (OR: 2.9, 95% CI, 1.0-8.2, P = .046) to be associated with limb loss, when adjusted for diabetes, hypertension, hyperlipidemia, smoking, location of wound, and PAOR. CONCLUSION Endovascular revascularization with PAOR results in acceptable patency and limb salvage rates in patients presenting with tissue loss, and is equivalent to other vessel runoff for patency, limb salvage and wound healing rates.

Accuracy of administrative data in trauma: splenic injuries as an example.

OBJECTIVES TransAtlantic Society Consensus (TASC)-II recommends bypass for TASC D and low-risk patients with TASC C lesions but does not specify graft types. Percutaneous balloon angioplasty/stenting (PTA/S) and above knee femoropopliteal bypass (AK-FPB) using polytetrafluoroethylene (PTFE) for these lesions were compared to determine if graft type should be part of the TASC-II recommendations for the treatment of TASC C lesions. METHODS Consecutive patients who underwent AK-FPB with PTFE, or PTA/S for TASC-II C (PTA/S-C) or D (PTA/S-D) SFA lesions between June 2001 and April 2007 were retrospectively analyzed. The primary end points were primary, assisted-primary, and secondary patency rates. RESULTS In 127 patients (mean age, 68.7 +/- 10.0 years; median, 68; range, 49-97), 139 limbs were treated (46 AK-FPB, 49 PTA/S-C, 44 PTA/S-D). The mean occlusion and stented lengths were 9.9 +/- 3.8 and 24.3 +/- 6.6 cm (median, 10 and 20 cm) in PTA/S-C, and 26.6 +/- 5.5 and 30.0 +/- 5.2 cm (median, 26 and 29 cm) in PTA/S-D. Technical success was 84% in PTA/S-D and 100% in other groups. Mean follow-up was 26.4 +/- 18.0 months (median, 24). The 12- and 24-month primary patency was 83% +/- 6% and 80% +/- 7% for PTA/S-C; 54% +/- 8% and 28% +/- 12% for PTA/S-D; and 81% +/- 6% and 75% +/- 7% for AK-FPB (P < .001 PTA/S-D vs PTA/S-C and AK-FPB); assisted-primary patency was 95% +/- 3% and 95% +/- 3% for PTA/S-C, 62% +/- 8% and 49% +/- 10% for PTA/S-D, and 81% +/- 6% and 75% +/- 7% for AK-FPB (P < .001, PTA/S-C vs PTA/S-D; P = .003, PTA/S-C vs AK-FPB; and P = .03, PTA/S-D vs AK-FPB). Secondary patency was 98% +/- 3% and 98% +/- 3% for PTA/S-C; 72 % +/- 7% and 54% +/- 11% for PTA/S-D, and 81% +/- 6% and 78% +/- 7% for AK-FPB. Secondary patency was significantly better in PTA/S-C than AK-FPB (P = .003) and PTA/S-D groups (P < .001). The difference was marginally better in AK-FPB than in PTA/S-D (P = .064). CONCLUSIONS PTA/S for TASC-II C lesions has a superior midterm patency than AK-FPB using PTFE, and AK-FPB with PTFE has better primary and assisted-primary patency than PTA/S-D. The TASC-II recommendations should be modified to recommend treatment of SFA TASC-II C lesions by PTA/S rather than PTFE bypass for all patients. PTA/S of TASC-II D lesions should only be considered in high-risk patients who cannot tolerate a bypass procedure using PTFE.

Patients with Depression are at Increased Risk for Secondary Cardiovascular Events after Lower Extremity Revascularization

BACKGROUND Accurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, have been used to evaluate performance and assess therapy in other medical specialties. This study was performed to determine whether administrative databases are accurate in the recording of information about trauma patients with splenic injuries. METHODS Patients who had blunt splenic injuries were identified using a state trauma registry. The medical records of those patients were reviewed. The data collected by chart review were compared with data in the statewide administrative database of patients who had splenic injuries at the same four Level I and II trauma centers in the same 5-year period. Age, sex, admission date, and hospital were matched to assure comparison of the identical cohort. chi2 analysis was used to compare dichotomous data and Students t test continuous data. RESULTS The administrative database identified 641 and the trauma registry identified 529 patients with a diagnosis of splenic injury. A total of 401 patients were found in both databases. Of these, 120 (22.7%) patients were not recorded in the administrative database. Injury Severity Score was underreported by the administrative database (25.74 +/- 14.7 vs. 19.52 +/- 11, p < 0.0001). The administrative database underreported orthopedic, chest, and head injuries (317 vs. 215, 325 vs. 228, and 234 vs. 155, respectively; all p < 0.0001). Use of abdominal computed tomographic scan and diagnostic peritoneal lavage were also underreported (260 vs. 56 and 104 vs.17, both p < 0.0001). The number of operations on the spleen and number of orthopedic procedures were underreported (259 vs. 225, p < 0.014 and 147 vs. 94, p < 0.0001). Complications were markedly underreported by the administrative database (200 vs. 47, p < 0.0001) CONCLUSION This study shows that administrative data lack accuracy in the recording of associated injuries, injury severity, diagnostics, procedures, and outcomes data in patients with splenic injuries. Whether these data should be used to evaluate treatment modalities or quality of care in trauma is questionable.

Relationships between renovascular disease, blood pressure, and renal function in the elderly: a population-based study

BackgroundFor patients with peripheral arterial disease (PAD), depression is associated with worse patency and recurrent symptoms in the treated leg, but its association with death or cardiovascular events in other vascular beds is unknown.ObjectiveTo assess the association between depression and mortality or cardiovascular events outside the affected leg after PAD revascularization.DesignRetrospective cohort study.SubjectsTwo hundred fifty-seven consecutive patients undergoing lower extremity revascularization for symptomatic PAD at a single institution between January 2000 and May 2005 were included in this study. By protocol, patients were previously screened for depression and diagnosed by the primary care provider.MeasurementsThe outcomes evaluated included a composite of death or major adverse cardiovascular events (MACE; coronary heart disease, contralateral PAD, or cerebrovascular event) as well as major outcome categories of death, coronary heart disease, contralateral PAD, or cerebrovascular events.ResultsAt revascularization, 35.0% patients had been diagnosed with depression. Those with depression were significantly younger and more likely to use tobacco. By life-table analysis, patients with depression had significantly increased risk for death/MACE, coronary heart disease, and contralateral PAD events, but not cerebrovascular events or death. By multivariate analysis, patients with depression were at significantly increased risk for death/MACE (hazard ratio [HR] = 2.05; p < .0001), contralateral PAD (HR = 2.20; p = .009), and coronary heart disease events (HR = 2.31; p = .005) but not cerebrovascular events or death.ConclusionsDepression is common among patients undergoing revascularization for symptomatic PAD. After intervention, patients with depression are at significantly increased risk for coronary heart disease events and progression of contralateral PAD. Prospective analysis is required to confirm these results.