Jose Trani

Modified eversion carotid endarterectomy.

BACKGROUND Eversion carotid endarterectomy is a well-described technique for carotid endarterectomy (CEA). The advantage of this technique is a completely autogenous repair. We describe a modification of eversion endarterectomy (MEE) that expeditiously extracts the plaque through a linear incision over the common carotid artery and the proximal bulbous internal carotid artery (ICA) only, allowing primary closure. Selective shunting can also be performed without difficulty. METHODS A retrospective review of CEAs using MEE at two institutions by three vascular surgeons during a 5-year period was performed. Data were collected from the medical records, with institutional review board approval. Information regarding neurologic symptoms, degree of ICA stenosis, CEA technique, ICA clamp time, shunting, electroencephalographic monitoring, and postoperative complications was tabulated. Rate of significant restenosis (stenosis >50% by duplex criteria) was also calculated during the follow-up period. RESULTS Between 2005 and 2009, a total of 221 patients underwent MEE for carotid artery stenosis (CAS): 69 patients (31%) underwent MEE for symptomatic and 152 (68.8%) underwent MEE for asymptomatic CAS. Neuromonitoring in the form of electroencephalography was used in 85 (39%) patients, and an intraluminal shunt was used in 29 patients (13%) who had either severe contralateral disease or a previous ipsilateral cerebral infarction. Postoperative complications included transient ischemic attack (four, 2%), cerebral infarction (three, 1%), myocardial infarction (three, 1%), and hematoma (six, 3%). Four patients (2%) required a return to the operating room (OR). within 24 hours for hematoma (one, 1%) or postoperative neurologic deficit (three, %). The 30-day mortality was 1%. One patient (1%) required patch angioplasty because of the extent of disease and inability to obtain a good end point. Average cross-clamp time for MEE was 12.8 minutes. Two patients (1%) were reported to have hemodynamically significant restenosis within 2 years, with one patient requiring intervention. CONCLUSIONS MEE is a safe and effective way of treating CAS, with acceptable morbidity, mortality, and low rate of recurrent stenosis despite the absence of a patch. Given the brief clamp time required, routine shunting and/or neuromonitoring for this technique may have questionable clinical value and expense.

An all-inclusive and transparent view of a vascular program's direct impact on its health system

OBJECTIVE This study explores the fiduciary advantage of a Vascular Surgery program to an academic, tertiary care hospital. METHODS This is a retrospective review of hospital (HealthQuest) and physician (IDX) billing databases from April 2009 to September 2010. We identified all patients interacting with Vascular Surgery (VS) to provide an overview of global finances. Patients introduced solely by VS were identified to minimize confounding of the downstream effect. Outcome measures obtained were revenue, average and total gross margin, relative value unit production, and service utilization. RESULTS A total of 552 cases were identified demonstrating

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

13 million in revenue. This translated into a gross margin of

Descending thoracic aortic mural thrombus presentation and treatment strategies

5 million. Examined per surgeon, VS was the most profitable, producing

PC130 Development and Implementation of a Level One Vascular Emergency Program

1.6 million. Lower extremity amputation had the highest average gross margin at

Access-Related Pseudoaneurysm and Complications of Thrombin Injection

34,000. Notably,

Secondary Interventions after Endovascular Repair of Aortic Dissections

8 million in direct cost is among the highest in the health system. A total of 137 cases unique to VS generated

IP215. Early Unplanned Return to the Operating Room and Mortality After Infrainguinal Revascularization

5 million in total revenue. This patient subset made use of up to 29 physician specialty services. General Medicine and Radiology were the most frequently utilized. CONCLUSION The overall profitability of a comprehensive vascular program is tremendously positive. This study verifies that new vascular-specific referrals are a significant catalyst for revenue.

IP009. Postoperative Mortality in Women After EVAR

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.

RVU-Based Compensation Incentivization in an Academic Vascular Practice Improves Productivity With No Early Adverse Impact on Quality

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.