William P. Shutze

Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery

The Hospital Privileges Practice Guideline Writing Group of the Society for Vascular Surgery is making the following five recommendations concerning guidelines for hospital privileges for vascular surgery and endovascular therapy. Advanced endovascular procedures are currently entrenched in the everyday practice of specialized vascular interventionalists, including vascular surgeons, but open vascular surgery remains uniquely essential to the specialty. First, we endorse the Residency Review Committee for Surgery recommendations regarding open and endovascular cases during vascular residency and fellowship training. Second, applicants for new hospital privileges wishing to perform vascular surgery should have completed an Accreditation Council for Graduate Medical Education-accredited vascular surgery residency or fellowship or American Osteopathic Association-accredited training program before 2020 and should obtain American Board of Surgery certification in vascular surgery or American Osteopathic Association certification within 7xa0years of completion of their training. Third, we recommend that applicants for renewal of hospital privileges in vascular surgery include physicians who are board certified in vascular surgery, general surgery, or cardiothoracic surgery. These physicians with an established practice in vascular surgery should participate in Maintenance of Certification programs as established by the American Board of Surgery and maintain their respective board certification. Fourth, we provide recommendations concerning guidelines for endovascular procedures for vascular surgeons and other vascular interventionalists who are applying for new or renewed hospital privileges. All physicians performing open or endovascular procedures should track outcomes using nationally validated registries, ideally by the Vascular Quality Initiative. Fifth, we endorse the Intersocietal Accreditation Commission recommendations for noninvasive vascular laboratory interpretations and examinations to become a Registered Physician in Vascular Interpretation, which is included in the requirements forxa0board eligibility in vascular surgery, but recommend that only physicians with demonstrated clinical experience in thexa0diagnosis and management of vascular disease be allowed to interpret these studies.

Midterm and long-term follow-up in competitive athletes undergoing thoracic outlet decompression for neurogenic thoracic outlet syndrome

Background: Neurogenic thoracic outlet syndrome (NTOS) results from compression of the brachial plexus by the clavicle, first rib, and scalene muscles and may develop secondary to repetitive motion of the upper extremity. Athletes routinely perform repetitive motions, and sports requiring significant arm and shoulder use may put the participant at increased risk for NTOS. Competitive athletes who develop NTOS may require first rib resection and scalenectomy (FRRS) for symptomatic relief. However, the effectiveness of FRRS has not previously been studied in this vulnerable population. Methods: This is a cross‐sectional study of competitive athletes with NTOS who received FRRS by the senior author between 2009 and 2014. Eligible patients were contacted by phone and invited to complete a nine‐item survey assessing the long‐term effects of FRRS on pain medication use, postoperative physical therapy duration, patient satisfaction, symptom relief, activities of daily living, athletic performance, time to return of athletic performance, and need for other operations. Multivariate analyses of the following risk factors were performed: age, pectoralis minor release, preoperative narcotic use, athletic shutdown, and involvement in a throwing sport. Results: There were 232 competitive athletes who met the inclusion criteria, and 67 of these (age, 14–48 years; 35 male; 99% white) responded to the survey. The average time between surgery and survey completion was 3.9 years (range, 2.2–7.0 years). The most frequent sports conducted by this group were baseball and softball (n = 44 [66%]), volleyball (n = 7 [10%]), and cheerleading and gymnastics (n = 5 [7%]), ranging from high‐school to professional levels. The survey results revealed that 96% were improved in pain medication use, 75% would undergo FRRS on the contralateral side if needed, 82% had resolution of symptoms, and 94% were able to perform activities of daily living without limitation; 70% returned to the same or better level of athletic activity after FRRS, and this occurred within 1 year in 50%. Multivariate regression analysis identified younger age as a predictor of the length of physical therapy and preoperative narcotics use as a predictor of symptom resolution. Conclusions: At our center, >40% of patients requiring FRRS for NTOS are competitive athletes. The results of this study show that the majority of them are able to return to their precompetitive state after FRRS, and few experience limitations in their daily living activities. Half can return to competition at or exceeding their premorbid ability level within 6 months of surgery. The majority are pleased with their decision to undergo FRRS. Further investigation is needed to identify predictive factors for successful return to competitive athletics.

The Impact of Aneurysm Morphology and Anatomic Characteristics on Long-Term Survival after Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUNDnHostile anatomic characteristics in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) and the placement of endografts not in concordance with the specific device anatomic guidelines (or instructions for use [IFU]) have shown decreased technical success of the procedure. But these factors have never been evaluated in regard to patient postoperative survival. We sought to assess the association between survival and (1) aneurysm anatomy and characteristics and (2) implantation in compliance with manufacturers anatomic IFU guidelines in patients undergoing endovascular aortic aneurysm repair.nnnMETHODSnThe cohort included 273 consecutive patients who underwent EVAR at Baylor Heart and Vascular Hospital between January 1, 2002 and December 31, 2009 and had their preoperative computed tomography (CT) scan digitally retrievable. The CT scans and operative notes were then reviewed, and the anatomic severity grading (ASG) score, maximum aneurysm diameter, thrombus width, patency of aortic side branch vessels, and implantation in compliance with IFU guidelines were assessed. The unadjusted association between survival (assessed until November 1, 2011) and these variables was assessed with the Kaplan-Meier method. Moreover, propensity-adjusted (for a comprehensive array of clinical and nonclinical risk factors) proportional hazard models were developed to assess the adjusted associations.nnnRESULTSnSeven (2.56%) patients died within 30xa0days from EVAR, and 88 (30.04%) patients died during the study follow-up. Patient mean survival was 6.3xa0years. The unadjusted analysis showed a statistically significant association between survival and thrombus width (Pxa0=xa00.007), ASG score (Pxa0=xa00.004), and implantation in compliance with IFU guidelines (Pxa0=xa00.007). However, the adjusted analysis revealed that none of the anatomic and compliance factors were significantly associated with long-term survival (ASG, Pxa0=xa00.149; diameter, Pxa0=xa00.836; thrombus, Pxa0=xa00.639; patency, Pxa0=xa00.219; and implantation compliance, Pxa0=xa00.219).nnnCONCLUSIONSnUnfavorable aneurysm morphologic characteristics and endograft implantation not in compliance with IFU guidelines did not adversely affect patient survival after EVAR in this group of patients. This implies that unfavorable anatomy, even that which would necessitate implantation of the EVAR device outside of the IFU guidelines, should not necessarily contraindicate EVAR.

Postoperative continuous catheter-infused local anesthetic reduces pain scores and narcotic use after lower extremity revascularization:

Objective Postoperative pain following lower extremity revascularization procedures is traditionally controlled with narcotic administration. However, this may not adequately control the pain and puts the patient at risk for complications from opiate use. Here we report an alternative strategy for pain management using a continuous catheter-infused local anesthetic into the operative limb. Design Retrospective case–control study. Methods Patients undergoing lower extremity revascularization procedures using continuous catheter-infused local anesthetic were compared to similar patients undergoing similar procedures during the same time period who did not receive continuous catheter-infused local anesthetic. Records were reviewed for pain scores, narcotics consumption, length of stay, need for postoperative chest X-ray, supplemental oxygen use, wound complications, and 30-day readmission. Results There were 153 patients (mean age 69.5 years) from September 2011 to December 2014 who underwent common femoral artery procedures, femoral-popliteal bypass, femoral-tibial bypass, popliteal aneurysm repair, popliteal to pedal bypass, popliteal artery thrombo-embolectomy, sapheno-popliteal venous bypass, or ilio-femoral bypass. There were no significant differences between the continuous catheter-infused local anesthetic (n=57) and control (n=96) groups regarding age, body mass index, cardiac history, diabetes, hypertension, and procedures performed. The continuous catheter-infused local anesthetic group showed better cumulative average pain scores, better high pain scores on postoperative days 1–3, and better average pain scores on postoperative days 2–3 (P<0.03). The continuous catheter-infused local anesthetic group had lower median narcotics consumption on postoperative days 1–2 (P=0.02). No differences were found in postoperative length of stay, urinary catheter use, number of postoperative chest X-rays, oxygen use, mobilization, or fever. Wound complications occurred in 8.8% of the continuous catheter-infused local anesthetic group and in 11.5% of controls (P=0.79). Readmission rates were 23% (continuous catheter-infused local anesthetic) and 21% (controls; P=0.84). Conclusion Postoperative continuous catheter-infused local anesthetic reduces pain scores and pain medication use compared to standard opiate therapy in these patients, without increasing wound complication or readmission rates. Continuous catheter-infused local anesthetic appeared to have no effect on the incidence of pulmonary complications, mobilization, or fever.

Gender Is Not an Independent Risk Factor for Long-Term Survival After Endovascular Aneurysm Repair

Background: The contemporary health care environment is complex, with mounting pressures to perform greater procedural volumes with less support staff to minimize costs and to maximize efficiency. This report details an analysis of routine endovascular procedures performed in a hybrid operating room with dedicated vascular support staff during daytime hours compared with similar cases performed after hours with general operating room staff. Methods: All lower extremity endovascular cases during a 25-month period were identified by Current Procedural Terminology codes from a query of our institutional operating room database. Emergent/urgent cases and cases with associated open surgical procedures were excluded. Cases were divided by the time of day and available clinical support structure into two groups according to procedure start time: specialty-specific daytime (SS), with case starting between 7 AM and 3 PM weekdays; and general staff after hours (AH) for all others. The resulting case list was examined by case type according to SS or AH designation, and case types occurring disproportionately during either time frame were excluded to create the most similar case type distribution among the two groups for analytic purposes. Demographics, case specifics, and cost data were then obtained from the electronic health record and our enterprise cost data warehouse. Multivariable mixed linear modeling was used to examine component costs (eg, anesthesia, supplies) and total costs controlling for a number of factors that could affect cost. Results: There were 275 routine endovascular-only procedures performed on 250 patients examined (203 SS, 47 AH). AH patients were younger, more likely to be female, and less likely to be taking antiplatelet agents at the time of the procedure than SS patients. Scheduled, elective cases made up 86% of SS cases and 55% of AH cases. No significant differences in procedure specifics were observed between the groups (number and location of access sites, type and number of interventions). Multivariable analyses controlled for factors affecting costs (including posting type, American Society of Anesthesiologists class, number of access sites, and interventional vs diagnostic case status). Costs associated with anesthesia (cost ratio, 1.85; P < .001), operating room supplies (cost ratio, 1.45; P 1⁄4 .01), and postanesthesia recovery (cost ratio, 1.20; P 1⁄4 .035) were all significantly increased in AH cases compared with SS cases. The average total hospital cost for routine endovascular cases performed AH was

The incidence and effect of noncylindrical neck morphology on outcomes after endovascular aortic aneurysm repair in the Global Registry for Endovascular Aortic Treatment

9010 compared with

Limited Clinical Relevance of Vertebral Artery Injury in Blunt Trauma

6143 for SS cases (cost ratio, 1.47; P < .001). Conclusions: Performance of routine endovascular cases by specialtyspecific teams during regular hospital hours was associated with significantly less cost to the hospital system, with a w50% increase in total cost associated with AH cases. In the current health care environment, investments in specialty-specific teams and process improvements to facilitate case performance with these teams are likely to be cost-effective.

Ultrasound Diagnosis of a Temporal Artery Aneurysm

Background: The Gore Global Registry for Endovascular Aortic Treatment (GREAT) was designed to evaluate real‐world outcomes after treatment with Gore aortic endografts used in a real‐world, global setting. We retrospectively analyzed the GREAT data to evaluate the incidence and effects of noncylindrical neck anatomy in patients undergoing endovascular aortic aneurysm repair. Methods: The present analysis included patients with data in the GREAT who had been treated with the EXCLUDER endograft from August 2010 to October 2016. A noncylindrical neck was defined when the proximal aortic landing zone diameter had changed ≥2 mm over the first 15 mm of the proximal landing zone, indicating a tapered, conical, or hourglass morphology. Cox multivariate regression analyses were performed for any reintervention (including reinterventions on aortic branch vessels), device‐related reinterventions, and reintervention specifically for endoleak. Independent binary (cylindrical vs noncylindrical necks) and continuous (percentage of neck diameter change) variables were assessed. The abdominal aortic aneurysm (AAA) diameter, proximal neck length, maximal infrarenal neck angle, gender, and use of aortic extender cuffs were also assessed. Results: Of 3077 GREAT patients with available proximal aortic landing zone diameter measurements available, 1765 were found to have cylindrical necks and 1312 had noncylindrical necks. The noncylindrical neck cohort had a significantly greater proportion of women (17.4% vs 12.6%; P < .001) and more severe infrarenal angulation (33.8° vs 28.4°; P < .001). A total 14.7% of noncylindrical neck patients and 11.2% cylindrical neck patients underwent implantation outside of the EXCLUDER instructions for use regarding the anatomic inclusion criteria (P = .004). The procedural characteristics were similar between the two cohorts; however, noncylindrical neck patients required significantly more aortic extender cuffs (P = .004). The average follow‐up was 21.2 ± 17.5 months and 17.8 ± 15.8 months for the cylindrical and noncylindrical cohorts, respectively (P < .001). The Cox multivariate regression models demonstrated female gender and maximum AAA diameter were significant risk factors for subsequent reintervention (overall, device‐related, and endoleak‐specific). Women were 2.2 times as likely to require device‐related intervention during the follow‐up period compared with men (P < .001). Neck shape morphology was not a significant predictor, except for device‐related intervention, for which cylindrical necks (binary definition) resulted in a slightly elevated risk (1.5 times; P = .03). Conclusions: Noncylindrical neck morphology was more common in women and was associated with an increased use of aortic extender cuffs but did not increase the risk of intervention. Female gender and AAA diameter were associated with an increased need for reintervention.

Bovine pericardial patch angioplasty in carotid endarterectomy

BACKGROUNDnBlunt cerebrovascular injury (BCVI), although rare, is more common than previously thought and carries a substantial stroke and mortality risk. The purpose of our study was to evaluate the differences between blunt carotid artery (CA) and vertebral artery (VA) injuries, assess the stroke and death rates related to these injuries, and identify the relationship of Injury Severity Score (ISS) with stroke and mortality in BCVI.nnnMETHODSnUsing a retrospective review of the trauma registry at a level I trauma center, we identified patients with BCVI. The study period began in January 2003 and ended in July 2014. Demographics, injuries reported, investigative studies performed, and outcomes data were obtained and analyzed. Radiographic images of both blunt CA and VA injuries were reviewed and graded by an independent radiologist, according to the current classification of blunt CA injuries.nnnRESULTSnBCVI involving 114 vessels was identified in 103 patients. This population consisted of 65 males and 38 females with an average age of 45xa0years (15-92, range). The average ISS was 22 (4-75, range). Cervical spine fracture occurred in 80% of VA injuries (64 total patients). Injuries involved the CA in 33, the VA in 59, and both in 11. The CA group had a higher incidence of traumatic brain injury (61% vs. 46%), ISS (27 vs. 18), and stroke (24% vs. 3%), compared to the VA group. Mortality in the CA group was 30% compared to 3% in the VA group. Patients with high ISS (≥25) had increased stroke rates compared to those with lower (<25) ISS (19% vs. 6.7%). All mortalities occurred with ISS >25. Logistic regression revealed that vessel injured, ISS, and Glasgow Coma Scale (GCS) were significant risk factors for mortality. Multivariate analysis demonstrated carotid injury, and lowest GCS were independently associated with mortality.nnnCONCLUSIONSnIn this comparison of CA and VA injuries in BCVI, VA injuries were more common and more frequently found with cervical spine fractures than CA injuries. However, VA injuries had a lower incidence of CVA and mortality. A high ISS was associated with stroke and mortality while carotid injury and lowest GCS were independently associated with increased mortality.

IP021. Gender Differences in Aortic and Iliac Artery Anatomy in Patients Undergoing Endovascular Aneurysm Repair

Superficial temporal artery aneurysms (STAA) are rare, almost always post traumatic, and their diagnosis can be challenging. When a middle aged man presented with a gradually enlarging non-pulsatile left fronto-temporal artery mass we were able to make a diagnosis of STAA using ultrasonography as well as confirm its resolution later following spontaneous thrombosis of the aneurysm.