Publications by authors named "Matthew R Smeds"

61 Publications

Aortic endograft sizing and endoleak, reintervention and mortality following endovascular aneurysm repair.

J Vasc Surg 2021 Apr 30. Epub 2021 Apr 30.

Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University. Electronic address:

Objectives: Endograft sizing for endovascular abdominal aortic repair (EVAR) is not consistent despite published instructions for use (IFU). We sought to identify factors associated with over/undersizing, determine sex influence on sizing, and examine sizing effects on endoleak, reintervention, and mortality by analyzing data obtained from the W.L. Gore & Associates Global Registry for Endovascular Aortic Treatment (GREAT).

Methods: All patients enrolled in GREAT undergoing EVAR were included for analysis. Proximal/distal aortic landing zones were compared to device implanted to assess sizing as related to IFU. Chi-square/Fisher's exact tests were used to evaluate associations between IFU sizing and demographics. Logistic regression modeling was used to identify predictors of outside IFU sizing. Cox proportional hazards regression analyzed the relationship between sizing and endoleak, device-related reinterventions, and all-cause/aortic mortality.

Results: There were 3,607 EVAR subjects enrolled in GREAT as of March 2020. 1,896 (53%) were within IFU for sizing; 791 (22%) were oversized; 540 (15%) were undersized; and 380 (10%) had both over- and undersized components. Factors predictive of use outside of IFU included female sex (p=0.001), non-white race (p=0.0003), decreased proximal neck length (p<0.061), or larger iliac diameters (p<0.0001). Women were more likely than men to have proximal neck undersizing and iliac limb oversizing, and men were more likely to have iliac limb undersizing. On multivariate analysis, undersizing of the proximal graft was associated with endoleak (HR 1.8) and aortic (HR 60.5) and all-cause (HR 18.0) mortality. Undersizing of iliac limbs was associated with endoleak (HR 1.5) and device-related reintervention (HR 1.4). Iliac limb outside IFU sizing was associated with aortic (HR 2.6) and all-cause (HR 1.3) mortality. Proximal and distal oversizing was not associated with adverse outcomes. Female sex was associated with mortality on univariate but not multivariate analysis.

Conclusions: Women undergoing EVAR with GORE® EXCLUDER® AAA Endoprosthesis are more likely to have proximal stent-graft undersizing and iliac limb oversizing, while men are more likely to have undersized iliac limbs. Proximal aortic graft undersizing is associated with endoleak and all-cause/aortic mortality, while undersizing of iliac limbs is associated with endoleak and device-related reintervention. Oversizing was not associated with adverse outcomes.
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http://dx.doi.org/10.1016/j.jvs.2021.04.045DOI Listing
April 2021

Area Deprivation Index Score Is Associated with Lower Rates of Long Term Follow-up after Upper Extremity Vascular Injuries.

Ann Vasc Surg 2021 Apr 25. Epub 2021 Apr 25.

Division of Vascular and Endovascular Surgery, St. Louis University, St. Louis, MO, USA.

Objective: The Area Deprivation Index (ADI) has been shown to be a determinant of healthcare outcomes in both medical and surgical fields, and is a measure of the socioeconomic status of patients. We sought to analyze outcomes in patients with upper extremity vascular injuries that were admitted over a five-year period to a Level I trauma center sorted by ADI.

Methods: All patients with upper extremity vascular injury presenting to a level one trauma center between January 2013 and January 2017 were retrospectively collected. The patients were divided into two groups based on their ADI with the first group representing the lowest quartile of patients and the second group the higher three quartiles. Patient's demographics were analyzed as well as modes of trauma, hospital transfer status prior to receiving care, type of intervention received, follow-up rates and outcomes including both complication and amputation rates.

Results: Over this time period, a total of 88 patients with traumatic upper extremity vascular injuries were identified. The majority of injuries were due to penetrating trauma (74/88, 84%) with 41% (10/24) of patients in the lower ADI being victims of gunshot wounds compared to 27% (17/64) of those in the higher ADI (p=0.19). Patients in the lowest ADI quartile were more likely to be African Americans (p=0.0001), and more likely to be transferred to our university hospital prior to receiving care (p=0.007). Arrival Glasgow Coma Scale (GCS) and Injury Severity Score (ISS) were similar as was time spent in the emergency room. Length of stay trended longer in the lowest ADI quartile as compared to the higher ADI (7.5 vs. 11.8, p=0.59). The rates of long term follow-up were significantly lower in patients with the lowest ADI scores as opposed to the higher ADI group (p= 0.0098), however, there was no statistically significant difference in outcomes between the two groups including both complication and amputation rates.

Conclusions: The Area Deprivation Index Is associated with lower rates of long term follow-up after upper extremity vascular injuries, despite patients in both the high and low ADI groups having similar outcomes in regards to complication and amputation rates. Further study is warranted to investigate the role of the socioeconomic status in outcomes following traumatic injury.
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http://dx.doi.org/10.1016/j.avsg.2021.03.037DOI Listing
April 2021

Feasibility and acceptability of virtual mock oral examinations for senior vascular surgery trainees and implications for the certifying exam.

Ann Vasc Surg 2021 Apr 7. Epub 2021 Apr 7.

Division of Vascular and Endovascular Surgery, Saint Louis University, Saint Louis, MO. Electronic address:

Objectives: The COVID-19 pandemic resulted in the cancellation of in-person testing across the country. We sought to understand the feasibility of conducting virtual oral examinations as well as solicit opinions of vascular surgery program directors (PD) regarding the use of virtual platforms to conduct both low stakes mock oral examinations with their trainees and potentially "real" high stakes certifying examinations (CE) moving forward.

Methods: Forty-four senior vascular surgery trainees from 17 institutions took part in a virtual mock oral examination conducted by 38 practicing vascular surgeons via Zoom. Each examination lasted 30 minutes with four clinical scenarios. An anonymous survey pertaining to the conduct of the examination and opinions on feasibility of using virtual examinations for the vascular surgery CE was sent to all examiners and examinees. A similar survey was sent to all vascular surgery program directors.

Results: The overall pass rate was 82% (36/44 participants) with no correlation with training paradigm. 32/44 (73%) of trainees, 29/38 (76%) of examiners and 49/103 (48%) of PDs completed the surveys. Examinees and examiners thought the experience was beneficial and PDs also thought the experience would be beneficial for their trainees. While the majority of trainees and examiners believed they were able to communicate and express (or evaluate) knowledge and confidence as easily virtually as in person, PDs were less likely to agree confidence could be assessed virtually. The majority of respondents thought the CE of the Vascular Surgery Board of the American Board of Surgery could be offered virtually, although no groups thought virtual exams were superior to in person exams. While cost benefit was perceived in virtual examinations, the security of the examination was a concern.

Conclusions: Performing virtual mock oral examinations for vascular surgery trainees is feasible. Both vascular surgery trainees as well as PDs feel that virtual CEs should be considered by the Vascular Surgery Board.
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http://dx.doi.org/10.1016/j.avsg.2021.03.005DOI Listing
April 2021

Progression of Changes in Vascular Surgery Practices during the Novel Corona Virus SARS-CoV-2 Pandemic.

Ann Vasc Surg 2021 Apr 6. Epub 2021 Apr 6.

Division of Vascular and Endovscular Surgery, Department of Surgery, Saint Louis University, St. Louis, MO. Electronic address:

Introduction: The novel coronavirus SARS-CoV-2 (COVID-19) has spread rapidly since it was identified. We sought to understand its effects on vascular surgery practices stratified by VASCON surgical readiness level and determine how these effects have changed during the course of the pandemic.

Methods: All members of the Vascular and Endovascular Surgery Society were sent electronic surveys questioning the effects of COVID-19 on their practices in the early pandemic in April (EP) and four months later in the pandemic in August (LP) 2020.

Results: Response rates were 206/731 (28%) in the EP group and 108/731 (15%) in the LP group (P < 0.0001). Most EP respondents reported VASCON levels less than 3 (168/206,82%), indicating increased hospital limitations while 6/108 (6%) in the LP group reported this level (P < 0.0001). The EP group was more likely to report a lower VASCON level (increased resource limitations), and decreased clinic, hospital and emergency room consults. Despite an increase of average cases/week to pre-COVID-19 levels, 46/108 (43%) of LP report continued decreased compensation, with 57% reporting more than 10% decrease. Respondents in the decreased compensation group were more likely to have reported a VASCON level 3 or lower earlier in the pandemic (P = 0.018). 91/108(84%) of LP group have treated COVID-19 patients for thromboembolic events, most commonly acute limb ischemia (76/108) and acute DVT (76/108). While the majority of respondents are no longer delaying the vascular surgery cases, 76/108 (70%) feel that vascular patient care has suffered due to earlier delays, and 36/108 (33%) report a backlog of cases caused by the pandemic.

Conclusions: COVID-19 had a profound effect on vascular surgery practices earlier in the pandemic, resulting in continued detrimental effects on the provision of vascular care as well as compensation received by vascular surgeons.
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http://dx.doi.org/10.1016/j.avsg.2021.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023786PMC
April 2021

Self-Perceived Comfort Performing Vascular Surgery Procedures among Senior Vascular Surgery Trainees and Recent Graduates.

Ann Vasc Surg 2021 Apr 5. Epub 2021 Apr 5.

Division of Vascular and Endovascular Surgery, Saint Louis University, St. Louis, Missouri.

Objective: In the last two decades, vascular surgery training evolved from exclusively learning open skills to learning endovascular skills in addition to a functional reduction in training duration with 0+5 residency programs. The implications for this on trainee evolution to independence are unknown. We aimed to assess self-perceived comfort performing open and endovascular procedures and to identify predictors of high comfort among senior vascular surgery trainees and recent graduates.

Methods: Junior and senior 0+5 vascular surgery residents, traditional fellows, and attendings in their first 4 years of practice were asked to complete a survey assessing the number of vascular procedures performed to date, comfort performing these procedures on a Likert scale, and validated scales of self-efficacy and grit. Groups were then matched by training level and age. Logistic regression identified independent predictors of the top quartile of self-perceived comfort performing procedures.

Results: Surveys were completed by 92 trainees and 71 attending surgeons in their first 4 years of practice. After matching, completing ≥7 open juxtarenal aortic repairs (OR = 4.73, 95% CI = 1.59-14.07) and a higher self-efficacy score (OR = 3.24, 95% CI = 1.20-8.76), were independent predictors of top quartile comfort performing open vascular procedures. 0+5 residency training inversely correlated with top quartile comfort performing open vascular operations (OR = 0.12, 95% CI = 0.03-0.47). Completing ≥7 complex EVARs (OR = 3.94, 95% CI = 1.61-9.59) and a higher self-efficacy personality score (OR = 2.76, 95% CI = 1.09-7.02) were predictors of top quartile comfort performing endovascular procedures.

Conclusion: In this nationally representative survey, both trainees and junior attendings completed a paucity of complex open vascular cases, which corresponded to reduced comfort performing these procedures. Furthermore, 0+5 residency training was associated with lower self-perceived comfort performing open vascular surgery, a trend that persisted through the first years of practice. Endovascular comfort did not show a similar correlation.
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http://dx.doi.org/10.1016/j.avsg.2021.03.019DOI Listing
April 2021

Anatomic suitability for commercially available percutaneous arteriovenous fistula creation systems.

Authors:
Matthew R Smeds

J Vasc Surg 2021 Mar;73(3):1005-1006

Division of Vascular and Endovascular Surgery, SSM Health St. Louis University Hospital, St. Louis University School of Medicine, St Louis, Mo.

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http://dx.doi.org/10.1016/j.jvs.2020.09.022DOI Listing
March 2021

Ensuring equity, diversity, and inclusion in the Society for Vascular Surgery: A report of the Society for Vascular Surgery Task Force on Equity, Diversity, and Inclusion.

J Vasc Surg 2021 Mar 14;73(3):745-756.e6. Epub 2020 Dec 14.

Division of Vascular Surgery, Baylor Scott & White Heart and Vascular Hospital, Dallas, Tex.

Diversity, equity, and inclusion represent interconnected goals meant to ensure that all individuals, regardless of their innate identity characteristics, feel welcomed and valued among their peers. Equity is achieved when all individuals have equal access to leadership and career advancement opportunities as well as fair compensation for their work. It is well-known that the unique backgrounds and perspectives contributed by a diverse workforce strengthen and improve medical organizations overall. The Society for Vascular Surgery (SVS) is committed to supporting the highest quality leadership, patient care, surgical education, and societal recommendations through promoting diversity, equity, and inclusion within the SVS. The overarching goal of this document is to provide specific context and guidance for enhancing diversity, equity, and inclusion within the SVS as well as setting the tone for conduct and processes beyond the SVS, within other national and regional vascular surgery organizations and practice settings.
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http://dx.doi.org/10.1016/j.jvs.2020.11.049DOI Listing
March 2021

The Importance of Autonomy.

Authors:
Matthew R Smeds

J Am Coll Surg 2021 Jan;232(1):15-16

St Louis, MO.

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.09.010DOI Listing
January 2021

Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery.

J Vasc Surg 2021 01 7;73(1S):87S-115S. Epub 2020 Nov 7.

Evidence-Based Practice Center, Mayo Clinic, Rochester, Minn.

Background: Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis.

Methods: The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus.

Results: Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion.

Conclusions: These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.
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http://dx.doi.org/10.1016/j.jvs.2020.10.029DOI Listing
January 2021

A modern appraisal of current vascular surgery education.

J Vasc Surg 2021 Apr 22;73(4):1430-1435. Epub 2020 Oct 22.

Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md. Electronic address:

Objective: Although general program requirements and curriculum content outlines are provided by the Accreditation Council for Graduate Medical Education, Association for Program Directors in Vascular Surgery, and Vascular Surgery Board of the American Board of Surgery, there is no single format for delivery of this content. The delivery of these defined educational components is, thus, likely to differ from site to site. The curriculum committee of the Association of Program Directors in Vascular Surgery was tasked with formalizing the content of the Vascular Surgery Surgical Council on Resident Education curriculum modules, and, therefore, we sought to appraise the current status of vascular educational programs in U.S. training programs before its implementation.

Methods: Program directors (PDs) of 112 U.S. vascular surgery residency and fellowship training programs were contacted via email and asked to participate in an anonymous electronic survey. This survey evaluated the educational components of individual programs, including vascular specific conferences, use of other training modalities, and determination of who was involved in the creation of these programs.

Results: Of the 112 PDs offered the survey, 80 (71%) responded. Most (42 of 80; 53%) have both an integrated vascular residency and a fellowship with the remaining being solely fellowship (31 of 80; 39%) or integrated residencies (7 of 80; 9%). The majority (79 of 81; 98%) of programs hold at least one vascular conference per week, with 75% (60 of 81) holding more than one each week. The total time spent in conference averaged 2.6 hours/wk, and the most common educational components of the weekly conferences were review of upcoming (48 of 79, 61%) or recently completed surgical cases (30 of 79; 38%), lectures on vascular disease processes (40 of 79; 51%), and review of book chapters from vascular surgery textbooks (27 of 78; 35%). PDs are responsible for creating the schedule at 50% (39 of 78) of the programs with most remaining programs relying on trainees (18 of 78; 23%) and assistant PDs (17 of 78; 22%). Vascular trainees present the majority of material at most programs' conferences (64 of 77; 83%). The majority of PDs feel that trainees should independently study 4 hours or more per week (51 of 79; 65%), but only 25% (20 of 79) believe that trainees actually spend this amount of time studying (P = .0001). Only 13 of 80 (16%) programs currently use a preformatted standardized vascular curriculum, but 64 of 80 (80%) believe that there is a need for the creation of this product and 72 of 80 (90%) would most likely use it.

Conclusions: There is a significant variation in vascular surgery educational programs with considerable dependence on trainees to create the curriculum. The majority of PDs in vascular surgery support the creation of a standardized vascular curriculum and would use it if made.
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http://dx.doi.org/10.1016/j.jvs.2020.10.028DOI Listing
April 2021

Implications of the severe acute respiratory syndrome associated with the novel coronavirus-2 on vascular surgery practices.

J Vasc Surg 2021 01 4;73(1):4-11.e2. Epub 2020 Sep 4.

Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, St. Louis, Mo. Electronic address:

Background: We sought to understand the effects of coronavirus disease-2019 (COVID-19) on vascular surgery practices as related to the Vascular Activity Condition (VASCON) scale.

Methods: All members of the Vascular and Endovascular Surgery Society were surveyed on the effects of COVID-19 in their practices, educational programs, and self-reported grading of their surgical acuity level using the VASCON scale.

Results: Total response rate was 28% (206/731). Most respondents (99.5%) reported an effect of COVID-19 on their practice, and most were VASCON3 or lower level. Most reported a decrease in clinic referrals, inpatient/emergency room consults, and case volume (P < .00001). Twelve percent of respondents have been deployed to provide critical care and 11% medical care for COVID-19 patients. More than one-quarter (28%) face decreased compensation or salary. The majority of respondents feel vascular education is affected; however, most feel graduates will finish with the necessary experiences. There were significant differences in answers in lower VASCON levels respondents, with this group demonstrating a statistically significant decreased operative volume, vascular surgery referrals, and increased hospital and procedure limitations.

Conclusions: Nearly all vascular surgeons studied are affected by the COVID-19 pandemic with decreased clinical and operative volume, educational opportunities for trainees, and compensation issues. The VASCON level may be helpful in determining surgical readiness.
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http://dx.doi.org/10.1016/j.jvs.2020.08.118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7471762PMC
January 2021

Predictors of Aneurysm Sac Shrinkage Utilizing a Global Registry.

Ann Vasc Surg 2021 Feb 2;71:40-47. Epub 2020 Sep 2.

Division of Vascular and Endovascular Surgery, Saint Louis University, Saint Louis, MO. Electronic address:

Background: Aneurysm sac remodeling is a complex multifactorial process with unknown factors influencing sac regression after endovascular aortic aneurysm repair (EVAR). We sought to identify factors associated with this process by analyzing data obtained from patients treated with the GORE EXCLUDER endovascular aneurysm repair (EVAR) endoprosthesis from December 2010 to October 2016 enrolled in the Global Registry for Endovascular Aortic Treatment (GREAT).

Methods: All patients enrolled in GREAT with three years CT angiography (CTA) follow-up in each of the three successive years after EVAR were included. The percentage of sac size reduction toward device diameter was calculated and used as a surrogate for sac regression with the formula used being: sac size reduction = ((AAA baseline diameter - AAA diameter at follow-up)/(AAA baseline diameter - device diameter))∗100. The cohort was divided into two groups in accordance with the percentage of aneurysm sac reduction at three years; one with the top quartile of patients and the other with the lowest three quartiles. Demographic and procedural variables were analyzed using univariate and regression modeling to determine factors predictive of sac regression.

Results: There were 3265 subjects enrolled with follow-up as of May 2018 of which 526 (16.2%) had three years of CTA surveillance. Overall aneurysm sac size decreased from a mean of 58.0 mm (Std Dev: 10.4, range: 34.2, 100.0) to a mean of 49.3 mm (Std Dev: 14.1, range: 0, 140) for a percentage reduction toward device diameter of a mean 28.2% (Std Dev: 39.0, range: -103.7, 183.9). On multivariate logistic regression model; two factors proved to be statistically significant contributors to a larger percentage reduction in aneurysm sac: a conical neck (odds ratio [OR] = 1.64, P-value = 0.023) and a larger proximal device diameter (OR = 1.09, P-value = 0.023). On the other hand, two factors were negative predictors of sac shrinkage, namely: old age (OR = 0.96, P-value = 0.002) and larger baseline aneurysm sac diameter (OR = 0.98, P-value = 0.028).

Conclusions: Aneurysms with conical necks and larger proximal device neck diameters have an increased percentage change in sac size over time after EVAR. Older age and larger initial diameters of aneurysms were negatively associated with percentage change in sac size as well as sac regression. Further study is needed to determine the clinical utility of these observations and applicability across multiple endoprosthesis platforms.
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http://dx.doi.org/10.1016/j.avsg.2020.08.110DOI Listing
February 2021

Heparin-bonded versus standard polytetrafluoroethylene arteriovenous grafts: A Bayesian perspective on a randomized controlled trial for comparative effectiveness.

Surgery 2020 Dec 26;168(6):1066-1074. Epub 2020 Aug 26.

Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; HCA Houston Healthcare and the University of Houston College of Medicine, TX. Electronic address:

Background: Heparin-bonded polytetrafluoroethylene grafts were marketed to improve hemodialysis access outcomes but are twice the cost of standard polytetrafluoroethylene. We launched a randomized trial of heparin-bonded polytetrafluoroethylene versus standard polytetrafluoroethylene for hemodialysis access to compare patency. Since the trial began, additional studies were published with heterogeneous findings. We performed an interim analysis by Bayesian methods using prior probability from meta-analysis of existing literature.

Methods: NCT01601873 is a randomized, blinded trial of heparin-bonded polytetrafluoroethylene versus standard polytetrafluoroethylene for dialysis access at 5 sites. Planned sample size was 200 with 1-year primary patency as the primary endpoint. At interim analysis (50% of sample size at 1 year), we also performed a meta-analysis for 1-year primary patency with a random effects model to compute summary rate ratio and standard-error estimates. Meta-analysis estimates formed a prior probability for a Bayesian Cox regression model, and trial data were reanalyzed to develop posterior probability of heparin-bonded polytetrafluoroethylene effectiveness at our hypothesized effect size. Futility analysis was conducted using posterior probability estimates.

Results: One hundred and five patients were enrolled at the time of interim analysis. One-year primary patency was 34.9% in the heparin-bonded-polytetrafluoroethylene group vs 32.7% in the standard-polytetrafluoroethylene group (P = .884). Summary rate ratio from the meta-analysis (1,209 patients) was 0.87 favoring heparin-bonded polytetrafluoroethylene (P = .33). Posterior hazard ratio from Cox regression was 0.90 (credible interval 0.70-1.13) favoring heparin-bonded polytetrafluoroethylene, which was not significant. Bayesian posterior probability of the a priori hypothesized 20% better patency with heparin-bonded polytetrafluoroethylene was 24%. Sample size to detect superiority with the small observed effect size would require about 3,800 subjects.

Conclusion: Current evidence does not demonstrate sufficiently large benefit of heparin-bonded polytetrafluoroethylene over standard polytetrafluoroethylene for dialysis access to justify higher cost. Given similar 1-year patency rates, a conclusive finding of superiority was judged to be infeasible, and the trial was stopped for futility.
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http://dx.doi.org/10.1016/j.surg.2020.07.013DOI Listing
December 2020

Factors Associated With Medication Adherence in Vascular Surgery Patients.

Vasc Endovascular Surg 2020 Oct 15;54(7):625-632. Epub 2020 Jul 15.

Division of Vascular Surgery, Department of Surgery, SSM Health 7547St. Louis University Hospital, St. Louis University School of Medicine, MO, USA.

Introduction: Patients with vascular disease have higher mortality rates than age-matched peers and medical management of coexisting diseases may alter these outcomes. We sought to understand factors associated with medication nonadherence in vascular surgery patients at a single University vascular surgery clinic over a 3-month period.

Materials And Methods: Consecutive vascular surgery patients were surveyed from June to August 2019. The survey included demographic questions, the validated Morisky Medication Adherence Scale, the 4-item Patient Health Questionnaire for Anxiety and Depression scales, and other medication-related questions. Medical and surgical histories were retrospectively collected from charts. Univariate and multivariate analyses were used to compare among high, intermediate, and low adherence.

Results: A total of 128 (74%) of 174 patients met study inclusion criteria. On univariate analysis, lower medication adherence was associated with younger age ( = .004), anxiety and depression ( = .001), higher daily pain ( < .001), and patients who believed their medications were less important for treating their vascular disease ( < .001). Adherence was not associated with symptomatic vascular disease, gender, education level, marital status, employment, insurance, or the use of medication usage reminders. Multivariate analysis significantly predicted high adherence relative to low adherence with 5-year increase in age (odds ratio [OR] = 1.252, = .021) and low adherence relative to high adherence with greater perceived pain (OR = 0.839, = .016).

Conclusions: Younger age and high level of pain were associated with lower medication adherence. Informing patients of the importance of prescribed medication and addressing anxiety or depression symptoms may improve adherence.
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http://dx.doi.org/10.1177/1538574420941300DOI Listing
October 2020

Proposed resumption of surgery algorithm after the coronavirus SARS-CoV-2 pandemic.

J Vasc Surg 2020 08 23;72(2):393-395. Epub 2020 May 23.

Division of Urology, Department of Surgery, St. Louis University, St. Louis, Mo.

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http://dx.doi.org/10.1016/j.jvs.2020.05.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245200PMC
August 2020

In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas.

J Vasc Surg 2021 01 21;73(1):210-221.e1. Epub 2020 May 21.

Division of Vascular Surgery, Keio University, Tokyo, Japan.

Objective: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF.

Methods: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed.

Results: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality.

Conclusions: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.
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http://dx.doi.org/10.1016/j.jvs.2020.04.515DOI Listing
January 2021

Real-World Usage of the WavelinQ EndoAVF System.

Ann Vasc Surg 2021 Jan 15;70:116-122. Epub 2020 May 15.

Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, St. Louis, MO. Electronic address:

Background: Dependent on existing deep to superficial perforating venous branches, the WavelinQ EndoAVF System is a novel technique used to create an arteriovenous fistula (AVF) between ulnar or radial veins and concomitant arteries for dialysis access. We sought to examine a single center's success rates and short-term follow-up using this device.

Methods: All consecutive patients undergoing placement of a WavelinQ AVF from October 2018 to July 2019 were included. Preoperative/intraoperative variables including demographics, preoperative/postoperative duplex ultrasonography, success rate of procedure, and subsequent endovascular/surgical procedures were obtained. Descriptive statistics and comparison of groups requiring subsequent intervention were performed.

Results: Thirty-five patients underwent placement of the WavelinQ AVF, with 32 (91%) patients having at least one documented follow-up. These patients were predominantly male (23/32, 72%) with an average age of 60.2 and 23 of 32 (72%) patients were on dialysis. Initial fistula creation success rate was 100%. Average procedural length was 120 min, fluoroscopy time 9.6 min, and contrast usage 52.2 mL. Eight of 32 (25%) patients had perioperative complications (3 hematomas, 3 contrast extravasations, 1 resolved vessel spasm all resolving spontaneously, and 1 pseudoaneurysm requiring surgical repair). Thirteen of 32 (41%) patients underwent subsequent endovascular interventions to assist with maturation [9/32 (28%) branch coiling, 5/32 (16%) angioplasty/stenting, and 3/32 (9%) access thrombectomy] and 4 of 32 (13%) patients required subsequent surgical interventions (1 pseudoaneurysm repair, 1 revision of fistula, and 2 definitive AVF creation in thrombosed grafts). The majority of accesses (30/32, 94%) were ulnar-ulnar fistulas and overall patency at average follow-up of 73 days was 88% (28/32) with average brachial artery inflow volume of 1,078 cc/min and average cephalic vein (18/32) outflow volume of 447 cc/min. Eleven of 23 (48%) patients on dialysis were successfully using the EndoAVF at follow-up.

Conclusions: The WavelinQ AVF system has a high initial procedural success rate, although a significant portion of patients require subsequent endovascular procedures to aid in maturation. Further work on determining factors predictive of need for reintervention is necessary.
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http://dx.doi.org/10.1016/j.avsg.2020.05.006DOI Listing
January 2021

Are Vascular Surgery Trainees Satisfied and are They Using the Right Factors to Choose a Training Program?

Ann Vasc Surg 2020 Aug 6;67:123-133. Epub 2020 Apr 6.

Division of Vascular and Endovascular Surgery, SSM Health St. Louis University Hospital, St. Louis University School of Medicine, St. Louis, MO.

Background: Medical students and residents often evaluate training sites in vascular surgery with minimal exposure to those programs. We sought to identify factors associated with vascular surgery trainee satisfaction in relation to their current work environment and how they made their rank list.

Methods: All integrated residents and fellows currently in United States vascular training programs were queried using an anonymous electronic survey for variables of their current training environment, factors that influenced their rank order list, and satisfaction. Questions were graded on a Likert scale. Continuous, ordinal, and categorical variables were respectively analyzed using the two-sample t-test, Mann-Whitney U-test/Wilcoxon rank sum test, and Fisher's exact test.

Results: A total of 166 of 517 (32%) trainees completed the survey with equal distribution across postgraduate years. Respondents reported high rates of satisfaction with their training program overall (84%), including 88% (n = 83) of residents and 78% (n = 56) of fellows. Several work environment variables were associated with both resident and fellow satisfaction including program-funded trips for conferences and presentations (P = 0.027 for residents; P = 0.001 for fellows), diversity of operative cases (P = 0.024; P < 0.001), perception of a strong supportive social network at the hospital (P = 0.006; P = 0.001), and perception of appreciation by attending surgeons (P < 0.001; P < 0.001). Fellows who felt appreciated by nursing staff (P = 0.047), ancillary staff (P = 0.013), and patients were more likely to be satisfied (P = 0.011); however, this was not true for integrated residents. Social outings with nontrainee family and friends were associated with satisfaction for fellows (P = 0.002) but not integrated residents (P = 0.138), whereas social outings with vascular trainees were associated with satisfaction for integrated residents (P = 0.047) but not fellows (P = 0.375). Similarly, satisfied integrated residents were more likely to have close relationships with their vascular cotrainees (P = 0.035) than fellows (P = 0.349). No rank list factors were found to be predictive of current trainee satisfaction for integrated residents. Rank list factors associated with fellow satisfaction included recommendation of the institution from a mentor (P < 0.001), success of program graduates (P = 0.002), faculty (P = 0.014), perceived program prestige (P = 0.040), and amount of early operative exposure (P = 0.042).

Conclusions: Vascular surgery trainees report a high level of satisfaction with their training program. Fellow satisfaction was more dependent on the perception of their workplace peers than integrated residents. Satisfied integrated residents were more likely to have close relationships with their vascular cotrainees than fellows.
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http://dx.doi.org/10.1016/j.avsg.2020.03.029DOI Listing
August 2020

Gender disparity and sexual harassment in vascular surgery practices.

J Vasc Surg 2020 08 14;72(2):692-699. Epub 2020 Feb 14.

Department of Surgery, Loyola University, Maywood, Ill.

Background: Sexual harassment is defined as unwelcome behaviors or obscene remarks that affect an individual's work performance or create an intimidating, hostile, or offensive environment. It is known to be more pervasive in male-dominated workplaces and flourishes in a climate of tolerance and culture of silence. We sought to examine its prevalence in faculty of vascular surgery training programs, to identify factors associated with occurrence, to determine reporting barriers, and to identify any gender bias that exists.

Methods: An anonymous survey consisting of questions on gender bias and sexual harassment was e-mailed to vascular surgery faculty members at 52 training sites in the United States. The survey asked about type, perpetrators, and locations; why and how the practice occurs; reporting mechanisms and barriers to reporting; and demographic information. Descriptive and univariate analyses were performed.

Results: Of 346 invitations sent, 149 recipients (43%) completed the survey. Of respondents, 48 of 149 (32%) thought harassment occurred more commonly in surgical specialties with historical male dominance, citing ignoring of behavior and hierarchy/power dynamics as the most common reasons for its occurrence; 61 of 149 (41%) reported having experienced workplace harassment, with unwanted sexually explicit comments or questions and jokes, being called a sexist slur or nickname, or being paid unwanted flirtation as the most common behaviors. Harassment was high in both men and women, although women had a higher likelihood of being harassed (67% of women respondents vs 34% of men respondents; P = .001) and on average had experienced 2.6 (of 11) types of harassment. The majority of harassment came from hospital staff, although women were more likely to receive harassment from other faculty. Despite that 84% of respondents acknowledged known institutional reporting mechanisms, only 7.2% of the harassing behaviors were reported. The most common reasons for not reporting included feeling that the behavior was "harmless" (67%) or "nothing positive would come of it" (28%). Of the respondents, 30% feared repercussions or felt uncomfortable identifying as a target of sexual harassment, and only 59% would feel comfortable discussing the harassment with departmental or divisional leadership. In examining workplace gender disparity, female surgeon responses differed significantly from male surgeon responses in regard to perceptions of gender differences.

Conclusions: A significant number of faculty of vascular surgery training programs have experienced workplace sexual harassment. Whereas most are aware of institutional reporting mechanisms, very few events are reported and <60% of respondents feel comfortable reporting to departmental or divisional leadership. Female vascular surgeons believe gender influences hiring, promotion, compensation, and assumptions of life goals. Further work is necessary to identify methods of reducing workplace sexual harassment and to optimize gender disparity in vascular surgery practice.
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http://dx.doi.org/10.1016/j.jvs.2019.10.071DOI Listing
August 2020

Acute Limb Ischemia Secondary to Patent Foramen Ovale-Mediated Paradoxical Embolism: A Case Report and Systematic Review of the Literature.

Ann Vasc Surg 2020 Jul 2;66:668.e5-668.e10. Epub 2020 Jan 2.

Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO. Electronic address:

Background: Paradoxical embolism is the translocation of a thrombus originating in the systemic venous circulation into the arterial circulation through a cardiac defect, most commonly a patent foramen ovale (PFO). PFO exists in 15-35% of the adult population. The most common manifestation is cerebrovascular accident; acute limb ischemia is much rarer.

Methods: A 67-year-old woman with multiple confounding risk factors for hypercoagulability presented with grade IIb left lower limb ischemia secondary to thromboembolism through a previously silent PFO. Management included urgent embolectomy, prophylactic fasciotomy, postoperative anticoagulation, and PFO closure. A systematic literature review of PFO-mediated acute limb ischemia was performed to identify the patient populations most commonly affected, the anatomic distribution of emboli, and patient management.

Results: Forty-three reports including 51 patients with first-time PFO-mediated paradoxical embolism were identified. Fifty-one percent were men, and the average age at presentation was 54 years. Multiple limbs were affected in 14 patients (27.5%), and a propensity for the lower limbs (72%) and left-sided circulation (82%) was noted. Deep venous thromboembolism was identified in 36 patients (71%). Immediate anticoagulation was instituted in 31 patients. Embolectomy and/or fibrinolysis were performed in 45 patients (88%).

Conclusions: Acute limb ischemia is a rare manifestation of PFO-mediated paradoxical embolism that requires a high index of suspicion for diagnosis. Middle-aged individuals appear to be more commonly affected, and acute limb ischemia most often occurs in the lower limbs and left-sided circulation, with the potential to affect multiple extremities simultaneously. Prompt identification and surgical embolectomy with prophylactic fasciotomy can facilitate successful outcomes. Perioperative management should include anticoagulation and may include workup with echocardiography, duplex ultrasound, and hypercoagulability testing.
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http://dx.doi.org/10.1016/j.avsg.2019.12.022DOI Listing
July 2020

Burnout and its relationship with perceived stress, self-efficacy, depression, social support, and programmatic factors in general surgery residents.

Am J Surg 2020 06 9;219(6):907-912. Epub 2019 Jul 9.

Department of Surgery, Yale University, New Haven, CT, USA.

Background: Burnout affects surgical residents' well-being.

Objective: We sought to identify factors associated with burnout among surgery residents.

Methods: An electronic/anonymous survey was sent to surgical residents at 18 programs, consisting of demographic/programmatic questions and validated scales for burnout, depression, perceived stress, self-efficacy, and social support. Residents were grouped into quartiles based off burnout, and predictors were assessed using univariate and multivariate analyses.

Results: 42% of residents surveyed completed it. Burnout was associated with depression, higher perceived stress/debt, fewer weekends off, less programmatic social events, and residents were less likely to reconsider surgery if given the chance. Low burnout was associated with lower depression/stress, higher social support/self-efficacy, more weekends off per month, program mentorship, lower debt, and residents being more likely to choose surgery again if given the chance. On multivariate analysis, higher depression/perceived stress were associated with burnout, and lower burnout scores were associated with lower stress/higher self-efficacy.

Conclusions: Burnout in surgery residents is associated with higher levels of depression and perceived stress. The addition of programmatic social events, limiting weekend work, and formal mentoring programs may decrease burnout.
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http://dx.doi.org/10.1016/j.amjsurg.2019.07.004DOI Listing
June 2020

Sexual Harassment in Vascular Surgery Training Programs.

Ann Vasc Surg 2020 Jan 18;62:92-97. Epub 2019 Jun 18.

Division of Vascular and Endovascular Surgery, SSM Health St. Louis University Hospital, St. Louis University School of Medicine, Saint Louis, MO. Electronic address:

Background: Sexual harassment is any unwelcome behavior or obscene remark that affects an individual's work performance or creates an intimidating, hostile, or offensive environment. We sought to examine its presence in vascular surgery training programs, identify factors associated with occurrence, and determine reporting barriers.

Methods: An anonymous survey consisting of questions on frequency of sexual harassment including type/perpetrators/locations; why/how the practice occurs; reporting mechanisms/barriers to reporting; and demographic information was emailed to all vascular surgery trainees in the United States. Descriptive and univariate analysis was performed.

Results: Of 498 invitations sent, 133 (27%) completed the survey. Fifty of 133 (38%) thought harassment occurred more commonly in surgical specialties with hierarchy/power dynamics, historical male dominance in field, and ignoring of behavior, being the most common reasons cited that it still occurs. Of 133, 81 (61%) respondents have either experienced (63/133, 47%) or witnessed (18/133, 14%) other trainees being harassed, with calling a sexist slur/intimate nickname being the most common behavior. Those affected were more commonly women (P = 0.0006), with the most common perpetrator being a surgical attending and the most common area of occurrence being the operating room. Reasons for not reporting included believing the behavior was harmless in intent (33/63, 52%) and feeling nothing would come of it if reported (28/63, 44%), but 15/63 (24%) feared repercussions and 15/63 (24%) feeling uncomfortable are identified as a target of sexual harassment. Of 133, 46 respondents were not aware of institutional mechanisms for reporting harassment, with only 70/133 (53%) feeling comfortable reporting to their departmental leadership.

Conclusions: A significant number of vascular surgery trainees have experienced sexual harassment during their training. Over a third of respondents do not know institutional mechanisms for reporting, and almost half do not feel comfortable reporting to departmental leadership. Increasing education on harassment and reporting mechanisms may be necessary in vascular surgery training programs.
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http://dx.doi.org/10.1016/j.avsg.2019.05.011DOI Listing
January 2020

Stent-Graft Length Is Associated with Decreased Patency in Treatment of Central Venous Stenosis in Hemodialysis Patients.

Ann Vasc Surg 2019 Aug 19;59:225-230. Epub 2019 Apr 19.

Division of Vascular and Endovascular Surgery, Department of Surgery, St. Louis University, Saint Louis, MO. Electronic address:

Background: Central venous occlusion may occur in hemodialysis patients, resulting in arm or facial swelling and failure of dialysis access. Endovascular management with balloon angioplasty or stenting has been described, but there are minimal data on the use of covered stents in this pathology. We sought to review a single institution's experience with the use of covered stents for central venous occlusive disease in hemodialysis patients.

Methods: A retrospective review of all patients undergoing placement of covered stents between April 2014 and December 2016 for central venous occlusive disease to preserve a failing dialysis access was performed. Patients' records were reviewed to identify demographics, medical comorbidities, operative variables, primary patency rates, and secondary interventions.

Results: A total of 29 patients were included in the analysis. Viabahn (W.L. Gore and Associates, Flagstaff, AZ) stent grafts were exclusively used in all patients. Technical success rate was 100%. The patients were predominantly female (65.5%), with a mean age of 67.9 ± 12.1 and medical comorbidities of hypertension (86%), diabetes (76%), and tobacco use (7%). The majority (86%) had prior angioplasty and 17 of 29 (59%) patients had previous central venous catheters. The right brachiocephalic vein was the most commonly stented vessel (28%). The median stent length and diameter used were 50 millimeters (range 25-100 millimeters) and 13 millimeters (range: 9-13 millimeters), respectively. The majority of patients (83%) received a single stent, with only 2 patients requiring more than one. Median follow-up was 24 months (range: 6-41 months). Four of 29 (13.8%) patients developed symptomatic stent restenosis requiring secondary intervention, all of which occurred in patients with primary stenosis between 50% and 75%. When compared to the patients without restenosis, longer stents were found to be significantly associated with restenosis (62.5 centimeters, interquartile range [IQR]: 0] vs. 50 centimeter, IQR: 0, P = 0.002). Primary patency rates were 92.9%, 91.7%, and 80.0% at 6, 12, and 24 months respectively. Secondary patency rates were 96.4%, 95.8%, and 93.3% at 6 months, 12 months, and 24 months, respectively. The overall primary patency rate was estimated at 86.2% using Kaplan-Meier analysis at 30.5 months (95% confidence interval: 26.5-34.5 months).

Conclusions: Covered stent grafts have reasonable primary patency and excellent secondary patency when used for central venous stenosis in dialysis patients. Stent-graft length is associated with poorer long-term patency rates.
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http://dx.doi.org/10.1016/j.avsg.2019.01.024DOI Listing
August 2019

Invited commentary.

Authors:
Matthew R Smeds

J Vasc Surg 2019 02;69(2):544

St. Louis, Mo.

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http://dx.doi.org/10.1016/j.jvs.2018.06.189DOI Listing
February 2019

Common femoral artery antegrade and retrograde approaches have similar access site complications.

J Vasc Surg 2019 04 4;69(4):1160-1166.e2. Epub 2018 Dec 4.

Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.

Objective: Ipsilateral antegrade access (AA) is an alternative access option for contralateral retrograde access (RA) in treating infrainguinal occlusive disease. Our goal was to assess whether AA is associated with higher access site complications.

Methods: The Vascular Quality Initiative database was searched from 2010 to 2017 for all infrainguinal peripheral vascular interventions. Cases without access through the common femoral artery or those with multiple accesses were excluded. Access types were classified on the basis of whether the approach was AA or RA. Propensity matching and multivariable analyses were performed to determine the effect of AA on access site complications.

Results: There were 45,816 access events identified, 6600 (14.4%) AA and 39,216 (85.6%) RA cases. Patients with AA were older (70.7 vs 69.1 years) and more frequently male (66.5% vs 59.1%), white (79.4% vs 74.6%), and on Medicare (58.4% vs 56%); they were more likely to have end-stage renal disease (12.1% vs 11%), and they were less frequently obese (29.3% vs 36.1%) and less likely to be currently smoking (25.5% vs 28.7%), to be diabetic (56% vs 59.8%), to have chronic obstructive pulmonary disease (20.7% vs 21.8%), and to ambulate independently (69.8% vs 72.5%; P < .05 for all). Patients with AA were more likely to have a history of a prior percutaneous vascular intervention (9.3% vs 7%), inflow bypass (6.2% vs 1.8%), and leg bypass (12.6% vs 8.9%; P < .001 for all). The AA technique was more frequently used in the setting of tissue loss (51.8% vs 45.1%) and for tibial intervention (46.3% vs 35.3%; P < .001 for both). There were no significant differences between AA and RA in overall hematoma (3% vs 2.7%; P = .21) or hematoma requiring intervention (0.4% vs 0.4%; P = .75) rates. There was no significant difference in access site occlusion or stenosis between AA and RA (0.2% vs 0.3%; P = .68). These findings were confirmed with 2:1 matching based on preoperative data and type of intervention. Multivariable analysis demonstrated that AA is not associated with increased risk of any hematoma (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.98-1.35; P = .082) or hematoma requiring intervention (OR, 0.88; 95% CI, 0.57-1.35; P = .56). Multivariable analysis of the matched data confirmed these findings between AA and RA for hematoma (OR, 0.88; 95% CI, 0.73-1.06; P = .17) and hematoma requiring intervention (OR, 1.17; 95% CI, 0.7-1.95; P = .55).

Conclusions: AA is safe, and it was not found to be associated with increased access site complications, such as hematoma, in the large Vascular Quality Initiative sample. This approach remains a viable alternative to traditional RA.
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http://dx.doi.org/10.1016/j.jvs.2018.06.226DOI Listing
April 2019

Use of Mock Oral Examinations in Vascular Surgery Training Programs: A Nationwide Survey.

J Surg Res 2018 12 4;232:94-98. Epub 2018 Jul 4.

Professor, Division Chief - Vascular Surgery, Program Director, Division of Vasculuar and Endovascular Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Background: Mock oral examinations (MOEs) are valuable tools for knowledge assessment and preparation for the surgical certifying examinations. Use of MOE is not standardized. We sought to determine the current use in vascular residencies/fellowships.

Methods: Program directors (PD) of all U.S. vascular training programs were sent anonymous online surveys in July of 2015 evaluating importance of MOEs, current use, barriers to implementation, and preparedness of trainees to sit for the certifying board examination (CE). Comparisons were performed between programs that use MOEs and those that do not.

Results: Fifty-four percent (59/108) of program directors completed the survey. The majority believed MOEs are important for vascular residents and fellows (86% versus 81%); however, only 51% (30/59) use them. The most common reason for using MOE was to provide feedback about readiness for the CE (90%). Of programs not giving MOE, 69% expected their trainees to get oral examinations at national conferences. The most common barriers to implementation/continuation of MOEs were availability of faculty (48%) or time (31%). Irrespective of whether they used MOE or not, 29% believed vascular fellows were better prepared for the CE than vascular residents.

Conclusions: MOEs are regarded as a valuable tool to prepare trainees for the CE. However, it is not a commonly adopted practice, due to variables such as institutional/faculty availability. A third of program directors believed that vascular fellows were more prepared to pass the CE than vascular residents which may warrant further investigation into how programs can more rigorously prepare vascular residents for the vascular CEs.
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http://dx.doi.org/10.1016/j.jss.2018.06.030DOI Listing
December 2018

Burnout, depression, perceived stress, and self-efficacy in vascular surgery trainees.

J Vasc Surg 2019 Apr 6;69(4):1233-1242. Epub 2018 Oct 6.

Division of Vascular and Endovascular Surgery, SSM Health St. Louis University Hospital, St. Louis University School of Medicine, St. Louis, Mo. Electronic address:

Objective: Burnout is a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that has become prevalent in all levels of medical training. We sought to understand factors associated with burnout identified in vascular surgery trainees.

Methods: An anonymous electronic survey consisting of demographic and programmatic information as well as validated scales for burnout, depression, perceived stress, self-efficacy, and social support was given to all vascular surgery trainees in the United States. Univariate and multivariate analyses were used to compare responses. Residents were grouped into quartiles based on burnout level, and predictors of burnout were determined.

Results: Of the 514 invitations sent, 177 (34%) respondents completed the survey. Trainees in the highest quartile of burnout were more likely to have moderate to severe depression (40% vs 4%; P < .01), higher perceived stress score (odds ratio [OR], 1.3; P < .01), lower social support (OR, 0.89; P < .01), and lower self-efficacy (OR, 0.76; P < .01), and they were less likely to reconsider vascular surgery as a career if given the chance to do it over (χ = 20; P < .01). Trainees without a self-identified mentor were significantly more likely to report burnout (χ = 15; P < .01). In addition, trainees who reported more frequent 80-hour work infractions each month (3.6 vs 2.3; P < .01) and those without access to programmatic social events (χ = 11; P < .01) had higher levels of burnout. In contrast, trainees with the lowest quartile of burnout scores reported lower depression (OR, 0.43; P < .01), lower stress (OR, 0.63; P < .01), more social support (OR, 0.1.2; P < .01), higher self-efficacy (OR, 1.2; P < .01), and fewer work week violations each month (2.3 vs 2.9; P = .04). Lower burnout scores were associated with program mentorship (χ = 7.3; P < .01), program-sponsored social events (χ = 8.7; P < .01), and being more likely to choose vascular surgery again if given the chance (χ = 6.3; P < .01). Highest burnout scores did not correlate with sex (χ < .01; P = 1), age (32 years vs 32 years; P = .65), marital status (χ < .01; P = 1), proximity to family (OR, 1.2; P = .26), alcohol consumption (χ = 0.23; P = .63), postgraduate year (OR, 1.1; P = .47), number of prior program graduates (OR, 0.95; P = .73), use of physician extenders in the program (OR, 0.93; P = .74), or total debt (OR, 1.0; P = .63). Similarly, there were no significant associations with these variables among trainees with the lowest quartile of burnout scores. On multivariate analysis, higher depression (OR, 1.6; P < .01) and higher perceived stress (OR, 1.2; P < .01) were associated with higher burnout scores, and lower burnout scores were associated with lower perceived stress (OR, 0.67; P < .01).

Conclusions: Burnout in vascular surgery trainees is associated with higher levels of depression and perceived stress and lower levels of social support and self-efficacy. The addition of programmatic social events, limiting 80-hour work week violations, and addition of formal mentoring programs may decrease levels of burnout.
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http://dx.doi.org/10.1016/j.jvs.2018.07.034DOI Listing
April 2019

Effects of the Affordable Care Act on Vascular Patient Amputation Rates in Arkansas.

Ann Vasc Surg 2019 Jan 10;54:48-53. Epub 2018 Sep 10.

Division of Vascular & Endovascular Surgery, Saint Louis University, Saint Louis, MO. Electronic address:

Background: The Patient Protection and Affordable Care Act was signed into law in 2010 and enacted in 2013 which improved insurance coverage across America due to increasing Medicaid eligibility as well as changes to individual insurance markets. In Arkansas, this was implemented by a Medicaid expansion waiver which allowed patients to purchase insurance with funds provided by the government to subsidize premiums through the marketplace. The goal of this study was to determine the effects of the Affordable Care Act (ACA) on Arkansas patients with peripheral arterial disease.

Methods: A pre-post research design using the Arkansas Hospital Discharge Dataset was used to study the impact of the ACA on limb amputation, distal bypass, discharge disposition, and total costs for patients diagnosed with peripheral arterial disease/atherosclerosis. The data were obtained for the years 2007 through 2009 (pre-ACA), 2011 through 2013 (post-ACA), and 2014 through 2015 (post-Arkansas expansion). Bivariate analysis, analysis of variance, and regression analyses were performed to analyze the data.

Results: A total of 10,923 patients were identified. Uninsured patients ("self-pay") decreased from 7% pre-ACA to 3.4% post-Arkansas expansion (P < 0.0001). There was a decrease in adjusted health-care costs after the Arkansas expansion (P < 0.0001). There was no change in mortality or transfer to rehabilitation facilities, but there was an increase in discharge to skilled nursing facilities along with a decrease in patients being discharged home (P < 0.0001). Regression analysis showed private insurance to be associated with a 49% reduction in the odds of an amputation (P < 0.0001). The Arkansas expansion was associated with a 26% reduction in the odds of an amputation when compared with that before the ACA implementation (P < 0.005). Having private insurance was associated with a 26% increase in the odds of having a bypass when compared with uninsured patients (P < 0.05).

Conclusions: Patients with private insurance have a decreased chance of amputation and increased odds of having a bypass when compared with patients who were of the self-pay category. The increase in private insurance coverage in our patient population could improve the rate of amputation in the vascular population in Arkansas by increasing early interventions for peripheral vascular disease.
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http://dx.doi.org/10.1016/j.avsg.2018.08.076DOI Listing
January 2019

Snoring and carotid artery disease: A new risk factor emerges.

Laryngoscope 2019 01 8;129(1):265-268. Epub 2018 Sep 8.

Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan.

Objectives/hypothesis: Previous studies have identified a relationship between snoring, carotid intima media thickening, and the presence of atherosclerosis. This study examines the correlation between snoring and carotid artery disease through use of duplex ultrasound identifying greater than 50% internal carotid artery stenosis.

Study Design: Prospective cohort study.

Methods: Patients presenting to three academic vascular laboratories for carotid duplex examination completed the following surveys: demographic information, assessment of risk factors for carotid stenosis, assessment of history of obstructive sleep apnea, or continuous positive airway pressure use and Snoring Outcomes Survey. Patients were categorized into 2 groups based on the presence or absence of carotid disease. Data were analyzed by univariate contingency tables and logistic regression analysis.

Results: Five hundred one patients completed the survey, of whom 243/501 (49%) had evidence of carotid occlusive disease. On univariate analysis, smoking, hypertension, heart disease, hypercholesterolemia, diabetes, and stroke all correlated with greater than 50% carotid stenosis. Multivariate analysis indicated that snorers were significantly more likely to have carotid disease. Three hundred twenty-seven participants were thought to have primary snoring. On univariate analysis, snorers were found to be significantly more likely to have carotid disease. After adjustment for covariates, snoring was not significant for carotid disease. However, multivariate analysis showed snorers to be significantly more likely to have bilateral carotid disease.

Conclusions: This study shows a potential relationship between snoring and bilateral carotid artery stenosis greater than 50%; snorers have risk of carotid stenosis twice that of nonsnorers. Further investigation is warranted to better elucidate this relationship.

Level Of Evidence: 2b Laryngoscope, 129:265-268, 2019.
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http://dx.doi.org/10.1002/lary.27314DOI Listing
January 2019