Selected Abstracts from the Journal of Vascular Surgery
Managing central venous access during a health care crisis
Tristen T. Chun, MD, MS, Dejah R. Judelson, MD, David Rigberg, MD, Peter F. Lawrence, MD, Robert Cuff, MD, Sherene Shalhub, MD, MPH, Max Wohlauer, MD, Christopher J. Abularrage, MD, Papapetrou Anastasios, MD, PhD, MSc, Shipra Arya, MD, SM, Bernadette Aulivola, MD, MS, Melissa Baldwin, MD, Donald Baril, MD, Carlos F. Bechara, MD, William E. Beckerman, MD, Christian-Alexander Behrendt, MD, Filippo Benedetto, MD, Lisa F. Bennett, MD, MS, Kristofer M. Charlton-Ouw, MD, Amit Chawla, MD, Matthew C. Chia, MD, Sungsin Cho, MD, PhD, Andrew M.T.L. Choong, MBBS, PhD, Elizabeth L. Chou, MD, Anastasiadou Christiana, MD, Raphael Coscas, MD, PhD, Giovanni De Caridi, MD, PhD, Sharif Ellozy, MD, Yana Etkin, MD, Peter Faries, MD, Adrian T. Fung, MD, Andrew Gonzalez, MD, JD, MPH, Claire L. Griffin, MD, London Guidry, MD, Nalaka Gunawansa, MBBS, MS, MCh, Gary Gwertzman, MD, Daniel K. Han, MD, Caitlin W. Hicks, MD, MS, Carlos A. Hinojosa, MD, MSc, York Hsiang, MB, ChB, MHSc, Nicole Ilonzo, MD, Lalithapriya Jayakumar, MD, Jin Hyun Joh, MD, PhD, Adam P. Johnson, MD, MPH, Loay S. Kabbani, MD, MHSA, Melissa R. Keller, MD, PhD, Manar Khashram, MBChB, PhD, Issam Koleilat, MD, Bernard Krueger, MD, Akshay Kumar, MD, Cheong Jun Lee, MD, Alice Lee, DO, Mark M. Levy, MD, C. Taylor Lewis, MD, Benjamin Lind, MD, Gabriel Lopez-Pena, MD, Jahan Mohebali, MD, MPH, Robert G. Molnar, MD, MS, Nicholas J. Morrissey, MD, Raghu L. Motaganahalli, MD, Nicolas J. Mouawad, MD, MPH, MBA, Daniel H. Newton, MD, Jun Jie Ng, MD, Leigh Ann O'Banion, MD, John Phair, MD, Zoran Rancic, MD, MSc, PhD, Ajit Rao, MD, Hunter M. Ray, MD, Aksim G. Rivera, MD, Limael Rodriguez, MD, Clifford M. Sales, MD, MBA, Garrett Salzman, MD, Mark Sarfati, MD, Ajay Savlania, MCh, Andres Schanzer, MD, Mel J. Sharafuddin, MD, MS, Malachi Sheahan, MD, Sammy Siada, DO, Jeffrey J. Siracuse, MD, MBA, Brigitte K. Smith, MD, Matthew Smith, MD, PhD, Ina Soh, MD, MS, Rebecca Sorber, MD, Varuna Sundaram, MD, Scott Sundick, MD, MS, Tadaki M. Tomita, MD, Bradley Trinidad, MD, Shirling Tsai, MD, Ageliki G. Vouyouka, MD, Gregory G. Westin, MD, MAS, Michael S. Williams, MD, Sherry M. Wren, MD, Jane K. Yang, MD, Jeniann Yi, MD, MS, Wei Zhou, MD, Saqib Zia, MD and Karen Woo, MD, MS
Objective: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic.
Methods: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19.
Results: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group).
Conclusions: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.
Safety and feasibility of transradial infrainguinal peripheral arterial disease interventions
Alex Sher, BS, Raghuram Posham, MD, Ageliki Vouyouka, MD, Rahul Patel, MD, Robert Lookstein, MD, Peter L. Faries, MD, Aaron Fischman, MD and Rami Tadros, MD
Objective: Transradial access (TRA) has traditionally been favored for coronary interventions. Tools with up to 200 cm length now allow operators to treat infrainguinal peripheral arterial disease (PAD) using TRA. This study aims to assess the safety and feasibility of TRA infrainguinal interventions.
Methods: Patients with infrainguinal PAD who underwent intervention via TRA from July 2013 through June 2019 were retrospectively reviewed. Exclusion criteria included Barbeau D waveform, a radial artery diameter of greater than 2 mm, radial artery occlusion, Raynaud syndrome, or peripheral vasculitis. Procedural success (adequate inline flow to the foot), TRA alone failure (crossover or use of an additional access site), clinical success (defined as improvement in ankle brachial index, clinical symptoms, or wound healing) and adverse events were recorded from procedure notes and follow-up visits.
Results: Thirty-six procedures were attempted using TRA in 32 patients (mean age, 65.8 years; range, 29-86; 22 male, 14 female) with mean height of 65.8 inches (range, 59.0-72.0 inches) and a body mass index of 28.7 (range, 19.1-43.9). Preprocedure Rutherford classification (II/III/IV/V/VI) was 8/15/2/7/4, respectively. The left radial artery was used for 35 of 36 procedures (97.2%). Treated vessels included the common femoral (n = 4), superficial femoral (n = 25), deep femoral (n = 1), popliteal (n = 10), tibioperoneal trunk (n = 2), tibial (n = 4), and plantar (n = 1) arteries. Interventions included angioplasty (n = 32, 100%), atherectomy (n = 8, 25%), and stenting (n = 13, 41%). Procedural success was 100%, the TRA alone failure rate was 11.1%, and clinical success was 89.3%. The median follow-up was 286.5 days (range, 0-919 days). Adverse events included radial artery pseudoaneurysm (n = 1), access site hematoma/bleeding (n = 3), radial artery occlusion (n = 1), groin hematoma (n = 1), popliteal artery dissection treated with stenting (n = 2), and a small superficial femoral artery perforation (n = 1) treated with prolonged balloon tamponade. No patients experienced signs of cerebrovascular events or distal embolism.
Conclusions: TRA is a useful option for treating patients with PAD; however, several limitations still exist.
Retrograde open mesenteric stenting should be considered as the initial approach to acute mesenteric ischemia
Elizabeth Andraska, MD, MS, Lindsey Haga, MD, Xiaoyi Li, MD, Efthymios Avgerinos, MD, PhD, MSc, Michael Singh, MD, Rabih Chaer, MD, MS, Michael Madigan, MD, MS and Mohammad H. Eslami, MD, MPH
Objective: Retrograde open mesenteric stenting (ROMS) is an alternative to traditional bypass in patients who present with acute mesenteric ischemia (AMI). However, there is a paucity of data comparing outcomes of ROMS with other open surgical approaches. This study represents the largest single-institution experience with ROMS and aims to compare outcomes of ROMS with those of conventional mesenteric bypass.
Methods: All patients who presented with AMI from 2008 to 2019 and who were treated with either ROMS or mesenteric bypass were included in the study. Patient, procedure, and outcome variables were compared. Bypass and ROMS patients were compared using univariate statistics.
Results: A total of 34 patients who presented with AMI needing bypass were included in the study; 16 underwent mesenteric bypass, and 18 underwent ROMS. ROMS patients tended to be older than bypass patients and had higher rates of comorbidities. Bypass patients were more likely to have a history of chronic mesenteric symptoms (68.8% vs 27.8%; P = .019). Bypass procedures also took longer than ROMS procedures (302 vs 189 minutes; P < .01). The majority of ROMS procedures were not performed in a hybrid room (77.8%). Within 1 year, one stent thrombosed in a ROMS patient, requiring later mesenteric bypass. In the bypass group, one conduit thrombosed, ultimately resulting in perioperative death, and one bypass anastomosis stenosed, requiring angioplasty. Complication, unanticipated reintervention, and mortality rates were otherwise similar between groups.
Conclusions: Complication, reintervention, and mortality rates after ROMS are similar to those of mesenteric bypass in the setting of AMI. Given similar postoperative outcomes and ability to perform these procedures in a conventional operating room but with significantly shorter operative times, ROMS should be considered a first-line option in acute situations when the operator is comfortable performing the procedure.
Clinical predictors of blood pressure response after renal artery stenting
J. Gregory Modrall, MD, Hong Zhu, PhD and Fred A. Weaver, MD
Objective: The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, a multicenter randomized controlled trial, failed to demonstrate a benefit of renal artery stenting (RAS) over medical therapy in patients with renal artery stenosis and hypertension. However, there are patients for whom RAS is a consideration because of failure of medical therapy. Unfortunately, selection of patients for RAS is complicated by a lack of validated predictors of blood pressure (BP) response. A previous single-center study identified three preoperative markers of BP response to RAS: requirement for four or more antihypertensive medications, preoperative diastolic BP >90 mm Hg, and preoperative clonidine use. To date, these markers of outcome have not been independently validated. The aim of this study was to validate these markers using data from the CORAL trial.
Methods: All patients randomized in the CORAL trial to RAS were included. American Heart Association guidelines were used to categorize patients as BP responders or nonresponders to RAS. BP responders were defined by a postoperative BP <160/90 mm Hg with a reduced number of antihypertensive medications or a reduction in diastolic BP to <90 mm Hg with the same medications after RAS. Patients with stable or worsened BP were labeled nonresponders. Variables associated with a favorable BP response were identified by multivariable logistic regression analysis.
Results: There were 436 patients who underwent RAS with a median age of 70 years (interquartile range [IQR], 63-76 years). The median systolic and diastolic BPs of the stented cohort at baseline were 149 mm Hg (IQR, 132-164 mm Hg) and 78 mm Hg (IQR, 70-87 mm Hg), respectively. A positive BP response occurred in 284 of 436 (65.1%) stented patients. Multivariable logistic regression analysis identified three independent markers of a positive BP response: requirement for four or more medications (odds ratio, 5.9; P < .001), preoperative diastolic BP >90 mm Hg (odds ratio 13.9; P < .001), and preoperative clonidine use (odds ratio, 4.52; P = .008). The percentage of patients with a positive BP response increased incrementally as the number of markers per patient increased, based on the Cochran-Armitage test for trend (P < .0001).
Conclusions: In patients from the CORAL trial who underwent RAS, the previously reported clinical markers of BP response were validated. A prospective trial to validate their utility as predictors of BP response to RAS is warranted.
The evolution of open abdominal aortic aneurysm repair at a tertiary care center
Alexander S. Fairman, MD, Amanda L. Chin, BA, Benjamin M. Jackson, MD, Paul J. Foley, MD, Scott M. Damrauer, MD, Venkat Kalapatapu, MD, Michael A. Golden, MD, Ronald M. Fairman, MD and Grace J. Wang, MD
Background: The characteristics of and indications for open abdominal aortic aneurysm (AAA) repair have evolved over time. We evaluated these trends through the experience at a tertiary care academic center.
Methods: A retrospective review was conducted for patients undergoing open AAA repair (inclusive of type IV thoracoabdominal aortic aneurysms) from 2005 to 2018 at an academic institution. Trends over time were evaluated using the Spearman test; Cox regression was used to determine predictors of mortality and to generate adjusted survival curves.
Results: There were 628 patients (71.5% male; 88.2% white) with a mean age of 70.5 ± 9.4 years who underwent open AAA repair with a mean aneurysm diameter of 6.2 ± 1.5 cm. The median length of stay was 10 days, and the median intensive care unit length of stay was 3 days. Urgent repair was undertaken in 21.1%; 22.3% were type IV thoracoabdominal aortic aneurysm repairs, and 9.9% were performed for explantation. Our series favored a retroperitoneal approach in the majority of cases (82.5%). The proximal clamp sites were supraceliac (46.1%), suprarenal (29.1%), and infrarenal (24.8%), with approximately a third requiring renal artery reimplantation. The average cross-clamp time was 25.5 ± 14.9 minutes; the mean renal ischemia time for supraceliac and suprarenal clamp sites was 28.4 ± 12.3 minutes and 23.5 ± 12.7 minutes, respectively. Postoperative renal dysfunction occurred in 19.6% of the overall cohort, with 6.2% requiring hemodialysis. Of those requiring postoperative hemodialysis, the majority (75%) received an urgent repair. The in-hospital mortality was 2.3% for elective cases vs 20.9% for urgent repair, and 29.8% of patients were discharged to rehabilitation, with an overall 30-day readmission rate of 7.9%. Over time, there were trends of increased aneurysm repair complexity, with decreasing infrarenal clamp sites, increasing supraceliac clamp sites, increasing proportion of explantations, and increasing need for bifurcated grafts. The acuity of aneurysm repair likewise changed, with the proportion of urgent repairs increasing over time, largely attributable to the rise in explantations. Clamp site influenced the frequency of perioperative complications. Urgent repairs and age at operation were associated with mortality, whereas mortality was not associated with need for explantation and clamp location.
Conclusions: Aneurysm repair reflected increasing complexity over time, with the need for explantation among urgent repairs significantly on the rise. Urgency and clamp location independently predicted long-term mortality, even after adjustment for age. These findings underscore the changing landscape of open AAA repair in the current era.
Gender disparities in academic vascular surgeons
Matthew Carnevale, MD, John Phair, MD, Paola Batarseh, BS, Samantha LaFontaine, BS, Erin Koelling, MD and Issam Koleilat, MD
Objective: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery.
Methods: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis.
Results: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001).
Conclusions: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery.
Footnotes
Full articles available online at www.jvascsurg.org