Faculty Bibliography

OBJECTIVE:Recent initiatives have targeted the issue of gender and ethnic/racial disparities in general surgery and vascular surgery. However, the prevalence of these disparities in general and vascular surgical training programs is unknown. DESIGN:A retrospective analysis was conducted using data from three separate sources, including the US Graduate Medical Education annual report, Electronic Residency Application Service database, and National Resident Matching Program annual report. Demographic information regarding gender distribution and ethnic/racial identity was collected from 328 general surgery residency programs, 59 vascular surgery residency programs, and 100 vascular surgery fellowship programs across the US. The primary outcomes of this study were to evaluate national trends in gender and ethnic diversity in general surgery and vascular surgery training programs, including both traditional fellowship and integrated residency paradigms. RESULTS:From 2011-2020, general surgery residency programs showed a positive trend towards both female applicants (from 31.9%-41.5%) and trainees (from 36.2%-43.1%) (p < 0.0001 each). The proportion of minority trainees decreased, primarily among Black (from 7.2%-5.4%) and Asian trainees (from 21.5%-19.2%) (p < 0.0001 each). Concurrently, the number of vascular integrated residency programs grew from 27 to 59, resulting in a fivefold increase in trainees (from 64-335). Despite this growth, there was no change in the proportion of women applicants or trainees for both vascular integrated residency (24.9% applicants; 36.2% trainees) and fellowship programs (27.4% applicants; 25.9% trainees) over the study period (p = 0.11, 0.89, 0.43, and 0.13 respectively). Moreover, there was no significant change in proportion of minority trainees in both vascular integrated residency and fellowship programs. CONCLUSION:While general surgery programs have expanded in proportion of both female applicants and trainees, racial diversity has decreased. Gender and racial diversity in vascular training has not changed. Future initiatives in general and vascular surgery should focus on recruitment and promotion of proficient women and minority trainees.

This study aimed to determine if there is an association between ABO blood type and severity of COVID-19 defined by intubation or death as well as ascertain if there is variability in testing positive for COVID-19 between blood types. In a multi-institutional study, all adult patients who tested positive for COVID-19 across five hospitals were identified and included from March 6th to April 16th, 2020. Hospitalization, intubation, and death were evaluated for association with blood type. Univariate analysis was conducted using standard techniques and logistic regression was used to determine the independent effect of blood type on intubation and/or death and positive testing. During the study period, there were 7648 patients who received COVID-19 testing throughout the institutions. Of these, 1289 tested positive with a known blood type. A total of 484 (37.5%) were admitted to hospital, 123 (9.5%) were admitted to the ICU, 108 (8.4%) were intubated, 3 (0.2%) required ECMO, and 89 (6.9%) died. Of the 1289 patients who tested positive, 440 (34.2%) were blood type A, 201 (15.6%) were blood type B, 61 (4.7%) were blood type AB, and 587 (45.5%) were blood type O. On univariate analysis, there was no association between blood type and any of the peak inflammatory markers (peak WBC, p = 0.25; peak LDH, p = 0.40; peak ESR, p = 0.16; peak CRP, p = 0.14) nor between blood type and any of the clinical outcomes of severity (admission p = 0.20, ICU admission p = 0.94, intubation p = 0.93, proning while intubated p = 0.58, ECMO p = 0.09, and death p = 0.49). After multivariable analysis, blood type was not independently associated with risk of intubation or death (referent blood type A; blood type B: AOR: 0.72, 95% CI: 0.42-1.26, blood type AB: AOR: 0.78, CI: 0.33-1.87, blood type O: AOR: 0.77, CI: 0.51-1.16), rhesus factor positive (Rh+): AOR: 1.03, CI: 0.93-1.86. Blood type A had no correlation with positive testing (AOR: 1.00, CI: 0.88-1.13), blood type B was associated with higher odds of testing positive for disease (AOR: 1.28, CI: 1.08-1.52), AB was also associated with higher odds of testing positive (AOR: 1.37, CI: 1.02-1.83), and O was associated with a lower risk of testing positive (AOR: 0.84, CI: 0.75-0.95). Rh+ status was associated with higher odds of testing positive (AOR: 1.23, CI: 1.003-1.50). Blood type was not associated with risk of intubation or death in patients with COVID-19. Patients with blood types B and AB who received a test were more likely to test positive and blood type O was less likely to test positive. Rh+ patients were more likely to test positive.

BACKGROUND:We investigated the outcome of vein stenting placement for chronic proximal venous outflow obstruction (PVOO) in a predominantly Asian-American cohort to improve patient selection, enhance technical approach, and better define quality measurements of this emerging vascular intervention. METHODS:A total of 462 consecutive patients, 73% Asian American (n = 336), who underwent iliac vein stenting for chronic PVOO from October 2013 to July 2016 were reviewed. Postoperative outcomes at five follow-up visits were assessed. Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were run for demographic and operative variables. Ordered logistic regressions were run for the outcome at each time point, and Chi-squared tests as well as Fisher's exact tests were used for categorical variables. RESULTS:Follow-up was maintained in 90% of patients, with a mean follow-up time of 695 days. Asian-American patients were more likely to present with varicose veins (77.4% vs. 54.8%, P < 0.001), and non-Asian patients were more likely to present with active ulceration (26.2% vs. 5.1%, P < 0.001). Asian-American patients were more likely to have bilateral stents placed (61.6% vs. 50%, P = 0.026) and were less likely to have reinterventions (11.3% vs. 27.8%, P < 0.001), a history of deep vein thrombosis (8.3% vs. 29.4%, P < 0.001), or intraoperative findings of chronic postphlebitic changes (17.6% vs. 33.3%, P < 0.001). Kruskal-Wallis tests were significant for improvement in patients of all the Clinical, Etiology, Anatomy, Pathophysiology classes at 30 days (P = 0.041), 90 days (P = 0.045), 6 months (P = 0.041), and 1 year (P < 0.01). The Asian-American population had improved but comparatively lower follow-up scores at the 30-day mark (48% significantly improved or better vs. 63%, P = 0.008) but higher follow-up scores at the >1 year mark (80% significantly improved or better vs. 59%, P < 0.001). CONCLUSIONS:Asian-American patients undergoing vein stent placement for chronic PVOO had comparatively worse outcomes than non-Asian patients at 30 days and better outcomes after one year. These patient groups had different outcomes postoperatively and outcomes which evolve differently over time.

OBJECTIVE:We aimed to compare mechanochemical ablation (MOCA) and thermal ablation (radiofrequency ablation and endovenous laser therapy) for venous ulcer healing in patients with clinical class 6 chronic venous insufficiency. METHODS:Electronic medical records were reviewed of patients with venous ulcers who underwent truncal or perforator ablation between February 2012 and November 2015. These records contained history of venous disease and ulcer history, procedures, complications, follow-up, method of wound care, and current status of the ulcer. The patients were grouped according to the method of ablation for comparison. RESULTS:In 66 patients, 82 venous segments were treated, 29 with thermal methods and 53 with MOCA; 16% of patients had prior venous intervention. Before ablation, three patients in the thermal group had a history of deep venous thrombosis compared with seven in the MOCA group. On average, patients treated with MOCA were older (thermal ablation, 57.2 years; MOCA, 67.9 years; P = .0003). Ulcer duration before intervention ranged from 9.2 months for thermal ablation to 11.2 months for MOCA (P = NS). In total, 74% of patients treated with MOCA healed their ulcers compared with 35% of those treated with thermal ablation (P = .01). A healed ulcer was defined as elimination of ulcer depth and superficial skin coverage. The mean time to heal was 4.4 months in the thermal ablation group compared with 2.3 months with MOCA (P = .01). The mean length of follow-up was 12.8 months after thermal ablation and 7.9 months after MOCA (P = .02). Both age (P = .03) and treatment modality (P = .03) independently had an impact on ulcer healing on multiple logistic regression analysis. All but two patients were treated with an Unna boot after venous ablation. Complications included readmission of two patients with nonaccess-related infections, one nonocclusive deep venous thrombosis, and one late death unrelated to the procedure second to pneumonia in the setting of advanced colon cancer. There were three recurrent ulcers at 1 week, 2 months, and 7 months after MOCA that rehealed with Unna boot therapy and continued compression. CONCLUSIONS:MOCA is safe and effective in treating chronic venous ulcers and appears to provide comparable results to methods that rely on thermal ablation. Younger age and use of MOCA favored wound healing. MOCA was an independent predictor of ulcer healing. Randomized studies are necessary to further support our findings.

OBJECTIVE:While determining the incidence of chronic deep vein thrombosis (DVT) and the hypercoagulation profiles of patients who underwent venous stenting for symptomatic venous insufficiency, we assessed the significance of Virchow's triad in the setting of proximal venous outflow obstruction and DVT. METHODS:tests, and multiple logistic regressions. RESULTS:tests were also significant for increased rates of intraoperative findings of CPPCs in patients with one or more positive hypercoagulation markers (67% vs 42%; P < .01). The most significant predictor for findings of CPPCs or DVT history was the presence of at least one hypercoagulation marker (n = 148; odds ratio, 2.41; P = .022). CONCLUSIONS:Remote history of DVT and intraoperative findings of CPPCs were prevalent. CPPC findings were found in many patients with no history of DVT. Hypercoagulation markers conferred significant predictive value for DVT. This information may influence our understanding of Virchow's triad and DVT etiology.

BACKGROUND:Intravascular ultrasound (IVUS) is the current standard for the diagnosis of obstruction in the iliac and femoral veins. However, multiple venographic findings including collaterals, pancaking, and contrast thinning have been suggested to improve the sensitivity of venography. The objective of our study was to further elucidate where and how anteroposterior venography may successfully guide the diagnosis of venous obstruction. METHODS:A retrospective review of patients with chronic venous insufficiency who received iliofemoral stenting by a single practitioner at a tertiary medical center between January 2014 and August 2016 was performed. Patients who had records of anteroposterior venography and IVUS were included. Patients who underwent reoperation, did not have complete records of venography and IVUS, or had preoperative acute deep vein thrombosis were excluded. All patients with a greater than 50% luminal area reduction by IVUS underwent balloon angioplasty and stent placement. The locations of stenosis, collaterals, pancaking, and contrast thinning with venography, the locations of stenosis with IVUS, and the location of each stent placed were recorded. RESULTS:There were 107 patients who underwent venous stenting guided by venography and IVUS in this study. Six patients who underwent reoperation, 1 patient who had an acute preoperative deep vein thrombosis, and 14 patients who had incomplete records were excluded. Thus, 86 patients with 77 left lower extremity and 68 right lower extremity studies were available for analysis. The sensitivity by stenosis on venography was 4% in the left common iliac vein (CIV), 44% in the left external iliac vein (EIV), and 44% in the common femoral vein (CFV). The sensitivity by stenosis on venography in the right CIV, EIV, and CFV was 21%, 46%, and 40%, respectively. Combined, pancaking and collaterals had a sensitivity of 97% in the left CIV. IVUS resulted in a change in plan in 2%, 32%, and 48% of patients in the left CIV, EIV, and CFV, and in 26%, 35%, and 48% of patients in the right CIV, EIV, and CFV, respectively. CONCLUSIONS:Anteroposterior venography can indirectly diagnose obstruction of the left CIV through the identification of collaterals and pancaking. The combination of low sensitivity and a high rate of change of plan owing to IVUS precludes complete reliance on anteroposterior venography for the diagnosis of lesions in the left EIV and CFV and the right CIV, EIV, and CFV. IVUS must be used to comprehensively identify all venous iliofemoral lesions.

The GORE Iliac Branch Endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) has been approved by the Food and Drug Administration for use in the treatment of aortoiliac and common iliac aneurysms, with promising results to date. The efficacy of using the device to overlap with a Dacron graft has yet to be elucidated. We present the case of a patient with prior open abdominal aortic aneurysm repair who we treated with bilateral iliac branch endoprostheses.

Carotid pseudoaneurysms are rare and, if treated endovascularly, are usually approached via the femoral artery. We report the case of transradial stenting of an anastomotic carotid pseudoaneurysm secondary to vertebral transposition through an existing carotid-subclavian bypass.

BACKGROUND:Vascular surgery patients typically have numerous comorbidities, which puts them at higher risk for postoperative readmissions. This study aims to investigate the risk factors for and appropriately categorize the various types of vascular surgery readmissions. METHODS:Nine hundred seventy-two patients were retrospectively reviewed. Readmissions were classified into 3 separate groups: readmissions that occurred between 0 and 30 days (30-day readmissions), 31-90 days (3-month readmissions), and 91-365 days (1-year readmissions). Each readmission was then assigned to 1 of the 4 categories based on whether they were related to the index procedure and whether they were planned. Univariate tests were performed for demographic variables based on their type of readmission, and logistic regressions were then performed to identify predictors of each unplanned, related readmissions. RESULTS:The overall 30-day readmission rate was 21.9% (n = 213). The unplanned, related readmission cohort (n = 83) had the highest readmission rate of 8.5%. The related, planned readmission rate was 5.9% (n = 58), while the unrelated, unplanned readmission rate was 5.6% (n = 55). In contrast, the overall 1-year readmission rate was 40.0% (n = 389), with the largest category being unplanned, unrelated readmissions at 19.7% (n = 191). The unplanned, related readmission rate was 8.7% (n = 85), whereas the planned, related readmission rate was 5.7% (n = 55). Compared with other types of readmissions, unplanned, related readmissions tended to affect patients who were younger, had poor glycemic control, and had higher body mass indexes (BMIs). Multivariate predictors of unplanned, related readmissions were poor glycemic control at 3 months (odds ratio [OR]: 2.16, P = 0.03), and BMI at 30 days (OR: 1.06, P = 0.04) and 1 year (OR: 1.05, P = 0.04). CONCLUSIONS:Readmissions have varying risk factors depending on their category; targeting glycemic control and obesity may reduce unplanned, related readmissions.