Faculty Bibliography

Surgical volumes continue to shift from inpatient and hospital outpatient departments to independent and co-owned Ambulatory Surgery Centers (ASCs). Consumer preferences, payer pressure, lower cost, possibility of site-neutral payments, equivalent safety, and clinical innovation have caused this outmigration. Physicians have embraced the shift due to dissatisfaction with current employment models, more professional autonomy, a sense of purpose, the ability to drive efficiency and quality of care, and the option to invest and benefit financially. Vascular surgeons can utilize their existing experience delivering outpatient care to grow their practices. The unique challenges and business structure of this care model, regulatory roadblocks, arbitrary reimbursement adjustments, and new corporate entrants to ASCs need to be understood. New models of outpatient care will likely include shifting higher-acuity procedures to ASCs. The care will be delivered by independent vascular surgeons or through alignment between physicians and hospital systems to provide optimal care to patients in convenient, secure, and cost-effective settings.

BACKGROUND:Pelvic venous disorders disproportionately affect women, but women-centered reporting in intervention studies remains unclear. METHODS:We performed a source-checked, cross-sectional bibliographic analysis of 42 PubMed-indexed original human studies identified from a reconciled 290-record search pool. Prespecified domains covered reproductive context, pelvic and sexual symptoms, patient-reported outcomes, function, and procedural outcomes. RESULTS:Thirty-four studies included only women (81.0%). Pregnancy history, parity, postpartum status, and menopausal/hormonal status were reported in 31 (73.8%), 26 (61.9%), 5 (11.9%), and 6 (14.3%) studies, respectively. Dyspareunia and vulvar varices were reported in 27 (64.3%) and 19 (45.2%). PROM/QoL and return-to-function/work outcomes were reported in 7 (16.7%) and 3 (7.1%), whereas symptom improvement and reintervention were reported in 35 (83.3%) and 28 (66.7%). Later studies more often reported dyspareunia and PROM/QoL, but reproductive and hormonal reporting did not improve uniformly. CONCLUSIONS:Despite the predominance of women-only studies, women-centered reporting remains inconsistent.

OBJECTIVE:The study aims to evaluate the incidence of thirty-day thrombosis following iliac vein stent placement, stratified by age, and to analyze long-term follow-up outcomes. METHODS:A retrospective analysis was conducted of 4,312 procedures performed in 2,642 patients with symptomatic chronic venous insufficiency (CEAP clinical classes 3-6) from 2012 to 2024. Patients underwent iliac vein assessment using intravascular ultrasound (IVUS) and received stent placement. Follow-up included iliac vein duplex ultrasound assessments at 3 to 7 days postoperatively, with additional evaluations at 3 to 6 months during the first year. For subsequent years, follow-up occurred at 6 to 12-month intervals. Intraoperative heparin was not administered, and postoperative management included daily clopidogrel (Plavix). Stents were assessed for partial and complete thrombosis. RESULTS:The mean age of the study population was 73 years (range, 30-108), with 39.30% male and 60.70% female patients. Age distribution by decade, based on the number of nonthrombotic iliac vein lesions (NIVLs) treated, was as follows: patients in their 30s (43), 40s (151), 50s (498), 60s (926), 70s (1,116), 80s (1,035), and >90 years (543). Thirty-day thrombosis rates by age group were: 30s (0%), 40s (0.01324%), 50s (0.0200%), 60s (0.0118%), 70s (0.0179%), 80s (0.0116%), and >90s (0.0074%). Thirty-day thrombosis rates by CEAP clinical class were: CEAP 3 (0.01395%), CEAP 4 (0.0121%), CEAP 5 (0.0172%), and CEAP 6 (0.0166%). Among patients with thrombosis within 30 days of stent placement, 76.3% experienced partial stent thrombosis and 27.7% experienced complete stent thrombosis. The mean age of patients with complete thrombosis was 71.4 ± 17 years, compared with 71.8 ± 12 years for those with partial thrombosis. Of patients with complete thrombosis, 71.43% were female. Of the 14 patients with complete thrombosis within 30 days, 10 cases occurred between 2012 and 2021, three in 2022, and one in 2023. Binary logistic regression revealed no significant association between thirty-day thrombosis and age (p = 0.719), CEAP clinical class (p = 0.938), or laterality (p = 0.326). CONCLUSIONS:Iliac vein stenting for symptomatic nonthrombotic iliac vein lesions (NIVL) is a safe and effective procedure with a low incidence of early thrombosis. Age, laterality, and CEAP clinical class were not significantly associated with 30-day thrombosis outcomes. This study supports the use of iliac vein stenting in patients across a broad spectrum of CVI severity, demonstrating its effectiveness in an outpatient-based laboratory (OBL) setting.

OBJECTIVE:To evaluate the effectiveness and safety of endovenous ablation across racial and ethnic groups by comparing rates of endovenous heat-induced thrombosis (EHIT) and recanalization. METHODS:We retrospectively analyzed 13,335 endothermal ablation procedures (radiofrequency or laser) performed from 2012 to 2022 at a single outpatient center. Patient demographics, including self-identified race/ethnicity (Asian, Black, Hispanic, White), were recorded. Post-procedural duplex ultrasound was conducted at 3-7 days, 3-6 months, and then every 6-12 months. EHIT (classes 1-4) and recanalization of the treated vein were identified on follow-up imaging. Outcomes were compared across racial/ethnic groups using univariable and multivariable logistic regression. RESULTS:Among 13,335 ablations (8,187 radiofrequency and 5,148 laser) in 3,218 patients, 67.1% were performed in women. Mean follow-up was 25.8 ± 12.9 months (range, 3-72 months). EHIT incidence was highest in Black patients (3.0%), followed by Asian (2.6%), White (1.7%), and Hispanic (1.4%) patients; the difference between Black and White patients was significant (p < 0.001), while other pairwise comparisons were not. Procedural success (no EHIT or recanalization) was high and comparable across groups: 96.1% in Asians, 95.2% in Blacks, 96.1% in Hispanics, and 96.2% in Whites. On multivariable analysis, Black race was associated with higher EHIT risk (OR = 1.92, p < 0.001), and Asian race with higher recanalization risk (OR = 1.65, p = 0.045). Additional predictors of recanalization included advanced disease (CEAP 6; p < 0.05), while the ablation of the great, anterior, or small saphenous veins was protective compared with perforator veins (all p < 0.001). Predictors of EHIT included older age (p < 0.0001) and prior recanalization (p < 0.0001), while laser ablation was associated with a significantly lower EHIT risk compared with radiofrequency (p < 0.0001). Baseline disease severity also varied: Black patients were more likely to present with advanced disease (CEAP 5-6) than Hispanic and Asian patients (p < 0.0001). CONCLUSIONS:Endovenous ablation is a safe and effective treatment for chronic venous insufficiency across different racial/ethnic groups, with overall success rates of 95-96%. However, racial differences were observed in complication rates and baseline severity: Black patients had higher EHIT risk and more advanced disease at presentation, while Asian patients had a slightly higher recanalization risk. These findings highlight the need for tailored post-ablation surveillance and improved early access to care to address differences in minority populations.

INTRODUCTION/BACKGROUND:This study highlights the presentation of inframalleolar ulcers in venous disease not classically described their wound healing factors, recurrence rate, and response to Unna boot treatment with adjunct endovenous and/or iliac vein stenting treatments. METHODS:This retrospective single-center study included 71 office-based patients with inframalleolar venous ulcers treated between May 2012 and May 2023. Of the 71 patients evaluated, 12 presented with bilateral ulcers, resulting in a total of 83 limbs. Patient demographics including age, sex, ulcer etiology, ulcer location, diabetes status, and treatment modality were evaluated. All patients presented with bilateral leg swelling and venous reflux greater than 500ms suggestive of venous insufficiency. Initially, patients were required to have palpable pedal pulses and a normal ankle-brachial index (ABI) for inclusion. Over time, inclusion criteria were broadened to accept patients with mixed arterial-venous disease, provided their ABI was greater than 0.6. Patients with isolated arterial pathology and an ABI < 0.6 and diabetic neuropathic ulcer etiology were excluded from this study. Patients received compression therapy that included an elastic ACE wrap and an inelastic Unna boot formulated with calamine, zinc oxide, and glycerin, both applied by trained medical assistants. Sixty-five patients received additional endovenous and/or iliac vein stenting treatments. RESULTS:The mean patient age was 67 years +/-14 years (range 25-96 years). Of the 71 patients treated, 12 (mean 16.9%, SE 4.45%) presented with ulcers on both of their limbs resulting in a total of 83 limbs treated. All ulcers were treated with weekly Unna boots with an average treatment duration of 12 weeks +/- 23 weeks (range 1-181 weeks), and median treatment duration of 5 weeks. After wound healing patients were followed for a mean duration of 16 +/- 28 months. The rate of success of > 90% healing for inframalleolar ulcers was 51.8%. Factors associated with wound healing were ulcers that were primarily venous in nature as opposed to mixed (p=0.01). Heel ulcers were not associated with inferior wound healing (p=0.10) as compared to other locations but were associated with higher rates of recurrence (p=0.002). 26.76% of patients had recurring ulcers while 45.13% did not, 8.4% of ulcers were still actively being treated with Unna boots and 19.71% were lost to follow-up. Improved healing of inframalleolar ulcers was significantly associated with the presence of a concomitant supramalleolar ulcer on the same limb (p=0.02). CONCLUSIONS:This study brings attention to the uncommon presentation of inframalleolar ulcers in venous stasis disease and is driven by the observation that bilateral leg swelling can lead to poor wound healing. Compression therapy using Unna boots is easily accessible, cost-effective, and should be considered as it offers significant therapeutic benefit in this patient population.

OBJECTIVE:Topical Oxygen therapy (tOT) is a novel treatment method capable of expediting granulation tissue formation in patients with non-healing lower extremity venous leg ulcers (VLUs). tOT provides cyclic oxygen with compression and is able to be administered at home, unlike chamber-based oxygen therapy. Although previous randomized prospective trials have demonstrated effectiveness of tOT in treating ulcers of diabetic etiology, its ability to promote healing in refractory venous ulcers requires additional exploration. Thus, we investigated preliminary outcomes of tOT administration in treatment-resistant VLUs. METHODS:We conducted a single-center retrospective review of treatment outcomes among 31 patients with 32 total extremities with VLUs following longitudinal administration of tOT. All patients received managed Medicaid approval for tOT after each ulcer failed to resolve following multiple alternative therapies, including Unnaboot compression, sclerotherapy, thermal ablation, iliac vein stenting, and debridement. Patient response to tOT was determined by assessing mid-treatment progression of ulcer length and width, in addition to final ulceration status at the conclusion of therapy. Mean treatment length, total ulcer duration, peak ulcer length, and peak ulcer width were determined for each patient and compared between healed and unhealed VLUs. RESULTS:Average age across all individuals was 73±19 years (range 27-99). 14 (45%) patients were male, with a racial breakdown of 18 (58%) White, 5 (16%) Hispanic, 6 (19%) Black, and 2 (6%) Asian patients. Comorbid conditions included hypertension in 31 (100%) patients, hyperlipidemia in 15 (48%), and diabetes in 12 (39%). 4 (13%) patients demonstrated a former history of smoking while 3 (10%) patients were currently using tobacco products during the study period. Total duration across all VLUs was 1075±1004 days. Average duration of tOT was 265±233 days, while average pre-treatment ulcer duration was 718±842 days. Mean ulcer length was 7.6±6.8 cm and mean ulcer width was 5.7±5.0 cm (range 2-24 cm for both). Following tOT administration, 11 (34%) VLUs healed entirely, 9 (28%) ulcers improved but did not completely heal, 8 (25%) remained unchanged, and 4 (13%) worsened despite treatment. Median time to healing among the 11 VLUs which healed completely was 121 days. For ulcers that did not heal, the mean duration of tOT was 333±261 days. No differences were observed in the pretreatment VLU duration (p=0.54), maximum length (p=0.50) or maximum width (p=0.80) of healed versus unhealed VLUs. CONCLUSIONS:20 (62.5%) of the 32 refractory VLUs treated with tOT either decreased in size or healed entirely after failing multiple previous therapies. 3 (27.3%) of the 11 ulcers which healed completely recurred following topical oxygen therapy.

Background Physicians from underrepresented groups in medicine have historically been less likely to enter surgical specialties. This project sought to evaluate changes in the demographics of surgical society leadership from 1980 to 2025. Methodology In total, 31 societies were included in this retrospective analysis, and data on age, sex, and ethnicity were gathered and analyzed using SPSS. Results There was a significant increase in the number of female presidents and non-White presidents in the 2010-2025 period compared to 1980-1995. The Association for Academic Surgery (AAS), American Society of Breast Surgeons, and the Association for Surgical Education all had more female presidents than average, while the American Urological Association had fewer. AAS and the Surgical Society of the Alimentary Tract both had more non-White presidents than other societies. The American Pediatric Surgical Association and Western Surgical Association presidents were significantly older, while the AAS, American Society of Colon and Rectal Surgeons, EAST Trauma Society, Midwestern Surgical Society, and Society for University Surgeons presidents were significantly younger than the overall median age. Conclusions Many surgical societies have improved their representation of women and non-White surgeons. These significant changes in representation signify an appreciation for the demographic changes in the United States within the past 45 years.

BACKGROUND:Perivenous tumescence with saline or a dilute lidocaine solution is routinely used for thermal ablation of refluxing superficial lower extremity veins to displace sensitive structures away from the thermal probe and provide better contact with the treated venous endothelium. In this study we introduce an adjunctive technique of tumescence infiltration at the most efferent segment of refluxing saphenous veins treated with 1% polidocanol endovenous microfoam (PEM). We hypothesize that by reducing the vein diameter, Proximal Tumescence (PT) prolongs apposition time of PEM to the endothelium by delaying venous outflow and microfoam propagation speed. We evaluated PT effects on vein closure, volume of PEM used as well as the incidence of superficial venous thrombosis (SVT) and ablation related thrombus extension (ARTE). METHODS:A single institution retrospective study was performed with PEM ablations for the above knee great saphenous vein (AK-GSV), below knee GSV (BK-GSV), and small saphenous vein (SSV) by two operators over a 12-month period. Duplex ultrasonography (DUS) within 3-to-7 days after ablation followed by a serial surveillance DUS schedule were used to evaluate for vein closure, VT, and ARTE per institutional protocol. Any treated vein segment found to be completely or partially patent with reflux after treatment was deemed an ablation failure. Demographics and outcomes of tumescent PEM ablations (T-PEM) were compared with non-tumescent PEM (NT-PEM) through univariate and generalized estimating equation modeling. RESULTS:Between June 2023 and May 2024, 183 adult patients (64 male, 119 female) treated with 1% PEM in 246 lower extremities (113 right, 133 left) met study criteria. Nineteen patients without documented follow up DUS were excluded from this study. Overall, 293 ablations (23 AK-GSV, 199 BK-GSV, 71 SSV) were performed with a mean PEM volume of 2.8cc (SD=0.6cc) per ablation with a combined closure rate of 91.8% (269 of 293). One hundred and nineteen (40.6%) ablations were augmented with PT (mean tumescence volume = 6cc, SD=2.4cc, range=3cc to 16cc). Veins treated with T-PEM were significantly larger (mean vein diameter=4.8mm, SD=1.3mm) than veins treated with NT-PEM (mean vein diameter=4.0mm, SD=0.9mm, p<.001). There were no significant differences in patient age (p=.37), sex (p=.06), laterality (p=.29), preoperative CEAP clinical severity scores (p=.34), PEM volume used (p=.09), VT (p=.65), ARTE (p=.41), or rate of treatment success (p=.16) on univariate comparison of T-PEM and NT-PEM ablations. Generalized estimating equation regression predicts lower microfoam volume use with PT (B=-0.4, p=.003) and similar treatment success rates when correcting for inter-operator variability. CONCLUSION/CONCLUSIONS:Proximal tumescence is a safe and effective adjunct to PEM ablation that provides high short and mid-term closure rates with low ARTE incidence for large and small saphenous veins. PT is associated with reduced microfoam volume use.

INTRODUCTION/BACKGROUND:Risk index calculator models are widely used to estimate perioperative risk of surgical procedures, directly impacting surgical planning and patient outcomes. This study assessed the accuracy of the National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC), Revised Cardiac Risk Index (RCRI) calculator, and Vascular Quality Initiative Cardiac Risk Index (VQI-CRI) calculators in predicting adverse event rates for common vascular procedures. METHODS:A retrospective cohort of all carotid endarterectomy (CEA), endovascular abdominal aortic aneurysm repair (EVAR), infrainguinal bypass, open abdominal aortic aneurysm (AAA) repair, and suprainguinal bypass procedures completed in a single hospital system between January 2020 - January 2023 was assembled. Preoperative demographics, medical history, and postoperative adverse events were collected through chart review. Preoperative data was entered into each calculator to produce a predicted risk of adverse events. These predicted adverse event rates were compared to the actual adverse event rates observed; comparison was conducted via χ2 goodness-of-fit tests. RESULTS:952 procedures were included, comprising 348 CEA, 33 open AAA repair, 218 EVAR, 258 infrainguinal bypass, and 95 suprainguinal bypass procedures. In conglomerate, the RCRI significantly overestimated 30-day postoperative cardiac arrest or myocardial infarction (p<0.0001); the VQI-CRI also significantly overestimated in-hospital postoperative myocardial infarction (p=0.0035). The NSQIP-SRC significantly underestimated severe complications (p<0.0001), any complications (p<0.0001), UTI (p<0.0001), renal failure (p=0.0344), and return to the OR (p<0.0001), while significantly overestimating SSI (p=0.0027) and discharge to nursing/rehabilitation (p<0.0001). By procedure, the RCRI significantly overestimated risk for CEA (p<0.0001) and EVAR (p=0.0014), while significantly underestimating risk for open AAA repairs (p=0.0259). The VQI-CRI significantly overestimated risk for infrainguinal bypass (p=0.0038). The NSQIP-SRC significantly underestimated severe complications for EVAR (p=0.0002), infrainguinal bypass (p<0.0001), and suprainguinal bypass (p<0.0001). The NSQIP-SRC significantly underestimated any complications for EVAR (p=0.0091), infrainguinal bypass (p=0.0015), and suprainguinal bypass (p=0.0049). CONCLUSIONS:Significant variability in the accuracy of the NSQIP-SRC, RCRI, and VQI-CRI calculators was found for prediction of adverse events for common vascular procedures. The degree of inaccuracy per calculator varied significantly based on the indexed procedure. Updated calculators inclusive of modern vascular surgery procedural data may better capture accurate predictions of adverse events to best inform vascular surgical planning.

OBJECTIVES/OBJECTIVE:Patients presenting with iliofemoral deep venous thrombosis (DVT) often undergo percutaneous thrombectomy intending to prevent post-thrombotic syndrome (PTS). However, the relationship between the extent of DVT and outcomes after thrombectomy has not been explored. The objective of this study was to compare rates of post-thrombectomy DVT recurrence between patients with isolated iliofemoral DVT and patients with iliofemoral DVT and extension more peripherally. METHODS:We conducted a single-center, retrospective analysis of all patients who underwent thrombectomy for iliofemoral DVT from 2014-2023. Patients were stratified into two cohorts: (1) iliofemoral DVT without popliteal/tibial extension or (2) iliofemoral DVT with popliteal/tibial extension. The primary outcome was acute DVT recurrence and multivariable analysis was performed to identify risk factors for recurrence. Chi-squared and t-tests were calculated for categorical and continuous data, respectively. Kaplan-Meier analysis was used to compare rates of acute DVT and chronic venous changes postoperatively. A P-value <0.05 was considered statistically significant. RESULTS:222 patients were identified during the study period (76 isolated iliofemoral DVT vs. 146 iliofemoral DVT with peripheral extension) with a median follow-up of 19 months. Patients who presented with iliofemoral DVT with peripheral extension were more likely to be older (57 vs. 50 years, p=0.004), have hypertension (64% vs. 41%, p=0.001) or hyperlipidemia (58% vs. 40%, p=0.01), and to have had surgery within the prior 6-months (29% vs. 17%, p=0.04). Amongst female patients, those on hormone therapy were more likely to have isolated iliofemoral DVT (17% vs. 3%, p<0.001). Patients with iliofemoral DVT with peripheral extension had a greater chance of developing recurrent acute DVT (48% vs. 20%, p<0.001) and chronic venous changes (51% vs. 30%, p=0.004) during follow-up. Multivariable analysis showed a significant correlation between iliofemoral DVT with peripheral extension (Odds ratio 3.8 [95% confidence interval 1.7-8.7], p=0.001) and acute DVT recurrence. There were no differences in the rates of reintervention or death. CONCLUSION/CONCLUSIONS:More extensive peripheral thrombus burden was associated with higher rates of follow-up DVT recurrence in patients undergoing thrombectomy for iliofemoral DVT. These findings suggest that such patients may require closer follow-up and more aggressive anticoagulation therapy postoperatively. Moreover, our results provide a framework for further studies to specifically study the role peripheral thrombus may play in venous hemodynamics and the development of recurrent DVT and, ultimately, PTS.