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Traumatic vascular injuries are infrequent but can be devastating. This study characterized their incidence and the need for vascular surgeons in their repair. Outcomes for patients repaired by vascular and trauma surgeons were compared. Patients age ≥14, needing operations for acute traumatic vascular injuries from January 1, 2008 to December 31, 2013 were included. Of the 27,224 adult trauma patients, 1.4% had vascular injuries needing operations. Trauma surgeons treated 40% of them. The need for repair by vascular surgeons varied based on mechanism, transfer status, injury location, time of injury, trauma staff practice, and experience (P < .05). Patients repaired by vascular surgeons had more transfusions, longer arrival-to-operation time, surgery duration, hospital stay but lower mortality (P < .05). This mortality difference dissipated after excluding early deaths. Approximately 3% of trauma patients had vascular injuries. Trauma surgeons treated a significant portion of them; using less resources and achieving similar outcomes in select patients when compared with vascular surgeons.

Abstract BACKGROUND: If a self-expanding stent has been placed during endovascular treatment of an aneurysm and subsequently an open aneurysm surgery becomes necessary in the same or an adjacent area, is it possible and safe to obtain proximal control by placing a temporary clip on the artery at a point where it contains the stent? OBJECTIVE: To evaluate the effect of temporary clip application to 3 separate stent systems in an in vitro flow model with the stated hypothesis that clip application to these stents will result in permanent stent deformation. METHODS: This is an in vitro flow model study using an accepted synthetic blood vessel substitute. The Neuroform3 (Boston Scientific), Enterprise (Cordis/Codman), and Pipeline (ev3) stents were deployed within the flow model; temporary clips were applied; and angiographic measurements subsequently made. RESULTS: Two 4 × 30-mm Neuroform3 stents, two 4.5 × 28-mm Enterprise stents, and two 3.75 × 20-mm Pipeline stents were successfully deployed and clipped repeatedly (4 iterations). Two- and 3-dimensional angiograms were obtained. After repeated clip occlusion, the Neuroform3 and Enterprise stents returned to their original configuration and diameter. Clip application to both also resulted in immediate flow arrest. In contrast, initial clip application to the Pipeline stents did not result in flow arrest, but the second single clip application did. The Pipeline stents were also irreversibly deformed after the experimental protocol, with an average luminal diameter reduction of 26.85% (P < .05). CONCLUSION: The Neuroform3 and Enterprise stents responded favorably to temporary clip application, returning to their original diameter after clip removal and showing no sign of permanent structural modification. The Pipeline flow-diverting stent, however, was irreversibly deformed by clip application. These data indicate that temporary clip application to certain stents is possible. Further in vivo study is required.

Objectives: The French population is growing and ageing. It is expected to increase by 2.7% by 2020, and the number of individuals over 65 years of age is expected to increase by 3.3million, a 33% increase, between 2005 and 2020. As the number of vascular surgery procedures is closely associated with the age of a population, it is anticipated that there will be a significant increase in the workload of vascular surgeons. Study design: A model is presented to predict changes in vascular surgery activity according to population ageing, including other parameters that could affect workload evolution.Methods: Three types of arterial procedures were studied: infrarenal abdominal aorticaneurysm (AAA) surgery, peripheral arterial occlusive disease (PAOD) procedures andcarotid artery (CEA) procedures. Data were selected and extracted from the national PMSI(Medical Information System Program) database. Data obtained from 2000 were used topredict data based on an ageing population for 2008. From this model, a weighted indexwas defined for each group by comparing expected and observed workloads.Results: According to the model, over this 8-year period, there was an overall increase invascular procedures of 52.2%, with an increase of 89% in PAOD procedures. Between 2000and 2009, the total increase was 58.0%, with 3.9% for AAA procedures, 101.7% for PAODprocedures and 13.2% for CEA procedures. The weighted model based on an ageing populationand corrected by a weighted factor predicted this increase.Conclusion: This weighted model is able to predict the workload of vascular surgeons overthe coming years. An ageing population and other factors could result in a significantincrease in demand for vascular surgical services.

Interventional radiologist rather than vascular surgeons have become the predominant clinicians placing inferior vena cava (IVC) filters since the percutaneous device was introduced more than a decade ago. We conducted a retrospective analysis of 592 patients treated at a single institution between 1987 and 2000 to determine the indications, referral pattern, and clinical outcome of IVC filter placement between the radiologist and surgeon groups. Before 1989 all filters were placed by surgeons in the operating room. The adoption of the percutaneous delivery method by radiologists in 1989 led to a dramatic increase in its practice volume accounting for 99 per cent of all filters placed from 1991 to 1993 (P < 0.001). The development of an endovascular program by the vascular surgeons in 1994 led to a steady increase in its IVC filter practice annually (P < 0.05) and accounted for 42 per cent of all filter placements in 2000. A distinct referral pattern also emerged as 74 per cent of all filter placements by surgeons were referred by surgical services. The proportion of filter placement for strict indications remained constant over time between the two groups (P = 0.86). The complications and survival rates were not significantly different between the two groups (P = 0.24). Percutaneous devices have dramatically increased the clinical volume of IVC filter placement by interventional radiologists. Vascular surgeons with endovascular interest are well suited to perform the procedure and can regain referral ground of IVC filter placement.

Background: Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members’ willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions. Methods: A checklist prototype was developed and OR team members were asked to implement it before 18 surgical procedures. A research assistant was present to prompt the participants, if necessary, to initiate each checklist discussion. Trained observers recorded ethnographic field notes and 11 brief feedback interviews were conducted. Observation and interview data were analyzed for trends. Results: The checklist was implemented by the OR team in all 18 study cases. The rate of team participation was 100% (33 vascular surgery team members). The checklist discussions lasted 1–6 minutes (mean 3.5) and most commonly took place in the OR before the patient’s arrival. Perceived functions of the checklist discussions included provision of detailed case related information, confirmation of details, articulation of concerns or ambiguities, team building, education, and decision making. Participants consistently valued the checklist discussions. The most significant barrier to undertaking the team checklist was variability in team members’ preoperative workflow patterns, which sometimes presented a challenge to bringing the entire team together. Conclusions: The preoperative team checklist shows promise as a feasible and efficient tool that promotes information exchange and team cohesion. Further research is needed to determine the sustainability and generalizability of the checklist intervention, to fully integrate the checklist routine into workflow patterns, and to measure its impact on patient safety.

Thrombophilia may be defined as the tendency to arterial or venous thrombosis. Thrombophilia can be acquired or hereditary. Acquired conditions leading to arterial thrombosis are commonly encountered in vascular surgical practice, but less well known is the potential influence of genetic factors. In recent years, evidence has accumulated for a crucial role of genetic factors in the pathogenesis of venous thrombosis, many previously unknown genetic defects having been recently identified. The role of genetic predisposition for the pathogenesis of arterial occlusive disease on the other hand is unknown, although recent publications suggest a definite link. This may have implications for the vascular surgeon in the management of patients with arterial disease. A medline search was performed in order to identify papers published between 1990-2002 on thrombophilia, arterial disease and peripheral arterial occlusive disease (PAOD). With regard to venous thrombosis we obtained a much wider knowledge about genetic defects leading to thrombophilia. This has altered the diagnostic and therapeutic approach to patients with venous thrombosis, and has had an important influence on counselling and screening of family members, especially females of childbearing age. With regard to arterial thrombosis, certain thrombophilic disorders have a definite pathophysiological role. Hyperhomocysteinaemia, inherited or acquired, has been demonstrated to be an independent risk factor for athero-thrombosis. The antiphospholipid antibody syndrome (APS), an acquired condition, also predisposes to arterial thrombosis. Other thrombophilic conditions, such as prothrombin gene G20210A variant or factor V Leiden, have been investigated, but current evidence does not unequivocally support the hypothesis of a pathophysiological role in athero-thrombosis. Routine screening for thrombophilia in patients with athero-thrombosis is therefore not generally recommended on the basis of current evidence, but there is a role for selective screening.

To outline the distribution of vascular surgeons in Canada and to determine the present and future human resource needs in vascular surgery practice in Canada. Voluntary questionnaires sent to all members of the Canadian Society for Vascular Surgery (CSVS), the administrators of hospitals in Canada with more than 100 beds, and interrogation of the membership database of the CSVS. The perceived present and future needs for full-time and part-time vascular surgeons, determined by a variety of methods. One hundred and forty active members of the CSVS and administrators of 120 hospitals. From the CSVS members 62 responses were received from those residing in Canada, revealing 47 full-time vascular (more than 75% of the practice) surgeons working with 0 to 5 colleagues (mean 1.8 [SD 1.3]). Fifteen responding surgeons combined the practice of vascular surgery with another specialty. Perceived immediate needs were 24 surgeons, with 42 required in 4.8 (1.8) years. Of 120 hospitals offering vascular surgery services, 90 stated that they met the needs of their community; however, additional immediate manpower requirements totalled 27 surgeons. Hospital administrators predicted a need of 55 additional vascular surgeons in a mean of 5.5 (4.6) years. Over 85% of hospitals stated that they had the resources to support the currently practising surgeons and their immediately required additions. Prediction of the need for additional vascular surgeons should be based on an estimated retirement age of 65 years, with an adjustment for the increasing percentage of the Canadian population reaching the age of 60 years. All methodologies used in this study predict the need for additional human resources in vascular surgery. The need for continued training of new vascular surgeons is apparent, but the optimal number of trainees per year is less clear.

Background The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework. Method Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators. Results In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135–191 procedures per 100,000 with a perioperative mortality rate of 2.5–3.3%. Patients requiring surgery have a 77.4–86.3 and 78.8–95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate. Conclusion Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.

Background There is a significant burden of disease in low-income countries that can benefit from surgical intervention. The goal of this survey was to evaluate the current ability of the Liberian health care system to provide safe surgical care and to identify unmet needs in regard to trained personnel, equipment, infrastructure, and outcomes measurement. Methods A comprehensive survey tool was developed to assess physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, equipment and medications, and the capacity of the surgical system to collect and evaluate surgical outcomes at district-level hospitals in Africa. This tool was implemented in a sampling of 11 county hospitals in Liberia (January 2011). Data were obtained from the Ministry of Health and by direct government-affiliated hospital site visits. Results The total catchment area of the 11 hospitals surveyed was 2,313,429—equivalent to roughly 67 % of the population of Liberia (3,476,608). There were 13 major operating rooms and 34 (1.5 per 100,000 population) physicians delivering surgical, obstetric, or anesthesia care including 2 (0.1 per 100,000 population) who had completed formal postgraduate training programs in these specialty areas. The total number of surgical cases for 2010 was 7,654, with approximately 43 % of them being elective procedures. Among the facilities that tracked outcomes in 2010, a total of 11 intraoperative deaths (145 per 100,000 operative cases) were recorded for 2009. The 30-day postoperative mortality at hospitals providing data was 44 (1,359 per 100,000 operative cases). Metrics were also used to evaluate surgical output, safety of anesthesia, and the burden of obstetric disease. Conclusions A significant volume of surgical care is being delivered at county hospitals throughout Liberia. The density and quality of appropriately trained personnel and infrastructure remain critically low. There is strong evidence for continued development of emergency and essential surgical services, as well as improved surgical outcomes tracking, at county hospitals in Liberia. These results serve to inform the international community and donors of the ongoing global surgical and anesthesia crisis.