Socioeconomic Status and Clinical Stage of Patients Presenting for Treatment of Chronic Venous Disease

OBJECTIVES: The association between socioeconomic status (SES) and chronic venous insufficiency has not been rigorously studied. This study aimed to determine the influence of SES on the clinical stage of patients presenting for chronic venous disease therapy. METHODS: We performed a retrospective study of a prospectively collected data from the Vascular Quality Initiative Varicose Vein Registry at our tertiary referral center. Medical records of patients who underwent therapy for chronic venous disease between January 2015 and June 2019 were queried. SES was quantified using the neighborhood deprivation index (NDI), which summarizes 8 domains of socioeconomic deprivation and is based on census tract data derived from the patients\u27 addresses at the time of the treatment. High NDI scores correspond with lower SES. The association between SES and severity of vein disease at presentation was assessed with bivariate analysis of variance and linear regression analysis. RESULTS: A total of 449 patients with complete SES and clinical-etiology-anatomy-pathophysiology (CEAP) class data were included in the study. The mean age was 58 years, 67% were female, and 60% were White. CEAP classes were distributed as follows C2, 22%; C3, 50%; C4, 15%; C5, 5%; and C6, 8%. Patients with lower SES (higher NDI score) tended to have a higher CEAP class at presentation (P \u3c 0.05). SES was not associated with history of deep venous thrombosis, use of compression therapy, or venous clinical severity score. CONCLUSIONS: At our institution, patients with more advanced venous disease tended to belong to a lower SES group. This may reflect that patient with a lower SES have a longer time to presentation due to delay in seeking medical help for venous disease

Stronger but Not Faster : Flipped Classroom Teaching Significantly Improves Resident\u27s Skills but Not Speed

Objective: Flipped classroom teaching is a nontraditional education model where instructional content is delivered outside the classroom. This constructivist approach emphasizes self-direction, active inquiry; the instructor’s role is to foster critical reflection and facilitate the application and understanding of concepts. Our objective was to study the difference in time taken and quality of patch graft angioplasty performed by residents with and without flipped teaching. Methods: The study was set in a skills simulation teaching session overseen by attending surgeons. The intervention consisted of introducing a video outlining the technical aspects of patch graft angioplasty, watched before the session. The first group (2018 postgraduate year [PGY] 1 and 2 residents) was given instructions at the time of the class without a prior educational video or resources (Figs 1 and 2). The second group (2019, 2020 PGY 1 and 2 residents) was asked to watch a 20-minute video on the technical aspects of the procedure before the class. Participants then performed a standardized patch graft closure of a 1 cm arteriotomy using a polytetrafluoroethylene patch. The groups were timed. The quality of the closure was tested by assessing the number of leaks and the quantity of leak of the patch (Fig 3). Bivariate analysis sample t-tests were used for statistical analysis. P value \u3c.05 was considered significant. Pre- and post-session surveys were conducted to assess residents’ experience. Results: Forty-two residents (PGY 1 and 2) were enrolled in the study, 15 in nonintervention group 1 and 27 in intervention group 2, compared with 7 staff vascular surgeons. The mean completion time was 26 minutes (group 1) vs 27 minutes (group 2), P ¼ .6. The staff completion time was 12 minutes, P ¼ .001. The number of major leaks (not needle holes) was 2.0 (group 1) vs 1.6 (group 2), P ¼ .007, none for staff. The total quantity of leak was 42 mL (group 1) vs 15 mL (group 2), P ¼ .0001 (Table I). There was perceived improvement in skill on analyzing pre- and post-session surveys (Table II). Conclusions: A structured educational intervention, watching a video of a procedure before the skills session, did not change the time needed to complete the skill. There was improvement in the technical outcome of the procedure defined by a decrease in the total quantity of leak. Reversed classroom teaching significantly improves resident’s skill, not speed. There was also a perceived improvement in skill by participants. This is a pilot study and further instructional outcomes are being studied

Decellularized dermis extracellular matrix alloderm mechanically strengthens biological engineered tunica adventitia-based blood vessels

The ideal engineered vascular graft would utilize human-derived materials to minimize foreign body response and tissue rejection. Current biological engineered blood vessels (BEBVs) inherently lack the structure required for implantation. We hypothesized that an ECM material would provide the structure needed. Skin dermis ECM is commonly used in reconstructive surgeries, is commercially available and FDA-approved. We evaluated the commercially-available decellularized skin dermis ECM Alloderm for efficacy in providing structure to BEBVs. Alloderm was incorporated into our lab\u27s unique protocol for generating BEBVs, using fibroblasts to establish the adventitia. To assess structure, tissue mechanics were analyzed. Standard BEBVs without Alloderm exhibited a tensile strength of 67.9 ± 9.78 kPa, whereas Alloderm integrated BEBVs showed a significant increase in strength to 1500 ± 334 kPa. In comparison, native vessel strength is 1430 ± 604 kPa. Burst pressure reached 51.3 ± 2.19 mmHg. Total collagen and fiber maturity were significantly increased due to the presence of the Alloderm material. Vessels cultured for 4 weeks maintained mechanical and structural integrity. Low probability of thrombogenicity was confirmed with a negative platelet adhesion test. Vessels were able to be endothelialized. These results demonstrate the success of Alloderm to provide structure to BEBVs in an effective way

Aortic pseudoaneurysm - An unusual presentation

Introduction: The esophagus is a frequent site of foreign body impaction, but esophageal perforation and subsequent aortic pseudoaneurysms, and aorto-esophageal fistulas are very rare but potentially life-threatening complications. We present a case of foreign body ingestion, complicated by erosion into the aorta causing a mycotic aneurysm. Case description: We introduce the case of a 60 year-old male with abdominal pain, nausea, fatigue and fevers. Blood cultures grew out gram-positive cocci. A CT scan revealed a distal thoracic aortic saccular aneurysm, with a 2.8 cm linear metallic body penetrating the inferior border of the aneurysm, and intraluminal thrombus formation. CT of the abdomen revealed portal vein thrombosis, splenic and hepatic abscesses. An Esophagogastroduodenoscopy was unremarkable. The patient was started on the appropriate antibiotic therapy. He was then taken to the operating room for an open thoracoabdominal aortic aneurysm repair with an interposition cryopreserved graft, with an intercostal muscle flap. A metal bristle was removed. He had an uneventful postoperative course and was discharged home on post-operative day 17. Follow-up CTA showed resolution of the infection and satisfactory repair. Post-operative esophagram showed no esophageal injury. Conclusion: We describe a case of a bristle from a metallic barbeque brush that was ingested. This penetrated the esophagus causing a mycotic aneurysm with septic embolization to the spleen and liver. Our successful treatment approach involved open aortic repair with an interposition cryopreserved graft, and an intercostal muscle flap.https://scholarlycommons.henryford.com/merf2020caserpt/1100/thumbnail.jp

Impact of Preoperative Anemia in Patients Undergoing Peripheral Vascular Intervention

Objectives: Transcarotid artery revascularization (TCAR) is an emerging novel approach to carotid intervention, adopted and well-suited for high-risk patients. Our objective was to assess the outcomes of TCAR and determine its impact on the volume of carotid endarterectomy (CEA) and non-TCAR carotid artery stenting (CAS) in a single-state experience. Methods: A large statewide quality consortium registry was queried. The indications and outcomes of TCAR compared with CEA and non-TCAR CAS from January 2018 to October 2019 were reviewed. Non-TCAR CAS included transfemoral, transbrachial stenting and transcarotid stenting without the flow reversal technique. We also assessed the impact of TCAR on the trend of CEA and non-TCAR CAS performed, analyzing data from 2012 to 2019. Outcome comparisons were performed using the χ 2 and Mann-Whitney U tests, depending on the distribution of the outcomes. Results: A total of 438 TCARs were performed by 39 physicians in 16 hospitals; 60% of the patients were asymptomatic and 40% symptomatic. The TCAR indication was physiologic high risk for 369 patients (84%) and restenosis for 69 patients (16%), with most occurring after prior CEA (94%). Of the non-TCAR CAS cases, 94% were performed via transfemoral access. The patients undergoing non-TCAR CAS had the highest 30-day mortality ( P \u3c .001) and the highest incidence of 30-day new neurologic deficits ( P = .008) compared with the patients undergoing CEA and TCAR. CEA had the lowest myocardial infarction rate ( P = .015; Table). The number of TCAR procedures performed and the number of physicians and hospitals performing them increased during the 2-year period. Since the introduction of TCAR, no significant frequency decrease has occurred in the number of non-TCAR CAS or CEA cases by hospitals or physicians (Fig). However, a significant negative trend was found in the number of CEAs performed by physicians since 2012 ( P \u3c .001; Fig). Conclusions: TCAR is a safe method of carotid revascularization and is becoming an increasingly used method. TCAR has not affected the CEA hospital or physician volume since its introduction. CEA volumes and physician usage are declining, which could have future credentialing implications. In the present single-state experience, TCAR compared favorably with CEA and non-TCAR CAS might be less appealing because of its higher neurologic event rate

Outcomes of patients with acute type A aortic dissection and concomitant lower extremity malperfusion

OBJECTIVE: The occurrence of acute lower limb ischemia (ALLI) is a serious risk within the context of aortic dissection repair. The aim of the present study was to examine the outcomes of patients with acute type A aortic dissection (ATAD) and concomitant lower extremity malperfusion. METHODS: We performed a retrospective medical record review at our tertiary referral center of patients who underwent ATAD repair from January 2002 to June 2018. We used univariate and multivariate analyses to compare the outcomes of patients with and without lower extremity malperfusion. The primary outcomes were 30-day and 1-year mortality. RESULTS: A total of 378 patients underwent ATAD repair during the study period. Their mean age was 57 years, 68% were men, and 51% were White. A total of 62 patients (16%) presented with concomitant ALLI, including 35 (9%) who presented with isolated ALLI and 27 (7%) who presented with ALLI and concomitant malperfusion of at least one other organ. Of the 62 patients with ALLI, 46 underwent only proximal aortic repair. Of the 378 patients, 6 died within the first 24 hours, and their limb perfusion was not assessed. Among the 40 patients who underwent isolated proximal repair and survived \u3e24 hours, 34 (85%) had resolution of their ALLI. Of the 16 patients who underwent concomitant lower extremity peripheral vascular procedures, 10 had bypass procedures and 1 died within 24 hours due to refractory coagulopathy and hypotension. All six patients with adequate follow-up imaging studies had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries. Patients who presented with any organ malperfusion had increased 30-day (odds ratio, 1.8; P = .04) and 1-year (odds ratio, 1.8; P = .04) mortality and decreased overall survival (P \u3c .01). For the patients with isolated ALLI, no significant differences were found in 30-day or 1-year mortality or overall survival (P = .57). CONCLUSIONS: Proximal repair of ATAD resolves most cases of associated ALLI, and isolated ALLI does not affect short- or long-term survival. All patients with follow-up in our study who underwent extra-anatomic bypass developed asymptomatic graft occlusion, which could be attributed to competitive flow from the remodeled native arterial system. We believe that rapid and aggressive restoration of flow to the lower extremity is the best method to treat ALLI malperfusion syndrome. Close monitoring for the development of compartment syndrome is recommended

Knowledge, Perception, Attitudes and Behavior on Influenza Immunization and the Determinants of Vaccination

BACKGROUND: We sought to determine the knowledge of, perception, attitudes, and behaviors toward influenza virus and immunization, and the determinants of vaccination among students, patients, and Healthcare Workers (HCWs) at the American University of Beirut and its affiliated Medical Center. METHODS: We conducted a cross-sectional study between October 2016 and January 2017 utilizing a self-administered questionnaire that was provided to 247 randomly selected adult participants. Data collected included socio-demographic characteristics, prior vaccination against influenza, knowledge, perception, attitudes, and behaviors toward influenza and influenza immunization. A multivariable regression model was used to evaluate for independent associations between the different variables and regular or yearly vaccination as a primary outcome. RESULTS: The overall survey response rate was 77%. A substantial proportion of respondents (47.4%) had never received the influenza vaccine. Only 10.2% of students, 19.1% of patients, and 35.6% of HCWs reported regular or yearly influenza vaccine uptake. HCWs had the lowest knowledge score about influenza and its vaccine despite high self-reported levels of knowledge. Barriers to vaccinations included lack of information (31%), fear of adverse effects (29%), and a perception of not being at risk (23%). Several factors were independently associated with regular or yearly vaccination uptake including having children (adjusted OR = 3.8; 95% CI 1.2-12.5), a "very good" self-reported level of knowledge (OR = 16.3; 95% CI 1.4-194.2) and being afraid of the consequences of influenza (OR = 0.2; 95% CI 0.1-0.6). CONCLUSION: Adherence rates with regular or yearly vaccination against influenza remain low across all study groups. We were able to identify predictors as well as barriers to vaccination. Future awareness and vaccination campaigns should specifically aim at correcting misconceptions about vaccination, particularly among HCWs, along with addressing the barriers to vaccination. Predictors of vaccination should be integrated in the design of future campaigns

Functional assessment using 3D movement analysis can better predict health-related quality of life outcomes in patients with adult spinal deformity: a machine learning approach

IntroductionAdult spinal deformity (ASD) is classically evaluated by health-related quality of life (HRQoL) questionnaires and static radiographic spino-pelvic and global alignment parameters. Recently, 3D movement analysis (3DMA) was used for functional assessment of ASD to objectively quantify patient's independence during daily life activities. The aim of this study was to determine the role of both static and functional assessments in the prediction of HRQoL outcomes using machine learning methods.MethodsASD patients and controls underwent full-body biplanar low-dose x-rays with 3D reconstruction of skeletal segment as well as 3DMA of gait and filled HRQoL questionnaires: SF-36 physical and mental components (PCS&MCS), Oswestry Disability Index (ODI), Beck's Depression Inventory (BDI), and visual analog scale (VAS) for pain. A random forest machine learning (ML) model was used to predict HRQoL outcomes based on three simulations: (1) radiographic, (2) kinematic, (3) both radiographic and kinematic parameters. Accuracy of prediction and RMSE of the model were evaluated using 10-fold cross validation in each simulation and compared between simulations. The model was also used to investigate the possibility of predicting HRQoL outcomes in ASD after treatment.ResultsIn total, 173 primary ASD and 57 controls were enrolled; 30 ASD were followed-up after surgical or medical treatment. The first ML simulation had a median accuracy of 83.4%. The second simulation had a median accuracy of 84.7%. The third simulation had a median accuracy of 87%. Simulations 2 and 3 had comparable accuracies of prediction for all HRQoL outcomes and higher predictions compared to Simulation 1 (i.e., accuracy for PCS = 85 ± 5 vs. 88.4 ± 4 and 89.7% ± 4%, for MCS = 83.7 ± 8.3 vs. 86.3 ± 5.6 and 87.7% ± 6.8% for simulations 1, 2 and 3 resp., p < 0.05). Similar results were reported when the 3 simulations were tested on ASD after treatment.DiscussionThis study showed that kinematic parameters can better predict HRQoL outcomes than stand-alone classical radiographic parameters, not only for physical but also for mental scores. Moreover, 3DMA was shown to be a good predictive of HRQoL outcomes for ASD follow-up after medical or surgical treatment. Thus, the assessment of ASD patients should no longer rely on radiographs alone but on movement analysis as well

Laser Fenestration of Renal Artery in Fenestrated Endograft Repair of Abdominal Aortic Aneurysm

Introduction: Fenestrated endografts have expanded the indication for endovascular abdominal aortic repair. We present a case of an abdominal aortic aneurysm (AAA) repair with fenestrated endograft (FEVAR) with in situ laser fenestration of the right renal artery. Methods: This is the case of a 72-year-old man who was referred for evaluation of a 5.8 cm abdominal aortic aneurysm. Results: Due to the proximity of the right renal artery and superior mesenteric artery (SMA) ostia, a prefabricated fenestrated endograft could not be manufactured. We therefore requested a fenestrated graft with an SMA scallop, a left renal fenestration, and no right renal fenestration. Access to the right renal artery was obtained through the left brachial approach and an uncovered S.M.A.R.T. (Cordis Corporation) was deployed to mark the origin of the right renal artery (Fig. B). A fenestrated endograft (Cook Medical) with a left renal fenestration and an SMA scallop was then deployed (Fig. C). Using the S.M.A.R.T. stent as a target, a fenestration was created using an endovascular laser (Philips Medical) (Fig. D). An iCAST covered stent (Atrium Medical) was then deployed through the new fenestration, and fully expanded using a high-pressure balloon (Fig. E). Another iCAST stent was deployed into the left renal artery. Completion angiogram illustrated patent renal arteries without endoleaks (Fig. F). Postoperative course was uncomplicated, and the patient was discharged on postoperative day 2. Conclusion: Some aortic pathologies still pose unique challenges to advanced endovascular modalities. FEVAR with in-situ laser fenestration is a feasible option for patients with unfavorable anatomy

PC222. Engineered Vascular Grafts Using Three-Dimensional Printed Guides and the Ring Stacking Method

Objective: Developing a prosthetic graft with equivalent function and durability to arteries or veins has proved to be elusive. We introduce a novel vascular tissue engineering technique that we hope will serve patients with no viable autologous vessels to harvest. Methods: We describe our ring stacking method, which uses smooth muscle cells or fibroblasts to create custom vessels of different calibers. We use a combination of hydrogel, three-dimensional printed guides, and custom-molded plates to create cellular vascular rings (Fig 1), which are then stacked to create a cylindrical, viable vascular construct (Fig 2). The media layer is formed by creating rings of human vascular smooth muscle cells. An adventitial layer is created by applying human fibroblasts into our vessel-making protocol, which is completed by stimulating the vessel with ascorbic acid and transforming growth factor β for collagen production. Mechanical testing was performed to assess tensile strength, histologic evaluation to assess anatomic structure, and perfusion testing to assess hemodynamics. Immunogenicity testing was carried out by submerging the engineered vessel in whole blood for 24 hours and then immunostaining for leukocytes (CD45). Results: Our ring stacking method can be used to create different caliber vessels (Fig 2). Tensile testing of the vessels shows elastic and tensile strength that correlated with ring and vessel girth. Histologic analysis shows high cellularity with smooth muscle cell phenotype comparable to a native vessel and organized collagen in the adventitia. During perfusion testing, vessels were able to endure flow rates of 100 to 417 mL/min. No CD45 immunostaining was visualized during immunogenicity testing, suggesting that our tissue-engineered vessels have low immunogenic potential. Conclusions: The ideal bioprosthetic cardiovascular bypass graft needs to satisfy a broad range of characteristics. Initial testing of our graft shows adequate strength, viscoelasticity, and biocompatibility. Future directions for our laboratory include in vivo graft studies and more extensive flow and immunogenicity testing. [Figure presented][Figure presented