Objective The introduction of the hemodialysis reliable outflow (HeRO) graft in 2009 presented an alternative upper extremity access for hemodialysis (HD) patients with failing access sites. Despite initial enthusiasm, experience has revealed strengths and limitations of HeRO access. This study’s objective is to assess the contemporary use of HeRO grafts at two tertiary care centers. Methods The operative logs for patients undergoing hemodialysis access procedures were retrospectively reviewed at two tertiary care sites between January 2012 to July 2024. Only patients that underwent placement of a HeRO graft were abstracted for analysis. The average patient age, HeRO graft indication, HeRO graft technical construct, use of post HeRO systemic anticoagulation, and hemodialysis interventions pre/post HeRO access procedure were abstracted. All other patients who did not undergo a HeRO graft intervention were excluded. Results 18 patients with end stage kidney disease (ESKD) were identified as having undergone placement of a HeRO graft. Prior to HeRO placement, patients underwent 4.61 ± 3.91 HD access maintenance procedure. The most common construct for HeRO graft inflow was brachial artery to polytetrafluoroethylene (PTFE), 55%, followed by arteriovenous outflow vein to PTFE, 33%, and PTFE graft to graft, 11%. After HeRO placement, patients underwent 1.94 ± 1.77 HD access maintenance procedures. The primary patency rates at 6 months and 1 year were 50% and 47%, while secondary patency at 1 and 5 years were 80% and 27% respectively. The most common post-HERO complication was graft thrombosis. Ultimately, 72% of patients required systemic anticoagulation to maintain HeRO graft patency. Conclusion This contemporary analysis of HeRO graft use indicates the value of HeRO access: a lower number of re-interventions to maintain graft function, and relatively low incidence of access complications. Anticoagulation was required in the majority of HeRO patients. There was a statistically significant reduction in the number of hemodialysis access interventions after HeRO placement.

BACKGROUND:The introduction of the hemodialysis reliable outflow (HeRO) graft in 2009 presented an alternative upper extremity access for hemodialysis (HD) patients with failing access sites. Despite initial enthusiasm, experience has revealed strengths and limitations of HeRO access. This study's objective is to assess the contemporary use of HeRO grafts at 2 tertiary care centers. METHODS:The operative logs for patients undergoing HD access procedures were retrospectively reviewed at 2 tertiary care sites between January 2012 and July 2024. Only patients that underwent placement of a HeRO graft were abstracted for analysis. The average patient age, HeRO graft indication, HeRO graft technical construct, use of post-HeRO systemic anticoagulation, and HD interventions pre-/post-HeRO access procedure were abstracted. All other patients who did not undergo a HeRO graft intervention were excluded. RESULTS:Eighteen patients with end-stage kidney disease were identified as having undergone placement of a HeRO graft. Prior to HeRO placement, patients underwent 4.61 ± 3.91 HD access maintenance procedures. The most common construct for HeRO graft inflow was brachial artery to polytetrafluoroethylene (PTFE), 55%, followed by arteriovenous outflow vein to PTFE, 33%, and PTFE graft to graft, 11%. After HeRO placement, patients underwent 1.94 ± 1.77 HD access maintenance procedures. The primary patency rates at 6 months and 1 year were 50% and 47%, while secondary patency at 1 and 5 years were 80% and 27%, respectively. The most common post-HERO complication was graft thrombosis. Ultimately, 72% of patients required systemic anticoagulation to maintain HeRO graft patency. CONCLUSION:This contemporary analysis of HeRO graft use indicates the value of HeRO access: a lower number of reinterventions to maintain graft function, and relatively low incidence of access complications. Anticoagulation was required in the majority of HeRO patients. There was a statistically significant reduction in the number of HD access interventions after HeRO placement.

Applicant interviews remain an integral part of the match process used in graduate medical education. In vascular surgery, in-person interviews of the applicant by program faculty at the institution have been the standard for decades. The COVID-19 pandemic forced a dramatic pivot to virtual interviews. With this unexpected change, there is now insight that interview format can affect equal and fair access, negatively impact the environment, as well as alter financial and administrative burden for both the applicants and programs. Future modifications to the match process will have to be explored to ensure both applicants and programs are able to mutually find their best match.

BACKGROUND:Radiofrequency ablation (RFA) of symptomatic, incompetent small saphenous veins (SSVs) is supported by clinical practice guidelines, but polidocanol microfoam ablation (MFA) is not addressed in these guidelines owing to the absence of high-quality clinical data. However, some anatomical variations and clinical scenarios in patients with SSV reflux may be associated with equivalent or superior results when MFA is used compared with RFA. This study aims to compare early outcomes after the treatment of SSV incompetence in patients with Clinical-Etiology-Anatomy-Pathophysiology (CEAP) 2 class to 6 disease using either RFA or MFA. METHODS:A retrospective review of a prospectively maintained database was conducted among patients who underwent treatment of incompetent SSVs with either RFA or MFA. Limbs that underwent concomitant phlebectomy were included. All patients underwent postoperative duplex ultrasound at 48 to 72 hours and at least one follow-up visit by a vascular surgery provider. Primary outcomes were immediate SSV closure and ablation-related thrombus extension. Secondary outcomes analyzed included demographic data, CEAP clinical class, Venous Clinical Severity Score (VCSS), deep venous thrombosis, and adverse events. RESULTS:Between March 2018 and July 2024, 182 SSVs treated for symptomatic reflux with either RFA (n = 120) or MFA (n = 62) were identified. Age, gender, body mass index, reflux times, and SSV diameters were similar between both groups. The mean preoperative VCSSs were 9.4 ± 3.0 and 10.8 ± 3.7 in the RFA and MFA groups, respectively (P = .05). More venous ulcers were present at the time of MFA (n = 16 [26%]) than RFA (n = 14 [12%]) (P = .015). Median follow-up was 164.5 days in the RFA cohort and 156 days after MFA. Symptomatic improvement after RFA and MFA was 91% and 88%, respectively. The mean postoperative VCSS decreased from 9.4 to 7.3 in the RFA group (P < .001) and from 10.9 to 9.2 after MFA (P < .001). Immediate vein closure was achieved in 98% of limbs in both groups; two late recanalizations occurred after MFA, but none after RFA. The number of ulcers healed at last follow-up was greater after MFA (n = 13 [81%] vs n = 10 [71%]; P = .02). The incidence of ablation-related thrombus extension was 4.8% (n = 3) after MFA and 1.7% (n = 2) after RFA (P = .52). One gastrocnemius deep venous thrombosis occurred in the MFA group. No pulmonary emboli or central nervous complications occurred. All adverse thrombotic events were asymptomatic and resolved with short-term anticoagulation. Superficial phlebitis was higher after MFA (n = 11 [17.7%] vs n = 5 [4.2%]; P = .002) One postoperative sural neuralgia occurred after RFA. CONCLUSIONS:RFA and MFA are both safe and effective treatments for patients with symptomatic, incompetent SSVs. Both resulted in excellent clinical relief and early truncal vein closure rates. The number of ulcers healed was higher in the MFA group, but this difference was significant on univariate analysis only. Adverse thrombotic events after RFA were low and consistent with other contemporary studies, although superficial phlebitis was more frequent after MFA.

BACKGROUND:Accurately predicting postoperative outcomes is fundamental to informed clinical decision-making, and alignment of patient and family expectations. The AMPREDICT Decision Support Tool is a predictive tool designed to assess the probability of mortality 1 year after major and minor amputations. We aimed to evaluate the prognostic accuracy of AMPREDICT in our Veteran patient population. METHODS:Retrospective review of lower extremity amputations completed at the West Los Angeles Veterans Affairs hospital from 2000 to 2020. Staged open amputations and previous minor amputations were excluded. Using the AMPREDICT tool, the probability of mortality 1 year postsurgery for single-stage transfemoral and transtibial amputations was calculated, then compared with observed patient outcomes. Observed to predicted mortality was compared through boxplots, at 1 year after surgery, confidence intervals were calculated, and group means were compared using Student's t-test. Receiver operator curves were constructed to assess discriminatory capacity of the tool. Significance was set at P < 0.05. RESULTS:Four hundred twenty three patients underwent 650 lower extremity amputations during our study period. Two hundred sixty seven patients underwent single-stage transfemoral or transtibial amputations comprising our study cohort. The average age at amputation was 66 years with an average age of death at 71 years. AMPREDICT tool's prognostic capability varied across the 2 amputations studied. For single-staged transfemoral amputations, prediction aligned closely with observed outcomes, as indicated by a significant P value of 0.0002 (confidence interval 12.73-36.37). For single-stage transtibial amputations, the predictions were also significant, P value 0.0017 (confidence interval 5.25-21.20), although had a wider prediction range. CONCLUSIONS:Our study confirms the reliability of the AMPREDICT tool in predicting 1-year mortality for patients undergoing major lower limb amputations. The predictive accuracy was found to be statistically significant for both single-staged transfemoral and transtibial amputations. These findings suggest that AMPREDICT may be a valuable tool in the clinical setting for patients undergoing major lower limb amputation.

OBJECTIVE:Polidocanol endovenous microfoam ablation (MFA) is approved by the US Food and Drug Administration for great saphenous vein (GSV) closure, yet there are few published data on the subsequent risk of ablation-related thrombus extension (ARTE). Recent societal practice guidelines recommend against routine postprocedure duplex ultrasound (DU) examination after thermal ablation of the GSV in asymptomatic patients. At present, limited data do not allow this recommendation to extend to MFA. Our aim is to identify characteristics and outcomes associated with ARTE following MFA vs radiofrequency ablation (RFA). METHODS:A retrospective review of a prospectively maintained database was conducted of patients who underwent MFA and RFA closure of incompetent above-knee GSVs. Patients treated for isolated tributary vein treatment or did not have a postprocedure DU examination within 48 to 72 hours were not included. Patients were classified into two groups: ARTE and no ARTE. Demographic data, Clinical, Etiologic, Anatomic and Pathophysiologic class, Venous Clinical Severity Score, operative details, postprocedure (48-72 hours) DU findings, and adverse events were analyzed. Variables that were significant on univariate analysis were evaluated using multivariate logistic regression with the primary outcome being development of ARTE. RESULTS:Between June 2018 and February 2023, 800 limbs were treated with either MFA (n = 224) or RFA (n = 576). Ninety-six GSVs treated with MFA met the study criteria. One hundred fifty successive GSVs treated with RFA during the same period were included as a comparison group. There was no statistically significant difference in baseline demographics between the two groups. Six patients (2.4%) demonstrated ARTE on postoperative DU examination at 48 to 72 hours (MFA, n = 5 [5.2%]; RFA, n = 1 [0.7%]; P = .02). Saphenous vein ablation with MFA (P = .045) and a vein diameter of >10 mm (P = .017) were associated with ARTE on both univariable and multivariable analysis. All patients who developed ARTE were treated with oral anticoagulants (mean, 15.6 days). Body mass index, Clinical, Etiologic, Anatomic and Pathophysiologic class, Venous Clinical Severity Score, microfoam volume, operative time, and prior deep venous thrombosis were not predictive of ARTE. CONCLUSIONS:ARTE after above-knee GSV closure occurred more frequently after MFA. Our results suggest that a saphenous vein diameter of >10 mm may be associated with ARTE. Despite this finding, all patients with ARTE were treated with short-term anticoagulation with no related complications. Until larger studies with high-risk subgroups have been studied after MFA, DU examination should be performed routinely after this procedure and patients with ARTE anticoagulated until the thrombus retracts caudal to the saphenofemoral junction or is no longer present on DU examination. Current societal guidelines recommending against routine post-thermal ablation DU examination should not be applied to similar patients after saphenous nonthermal MFA ablation.

Background: The literature suggests that for patients to experience the purported advantages of an arteriovenous fistula (AVF) over arteriovenous graft (AVG), a minimum survival of 18 months is required. With the vasc ular access guideline shift away from "Fistula First"toward shared decision making, patient survival after vascular access creation is a major factor to consider in optimal access selection. The objective of this study is to examine outcomes of vascular access in patients with short survival and factors associated with short survival, including frailty. Methods: We performed a retrospective review of 200 access procedures performed between August 2018 and November 2020 at a single institution. Maturation was defined as the date when the surgeon deemed the access ready to be used for dialysis. A modified Risk Analysis Index (RAI) score was used to calculate frailty. Results: Within 3 years after access creation, 55 (27.5%) patients were recorded as dead (mortality within 3 years of access creation [3YMORT]). In the 3YMORT group, 5 did not follow-up with the surgeon prior to death and 22/34 (65%) of AVF versus 15/16 (94%) of AVGs were deemed mature prior to death ( P = 0.03). Of the accesses that matured, the median days to maturation for AVF was 69 (interquartile range [IQR] 53, 87) versus 28 (IQR 18, 32) for AVG ( P < 0.001). Patients in the 3YMORT group were older (70.6 vs. 63.4, P = 0.004) and had a lower body mass index (24.8 vs. 27.4, P = 0.03). Patients in the 3YMORT group had higher prevalence of dysrhythmia (35% vs. 15%, P = 0.002), chronic obstructive pulmonary disorder (20% vs. 10%, P = 0.048) and dialysis dependence at the time of access creation (91% vs. 75%, P = 0.01). There was no significant difference in sex, white race, Hispanic ethnicity, coronary artery disease, congestive heart failure, previous coronary artery bypass graft or percutaneous coronary intervention, diabetes, hypertension, and peripheral arterial disease between the 2 groups. The 3YMORT group had a significantly higher prevalence of frailty (78% vs. 49%, P = 0.0002). Patients categorized as frail by the RAI had a significantly higher risk of 3YMORT (odds ratio [OR] 3.74, 95% confidence interval [CI] 1.82-7.66) compared to nonfrail patients. Patients categorized as very frail by the RAI had an even higher risk of 3YMORT (OR 4.20, 95% CI 1.95-9.05), compared to nonfrail patients. Conclusions: Patients with short life expectancy after vascular access creation may have high rates of AVF nonmaturation and longer time to maturation. Factors associated with high risk of mortality within 3 years of vascular access creation correlate well with factors included in the RAI frailty score. Patients who are frail or very frail may be appropriate candidates for AVG creation over AVF considering their high risk for short life expectancy.

PURPOSE:The graduate medical education community implemented virtual residency interviews in response to travel restrictions during the COVID-19 pandemic, and this approach has persisted. Although many residency applicants wish to visit in-person prospective training sites, such opportunities could bias programs toward those who are able to meet this financial burden, exacerbating equity concerns. One proposed solution is to offer applicants the opportunity to visit only after a program's rank list is "locked," avoiding favoritism to applicants who visit, but allowing applicants to experience some of the camaraderie, geography, and local effects of an in-person visit. As debate about the optimal format of residency interviews continues, it is important to investigate whether in-person program visits, completed after program rank list certification, provide meaningful benefits to applicants in the residency match process. METHODS:All vascular programs entering the 2023 integrated vascular surgery residency match were invited to participate. Programs agreed to certify their National Resident Matching Program rank lists by February 1, 2023. Applicants then had the opportunity to visit the programs at which they interviewed. The particulars of the visit were determined by the individual programs. Applicants completed their standard rank list and locked on the standard date: March 1, 2023. Applicants then completed a survey regarding the impact of the visits on their rank order list decision-making. Program directors (PDs) completed a survey regarding their experiences as well. Data were collected using REDCap. RESULTS:Twenty-one of the 74 (28%) programs participated. Nineteen PDs completed the postinterview site visit survey (response rate 90%). Applicants interviewing at the participating programs (n = 112) were informed of the study, offered the opportunity to attend postinterview site visits, and received the survey. Forty-seven applicants responded (response rate 42%). Eighty-six percent of applicants stated that the visit impacted their rank list. Most important factors were esprit de corps of the program (86%), the faculty/trainees/staff (81%), and the physical setting (62%). Seventy-one percent of those participating spent ≤$800 on their visit. Eighty-one percent were satisfied with the process. Twenty-one percent of PDs would have changed their rank list if they could have based on the applicants' in-person visit. Sixty-three percent of the visit sessions cost the programs ≤$500, and 63% were satisfied with the process. CONCLUSIONS:This study is the first to document the impact of in-person site visits by applicants on a graduate medical education match process in one specialty. Our results suggest that this process provides meaningful data to applicants that helped them with their decision-making evidenced by most altering their rank lists, while avoiding some of the critical equity issues that accompany traditional in-person interviews. This may provide a model for future interview processes for residency programs.

OBJECTIVE:Arteriovenous fistula (AVF) for hemodialysis access is traditionally considered superior to grafts due to infection resistance and purported improved patency. However, challenges to AVF maturation and limited patient survival may reduce AVF benefits. The objective of this study is to identify factors associated with risk of AVF requiring revision before maturation and/or mortality within 2 years of creation. METHODS:We performed a retrospective review of 250 AVFs created between May 2017 and November 2020 at a single institution. Maturation was defined as the date the surgeon deemed the AVF ready for use or the patient successfully used the AVF for dialysis. The Risk Analysis Index was used to calculate frailty. The primary outcome was a composite of endovascular/surgical revision to promote maturation and/or mortality within 2 years of AVF creation (REVDEAD). The primary outcome was categorized as met if the patient required a revision to promote maturation or if the patient experienced mortality within 2 years of AVF creation, or if both occurred. REVDEAD was compared with those who did not meet the primary outcome and will be referred to as NOREVDEAD. RESULTS:Survival at 2 years after AVF creation was 82%, and 54 (22%) patients underwent AVF revision. Of those, 31 (59%) patients progressed to AVF maturation. Of the 250 AVFs, 91 (36%) met the primary outcome of REVDEAD and 159 (64%) did not (NOREVDEAD). There was no difference between the REVDEAD and NOREVDEAD groups in age (P = .18), sex (P = .75), White race (P = .97), Hispanic ethnicity (P = .62), obesity (P = .76), coronary artery disease (P = .07), congestive heart failure (P = .29), diabetes mellitus (P = .78), chronic obstructive pulmonary disease (P = .10), dialysis status (P = .63), hypertension (P = .32), peripheral arterial disease (P = .34), or dysrhythmia (P = .13). There was no difference between the groups in the forearm vs the upper arm location of AVF (P = .42) or the vein diameter (P = .58). Forearm access, as opposed to upper arm AVF creation, was associated with higher rate of revision before maturation (P = .05). More patients in REVDEAD were frail or very frail (60% vs 48%, P = .05). Of the AVFs that matured, maturation required longer time in REVDEAD at 110.0 ± 9.1 days vs 78.8 ± 5.6 days (mean ± standard deviation) (P = .003). Adjusted for the vein diameter and the forearm vs the upper arm, frailty increased the odds of REVDEAD by 1.9 (95% confidence interval: 1.1, 3.3). CONCLUSIONS:Frail patients who underwent AVF were significantly more likely to die within 2 years of AVF creation with no significant association between frailty and the need for revisions to promote maturation. Forearm AVFs were more likely to require revisions; in patients who are frail, with a high likelihood of 2-year mortality, graft may be more appropriate than AVF. If AVF is being considered in a frail patient, upper arm AVFs should be prioritized over forearm AVFs.

A recent publication from our colleagues in internal medicine is quite illuminating. Boatright and authors looked at the impact of racial and ethnic differences on trainees’ ACGME Milestone scores.1 This study involved over 9,000 residents and was conducted over several years of training. Residents were divided into 3 categories: White, Asian and Underrepresented in Medicine (URiM, which includes Hispanic, non-Hispanic American Indian, Black/African American, and other non-Asian minority people). The authors found that across the domains, the white trainees received higher scores compared to their Asian and URiM colleagues, peaking in the second year of training. Although these scores balanced out by the end of the third year of training, job searches and fellowship applications are likely impacted by these evaluations. They concluded that this limits opportunities for the minority trainees and subsequently workforce diversity. There is other literature with similar findings. Klein et al looked looked at milestones and the impact of minority status and also gender across 6 internal medicine programs.2 Non-URiM residents scored higher on domains as diverse as patient care, systems-based practice, problem-based learning & Improvement and Professionalism. Interestingly, when the evaluators were broken down by gender, female faculty members were much harsher in their scores across the board, but also had more pronounced differences in their lower scores for the URiM versus non-URiM colleagues. It can be helpful to look at the business world to see how it deals with these problems. Although the social justice aspects of equity ought to be sufficient motivation to correct such issues, many in business also recognize the dollar costs to companies inherent in a system that does a poor job rating, and thus promoting and taking advantage of the talents of its employees. Williams and authors in a recent Harvard Business Review article described a company’s experience combating performance review bias.3 They give multiple examples of these biases, for example, only 9.5 percent of reviews for people of color mentioned leadership (a term predictive of higher competency ratings), while greater than 70 percent of those for white woman did. The authors set about determining if there were patterns to these biases and defined them as (1Boatright D. Anderson N. Kim J.G. Holmboe E.S. McDade W.A. Fancher T. Gross C.P. Chaudhry S. Nguyen M. Nguemeni Tiako M.J. Colson E. Xu Y. Li F. Dziura J.D. Saha S. Racial and Ethnic Differences in Internal Medicine Residency Assessments.JAMA Netw Open. 2022 Dec 1; 5 (PMID: 36580337; PMCID: PMC9857126)e2247649https://doi.org/10.1001/jamanetworkopen.2022.47649Crossref Scopus (1) Google Scholar) “prove it again” – white men tended to be judged on their potential, while minorities and women were judged on performance (2Klein R. Ufere N.N. Schaeffer S. Julian K.A. Rao S.R. Koch J. Volerman A. Snyder E.D. Thompson V. Ganguli I. Burnett-Bowie S.M. Palamara K. Association Between Resident Race and Ethnicity and Clinical Performance Assessment Scores in Graduate Medical Education.Acad Med. 2022 Sep 1; 97 (Epub 2022 May 17. PMID: 35583954; PMCID: PMC9910786): 1351-1359https://doi.org/10.1097/ACM.0000000000004743Crossref Scopus (12) Google Scholar) “the tightrope” – women and minorities had a narrower range of acceptable behavior and were more apt to be labelled as “aggressive” or “difficult” (3Williams J.C. Loyd D.L. Boginsky M. Armas-Edwards F. How One Company Worked to Root out Bias from Performance Reviews.Harvard Business Review. 21 Apr. 2021; hbr.org/2021/04/how-one-company-worked-to-root-out-bias-from-performance-reviewsDate accessed: May 7, 2023Google Scholar) A “Maternal Wall” exists – women are assumed to be less ambitious and are given jobs that fit that stereotype (office “housework”), and (4Mount M.K. Judge T.A. Scullen S.E. Sytsma M.R. Hezlett S.A. Trait, rater and level effects in 360-degree performance ratings.Personnel Psychology. 1998; 51: 557-576https://doi.org/10.1111/j.1744-6570.1998.tb00251.xCrossref Scopus (131) Google Scholar) racial stereotypes still persist. The company came up with several solutions to these problems. As we have done in medicine, they moved from open questions to competencies for a start. Although we are taught to use open questions when interviewing patients, this is actually a technique that can accentuate biases when used for performance evaluations. In addition, evaluators needed to supply three pieces of supportive evidence to accompany the opinions given in their assessments. This helps to blunt the “halo-horns” effect – that is, the tendency to generalize strengths or weaknesses in a group depending on biases. Workshops were held to instruct employees on using the new evaluation techniques, and an iterative process was developed whereby the results of these changes could be monitored. After 2 years, the authors noted many positive changes. Constructive feedback comments for people of color increased from 17 to 49 percent, world count and complexity became similar across all groups, negative personality comments disappeared (14 percent to zero) and comments such as “takes initiative” increased from 19 percent at year 1 to 94 percent at year two. The authors did not think that they had “solved” the problem – for example, positive but unhelpful comments continued to be an issue (the “women are wonderful” problem – these comment don’t lead to promotion) for some groups, the “prove it again” category was still more common with people of color (78 percent versus 43 percent for white employees), but the company recognized that continued work was needed, and continues to make changes to address these issues. A core problem in evaluations is the idiosyncratic rater effect. That is, there is a tremendous amount of variation at the individual evaluator level . This doesn’t just include cognitive and social biases, but also things as simple as how a rater interprets the criteria being utilized and how judgmental he/she is. Psychology literature suggests that up to 72 percent of performance ratings are more reflective of the assessor than that of the assessed.4 We can combat some of this by making questions as objective as possible, although this is still open to variation – think of faculty opinions at the end of a long interview day – but it is a step in the right direction. As we try to correct some of these issues, the role of bias looms large, and is helpful to recognize the tremendous number and variations of bias that impact our evaluations. We have already discussed some of these (“halo-horns” effect, racial stereotypes), and there are many more. Confirmation bias, distance bias and self-rater bias to name but a few most of us are familiar with. The cultural implications of the self-rater bias is well described by Menzies with the example of two proverbs from two cultures and how they may impact self evaluation: the American “the squeaky wheel gets the grease” and the Japanese “the nail that stands up gets hammered down”.5 Menzies set forth a numbers of solutions to these problems in the business world. These stress the importance of specific, objective criteria for evaluators and for employees, using well-defined rating scales, getting limiting rating scales, and getting multiple perspectives in evaluations (the 360 evaluations we use) and the limiting of rating scales. This last point is illustrative of how small change can make a big difference, with a study showing switching from a 10 point to a 6 point rating scale eliminated the gender gap for a university’s teaching evaluations.6 Given what we know, and the lessons we can learn from the business world, Entrustable Professional Activities (EPA’s) are a promising component to solving the assessment problem. Tasks that trainees are eventually able to complete unsupervised, these are by definition designed to be observable and measurable. As the discussion above indicates, it should be our goal to be less abstract and more defined in assessment tools, and as anyone who has worked with Competencies knows, these tend to be the opposite. They also are not particularly good at representing the actual day to day work of a resident. EPA’s are being designed to reflect this work. For those of us who have been using the milestones, it is worth noting that EPA’s do not abandon them – specific tasks are mapped to the categories we have already been using, so that we are not throwing out the good with the bad. To give a specific example from the general surgery EPA’s, phrases like “these residents are not able to describe the anatomic boundaries of the critical view of safety and lack spatial awareness” becomes “they are able to describe the anatomic boundaries of the Hepatocystic triangle and understand the relationship between the gallbladder and common bile duct” – verbiage that is task-oriented, specific and well-defined. We do have some early data on the use of EPA’s in general surgery – and it is promising. Padilla and colleagues reported on the impact of EPA use and gender.7 Assessments using EPA’s did not show any differences in EPA levels between male and female trainees. Interestingly, female trainees in this study rated themselves lower by almost an entire year of training – a tendency we as educators must also be aware of. We await data on EPA’s and and URiM trainees and certainly across specialties as their use gains acceptance. It is worth noting that work on the EPA’s for Vascular Surgery is ongoing and we should be a relatively early adopter. As we apply this new system, we will need to continuously review the results to ensure the biases we are trying to avoid do not creep into the system. In conclusion, bias in evaluations is real. We have made changes that are supported by data to help combat this problem – more specific, objective criteria, 360 evaluations and the adoption of Milestones. However, the problem is far from solved, and EPA’s may provide meaningful progress in evaluation equity. Ultimately, it will also be important to correlate this improvement in evaluations with beneficial impacts on longer-term measurable outcome metrics, such as board certification. 5Menzies, Felicity. “Eliminating Bias from Performance Appraisals.” LinkedIn, 27 June 2021, https://www.linkedin.com/pulse/eliminating-bias-from-performance-appraisals-felicity-menzies-fca?trk=read_related_article-card_title.Google Scholar, 6Rivera L.A. Tilcsik A. Scaling down inequality: Rating scales, gender bias, and the architecture of evaluation.American Sociological Review. 2019; 84: 248-274https://doi.org/10.1177/0003122419833601Crossref Scopus (79) Google Scholar, 7Padilla E.P. Stahl C.C. Jung S.A. Rosser A.A. Schwartz P.B. Aiken T. Acher A.W. Abbott D.E. Greenberg J.A. Minter R.M. Gender Differences in Entrustable Professional Activity Evaluations of General Surgery Residents.Ann Surg. 2022 Feb 1; 275 (PMID: 33856381; PMCID: PMC8514571): 222-229https://doi.org/10.1097/SLA.0000000000004905Crossref Scopus (11) Google Scholar.

The paper by van Hoof et al presents longer term follow-up on a large number of patients with iliac endofibrosis who have undergone operative repair with endarterectomy and patching (excluding those treated only for a kink, which they have previously published).1,2 The results after a median of 11 years are excellent, with overall operative satisfaction at 91.7% and 94.5% continued symptom reduction. This outcome is even more encouraging than the numbers suggest, because these patients are involved in very high levels of athletic performance.

The rapid adoption of artificial intelligence (AI) into everyday use has presented multiple issues for surgical educators to consider. In this article, the authors discuss some of the ethical aspects of academic integrity and the use of AI. These issues include the importance of understanding the current limits of AI and the inherent biases of the technology. The authors further discuss the ethical considerations of the use of AI in surgical training and in clinical use, with an emphasis on vascular surgery.

Background: Frailty is a known risk factor for adverse outcomes following surgery and affects at least 3 of every 10 US Veterans aged 65 years and older. We designed a study to charac-terize the association between frailty and complications after endovascular aneurysm repair (EVAR) compared to open aneurysm repair (OAR) at our regional Veterans Affairs Medical Center.Methods: Veterans who underwent either OAR or EVAR at our institution between January 1, 2000 and December 31, 2020 were identified. We examined medical history, procedure charac-teristics, perioperative complications, and frailty as measured by the 5-factor modified frailty in-dex (mFI-5). Frailty was defined as an mFI-5 score >2. Primary endpoints were postoperative complications, duration of surgery, and length of hospital stay. Tests of association were per-formed with t-test and chi-squared analysis.Results: Over the 21-year period, we identified 314 patients that underwent abdominal aortic aneurysm (AAA) repair with 115 (36.6%) OAR and 199 EVAR (63.4%) procedures. Patients un-dergoing EVAR were older on average (72.1 years vs. 70.2 years) and had a higher average mFI-5 compared to the open repair group (1.49 vs. 1.23, P = 0.036). When comparing EVAR and OAR cohorts, patients undergoing OAR had a larger AAA diameter (6.5 cm, standard devi-ation [SD]: 1.5) compared to EVAR (5.5 cm, SD: 1.1 P < 0.0001). Fewer frail patients underwent OAR (n = 40, 34.8%) compared to EVAR (n = 86, 43.2%), and frail EVAR patients had higher AAA diameter (5.8 cm, SD: 1.0) compared to nonfrail EVAR patients (5.3 cm, SD 1.2), P = 0.003. Among OAR procedures, frail patients had longer operative times (296 min vs. 253 min, P = 0.013) and higher incidence of pneumonia (17.5% vs. 5.3%, P = 0.035). Among frail EVAR patients, operative time and perioperative complications including wound dehiscence, surgical site infection, and pneumonia were not significantly different than their nonfrail counter-parts. Overall, frail patients had more early complications (n = 55, 43.7%) as compared to nonf-rail patients (n = 48, 25.5%, P = 0.001). OAR patients had higher rates of postoperative complications including wound dehiscence (7.0% vs. 0.5%, P = 0.001), surgical site infections (7.0% vs. 1.0%, P = 0.003), and pneumonia (9.6% vs. 0.5%, P=<0.0001). Open repair was also associated with overall longer average intensive care unit stays (11.0 days vs. 1.6 days, P < 0.0001) and longer average hospitalizations (13.5 days vs. 2.4 days, P < 0.0001).Conclusions: Our findings demonstrate that frailty is associated with higher rates of adverse outcomes in open repair compared to EVAR. Patients who underwent open repair had higher rates of wound dehiscence, surgical site infection, and pneumonia, compared to those undergo-ing endovascular repair. Frailty was associated with larger AAA diameter in the EVAR cohort and longer operative times, with higher frequency of postoperative pneumonia in the OAR cohort. Frailty is a strong risk factor that should be considered in the management of aortic aneurysms.

Background: Veterans are disproportionately affected by housing insecurity (HI), which can lead to adverse health outcomes and reduced life expectancy. We sought to examine the impact of HI on the outcomes of veterans who underwent abdominal aortic aneurysm (AAA) repair at our regional Veterans Affairs medical center. Methods: Retrospective chart review was performed on patients who underwent AAA repair at our institution between January 1, 2000, and December 31, 2020. We examined medical history, procedure details, hospitalization course, and postoperative outcomes. Primary endpoints were a 30-day mortality and median survival. Secondary endpoints were hospital length of stay, readmission rate, and perioperative complications. Hypothesis testing was performed with t-test and chi-squared analysis. Survival analysis was conducted using KaplaneMeier estimation. Results: Of the 314 veterans that underwent AAA repair (mean age of 71.4 +/- 7.8 years, 99.7% male) over the 21-year period, we identified 39 (12.4%) patients with a history of HI. The HI was associated with a positive smoking history (100% vs. 88.0%, P = 0.022), lower rate of hypertension diagnosis (69.2% vs. 84.0%, P = 0.024), and increased rate of surgical site infections (SSI) (10.3% vs. 1.8%, P = 0.016). The median postoperative survival was lower in the HI group (7.6 years [CI 6.0-11.2] vs. 8.9 [CI 6.9-10.3]). Conclusions: HI was associated with reduced median postoperative survival, greater readmission rate, and increased risk of SSI following AAA repair.

Ureteroiliac fistula is a rare complication associated with ureteral stenting and iliac artery reconstruction and can lead to life-threatening hemorrhage. We report a case of acute bleeding from a ureteroiliac fistula in an 89-year-old man with bladder cancer who had undergone pelvic radiation, radical cystectomy, and ileal conduit complicated by ureteral strictures requiring routine stent exchanges. Multidisciplinary diagnostic therapies revealed the fistula, which was treated with hypogastric artery coiling and covered stent placement. No further bleeding issues had resulted from the fistula at 11 months of follow-up. The presence of a ureteroiliac fistula should be considered in any patient with a similar history.

Background: Endovenous ablation techniques have replaced greater saphenous vein (GSV) ligation and stripping for treatment of venous insufficiency. Our objective was to investigate our initial procedural experience and clinical presentation of patients undergoing mechanochemical ablation (MOCA) at a single institution. We hypothesized that closure level and success rate improved over time and were comparable to other endovenous ablation techniques. Methods: We retrospectively reviewed all MOCA procedures performed at the Greater Los Angeles Veterans Affairs Hospital from 2015 - 2020. Variables included CEAP and VCSS scores, patient symptoms, post procedure duplex ultrasound, closure level, and need for anticoagulation. Success was defined as GSV thrombosis on initial post procedure duplex ultrasound. Procedure associated extension of thrombus into the deep veins was defined using the American Venous Forum (AVF) endothermal heat induced thrombosis (EHIT) classification. Results: 104 venous ablation procedures were performed on 86 patients. Eleven (12.8%) patients received bilateral interventions, and six (7%) patients had asynchronous interventions on the same leg. The average age was 58.4 years (SD 12) and 93% were male. Pre-procedural symptoms included pain (102, 98.1%), varicose veins (87, 83.7%), edema (58, 55.8%), and active ulcers (19, 18.3%). A CEAP category of C2 was the most common indication (34.6%), followed by C3 (22.1%) and C6 (21.2%). Forty-five (43.2%) patients had deep system reflux, and 53% had concomitant phlebectomies. Average VCSS score was 7.5 (SD 3.5).We observed a GSV ablation rate of 92.7% (n = 89) in the 96 procedures which had post-procedure follow up, with no temporal evidence of a learning curve. On post procedure duplex of the 89 technically successful ablations, 77 (86.5%) patients had AVF EHIT level 1 closure, three (3.4%) had level 2 closure, eight (8.9%) had level 3 closure, and one had a level 4 closure. Fourteen (15.7%) patients were newly started on anticoagulation for an average of 33.2 days (SD 34.1). Of the 19 legs treated for active venous ulcers, 13 (68.4%) had improvement or resolution of their venous ulcers. No pulmonary embolic complications were reported. Conclusions: We observed a successful GSV thrombosis rate of 92.7% using MOCA without evidence of a learning curve and comparable to that reported in the literature. The rate of thrombus extension into the deep veins was 14.6%, with no adverse effects associated with anticoagulation or clinically significant sequelae of AVF EHIT level 2 or greater. Comparisons with MOCA associated thrombus extension into deep veins in the literature are limited as post procedure screening duplex are not standard of care. However, we demonstrated that MOCA ablation of the GSV is a safe procedure that may be performed with good technical success.

INTRODUCTION:Most patients with acute Paget-Schroetter syndrome (PSS) present in one of two manners: (1) thrombosis managed initially with thrombolysis and anticoagulation and then referred for surgery, and (2) initial treatment with anticoagulation only and later referral for surgery. Definitive benefits of thrombolysis in the acute period (the first 2 weeks after thrombosis) over anticoagulation alone have not been well reported. Our goal was to compare patients managed with early thrombolysis and anticoagulation followed by first rib resection (FRR) and later postoperative venography with venoplasty (PTA) with those managed with anticoagulation alone followed by FRR and PTA using vein patency assessed with venography and standardized outcome measures. METHODS:We reviewed a prospectively collected database from 2000 to 2019. Two groups were compared: those managed with early thrombolysis at our institution (Lysis) and those managed with anticoagulation alone (NoLysis). All patients underwent FRR. Venography was routinely performed before and after FRR. Standardized outcome measures included Quick Disability of Arm, Shoulder, and Hand (QuickDASH) scores and Somatic Pain Scale. RESULTS:A total of 50 Lysis and 50 NoLysis patients were identified. Pre-FRR venography showed that thrombolysis resulted in patency of 98% of veins, whereas 78% of NoLysis veins were patent. After FRR, postoperative venography revealed that 46 (92%) patients in the Lysis group and 37 (74%) patients in the NoLysis group achieved vein patency. Thrombolysis was significantly associated with final vein patency (odds ratio: 17 [4-199]; P < .001). Lysis patients had a trend toward lower QuickDASH scores from pre-FRR to post-FRR compared with NoLysis patients with a mean difference of -16.4 (±19.7) vs -5.2 (±15.6) points (P = .13). The difference in reduction of Somatic Pain Scale scores was not statistically significant. CONCLUSIONS:Thrombolysis as initial management of PSS, combined with anticoagulation, followed by FFR and VenoPTA resulted in improved final vein patency and may lead to an improved functional outcome measured with QuickDASH scores. Therefore, clinical protocols using thrombolysis as initial management should be considered when planning the optimal treatment strategy for patients with acute PSS.

Objective: Over the past two decades, vascular surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of ATOS by vascular surgeons and outcomes after both endovascular and open repair of the subclavian artery. Methods: We queried a single-institution, prospectively maintained thoracic outlet syndrome database for ATOS cases managed by vascular surgeons. For comparison, cases were divided into two equal time periods, January 1986 to August 2003 (P-1) vs September 2003 to March 2021 (P-2), and by treatment modality, open vs endovascular. Clinical presentation, outcomes, and the involvement of vascular surgeons in endovascular therapy were compared between groups. Results: Of 2200 thoracic outlet syndrome cases, 51 were ATOS (27 P-1, 24 P-2) and underwent 50 transaxillary decompressive operations. Forty-eight cases (92%) presented with ischemic symptoms. Thrombolysis was done in 15 (29%). During P-1, vascular surgeons performed none of the catheter-based interventions. During P-2, vascular surgeons performed 60% of the angiograms, 50% of thrombolysis, and 100% of stent grafting. Subclavian artery pathology included 16 aneurysms (31%), 15 stenoses (29%), and 19 occlusions (37%). Compared with open aneurysmal repair, endovascular stent graft repairs took less time (241 vs 330 minutes; P = .09), incurred lower estimated blood loss (103 vs 150 mL; P = .36), and had a shorter length of stay (2.4 vs 5.0 days; P = .10). Yet the endovascular group had decreased primary (63% vs 77%; P = .481), primary assisted (75% vs 85%; P = .590), and secondary patency rates (88% vs 92%; P = .719), at a mean follow-up time of 3.0 years for the endovascular group and 6.9 years for the open group (P = .324). These differences did not achieve statistical significance. Functionally, 84% of patients were able to resume work or school. A majority of patients (88%) had a good to excellent functional outcome based on their Derkash score. Somatic pain scores and QuickDASH (disabilities of the arm, shoulder, and hand) scores decreased postoperatively, 2.9 vs 0.8 (P = .015) and 42.6 vs 12.6 (P = .004), respectively. Conclusions: This study describes the evolving role of endovascular management of ATOS over the past two decades and documents the expanded role of vascular surgeons in the endovascular management of ATOS at a single institution. Compared with open repair, stent graft repair of the subclavian artery may be associated with shorter operative times, less blood loss, but decreased patency, without changes in long-term functional outcomes.

Background: We hypothesize among patients undergoing lower extremity amputation, access to pre-, and post operative rehabilitation services; as well as improved medical care, have led to higher rates of postoperative ambulation, and improved survival.Methods: Retrospective single center review of all major lower extremity amputations per-formed at the Greater Los Angeles Veterans Affairs Healthcare System from 2000-2020 strat-ified into multiyear cohorts. We abstracted demographics, operative indication, comorbidities, preoperative medical management, perioperative complications, discharge location, and pre and postoperative ambulatory status. Odds of ambulation after amputation were analyzed using multivariate logistic regression. Survival was analyzed using multivariate logistic regression and Kaplan-Meier survival analysis. Multivariate logistic predictors were selected based on prior liter-ature and clinical experience.Results: We identified 654 operations in our study, noting fewer amputations performed in the latest 3 cohort years as compared to the initial cohort (2000-2004). Patients undergoing below -knee amputations (BKA) had 2.7 times (P < 0.05) greater odds of postoperative ambulation and 86% (P < 0.05) increased odds of survival compared to above-knee amputations (AKA). The odds of ambulation increased by 8.8% (P < 0.05) for each consecutive study year. Ambulation post-amputation conferred 13.2 times (P < 0.05) greater odds of survival. The odds of survival in "emergent"operations decreased by 48% (P < 0.05) compared to an "elective"operation. For each additional comorbidity, the odds of survival decreased by 18% (P < 0.05). Patients with any perioperative complication had a 48% (P < 0.05) lower odds of survival. Kaplan-Meier sur-vival estimates demonstrated significant survival difference between patients by amputation level and postoperative ambulatory status (P < 0.05).Conclusions: Ambulatory status following distal amputation has improved over time and is significantly associated with increased survival post-amputation. Patients undergoing a BKA or discharged home were most likely to ambulate postoperatively. Amputation level, preopera-tive comorbidities, and perioperative complications remain strong predictors of survival.

OBJECTIVE:Patients requiring thermal or chemical ablation of below knee (BK) truncal veins often have their proximal saphenous veins treated initially and comprise a study population with multilevel, refractory chronic venous insufficiency. The study objective was to assess the outcomes after microfoam ablation of BK truncal and tributary veins in patients with a history of proximal great saphenous vein (GSV) ablation or stripping. METHODS:A retrospective review of a prospectively maintained database was performed. All the patients who had undergone endovenous chemical ablation with commercially manufactured polidocanol microfoam for symptomatic BK truncal vein reflux after a previous saphenous ablation or stripping were identified. The patients had undergone duplex ultrasound scanning 48 to 72 hours after the procedure; those who had not adhered to the recommended follow-up protocol were excluded. The demographic data, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, venous clinical severity score (VCSS), procedure details, adverse thrombotic events, and follow-up data were abstracted. RESULTS:Between April 2018 and April 2021, 201 limbs were treated for symptomatic superficial truncal vein reflux with microfoam ablation. Of the 201 limbs, 68 in 49 patients met the inclusion criteria for the present study. The veins treated included the BK GSV (n = 45) and small saphenous vein (n = 23). The median follow-up was 97 days (range, 33-457 days) for the entire cohort. Most patients (63%) had a preoperative CEAP classification of C4 to C6. The median preoperative VCSS was 12.5. All the limbs that had undergone microfoam ablation in this cohort had a previously treated proximal ipsilateral GSV, with either thermal ablation or stripping. The median postoperative VCSS after BK treatment decreased to 10 (P < .001). The closure rate at the last follow-up was 96%. The overall symptomatic relief was 78% at the last follow-up. The absolute ulcer healing rate during the study period was 64% (16 of 25 ulcers had healed). One patient had developed thrombus extension into the popliteal vein, which resolved with anticoagulation therapy. One asymptomatic patient had developed nonocclusive thrombus in a gastrocnemius vein after small saphenous vein ablation. Because she was asymptomatic, anticoagulation therapy was not prescribed. Postoperative pain, phlebitis, and swelling were reported in 12%, 12%, and 2% of patients, respectively, and all had resolved at the last follow-up visit. Three limbs treated with chronic oral anticoagulant agents had had recanalized truncal veins during the study period after initial closure. No pulmonary emboli or neurologic adverse events were reported. No symptoms of saphenous or sural nerve injury had occurred. CONCLUSIONS:Endovenous chemical ablation with commercially manufactured polidocanol microfoam of BK truncal veins is a safe and effective treatment for patients with severe, refractory chronic venous insufficiency and prior saphenous interventions. This technique results in excellent overall closure rates and symptomatic relief with low adverse venous thrombotic events, across a wide range of CEAP classes.