Background Surgeons possess an intimate understanding of their clinical missions but often lack awareness of how national professional societies advance the interests of both physicians and patients. In a healthcare sector approaching $5 trillion in annual spending, individual voices struggle to move policy. National societies provide the necessary scale, expertise, and longitudinal relationships to navigate complex federal legislative and regulatory environments. Objectives The effectiveness of national surgical organizations is fundamentally dependent on the active support and engagement of individual surgeons. While societies provide the infrastructure for advocacy, from lobbying Congress and commenting during the agency rulemaking process to organizing grassroots advocacy messaging, their credibility and impact are driven by the real-world experience and participation of their members. Discussion The advocacy framework of national societies is examined through four key pillars: (1) Federal Advocacy: Organizations maintain critical relationships with Congress and federal agencies (CMS, FDA, NIH) to shepherd beneficial policy and preempt harmful regulations. (2) Data-Driven Advocacy: Policy critiques and suggestions can be illustrated by compelling real-life examples, but are also anchored in hard data. This can include traditional analysis such as the recent rapid-response analysis of trends in operative length complexity in response to proposed efficiency-linked cuts or highly accessible policy tools, such as “heat maps” showing population-level data searchable by different demographics and geographic designations. (3) Collaborative Power: Surgeons benefit from leveraging the “House of Surgery” convener role to project a unified message, recognizing that collective action from over 130 organizations carries more weight than fragmented individual efforts. (4) Engagement Tiers: Surgeon advocacy is a scalable commitment, ranging from minutes to engage in digital grassroots letters or PAC contributions to intensive health policy leadership programs like the Brandeis Health Leadership Program. Conclusion National surgical societies serve as a vital bridge between clinical reality and federal policy. However, to sustain this influence and protect the viability of surgical practice, individual surgeons must invest to move from passive membership to active advocacy. Surgeons are encouraged to explore their societies’ resources and lend their professional voices to the advocacy effort.

Background Hospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, post-operative outcomes and 1-year survival following B-FEVAR. Methods Patients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair (TEVAR)/complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test and mixed effects Cox regression were used to evaluate 1-year survival. Results A total of 4,302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortality did not differ by hospital volume (Q1=35/1059 (3.3%), Q2=30/1063 (2.8%), Q3=33/1120 (2.9%), and Q4=44/1060 (4.2%), p = 0.308). The high volume group had a higher rate of major complication (Q1=14.9%, Q2=12.8%, Q3=13.3%, and Q4=20.1%, adjusted p < 0.001). Physician modified grafts were more frequently employed in high-volume centers (Q1=4.5%, Q2=18.7%, Q3=11.3%, and Q4=19.2%, p < 0.001) with a decreased incidence of any endoleak noted at the end of the procedure (Q1=34.9%, Q2=32.8%, Q3=30.0%, and Q4=29.0%, p = 0.003). In the multivariable analysis, in-hospital mortality was not associated with center volume comparing very low volume to medium and high volume centers (OR [95% CI] vs Q4: Q1 =1.1 [0.6-1.9], Q2 =0.6 [0.4-1.1], and Q3 =0.9 [0.5–1.5], p all >0.05). No significant difference was found in 1-year survival between center-volume groups. Conclusions In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.

Objectives The effect of gender on the outcomes of revascularization procedures in young patients with premature atherosclerotic peripheral arterial disease (PAD) is not known. The objective of this study was to compare short-term and long-term outcomes between young males and females undergoing infra-inguinal revascularization procedures. Methods We examined postoperative outcomes of male and female PAD patients under the age of 55 who underwent infra-inguinal revascularization procedures at a single tertiary institution from 2011 to 2019. Primary outcomes included 30-day morbidity, patency of the revascularization procedures, and major adverse limb events (MALE). Secondary outcomes included survival, amputation rate, reintervention rate, improvement of ankle-brachial index (ABI), and number of reinterventions. Results Eighty-one infra-inguinal revascularization procedures (46 endovascular and 35 open procedures) were reviewed including 45 procedures in 37 males and 36 procedures in 31 females. Fifty-three (65.4%) of the procedures were performed in patients with chronic limb-threatening ischemia symptoms. The rest were treated for life-disabling claudication. The female patients were younger, had higher body mass index, and were more likely to have diabetes, hyperlipidemia, or chronic obstructive pulmonary disease in comparison to males. Thirty-day major adverse cardiovascular event was 0.0% and MALE was 16.0%. Mean follow-up was 806.2 days. At 1 year, primary patency was 34.4 ± 6.2%, primary assisted patency was 52.7 ± 6.5%, secondary patency was 61.8 ± 6.3%, and MALE-free rate was 47.0 ± 6.4%. For secondary outcomes at 1 year, amputation-free rate was 92.5 ± 3.2%, reintervention-free rate was 50.2 ± 6.4%, and survival was 96.2 ± 2.6%. By the end of the study, overall mortality rate was 14.8% and major amputation rate was 13.6%. No major differences were observed between males and females among these outcomes. A smaller improvement in ABI after revascularization was noted in females compared to males (female 0.2 ± 0.2 vs male 0.4 ± 0.2, p = .04). Among patients who required reintervention, females required a higher number of reinterventions than males (female 1.7 ± 2.5 vs male 0.8 ± 1.1, p = .03). Conclusions There were no significant differences in short-term and long-term outcomes between males and females under the age of 55 after infra-inguinal revascularization. Poor patency, high MALE rate, and high mid-term mortality, and amputation rates after revascularization in young PAD patients highlight the need for improved strategies to treat premature PAD.

Catheter-directed thrombolysis (CDT) is a common treatment for acute lower extremity arterial occlusions. The Rutherford classification scheme is a well-known tool for risk-stratifying and guiding treatment in patients with acute limb ischemia (ALI). In this study, we examine the relationship between Rutherford classification and outcomes of CDT.

Background: Operative risk for supra-aortic trunk (SAT) surgical revascularization for occlusive disease, particularly transthoracic reconstruction (TR), remains ill-defined. This study sought to describe and compare 30-day outcomes of TR and extra-anatomic (ER) SAT surgical reconstruction for an occlusive indication across the United States over a contemporary 15-year period. Methods: Using the National Surgical Quality Improvement Program, TR and ER performed during 2005-2019 were identified. Procedures performed for nonocclusive indications and those concomitant with coronary or valve operations were excluded. Rates of stroke, death, myocardial infarction (MI) and these as composite outcome (S/D/M) were compared. Logistic regression with stabilized inverse probability weighting (IPW) was used to compare groups via average treatment effect (ATE) while adjusting for covariate imbalances. Results: Over the 15-year period, 166 TR and 1,900 ER patients were identified. The majority of ERs were carotid-subclavian bypass (n = 1,344; 70.7%) followed by carotid-carotid bypass (n = 261; 13.7%) and subclavian/carotid transpositions (n = 123; 6.5%). TR consisted of aorto-SAT bypass (n = 120; 72.3%) and endarterectomy (n = 46; 27.7%). The median age was 64 years for TR and 65 years in ER (P = 0.039). Those undergoing TR were more often women (69.0% vs. 56.9%; P = 0.001) and less likely to have undergone previous cardiac surgery (9.2% vs. 20.8%; P = 0.006). TR were also less frequently hypertensive (68.1% vs. 75.4%; P = 0.038) and had statistically lower preoperative creatinine levels (0.86 vs 0.91; P = 0.002). Unadjusted rates of MI (0.6% vs. 1.3%; P = 0.72) and stroke (3.6% vs. 1.9%; P = 0.15) were similar between groups with mortality (3.6% vs. 1.5%; P = 0.05) and S/D/M (6.6% vs. 3.9%; P = 0.10) trending higher with TR. IPWs could be calculated for 1,754 patients (148 TR; 1,606 ER). The estimated probability of S/D/M was 3.8% in the ER group and 6.2% in TR; no difference was seen in ATE (2.4%; 95% confidence interval [CI]: -1.5 to 6.2; P = 0.23). No differences were seen in individual component ATEs (stroke: 3.0% vs. 1.7%; ATE = 1.3%; 95% CI: -3.9 to 1.3; P = 0.32; mortality: 3.8% vs. 1.4%; ATE = 2.4%; 95% CI: -5.6 to 0.7; P = 0.13). Secondary outcomes showed TR patients were more likely to have non-home discharge (18.7% vs. 6.6%; ATE = 12.1%; 95% CI: 5.0-19.2; P < 0.001) and longer lengths of stay (6.1 vs. 4.0; ATE = 2.2 days; 95% CI: 0.9-3.4; P < 0.001). Moreover, TR patients were more likely to require transfusion (22.7% vs. 5.0%; ATE = 17.7%; 95% CI: 10.2-25.2; P < 0.001) and develop sepsis (2.7% vs. 0.2%; ATE = 2.5%; 95% CI: 0.1-5.0; P = 0.04). Conclusions: Transthoracic and extra-anatomic surgical reconstruction of the SATs for occlusive disease have similar operative cardiovascular risk. However, morbidity tends to be higher with TR due to higher transfusion requirements, sepsis risk, and need for facility stay. These results suggest ER as a first-line approach in those with proper disease anatomy is reasonable with lower morbidity, while TR remains justified in appropriate patients.

There are approximately 880 and 3,600 major league baseball and minor league baseball players who currently are active in their respective leagues, with thousands of players in the collegiate, high school, and little league ranks. Although relatively uncommon, vascular injuries, such as thoracic outlet syndrome, axillary artery compression, quadrilateral space syndrome, and direct vascular trauma, can afflict these players. These career- and limb-threatening injuries can mimic often seen muscular sprains and strains in their early stages with nonspecific symptoms, such as exertional fatigue, which can delay diagnosis with disastrous sequelae, including thrombus propagation, aneurysm rupture, and ischemia from distal embolization. The goal of this review is to discuss the pathophysiology, diagnosis, and treatment of these injuries to increase awareness of sport-related vascular phenomena among the hand and upper-extremity surgery community because these players typically are seen first in the training room or a hand specialist's office.

Repair of extensive thoracoabdominal aortic aneurysms (TAAA) carries significant risk. Hybrid repair incorporating thoracic endovascular aortic repair (TEVAR) followed by distal open repair as a strategy to reduce open repair to type IV extent has been described. Our group has observed thoracic aortic remodeling and health care value with hybrid repair. This strategy may also be used with proximal treatment and monitoring of distal aortic disease not requiring treatment at initial operation. Yet, reports of operative results remain sparse.

α-Gal syndrome (AGS) is an allergy to meat and other products derived from non-primate mammals resulting from development of IgE antibodies against the oligosaccharide galactose-α,1,3-galactose (α-Gal). Sensitivity to α-Gal is linked to tick bites, particularly bites from Amblyomma americanum (lone star tick). Recent studies demonstrate early failure of bioprosthetic valves in the setting of chronic inflammation following exposure to animal-derived surgical implants. We report a case of AGS associated with restenosis of prior bovine pericardium used for a common femoral patch angioplasty requiring reoperation.

The surgical management of aortic occlusive disease can be significantly complicated by the extension of disease, or occlusion, to the level of the renal arteries. The juxtarenal occlusion necessitates careful consideration of operative exposure, technique, and the method and extent of reconstruction. While endovascular techniques have revolutionized the management of occlusive disease of the distal aorta and iliacs, both the presence of bulky, eccentric or exophytic calcification and thrombus at the level of the renal arteries increase the technical difficulty and risk of perforation, stent compromise, or embolization. Disease extending to the visceral segment often necessitates the application of lessons learned in an earlier era and techniques less familiar to the modern surgeon. We will focus on direct, rather than extraanatomic surgical reconstruction.

It is with some irony that one notes that the preamble to the Medicare law declares: “Nothing in this subchapter shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided… .”1 To the contrary, we have, in the United States, long since accepted that the manner in which health care is funded is inextricably tied to health outcomes and the manner in which its services are available to the public.

Long-term outcomes after invasive versus non-invasive treatment for patients with IC.CLTI=chronic limb threatening ischemia; NS=not significant; RR=rate ratio* per 1000 person-year

Objective: Optimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches. Methods: The Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days pre-ceding or after CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared. Results: There were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P< .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07-2.08; P = .02). Conclusions: In patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short-and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.

Hospital volume is associated with improved mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms but a center-volume analysis using a national database has not been reported. We aimed to measure the association of center volume with in-hospital mortality, postoperative outcomes and 5-year survival following fenestrated and branched endovascular aortic repair. Patients undergoing nonemergent endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2010-2022) listed within the national Vascular Quality Initiative thoracic endovascular aortic repair/complex endovascular aortic repair database were analyzed. Centers were grouped into quartiles by median annual procedure volume. Multivariable generalized linear mixed-effects model was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation and log-rank test were used to evaluate long-term survival. We identified 4076 adult elective fenestrated and branched endovascular aortic repair procedures at a total of 163 centers. There was minimal variation in the frequency of comorbidities and patients underwent procedures of similar complexity. In-hospital mortality did not differ by hospital volume (Q1 3.7%; Q2 2.7%; Q3 2.6%; and Q4 4.0%; P = .2). No difference was found in the rate of major complication by quartile (Q1 14.6%; Q2 13.4%; Q3 13.0%; and Q4 18.1%; adjusted P = .1). Custom-modified grafts were more frequently used in high-volume centers (Q1 51.3%; Q2 52.7%; Q3 70.1%; and Q4 57.5%; P ≤ .001) with a decreased incidence of any endoleak noted at the end of the procedure (Q1 37.7%; Q2 32.9%; Q3 35.0%; and Q4 26.6%; adjusted P ≤ .001). In the multivariate analysis, center volume was not associated with in-hospital mortality (odds ratio [95% confidence interval] vs Q1: Q2 = 0.6 [0.4-1.1]; Q3 =0.6 [0.4-1.0]; and Q4 =1.0 [0.6–1.6]; all P > .05). No significant difference was found in overall survival between center-volume groups (Figure). In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, technical success may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.

Upper extremity vascular injuries, although not frequent, can have an impact on patient's quality of life and carry significant morbidity in trauma patients. This study aims to evaluate clinical outcomes associated with operative management of upper extremity vascular trauma. Patients with upper extremity vascular injuries presenting to our Level 1 trauma center from 2016 to 2022 were identified from trauma database registry. Patients with nonvascular injuries and nontraumatic upper extremity injuries were excluded. Mechanisms of injury, anatomical distribution of vascular injury, types of vascular repair, clinical outcomes, and rates of limb loss were retrospectively analyzed in patients requiring operative vascular interventions. A total of 74 patients with upper extremity vascular injuries were identified, with 60 patients (81%) undergoing operative management. The majority of patients had penetrating traumas (85%), and the average age was 39 ± 17 years, with a higher proportion of men (75%). Psychiatric issues, including substance abuse, were the most common comorbidity (30%). Bypasses (18), primary vessel repairs (17), vessel ligations (15), explorations (6), mangled extremity amputations (3), and isolated thrombectomies (1) were the index operative interventions. Upper arm interposition axillary-axillary, axillary-brachial or brachial-brachial bypasses were performed in 67% (12/18) of bypass cases, with great saphenous vein (58%) and cephalic vein (25%) being the most commonly used conduits. The primary patency rate for these bypasses was 91.7% at 30 days and 1 year. Overall, 7% (4) of patients required major amputation and 10% (6) underwent minor amputation. The causes of amputations were revision of traumatic amputation (8%), infection (2%), and revascularization failure (7%). All revascularization failures were associated with hand digit or forearm vessel revascularizations, resulting in minor amputations. In-hospital mortality was 1.7% (1/60). Amputation-free survival rates at 30-days, 1 year, and 3 years were 83.3%, 81.5%, and 78.9%, respectively. In a civilian Level 1 trauma center, operative management of upper extremity vascular injuries resulted in favorable outcomes, with high primary bypass patency rates for upper arm revascularizations and acceptable overall amputation-free survival rates. These results help enhance clinical decision-making for these challenging injuries.