- Email: [email protected]
Comparison of Superior Femoral Artery Angioplasty Combined With Open Femoral Endarterectomy to Open Surgical Bypass for Femoropopliteal Occlusive Disease
1542
Abstracts
Journal of Vascular Surgery November 2016
Fig 2. Forest plot of studies comparing early graft thrombosis following revascularization between women and men (odds ratios [ORs]). CI, Confidence interval; M-H, Mantel-Haenszel.
with men. Gender-specific consideration might be required in patients undergoing lower extremity revascularization. A higher treatment threshold may be warranted in considering intervening on women with symptomatic peripheral arterial disease owing to the increased risks of postprocedural mortality and complications. Author Disclosures: J. Wang: Nothing to disclose; Y. He: Nothing to disclose; C. Shu: Nothing to disclose; J. Zhao: Nothing to disclose; L. Dubois: Nothing to disclose.
Magnetic Resonance Imaging as a Predictor of Forces Required to Cross Peripheral Arterial Lesions With a Guidewire Trisha Roy, Garry Liu, Noor Shaikh, Andrew D. Dueck, Graham A. Wright. Sunnybrook Research Institute, University of Toronto, Toronto, Canada Objective: Percutaneous vascular interventions are associated with frequent immediate technical failure and medium/long-term restenosis leading to reintervention or failure. Current imaging has limitations that make it difficult to precisely predict whether patients will fail to respond to percutaneous vascular intervention. Immediate risk of technical failure is typically judged only by length and degree of lesion calcification. In this study, we sought to delineate risk of immediate technical failure by using magnetic resonance imaging (MRI) to characterize peripheral arterial lesions beyond degree of calcification. Following this, we sought to measure guidewire crossing forces required for specific plaque morphologies as a surrogate for risk of immediate technical failure. Methods: Forty excised peripheral arterial plaques from six amputation patients were imaged at 7T using T2-weighted and ultrashort echo time sequences at high resolution (75 mm3 voxels). Fifteen samples were studied to validate MRI signatures with micro-computed tomography and histology. Twenty-five lesions were chronic total occlusions (CTOs). CTOs were classified as soft (those with fat, thrombus, or microchannels), intermediate (those with loose fibrous tissue), hard (those with dense fibrous tissue/collagen), or calcified (those containing calcium). A 2-kg load cell advanced the back end of a 0.035-inch stiff guidewire at a fixed displacement rate of 0.05 mm/s through the CTOs, and the force required to cross the lesion was measured. Results: Densely calcified CTOs (n ¼ 4) immediately failed mechanical testing. Noncalcified hard CTOs (n ¼ 6) required a puncture force of
Fig. “Hard” dense collagen chronic total occlusion (CTO) and associated force displacement curve. The magnetic resonance imaging (MRI) signature of collagen (outlined in yellow) is hypointense on T2weighted (T2W) image and isointense on ultrashort echo time (UTE) sequence (using smooth muscle as the reference intensity).
1.74 N 6 0.58 (Fig). Intermediate CTOs (n ¼ 11) required a puncture force of 0.45 N 6 0.33. Soft CTOs (n ¼ 4) required a puncture force of 0.07 N 6 0.02. The difference between groups was statistically significant (one-way analysis of variance [F2,18] ¼ 27.490; P < .05). Conclusions: These results demonstrate the potential of high-resolution MRI to predict guidewire crossing forces in peripheral CTOs. Future work will determine lesion crossability in vivo with clinical MRI scanners. Author Disclosures: T. Roy: Nothing to disclose; G. Liu: Nothing to disclose; N. Shaikh: Nothing to disclose; A. Dueck: Nothing to disclose; G. Wright: Nothing to disclose.
Comparison of Superior Femoral Artery Angioplasty Combined With Open Femoral Endarterectomy to Open Surgical Bypass for Femoropopliteal Occlusive Disease Samuel Gurupatham, BHSc, John Harlock, MD, FRCS, Tara Andrinopoulos. Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada Objective: Open bypass repairs are recommended for treating severe TransAtlantic Inter-Society Consensus (TASC) class C and D femoropopliteal lesions, whereas TASC A and B lesion interventions preferentially involve endovascular techniques. A hybrid approach, an open endarterectomy followed by percutaneous transluminal angioplasty, has been increasingly used as an alternative to entirely open surgical repair of femoropopliteal lesions of lower severities. This study reviews and reports our experiences with open and hybrid repairs.
Journal of Vascular Surgery
Abstracts
1543
Volume 64, Number 5 Methods: A total of 56 patients who underwent open or hybrid repair for femoropopliteal lesions were identified. All primary surgeries were completed between 2012 and 2015 at two selected institutions. The primary end point was the primary patency (PP) of the diseased vessel. Results: The mean age of patients was 69.2 years (75.0% male, 25.0% female). Of the 12 TASC A and B lesions, 3 were treated with open repair and 9 were treated with hybrid repair. Technical success rates were 100% in all subgroups, with the exception of the TASC C and D hybrid repair group, in which the technical success rate was 66.6%. Among the 44 TASC C and D lesions, 32 were treated with open repair, whereas 12 were treated with hybrid repair. The 6-month postoperative PPs in the TASC A and B open repair and hybrid repair groups were 100% and 85.7%, respectively. The 6-month postoperative PPs in the TASC C and D open repair and hybrid repair groups were 64.5% and 81.8%, respectively. During a 1-year postoperative follow-up period, the PPs in the TASC A and B open repair and hybrid repair groups were 100% and 60.0%, respectively. The corresponding PPs in the TASC C and D open repair and hybrid repair groups were 43.5% and 62.5%, respectively. Conclusions: Hybrid interventions are a viable alternative to completely open surgical repair for femoropopliteal lesions of lower severity and may be of particular interest to patients who are poor surgical candidates. For clinical recommendations to be made, further study with randomized intervention allocation and larger sample sizes are required. Author Disclosures: S. Gurupatham: Nothing to disclose; J. Harlock: Nothing to disclose; T. Andrinopoulos: Nothing to disclose.
A Randomized Controlled Trial Evaluating the Impact of Expert Feedback on the Acquisition of Technical Skills in Vascular Surgery Laura Drudi,1 Melina Vassiliou,2 Liane S. Feldman,2 Heather L. Gill,1 Oren K. Steinmetz1. 1Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada; 2SteinbergBernstein Centre for Minimally Invasive Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada Objective: The objective of this study was to determine the effect of expert feedback (EF) on technical skill acquisition in medical students and junior residents using an end-to-side vascular anastomosis model. Methods: Medical students and junior surgical residents were enrolled into a vascular surgery technical skills curriculum requiring an end-toside vascular anastomosis on a simulated synthetic LifeLike BioTissue (London, Ontario, Canada) model. Participants were randomized into intervention (with EF) and control groups. A 5-minute instructional video was given to all subjects. Baseline performance was assessed by counting fatal errors and using the Objective Structured Assessment of Technical Skills (OSAT) and Standardized Vascular Skills Assessment (SVSA) scores with the endto-side vascular anastomosis model. The control group then completed a second anastomosis; the EF group received feedback and then completed their second anastomosis following the intervention. The primary outcome was the difference in proportions of fatal errors between the groups compared with their baseline performances. A two-sided paired z score test was used to evaluate the proportional difference in fatal errors before and after intervention. The nonparametric Wilcoxon rank sum test was used to compare OSAT and SVSA scores. Results: There were 52 participants, 27 in the EF group (4 postgraduate year 1 residents and 23 students) and 25 in the control group (2 postgraduate year 1 residents and 23 students). At baseline, 46% of the feedback group and 27% of the control group had fatal errors. At baseline, mean OSAT scores were 15.5 6 5.3 in the EF group and 18.3 6 5.3 in the control group, and the mean SVSA scores were 14.9 6 5.1 in the EF group and 17.2 6 4.2 in the control group. The mean proportional difference in fatal errors was reduced by 26% (95% confidence interval, 5.17%-46.69%; P ¼ .014) in the EF group and by 8% (95% confidence interval, 13.57% to 29.57%; P ¼ .47) in the control group. There was an improvement in mean differences in OSAT scores and SVSA scores in both groups; however, the EF group had a statistically significant higher mean difference in OSAT scores (P ¼ .03) as well as in SVSA scores (P ¼ .02) compared with the control group. Conclusions: This pilot study demonstrates that EF reduces the number of fatal errors in an end-to-side vascular anastomosis model and results in improved objective OSAT and SVSA scores compared with the control group.
Author Disclosures: L. Drudi: Research grantd2013 CSVS Provan Award; other research supportd2015 CIHR-CGS-FRQS Master’s award; M. Vassiliou: Proctor for Medtronic; L. Feldman: Nothing to disclose; H. Gill: Nothing to disclose; O. Steinmetz: Nothing to disclose.
Bringing Simulation Training to the Masses: Why Group Learning Can Be an Effective Low-Cost Alternative to the Traditional Hot-Seat Model Husain Khambati,1 Michael Yacob,1 Christine Seabrook,2 Laura Gerridzen,2 Yvonne Ying2,3. 1Division of Vascular and Endovascular Surgery, University of Ottawa, Ottawa, Ontario, Canada; 2Surgical Foundations, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; 3Division of Pediatric Plastic Surgery, University of Ottawa, Ottawa, Ontario, Canada Background: With the advent of competency-based training, most surgical programs will begin to rely heavily on simulation to better prepare residents for practice. Participation in simulation sessions has been shown to improve future performance, but it is unclear if passive observation of simulation scenarios in larger group settings can produce an equivalent benefit. Methods: First-year surgery residents at the University of Ottawa were enrolled in a week-long simulation course. Groups of four to five residents were exposed to various simulation-based scenarios, through either active participation or passive observation. Residents were individually assessed by blinded medical experts on three of the scenarios using a global rating scale consisting of medical management, communication, and overall performance. Scores were analyzed using multivariate analyses. Costs of the simulation were analyzed using two models: the participant-observer model, which estimated the cost of one resident’s running the simulation while the remaining group observes; and the participant-centered model, which estimated the cost of running each resident through each station. Results: There were 32 residents enrolled in the course, and 28 underwent testing on each of the three scenarios. Scores were analyzed on the basis of the resident’s exposure during the course; previous exposure to the scenario, through active participation or passive observation, led to improved performance on medical management and overall performance compared with those who had not been exposed (P < .05). However, active participation did not improve performance relative to passive observation. Previous exposure to the scenarios did not improve the resident’s performance on communication aspects of the scenarios. The cost/resident/session was CaD $53,125 for the participant-observer model vs CaD $140,625 for the participant-centered model. Conclusions: Analyses not only confirm the overall advantage of simulation-based training but additionally suggest that active participation is not necessary to benefit from the experience; residents were able to learn from passive observation in the scenarios. This, coupled with the lower costs, supports the idea of simulation-based training in larger group settings to allow exposure to more scenarios rather than increased active participation. Author Disclosures: H. Khambati: Nothing to disclose; M. Yacob: Nothing to disclose; C. Seabrook: Nothing to disclose; L. Gerridzen: Nothing to disclose; Y. Ying: Nothing to disclose.
Ontario Current State Assessment and Proposed Program Framework: Acute Care Vascular Services Thomas L. Forbes,1 Michael Setterfield,2 Vevien Braga,2 on behalf of themembers of the Vascular Care Working Group of the Cardiac Care Network 1Division of Vascular Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada; 2 Cardiac Care Network, Toronto, Ontario, Canada Objective: The objective of this study was to determine the current status of vascular services provision in Ontario and to propose a provincial vascular framework to improve the quality of and access to hospitalbased care.
Abstracts
Journal of Vascular Surgery November 2016
Fig 2. Forest plot of studies comparing early graft thrombosis following revascularization between women and men (odds ratios [ORs]). CI, Confidence interval; M-H, Mantel-Haenszel.
with men. Gender-specific consideration might be required in patients undergoing lower extremity revascularization. A higher treatment threshold may be warranted in considering intervening on women with symptomatic peripheral arterial disease owing to the increased risks of postprocedural mortality and complications. Author Disclosures: J. Wang: Nothing to disclose; Y. He: Nothing to disclose; C. Shu: Nothing to disclose; J. Zhao: Nothing to disclose; L. Dubois: Nothing to disclose.
Magnetic Resonance Imaging as a Predictor of Forces Required to Cross Peripheral Arterial Lesions With a Guidewire Trisha Roy, Garry Liu, Noor Shaikh, Andrew D. Dueck, Graham A. Wright. Sunnybrook Research Institute, University of Toronto, Toronto, Canada Objective: Percutaneous vascular interventions are associated with frequent immediate technical failure and medium/long-term restenosis leading to reintervention or failure. Current imaging has limitations that make it difficult to precisely predict whether patients will fail to respond to percutaneous vascular intervention. Immediate risk of technical failure is typically judged only by length and degree of lesion calcification. In this study, we sought to delineate risk of immediate technical failure by using magnetic resonance imaging (MRI) to characterize peripheral arterial lesions beyond degree of calcification. Following this, we sought to measure guidewire crossing forces required for specific plaque morphologies as a surrogate for risk of immediate technical failure. Methods: Forty excised peripheral arterial plaques from six amputation patients were imaged at 7T using T2-weighted and ultrashort echo time sequences at high resolution (75 mm3 voxels). Fifteen samples were studied to validate MRI signatures with micro-computed tomography and histology. Twenty-five lesions were chronic total occlusions (CTOs). CTOs were classified as soft (those with fat, thrombus, or microchannels), intermediate (those with loose fibrous tissue), hard (those with dense fibrous tissue/collagen), or calcified (those containing calcium). A 2-kg load cell advanced the back end of a 0.035-inch stiff guidewire at a fixed displacement rate of 0.05 mm/s through the CTOs, and the force required to cross the lesion was measured. Results: Densely calcified CTOs (n ¼ 4) immediately failed mechanical testing. Noncalcified hard CTOs (n ¼ 6) required a puncture force of
Fig. “Hard” dense collagen chronic total occlusion (CTO) and associated force displacement curve. The magnetic resonance imaging (MRI) signature of collagen (outlined in yellow) is hypointense on T2weighted (T2W) image and isointense on ultrashort echo time (UTE) sequence (using smooth muscle as the reference intensity).
1.74 N 6 0.58 (Fig). Intermediate CTOs (n ¼ 11) required a puncture force of 0.45 N 6 0.33. Soft CTOs (n ¼ 4) required a puncture force of 0.07 N 6 0.02. The difference between groups was statistically significant (one-way analysis of variance [F2,18] ¼ 27.490; P < .05). Conclusions: These results demonstrate the potential of high-resolution MRI to predict guidewire crossing forces in peripheral CTOs. Future work will determine lesion crossability in vivo with clinical MRI scanners. Author Disclosures: T. Roy: Nothing to disclose; G. Liu: Nothing to disclose; N. Shaikh: Nothing to disclose; A. Dueck: Nothing to disclose; G. Wright: Nothing to disclose.
Comparison of Superior Femoral Artery Angioplasty Combined With Open Femoral Endarterectomy to Open Surgical Bypass for Femoropopliteal Occlusive Disease Samuel Gurupatham, BHSc, John Harlock, MD, FRCS, Tara Andrinopoulos. Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada Objective: Open bypass repairs are recommended for treating severe TransAtlantic Inter-Society Consensus (TASC) class C and D femoropopliteal lesions, whereas TASC A and B lesion interventions preferentially involve endovascular techniques. A hybrid approach, an open endarterectomy followed by percutaneous transluminal angioplasty, has been increasingly used as an alternative to entirely open surgical repair of femoropopliteal lesions of lower severities. This study reviews and reports our experiences with open and hybrid repairs.
Journal of Vascular Surgery
Abstracts
1543
Volume 64, Number 5 Methods: A total of 56 patients who underwent open or hybrid repair for femoropopliteal lesions were identified. All primary surgeries were completed between 2012 and 2015 at two selected institutions. The primary end point was the primary patency (PP) of the diseased vessel. Results: The mean age of patients was 69.2 years (75.0% male, 25.0% female). Of the 12 TASC A and B lesions, 3 were treated with open repair and 9 were treated with hybrid repair. Technical success rates were 100% in all subgroups, with the exception of the TASC C and D hybrid repair group, in which the technical success rate was 66.6%. Among the 44 TASC C and D lesions, 32 were treated with open repair, whereas 12 were treated with hybrid repair. The 6-month postoperative PPs in the TASC A and B open repair and hybrid repair groups were 100% and 85.7%, respectively. The 6-month postoperative PPs in the TASC C and D open repair and hybrid repair groups were 64.5% and 81.8%, respectively. During a 1-year postoperative follow-up period, the PPs in the TASC A and B open repair and hybrid repair groups were 100% and 60.0%, respectively. The corresponding PPs in the TASC C and D open repair and hybrid repair groups were 43.5% and 62.5%, respectively. Conclusions: Hybrid interventions are a viable alternative to completely open surgical repair for femoropopliteal lesions of lower severity and may be of particular interest to patients who are poor surgical candidates. For clinical recommendations to be made, further study with randomized intervention allocation and larger sample sizes are required. Author Disclosures: S. Gurupatham: Nothing to disclose; J. Harlock: Nothing to disclose; T. Andrinopoulos: Nothing to disclose.
A Randomized Controlled Trial Evaluating the Impact of Expert Feedback on the Acquisition of Technical Skills in Vascular Surgery Laura Drudi,1 Melina Vassiliou,2 Liane S. Feldman,2 Heather L. Gill,1 Oren K. Steinmetz1. 1Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada; 2SteinbergBernstein Centre for Minimally Invasive Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada Objective: The objective of this study was to determine the effect of expert feedback (EF) on technical skill acquisition in medical students and junior residents using an end-to-side vascular anastomosis model. Methods: Medical students and junior surgical residents were enrolled into a vascular surgery technical skills curriculum requiring an end-toside vascular anastomosis on a simulated synthetic LifeLike BioTissue (London, Ontario, Canada) model. Participants were randomized into intervention (with EF) and control groups. A 5-minute instructional video was given to all subjects. Baseline performance was assessed by counting fatal errors and using the Objective Structured Assessment of Technical Skills (OSAT) and Standardized Vascular Skills Assessment (SVSA) scores with the endto-side vascular anastomosis model. The control group then completed a second anastomosis; the EF group received feedback and then completed their second anastomosis following the intervention. The primary outcome was the difference in proportions of fatal errors between the groups compared with their baseline performances. A two-sided paired z score test was used to evaluate the proportional difference in fatal errors before and after intervention. The nonparametric Wilcoxon rank sum test was used to compare OSAT and SVSA scores. Results: There were 52 participants, 27 in the EF group (4 postgraduate year 1 residents and 23 students) and 25 in the control group (2 postgraduate year 1 residents and 23 students). At baseline, 46% of the feedback group and 27% of the control group had fatal errors. At baseline, mean OSAT scores were 15.5 6 5.3 in the EF group and 18.3 6 5.3 in the control group, and the mean SVSA scores were 14.9 6 5.1 in the EF group and 17.2 6 4.2 in the control group. The mean proportional difference in fatal errors was reduced by 26% (95% confidence interval, 5.17%-46.69%; P ¼ .014) in the EF group and by 8% (95% confidence interval, 13.57% to 29.57%; P ¼ .47) in the control group. There was an improvement in mean differences in OSAT scores and SVSA scores in both groups; however, the EF group had a statistically significant higher mean difference in OSAT scores (P ¼ .03) as well as in SVSA scores (P ¼ .02) compared with the control group. Conclusions: This pilot study demonstrates that EF reduces the number of fatal errors in an end-to-side vascular anastomosis model and results in improved objective OSAT and SVSA scores compared with the control group.
Author Disclosures: L. Drudi: Research grantd2013 CSVS Provan Award; other research supportd2015 CIHR-CGS-FRQS Master’s award; M. Vassiliou: Proctor for Medtronic; L. Feldman: Nothing to disclose; H. Gill: Nothing to disclose; O. Steinmetz: Nothing to disclose.
Bringing Simulation Training to the Masses: Why Group Learning Can Be an Effective Low-Cost Alternative to the Traditional Hot-Seat Model Husain Khambati,1 Michael Yacob,1 Christine Seabrook,2 Laura Gerridzen,2 Yvonne Ying2,3. 1Division of Vascular and Endovascular Surgery, University of Ottawa, Ottawa, Ontario, Canada; 2Surgical Foundations, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; 3Division of Pediatric Plastic Surgery, University of Ottawa, Ottawa, Ontario, Canada Background: With the advent of competency-based training, most surgical programs will begin to rely heavily on simulation to better prepare residents for practice. Participation in simulation sessions has been shown to improve future performance, but it is unclear if passive observation of simulation scenarios in larger group settings can produce an equivalent benefit. Methods: First-year surgery residents at the University of Ottawa were enrolled in a week-long simulation course. Groups of four to five residents were exposed to various simulation-based scenarios, through either active participation or passive observation. Residents were individually assessed by blinded medical experts on three of the scenarios using a global rating scale consisting of medical management, communication, and overall performance. Scores were analyzed using multivariate analyses. Costs of the simulation were analyzed using two models: the participant-observer model, which estimated the cost of one resident’s running the simulation while the remaining group observes; and the participant-centered model, which estimated the cost of running each resident through each station. Results: There were 32 residents enrolled in the course, and 28 underwent testing on each of the three scenarios. Scores were analyzed on the basis of the resident’s exposure during the course; previous exposure to the scenario, through active participation or passive observation, led to improved performance on medical management and overall performance compared with those who had not been exposed (P < .05). However, active participation did not improve performance relative to passive observation. Previous exposure to the scenarios did not improve the resident’s performance on communication aspects of the scenarios. The cost/resident/session was CaD $53,125 for the participant-observer model vs CaD $140,625 for the participant-centered model. Conclusions: Analyses not only confirm the overall advantage of simulation-based training but additionally suggest that active participation is not necessary to benefit from the experience; residents were able to learn from passive observation in the scenarios. This, coupled with the lower costs, supports the idea of simulation-based training in larger group settings to allow exposure to more scenarios rather than increased active participation. Author Disclosures: H. Khambati: Nothing to disclose; M. Yacob: Nothing to disclose; C. Seabrook: Nothing to disclose; L. Gerridzen: Nothing to disclose; Y. Ying: Nothing to disclose.
Ontario Current State Assessment and Proposed Program Framework: Acute Care Vascular Services Thomas L. Forbes,1 Michael Setterfield,2 Vevien Braga,2 on behalf of themembers of the Vascular Care Working Group of the Cardiac Care Network 1Division of Vascular Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada; 2 Cardiac Care Network, Toronto, Ontario, Canada Objective: The objective of this study was to determine the current status of vascular services provision in Ontario and to propose a provincial vascular framework to improve the quality of and access to hospitalbased care.