- Email: [email protected]
Pediatric Vascular Surgical Practice Patterns
Accepted Manuscript Pediatric Vascular Surgical Practice Patterns Patrick C. Bonasso, MD, Melvin S. Dassinger, MD, Matthew R. Smeds, MD, Mohammed M. Moursi, MD PII:
S0890-5096(18)30486-2
DOI:
10.1016/j.avsg.2018.05.033
Reference:
AVSG 3921
To appear in:
Annals of Vascular Surgery
Received Date: 1 February 2018 Revised Date:
26 April 2018
Accepted Date: 3 May 2018
Please cite this article as: Bonasso PC, Dassinger MS, Smeds MR, Moursi MM, Pediatric Vascular Surgical Practice Patterns, Annals of Vascular Surgery (2018), doi: 10.1016/j.avsg.2018.05.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Pediatric Vascular Surgical Practice Patterns
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Patrick C. Bonasso MD1, Melvin S. Dassinger MD1, Matthew R. Smeds MD2, Mohammed M.
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Moursi MD1
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University of Arkansas for Medical Sciences; 4301 W Markham St. Little Rock, Arkansas.
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Saint Louis University; 3655 Vista Ave. Saint Louis, Missouri. 63110
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[email protected] [email protected] [email protected]
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M. Sidney Dassinger Matthew R Smeds Mohammed M Moursi
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Corresponding Author: Patrick C. Bonasso, MD University of Arkansas for Medical Sciences Division of Pediatric Surgery 1 Children’s Way, Slot 837 Little Rock, AR 72202 Phone: 501-364-2832 Fax: 501-364-1516 Email: [email protected]
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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This manuscript was presented as a podium presentation at the 28th Annual meeting of the Vascular and Endovascular Surgery Society (VESS) in Vail, CO on February 3, 2018.
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ABSTRACT
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Introduction Vascular surgeons infrequently care for pediatric patients. As such, variability in operative management and available hospital resources at free-standing children’s hospitals may exist. The study aims were: 1) determine vascular surgeon comfort level with pediatric vascular surgery, and 2) determine variations in pediatric vascular surgery practice patterns.
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Material and Methods A survey composed of clinical vignettes emailed to all members of Vascular and Endovascular Surgery Society was designed to assess operative management of pediatric vascular conditions and hospital resources. Comparisons of surgeon satisfaction between free-standing children’s hospitals and a children’s hospital within an adult general hospital were made using Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made using a McNemar’s test. P-values less than or equal to 0.05 indicated statistical significance.
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Results Response rate was 18% (93/525) with 96% (89/93) indicating completion of a 2 year vascular fellowship. Surgeon satisfaction with operative equipment (p =0.002), support staff (P<0.001), and vascular lab availability (p=0.01) was significantly lower at CH. 87% of surgeons operated on fewer than two children over the preceding three months. For the different clinical vignettes, there was a wide variation in practice patterns with a range of 50% to 89% of the surgeons performing fewer than 5 cases over the preceding ten years. There was a significant decrease in surgeon’s comfort level with elective pediatric vascular operations compared to the operative management of pediatric vascular trauma (p=0.0025). Conclusions Most vascular surgeons do not feel comfortable in the operative management of pediatric vascular disease and optimal resource availability within pediatric children’s hospitals may be lacking. Centralized care of this patient population may be warranted.
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Key Words: Vascular, Survey, Practice Patterns
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Introduction Vascular surgeons care for pediatric patients for both elective cases and traumatic
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injuries. Vascular surgeons infrequently care for pediatric patients due to limited referral
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patterns and low case volume. This may affect the vascular surgeon’s comfort level in dealing
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with this patient population. A recent survey of pediatric trauma providers found that there may
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be variability in the care and operative management of these children depending on the
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institution and available hospital resources at free-standing children’s hospitals (CH) [1].
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Furthermore, current training does not frequently include designated time on a pediatric surgery,
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pediatric interventional radiology or pediatric vascular services [2]. There is little in the current
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literature on availability and comfort level of vascular surgeons in managing pediatric patients
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for both elective cases and traumatic injuries.
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The aims of this study, thus, are to: 1) determine modern vascular surgeon comfort level
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with pediatric vascular surgery, 2) determine variations in practice patterns for the management
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of pediatric vascular operations, and 3) evaluate the operation of choice for management of
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pediatric vascular diseases and pediatric vascular trauma.
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Materials Methods
After institutional review board approval, a twenty- three question survey was sent to all
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active and senior members of the Vascular and Endovascular Surgery Society (VESS). The
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survey was reviewed and approved by the VESS executive committee for distribution to its
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membership. VESS members were chosen because the membership reflects a wide range of
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practice types that is nationally represented. The survey was created by the senior vascular
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surgeon at our institution and represented a variety of pediatric vascular surgical diseases and
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traumatic vascular injuries. It was administered via REDCap (Research Electronic Data
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Capture), a secure Web-based application designed to support data capture for research studies
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(Appendix). The survey asked basic demographic questions. It assessed comfort level (very
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comfortable, comfortable, and uncomfortable) with pediatric procedures and evaluated
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anticipated management of pediatric vascular surgeries, emergent vascular injuries, and available
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hospital resources.
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active VESS members. If survey was not completed after first email, a second follow-up email
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was sent three weeks later to improve participant response rate. The survey was closed on May
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24, 2017. Participants had the option to answer either all of the questions or some of the
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questions on the survey. If identified as a program director, then four additional questions were
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asked.
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An email was sent on April 24, 2017 from the study senior author to all 525
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All data were analyzed using statistical software R v3.1.0 (R Foundation for Statistical
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Computing, Vienna, Austria). Categorical variables summarized using percentage (count) and
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comparisons were made using Fisher’s exact tests. Continuous variables were compared using
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Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made
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using a McNemar’s test. P-values less than or equal to 0.05 were considered statistically
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significant.
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Results
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3.1 Demographics and Training
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93 of 525 (18%) VESS members participated. The mean year of fellowship completion was 2003. 96% (89/93) of the survey participants trained at an independent vascular surgery
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fellowship (5+2) and 4% (4/93) trained at an integrated vascular surgery residency (0+5).
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Regarding experience of operative pediatric vascular surgery procedures, 50% operated with
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vascular surgeons during fellowship, 42% operated with pediatric surgeons during fellowship,
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and 8% observed in the operating room. Only 7 respondents (8%) spent dedicated time on a
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pediatric surgery rotation during fellowship (p=0.045).
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Two-thirds (65) of the respondents currently train vascular fellows or vascular residents on a daily basis. Training programs included 52% independent vascular surgery fellowship, 9%
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integrated vascular surgery residency, and 39% both program types.
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The mean number of vascular surgeons within the respondent’s vascular division was six. An average of three vascular surgeons within the division reported operating on pediatric
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patients both in elective and emergent situations. 35/93 (38%) responded that they were the
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primary pediatric vascular surgeon in their division with 11 of those respondents stating they
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were the lone vascular surgeon caring for pediatric patients in the division.
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Two-thirds of the respondents have an affiliation with a pediatric hospital: 38/61
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affiliated with a CH and 23/61 with a pediatric hospital within an Adult Hospital (AH). Of those
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with CH affiliation, 74% have privileges at the CH. The majority (87%) of the participants
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operated at the CH two times or less over the past 3 months. Vascular surgeons were more
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satisfied with available operating room equipment (p=0.002), support staff (p<0.001), and
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vascular lab capabilities (p=0.01) at AH than at Free-standing CHs (Table I), with those who
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work in a free-standing hospital.
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Comfort level was assessed. 37% of the respondents stated they were not comfortable
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with the pre-operative, post-operative, and medical management of elective pediatric vascular
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disease. For the other participants, 48% responded that they were comfortable and 15%
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responded they were very comfortable.
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3.2 Program Directors
There were 22 program directors identified. 86% (19/22) do not have the fellows rotate
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on a pediatric vascular surgery service and 95% (21/22) do not have a dedicated pediatric
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vascular team.
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3.3 Elective Vascular Surgery Clinical Vignettes
Three clinical vignettes for elective pediatric vascular surgical cases were surveyed: renal artery stenosis (RAS), middle aortic syndrome (MAS), and hemodialysis (HD) access.
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3.3.1 Renal Artery Stenosis
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22/93 (23%) of the respondents operated on pediatric patients with RAS during their
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training and 29/93 (31%) care for pediatric patients with RAS in their current practice. 69%
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(20/29) of respondents have operated on less than five patients in the past 10 years (Table VI).
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32% of respondents would perform bypass with autogenous hypogastric artery (Table II). Only
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7% responded that they were uncomfortable with their procedure of choice (Table VI).
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3.3.2 Middle Aortic Syndrome
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27/93 (29%) of the respondents operated on pediatric patients with MAS during their
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training and 29/93 (31%) care for pediatric patients with MAS in their current practice. 86%
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(25/29) have operated on less than five patients in the past 10 years (Table VI). 48% of
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respondents would perform thoraco-to infrarenal aortic bypass and 41% would perform patch
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aortoplasty (Table III). One respondent was uncomfortable with their procedure of choice,
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patch aortoplasty.
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3.3.3 Hemodialysis Access
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39/93 (41%) of the respondents operated on pediatric patients needing HD access during their training and 34/93 (36%) perform HD access procedures in their current practice. 44%
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(17/39) have operated on less than five patients in the past 10 years (Table VI). There was no
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consensus on type of operation including homograft, PTFE/Dacron, and Bovine (Table IV).
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Two respondents were uncomfortable with their procedure of choice, homograft.
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3.3.4 Patient Transfer
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Respondents were asked if they would perform the operation or transfer the pediatric patient when the main vascular surgeon was not available. The majority of vascular surgeons
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would transfer the patient for both renal artery stenosis and middle aortic syndrome and near
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equal proportion for performing the operation and transferring for hemodialysis (Table V).
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3.3.5 Comfort level
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The number of cases performed over the past 10 years was associated with an increased
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comfort level for both RAS (P=0.0422) and MAS (p=0.0177). No association with the number
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of cases performed was found for HD (p=0.1547) (Table VI).
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3.4 Trauma Vignettes
Five vignettes for pediatric vascular trauma cases were surveyed. 24% of the respondents
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stated they were not comfortable with the pre-operative, post-operative, and medical
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management of pediatric vascular trauma.
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3.4.1 Brachial Artery 91% of the respondents said if they were on call, they would operate on the pediatric patient. 11% were uncomfortable with performing the identified procedure of choice and would
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call the main pediatric vascular surgeon in division for advice even if he/she was not on call.
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93% of the respondents would perform interposition vein graph (Table VII).
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3.4.2 Superficial femoral artery
99% of the respondents said if they were on call, they would operate on the patient. 7%
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were uncomfortable with performing the identified procedure of choice and would call the main
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pediatric vascular surgeon in division for advice even if he or she was not on call. 95% of the
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respondents would perform vein bypass (Table VIII).
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3.4.3 Popliteal artery
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82% of the respondents said if they were on call, they would operate on the patient. 80%
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responded that they would perform additional imaging prior to going to the operating room with
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52% performing and on table arteriogram and 48% performing a CTA. 4% were uncomfortable
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with performing the identified procedure of choice. 76% would perform vein bypass (Table IX).
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3.4.4 Carotid artery
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91% of the respondents said if they were on call, they would operate on the patient. 15%
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were uncomfortable with performing the identified procedure of choice and would call the main
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pediatric vascular surgeon in division for advice even if he/she was not on call. 48% would
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perform bypass with vein and 36% would perform patch angioplasty (Table X).
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3.4.5 Aorta
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94% of the respondents said if they were on call, they would operate on the patient. 15%
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were uncomfortable with performing the identified procedure of choice and would call the main
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pediatric vascular surgeon in division for advice even if he/she was not on call (Table XI).
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3.4.6 Comfort level
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Case numbers over past 10 years and comfort level were compared. For all anatomic locations other than popliteal artery injury there was a statistically significant positive correlation
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between number of cases and comfort level, brachial artery (p=0.02), superficial femoral artery
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(p<0.001), carotid artery (p=0.001), and aorta (p=0.005) (Table XII).
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The current definition of the Vascular Surgery specialty by the American Board of
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Surgery includes having significant experience with all aspects of treating patients with all types
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of vascular disease [3]. Interestingly, the current definition does not include the care of pediatric
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vascular patients. Moreover, vascular trainee competency includes demonstration of the
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knowledge of the basic principles of vascular surgery which does not include pediatric surgical
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care [4]. Our survey indicates that significant variation exists in the operative management of
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both elective and traumatic injuries as well as vascular surgeon comfort level in caring for
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pediatric patients.
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The elective vascular surgical clinical vignettes included RAS, MAS, and HD. RAS and
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MAS, a common cause of childhood hypertension, has a limited number of studies assessing the
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risk of surgical or endovascular intervention and outcomes [5]. Only 25% of the vascular
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surgeons were trained in and currently care for patients with either RAS or MAS. For those
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performing the operations for RAS and MAS, comfort level in performing the operation of
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choice improved with the number of cases. For RAS and MAS operations without availability of
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the main pediatric vascular surgeon, the majority of respondents would transfer patients to
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another facility. The likelihood of transfer was 79% and 87% for RAS and MAS, respectively.
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In comparison, comfort level and number of cases increased for patients in need of HD
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access. The incidence of end-stage renal disease requiring hemodialysis in the United States is
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approximately 1,000 cases per year [6]. Infants and young children are more frequently
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maintained with PD therapy as compared with older adolescents, who are more likely to receive
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HD [7]. Children older than 10 years and/or weighing >20 kg and will be on HD for more than
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a few months, arteriovenous fistulas or arteriovenous grafts are preferred [8]. Only about half
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the American children receive care at a pediatric center, with the rest receiving dialysis services
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at an adult facility [7]. Since vascular surgeons have experience with adult HD fistula creation,
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they may be more willing to operate on pediatric patients, especially those older than 10 years of
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age. However, no consensus operation was noted from the respondents with either homograft,
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PTFE/Dacron, or Bovine.
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Vascular trauma accounts for less than two percent of injured children admitted to hospitals in the United States [9,10]. Pediatric vascular injuries can present difficult challenges
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to the surgeons providing care [1]. Vascular surgeons were more comfortable caring for
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pediatric vascular trauma in comparison to elective pediatric vascular disease cases as vascular
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surgical principles can be applied from the adult [11]. Yet, 24% of the respondents were
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uncomfortable managing pediatric vascular trauma. Traumatic arterial injury operative
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intervention comfort level improved as the number of cases increased for all injuries except
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popliteal artery injury. For all the vignettes, between 88 to 99% of respondents would operate
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on the pediatric patient if on call and less than 15% of the respondents were uncomfortable
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performing the procedure of choice. Traumatic vascular injuries are emergent procedures and
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unlikely to permit transfer to a regionalized center of care without risk of life or limb. One or
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more vascular surgeons within the division could be identified as the primary or expert vascular
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surgeon for the care of pediatric patients and help advise and assist their partners in emergent
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cases.
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Care of pediatric vascular disease and injuries encompasses an undefined space in the vascular surgery practice. Vascular surgeons are neither required to complete a pediatric surgery
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rotation nor do they have dedicated time allotted to managing pediatric vascular patients during
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vascular residency or fellowship [4]. Our results show a limited number of training fellowships
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with a dedicated service for pediatric vascular surgery. Based on the responses, there are a
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limited number of vascular surgeons operating on pediatric patients for both elective and
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traumatic cases. Comfort level in caring for pediatric vascular disease improves as the case
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volume increases. Yet, even those who are comfortable performing the cases and without main
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pediatric surgeon availability, the majority would transfer patients to another facility. These
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finding may suggest a centralized care strategy for pediatric vascular disease. For vascular
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surgery trainees, a pediatric surgery rotation may benefit the trainee as far as increasing the
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comfort level with taking care of pediatric patients. However, few centers have a large enough
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pediatric vascular surgery volume; thus, comfort level caring for and treating these pediatric
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vascular issues may stay the same.
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There is a potential for a lack resources in caring for children at CHs as the vascular
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surgeons were less satisfied with operating room equipment, support staff, and vascular lab
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capabilities in comparison to AH. This discomfort with caring for vascular pediatric patients at
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free-standing hospitals rather than their primary adult hospital may stem from unfamiliarity with
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the staff, and differences of stocking, given lack of vascular pediatric vascular surgery volume. Limitations do exist for this study. First, there are limitations primarily due to the survey
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nature of the study. With a response rate of 18%, bias may exist. Specifically, there was a large
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variation in the training and current practice of the respondents. This may skew the results to
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favor those with pediatric vascular training or those with interest in caring for pediatric patients.
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Another limitation is the bias introduced by the wording of the clinical vignettes. For comfort in
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the peri-operative care of these patients, they could be managed by a different pediatric service;
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thus, comfort level would not be a valuable tool as care for by the vascular surgery service in the
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perioperative period may be limited. At some institutions, a multi-disciplinary team may care for
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these patients. Additionally, surgical specialists who may be caring for these pediatric trauma
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patients including pediatric surgeons, pediatric transplant surgeons, pediatric cardiovascular
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surgeons, or others were not included in the survey.
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In summary, this survey describes the current practice of vascular surgeons who are members of the VESS caring for children for both elective vascular procedures and vascular
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trauma. These data may be used to inform future decisions on pediatric vascular care of
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potentially change discussion about education and clinical training for vascular surgeons [1].
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The results should encourage institutions caring for children to develop and maintain plans for
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the comprehensive and definitive management of pediatric vascular disease and vascular trauma
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[1].
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Conclusion
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Most centers do not have a dedicated team for pediatric vascular cases, and many
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vascular fellows do not rotate on a pediatric vascular surgery service. Adequate vascular
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resources within a FSCH including equipment, support staff, and vascular lab technologists are
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not available to vascular surgeons. A significant portion of vascular surgeons do not feel
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comfortable in the management of pediatric vascular disease. Centralized care of this patient
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population may be warranted.
292 Acknowledgements
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No additional acknowledgements to address.
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Appendix: Survey Questions
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Research data for this article
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Due to the sensitive nature of the questions asked in this study, survey respondents were assured
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raw data would remain confidential and would not be shared
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References
1. American College of Surgeons. A Guide to Surgical Specialists. Available at: https://www.facs.org/education/patient-education/patient-resources/specialists; [accessed
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January 2018].
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2. The American Board of Surgery. Training and Certification: Vascular Surgery.
http://www.absurgery.org/default.jsp?aboutvascularsurgerydefined; [accessed January 2018].
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3. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate medical Education in Vascular Surgery.
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https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/450_vascular_surgery_2017
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-07-01.pdf?ver=2017-10-24-143917-207; [accessed January 2018].
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4. Rumman RK, Matsuda-Abedini, M, Langlois V, Radhakrishnan S, Lorenzo AJ, Amaral J, Mertens L, Parekh RS. Management and Outcomes of Childhood Renal Artery
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Stenosis and Middle Aortic Syndrome. Am J of Hypertension 2018;
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doi.org/10.1093/ajh/hpy014
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5. Saran R, Li Y, Robinson B, et al. US Renal Data System 2015 Annual Data Report: epidemionlogy of kidney disease in the United States. Am J Kidney Dis 2016; 67: S1-
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6. Chand DH, Swartz S, Tuchman S, Valentini RP, Somers MJG. Dialysis in Children and
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Adolescents: The Pediatric Nephrology Perspective. Am J of Kidney Dis 2017; 69: 278-
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7. National Kidney Foundation. DOQI clinical practice guidelines for vascular access. Am J Kidney Dis 1997; 30: S150-S191.
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8. Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, Green D, Demetriades D.
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9. Tepas JJ, Walsh DS. Vascular Injury. In: Coran AG, ed. Pediatric Surgery. 7th ed. Philadelphia, PA: Elsevier Saunders; 2012, p. 361-368.
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11. Sciarretta JD, Macedo FI, Chung EL, Otero CA, Pizano LR, Namias N. Management of
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center experience. J of Trauma Acute Care Surg 2014; 76: 1386-9.
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Appendix As a potential participant in the study as a member of the Vascular and Endovascular Surgery Society (VESS), you are receiving this link and being asked to participate in a research project. Participation in this project will involve completion of a brief 23-27 question survey that should take 10 minutes. Participation is voluntary and neither the decision to participate nor the survey responses will have any bearing on professional status, and indicate that responses are anonymous.
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Wide variation and level of comfort in pediatric vascular operations appears to exist across the United States. The aims of this survey are to: 1) determine variations in practice patterns for the management of pediatric vascular procedures; 2) determine number of vascular surgeons caring for pediatric patients in the United States; and 3) evaluate the operation of choice for management of pediatric vascular diseases and pediatric vascular trauma
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Pediatric Vascular Practice Patterns 1) What program are you associated with? All members of the Vascular and Endovascular Surgery Society. 2) What year did you complete your vascular surgery fellowship?
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3) What type of fellowship did you participate in? a. 2 year post general surgery fellowship i. Please select the choice that best describes your experience regarding operative pediatric vascular surgery procedures during your general surgery training. 1. Observe in OR 2. Operate with vascular surgeon 3. Operate with pediatric surgeon ii. Did you spend dedicated time on a pediatric surgery rotation during your vascular fellowship training? 1. Yes 2. No b. Integrated Program (0/5) i. Please select the choice that best describes your experience regarding operative pediatric vascular surgery procedures during your vascular fellowship. 1. Observe in OR 2. Operate with vascular surgeon 3. Operate with pediatric surgeon ii. Did you spend dedicated time on a pediatric surgery rotation during your residency? 1. Yes 2. No
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4) Do you train vascular fellows or vascular residents on a daily basis? a. Yes i. 2 year post general surgery fellowship ii. Integrated Program (0/5) iii. Both b. No
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5) Does your current institution have an affiliation with a Pediatric Hospital? a. No b. Yes i. What is the setting of your pediatric hospital? 1. Free-standing children’s hospital (FSCH) a. Do you have privileges at the FSCH? i. Yes ii. No b. If FSCH, how many times in 3 month period do you operate there? i. 0 ii. 1-2 iii. 3-5 iv. 6-10 v. > 10 c. On a scale of 1-5 (1 being the worst), how would you rate your satisfaction with the following at the FSCH: i. Available equipment in OR: ii. Support staff in OR for endovascular procedure: iii. Vascular lab technologist available: 2. Pediatric hospital within a general adult hospital a. On a scale of 1-5, how would you rate your satisfaction with the following: i. Available equipment in OR: ____ ii. Support staff in OR for endovascular procedure: _____ iii. Vascular lab technologist available: ____
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6) How many partners are within your vascular division, including yourself? 7) How many partners operate on pediatric patients, including yourself? 17
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8) How many partners will operate but only under emergent situations on pediatric patients, including yourself?
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9) How many partners will not operate on pediatric patients, including yourself?
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10) Are you the main vascular surgeon in your division operating on pediatric patients? a. Yes i. If yes, are you the only vascular surgeon in your division operating on pediatric patients? 1. Yes 2. No a. If No, write in how many other vascular surgeons in your division would you consider main surgeons caring for pediatric patients? ________ b. No i. If no, do you operate on pediatric patients? 1. Yes a. Do you call themain pediatric vascular surgeon when performing procedures on pediatric patients? i. Yes 1. Call them to discuss the case. 2. Call them for standby. 3. Call them to take over the case. ii. No 2. No Clinical Vignettes Pediatric Vascular
11) How would you describe your level of comfort in pre-operative, post-operative, and medical management of pediatric vascular disease? a. Very comfortable. b. Comfortable. c. Uncomfortable.
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12) Did you operate on pediatric patients with renal artery stenosis during your training? a. Yes b. No 13) Do you care for pediatric patients with renal artery stenosis in your current clinical practice? 18
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b. No
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i. A nine year old male has uncontrolled hypertension despite three drug therapy and CTA shows left renal artery stenosis. What is your procedure of choice? 1. Unilateral Balloon angioplasty and stenting 2. Renal autotransplantation 3. Patch angioplasty 4. Splenorenal bypass 5. Reimplantation 6. Bypass a. autogenous hypogastric artery b. saphenous vein 7. Other ii. What is the number of cases/your experience with pediatric patients with renal artery stenosis over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable
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14) Did you operate on pediatric patients with Middle Aortic Syndrome during your training? a. Yes 19
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15) Do you care for pediatric patients with Middle Aortic Syndrome in your current clinical practice? a. Yes i. A twelve year old female complains of bilateral lower-limb claudication. CTA shows stenosis from the mid descending aorta to the aortic bifurcation without concomitant stenosis of the renal or visceral arteries. What is your procedure of choice? 1. Balloon angioplasty 2. Patch aortoplasty 3. Homograft 4. Thoraco-to-infrarenal aortic bypass ii. What is the number of cases/your experience with pediatric patients with Middle Aortic Syndrome over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. A twelve year old female complains of bilateral lower-limb claudication. CTA shows stenosis from the mid descending aorta to the aortic bifurcation without concomitant stenosis of the renal or visceral arteries. Would you refer this patient to the main pediatric vascular surgeon in your division? 1. Yes a. If the main surgeon was not available, would you perform the operation or transfer the patient to another facility? i. Perform operation ii. Transfer 2. No ii. Would you be willing to operate on this patient? 1. Yes 2. No
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16) Did operate for pediatric patients needing long-term hemodialysis access during your training? a. Yes b. No
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17) Do you care for pediatric patients requiring hemodialysis access in your current clinical practice? a. Yes i. An 8-year-old male will require long-term hemodialysis and you are consulted for upper extremity vascular access. You do not have an autologous vein available for fistula creation. What is your conduit of choice? 1. Homograft 2. PTFE/Dacron 3. Bovine ii. What is the number of cases/your experience with pediatric patients with need for hemodialysis over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. An 8-year-old male will require long-term hemodialysis and you are consulted for upper extremity vascular access. You do not have an autologous vein available for fistula creation. Would you refer this patient to the main pediatric vascular surgeon in your division? 1. Yes a. If the main surgeon was not available, would you perform the operation or transfer the patient to another facility? i. Perform operation ii. Transfer 2. No ii. Would you be willing to operate this patient? 1. Yes
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Clinical Vignettes Trauma
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18) How would you describe your level of comfort in pre-operative, post-operative, and medical management of pediatric vascular trauma? a. Very comfortable. b. Comfortable. c. Uncomfortable.
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19) A 12 year old sustains a brachial artery transection secondary to supracondylar humerus fracture with 5 centimeter segment of artery transected and not amenable to primary repair. If you were on call and consulted, would you operate on this patient? a. Yes i. How would you perform the arterial repair? a. Autogenous arterial autograph b. Interposition vein graph c. PTFE/Dacron d. Ligation and evaluation of hand perfusion ii. What is the number of cases/your experience with pediatric patients with traumatic brachial artery injury over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. Would you call the main vascular surgeon in your division if he/she was not on call? 1. Yes 2. No a. Who would perform the repair? _____
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20) A 16 year old sustains a gunshot wound to the left thigh. A CTA demonstrates an injury to the superficial femoral artery that is too extensive to repair primarily. If you were on call and consulted, would you operate on this patient? a. Yes i. How would you perform the arterial repair? 1. Patch angioplasty 2. Autogenous arterial autograph 3. Endovascular stent 4. Bypass a. Vein b. Artery 5. Other ii. What is the number of cases/your experience with pediatric patients with traumatic superficial femoral artery injury over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. Would you call the main vascular surgeon in your division if he/she was not on call? 1. Yes 2. No a. Who would perform the repair? _____
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21) An 8 year old sustains a posterior knee dislocation without palpable dorsalis pedis and posterior tibial pulses. If you were on call and consulted, would you operate on this patient? a. Yes i. Would you perform additional imaging prior to going to the operating room? 1. Yes a. CTA b. On table arteriogram 2. No 23
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ii. How would you perform the arterial repair? 1. Patch angioplasty 2. Autogenous arterial autograph 3. Endovascular 4. Bypass a. Vein b. Artery iii. What is the number of cases/your experience with pediatric patients with traumatic popliteal artery injury over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iv. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No
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i. Would you call the main vascular surgeon in your division if he/she was not on call? 1. Yes 2. No a. Who would perform the repair? _____
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22) A 6 year old arrives to the ED with a gunshot wound to zone II of the neck with an expanding hematoma. You are called by pediatric surgeon during emergent neck exploration who found a 2 cm common carotid injury. If you were on call and consulted, would you operate on this patient? a. Yes i. How would you perform the arterial repair? 1. Patch angioplasty 2. Bypass with PTFE/Dacron 3. Bypass with vein 4. Bypass with artery. ii. What is the number of cases/your experience with pediatric patients with traumatic carotid artery injury over past 10 years as an attending surgeon? 1. 0 2. 1-2
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3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No
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i. Would you call the main vascular surgeon in your division? 1. Yes 2. No a. Who would perform the repair? _____
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23) A 10 year old sustains a gunshot wound to the abdomen. The pediatric surgeon performs emergent exploratory laparotomy and found an expanding hematoma from an injury to the infrarenal aorta. There is no associated bowel injury. If you were on call and consulted, would you operate on this patient? a. Yes i. How would you perform the arterial repair? 1. Patch angioplasty 2. Bypass a. Vein b. Artery 3. PTFE/ Dacron ii. What is the number of cases/your experience with pediatric patients with traumatic aortic injury over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. Would you call the main vascular surgeon in your division if he/she was not on call? 1. Yes 2. No
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a. Who would perform the repair? _____
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1) Are you the program director of the vascular program at your institution? a) Yes b) No (If no answered, will skip this portion of survey)
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2) Does your institution have a fellowship trained vascular surgeon available at all times, including emergencies, for operative management of pediatric patients? a) Yes b) No c) Unsure
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3) Does your institution have a fellowship trained vascular surgeon listed on a circulated call schedule at all times? a) Yes b) No c) Unsure 4) Do your fellows rotate on a pediatric vascular surgery service? a) Yes b) No
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5) Is there a dedicated team for pediatric vascular at your institution? a) Yes b) No
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Vascular Program Directors Survey
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Table I Satisfaction rating on scale of 1 to 5 with available equipment OR, support staff, and availability of vascular laboratory technologist by pediatric hospital setting. Adult Hospital
p-value*
Rating of available equipment in OR
3;3;4
4;5;5
0.002*
Rating of support staff for endovascular procedure
1;2;4
Rating of vascular lab technologist available
2;2;4
4;5;5
<0.001*
3;5;5
0.010*
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*Indicated statistical significance using Wilcoxon rank-sum tests.
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Children’s Hospital
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A nine year old male has uncontrolled hypertension despite three drug therapy and CTA shows left renal artery stenosis. What is your procedure of choice? Unilateral Balloon Angioplasty and Stenting 18% (5) Renal Autotransplantation 0% (0) Patch Angioplasty 7% (2) Splenorenal Bypass 4% (1) Reimplantation 14% (4) Bypass - Autogenous Hypogastric Artery 32% (9) Bypass - Saphenous Vein 7% (2) Other 18% (5)
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Table II Operation of choice and number of cases for Renal Artery Stenosis clinical vignette.
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Table III Operation of choice and number of cases for Middle Aortic Syndrome clinical vignette.
10% ( 3) 41% (12) 0% ( 0) 48% (14)
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Balloon Angioplasty Patch Aortoplasty Homograft Thoraco-to-infrarenal Aortic Bypass
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A twelve year old female complains of bilateral lower-limb claudication. CTA shows stenosis from the mid descending aorta to the aortic bifurcation without concomitant stenosis of the renal or visceral arteries. What is your procedure of choice?
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Table IV Operation of choice and number of cases for Hemodialysis clinical vignette.
32% (11) 41% (14) 26% ( 9)
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Homograft PTFE/Dacron Bovine
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An 8-year-old male will require long-term hemodialysis and you are consulted for upper extremity vascular access. You do not have an autologous vein available for fistula creation. What is your conduit of choice?
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Table V Patient transfer decision for clinical vignettes when main vascular surgeon is not available. p-value
27 27
0.210 0.156
Hemodialysis
13
17
0.119
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Transfer
Renal Artery Stenosis Middle Aortic Syndrome
Perform Operation 7 4
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Table VI Association of number of cases performed in past 10 years and comfort level for operative management of RAS, MAS, HD. Comfortable
Uncomfortable
RAS 0 1-2 3-5 6-10 >10
0% (0) 0% (0) 44% (4) 33% (3) 22% (2)
6% (1) 44% (8) 28% (5) 22% (4) 0% (0)
0% (0) 0% (0) 100% (2) 0% (0) 0% (0)
MAS 0 1-2 3-5 6-10 >10
0% (0) 29% (2) 43% (3) 0% (0) 29% (2)
5% (1) 67% (14) 19% (4) 10% (2) 0% (0)
100% (1) 0% (0) 0% (0) 0% (0) 0% (0)
HD 0 1-2 3-5 6-10 >10
0% (0) 0% (0) 27% (4) 47% (7) 27% (4)
18% (3) 6% (1) 41% (7) 29% (5) 6% (1)
p-value 0.0422
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P-values calculated using Fisher’s exact tests
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0.0177
50% (1) 0% (0) 50% (1) 0% (0) 0% (0)
0.1547
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Table VII Operation of choice for brachial artery trauma vignette.
4% ( 3) 93% (78) 0% ( 0) 4% ( 3)
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Autogenous arterial autograph Interposition vein graph PTFE/Dacron Ligation and evaluation of hand perfusion
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Table VIII Operation of choice for superficial femoral artery trauma vignette.
4% ( 4) 0% ( 0) 0% ( 0) 95% (87) 0% ( 0) 1% ( 1)
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Patch Angioplasty Autogenous Arterial Autograph Endovascular Stent Bypass - Vein Bypass - Artery Other
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A 16 year old sustains a gunshot wound to the left thigh. A CTA demonstrates an injury to the superficial femoral artery that is too extensive to repair primarily. What is your procedure of choice?
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An 8 year old sustains a posterior knee dislocation without palpable dorsalis pedis and posterior tibial pulses. What is your procedure of choice? Patch angioplasty 14% (11) Autogenous arterial autograph 4% ( 3) Endovascular 4% ( 3) Bypass - Vein 76% (58) Bypass - Artery 1% ( 1)
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Table IX Operation of choice for popliteal artery trauma vignette.
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Table X Operation of choice for carotid artery trauma vignette.
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Patch angioplasty Bypass with PTFE/Dacron Bypass with vein Bypass with artery.
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Table XI Operation of choice for Aorta trauma vignette. A 10 year old sustains a gunshot wound to the abdomen. The pediatric surgeon performs emergent exploratory laparotomy and found an expanding hematoma from an injury to the infrarenal aorta. There is no associated bowel injury. What is your procedure of choice? 45% (39) 7% ( 6) 6% ( 5) 43% (37)
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Patch angioplasty Bypass - Vein Bypass - Artery PTFE/ Dacron
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Table XII Association of number of cases performed in past 10 years and comfort level for operative traumatic arterial injury. Comfortable
Uncomfortable
p-value
Brachial Artery 0 1-2 3-5 6-10 >10
16% (5) 12% (4) 38% (12) 19% (6) 16% (5)
14% (6) 44% (19) 30% (13) 7% (3) 5% (2)
33% (3) 56% (5) 11% (1) 0% (0) 0% (0)
0.0213
Superficial femoral artery 0 1-2 3-5 6-10 >10
16% (7) 12% (5) 37% (16) 16% (7) 19% (8)
14% (6) 58% (25) 16% (7) 2% (1) 9% (4)
50% (3) 50% (3) 0% (0) 0% (0) 0% (0)
<0.0001
Popliteal artery 0 1-2 3-5 6-10 >10
19% (5) 37% (10) 19% (5) 22% (6) 4% (1)
28% (13) 57% (26) 11% (5) 2% (1) 2% (1)
33% (1) 33% (1) 33% (1) 0% (0) 0% (0)
0.0729
Carotid artery 0 1-2 3-5 6-10 >10
21% (4) 42% (8) 32% (6) 0% (0) 5% (1)
69% (35) 29% (15) 2% (1) 0% (0) 0% (0)
83% (10) 8% (1) 8% (1) 0% (0) 0% (0)
0.0001
57% (30) 36% (19) 8% (4) 0% (0) 0% (0)
92% (12) 0% (0) 8% (1) 0% (0) 0% (0)
0.0055
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Aorta 0 1-2 3-5 6-10 >10
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S0890-5096(18)30486-2
DOI:
10.1016/j.avsg.2018.05.033
Reference:
AVSG 3921
To appear in:
Annals of Vascular Surgery
Received Date: 1 February 2018 Revised Date:
26 April 2018
Accepted Date: 3 May 2018
Please cite this article as: Bonasso PC, Dassinger MS, Smeds MR, Moursi MM, Pediatric Vascular Surgical Practice Patterns, Annals of Vascular Surgery (2018), doi: 10.1016/j.avsg.2018.05.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Pediatric Vascular Surgical Practice Patterns
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Patrick C. Bonasso MD1, Melvin S. Dassinger MD1, Matthew R. Smeds MD2, Mohammed M.
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Moursi MD1
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University of Arkansas for Medical Sciences; 4301 W Markham St. Little Rock, Arkansas.
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Saint Louis University; 3655 Vista Ave. Saint Louis, Missouri. 63110
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[email protected] [email protected] [email protected]
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M. Sidney Dassinger Matthew R Smeds Mohammed M Moursi
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Corresponding Author: Patrick C. Bonasso, MD University of Arkansas for Medical Sciences Division of Pediatric Surgery 1 Children’s Way, Slot 837 Little Rock, AR 72202 Phone: 501-364-2832 Fax: 501-364-1516 Email: [email protected]
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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This manuscript was presented as a podium presentation at the 28th Annual meeting of the Vascular and Endovascular Surgery Society (VESS) in Vail, CO on February 3, 2018.
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ABSTRACT
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Introduction Vascular surgeons infrequently care for pediatric patients. As such, variability in operative management and available hospital resources at free-standing children’s hospitals may exist. The study aims were: 1) determine vascular surgeon comfort level with pediatric vascular surgery, and 2) determine variations in pediatric vascular surgery practice patterns.
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Material and Methods A survey composed of clinical vignettes emailed to all members of Vascular and Endovascular Surgery Society was designed to assess operative management of pediatric vascular conditions and hospital resources. Comparisons of surgeon satisfaction between free-standing children’s hospitals and a children’s hospital within an adult general hospital were made using Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made using a McNemar’s test. P-values less than or equal to 0.05 indicated statistical significance.
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Results Response rate was 18% (93/525) with 96% (89/93) indicating completion of a 2 year vascular fellowship. Surgeon satisfaction with operative equipment (p =0.002), support staff (P<0.001), and vascular lab availability (p=0.01) was significantly lower at CH. 87% of surgeons operated on fewer than two children over the preceding three months. For the different clinical vignettes, there was a wide variation in practice patterns with a range of 50% to 89% of the surgeons performing fewer than 5 cases over the preceding ten years. There was a significant decrease in surgeon’s comfort level with elective pediatric vascular operations compared to the operative management of pediatric vascular trauma (p=0.0025). Conclusions Most vascular surgeons do not feel comfortable in the operative management of pediatric vascular disease and optimal resource availability within pediatric children’s hospitals may be lacking. Centralized care of this patient population may be warranted.
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Key Words: Vascular, Survey, Practice Patterns
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Introduction Vascular surgeons care for pediatric patients for both elective cases and traumatic
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injuries. Vascular surgeons infrequently care for pediatric patients due to limited referral
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patterns and low case volume. This may affect the vascular surgeon’s comfort level in dealing
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with this patient population. A recent survey of pediatric trauma providers found that there may
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be variability in the care and operative management of these children depending on the
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institution and available hospital resources at free-standing children’s hospitals (CH) [1].
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Furthermore, current training does not frequently include designated time on a pediatric surgery,
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pediatric interventional radiology or pediatric vascular services [2]. There is little in the current
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literature on availability and comfort level of vascular surgeons in managing pediatric patients
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for both elective cases and traumatic injuries.
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The aims of this study, thus, are to: 1) determine modern vascular surgeon comfort level
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with pediatric vascular surgery, 2) determine variations in practice patterns for the management
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of pediatric vascular operations, and 3) evaluate the operation of choice for management of
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pediatric vascular diseases and pediatric vascular trauma.
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Materials Methods
After institutional review board approval, a twenty- three question survey was sent to all
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active and senior members of the Vascular and Endovascular Surgery Society (VESS). The
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survey was reviewed and approved by the VESS executive committee for distribution to its
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membership. VESS members were chosen because the membership reflects a wide range of
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practice types that is nationally represented. The survey was created by the senior vascular
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surgeon at our institution and represented a variety of pediatric vascular surgical diseases and
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traumatic vascular injuries. It was administered via REDCap (Research Electronic Data
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Capture), a secure Web-based application designed to support data capture for research studies
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(Appendix). The survey asked basic demographic questions. It assessed comfort level (very
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comfortable, comfortable, and uncomfortable) with pediatric procedures and evaluated
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anticipated management of pediatric vascular surgeries, emergent vascular injuries, and available
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hospital resources.
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active VESS members. If survey was not completed after first email, a second follow-up email
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was sent three weeks later to improve participant response rate. The survey was closed on May
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24, 2017. Participants had the option to answer either all of the questions or some of the
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questions on the survey. If identified as a program director, then four additional questions were
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asked.
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An email was sent on April 24, 2017 from the study senior author to all 525
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All data were analyzed using statistical software R v3.1.0 (R Foundation for Statistical
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Computing, Vienna, Austria). Categorical variables summarized using percentage (count) and
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comparisons were made using Fisher’s exact tests. Continuous variables were compared using
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Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made
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using a McNemar’s test. P-values less than or equal to 0.05 were considered statistically
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significant.
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Results
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3.1 Demographics and Training
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93 of 525 (18%) VESS members participated. The mean year of fellowship completion was 2003. 96% (89/93) of the survey participants trained at an independent vascular surgery
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fellowship (5+2) and 4% (4/93) trained at an integrated vascular surgery residency (0+5).
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Regarding experience of operative pediatric vascular surgery procedures, 50% operated with
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vascular surgeons during fellowship, 42% operated with pediatric surgeons during fellowship,
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and 8% observed in the operating room. Only 7 respondents (8%) spent dedicated time on a
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pediatric surgery rotation during fellowship (p=0.045).
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Two-thirds (65) of the respondents currently train vascular fellows or vascular residents on a daily basis. Training programs included 52% independent vascular surgery fellowship, 9%
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integrated vascular surgery residency, and 39% both program types.
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The mean number of vascular surgeons within the respondent’s vascular division was six. An average of three vascular surgeons within the division reported operating on pediatric
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patients both in elective and emergent situations. 35/93 (38%) responded that they were the
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primary pediatric vascular surgeon in their division with 11 of those respondents stating they
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were the lone vascular surgeon caring for pediatric patients in the division.
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Two-thirds of the respondents have an affiliation with a pediatric hospital: 38/61
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affiliated with a CH and 23/61 with a pediatric hospital within an Adult Hospital (AH). Of those
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with CH affiliation, 74% have privileges at the CH. The majority (87%) of the participants
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operated at the CH two times or less over the past 3 months. Vascular surgeons were more
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satisfied with available operating room equipment (p=0.002), support staff (p<0.001), and
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vascular lab capabilities (p=0.01) at AH than at Free-standing CHs (Table I), with those who
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work in a free-standing hospital.
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Comfort level was assessed. 37% of the respondents stated they were not comfortable
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with the pre-operative, post-operative, and medical management of elective pediatric vascular
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disease. For the other participants, 48% responded that they were comfortable and 15%
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responded they were very comfortable.
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3.2 Program Directors
There were 22 program directors identified. 86% (19/22) do not have the fellows rotate
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vascular team.
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3.3 Elective Vascular Surgery Clinical Vignettes
Three clinical vignettes for elective pediatric vascular surgical cases were surveyed: renal artery stenosis (RAS), middle aortic syndrome (MAS), and hemodialysis (HD) access.
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3.3.1 Renal Artery Stenosis
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22/93 (23%) of the respondents operated on pediatric patients with RAS during their
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training and 29/93 (31%) care for pediatric patients with RAS in their current practice. 69%
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(20/29) of respondents have operated on less than five patients in the past 10 years (Table VI).
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32% of respondents would perform bypass with autogenous hypogastric artery (Table II). Only
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7% responded that they were uncomfortable with their procedure of choice (Table VI).
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3.3.2 Middle Aortic Syndrome
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27/93 (29%) of the respondents operated on pediatric patients with MAS during their
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training and 29/93 (31%) care for pediatric patients with MAS in their current practice. 86%
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(25/29) have operated on less than five patients in the past 10 years (Table VI). 48% of
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respondents would perform thoraco-to infrarenal aortic bypass and 41% would perform patch
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aortoplasty (Table III). One respondent was uncomfortable with their procedure of choice,
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patch aortoplasty.
155
3.3.3 Hemodialysis Access
156
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39/93 (41%) of the respondents operated on pediatric patients needing HD access during their training and 34/93 (36%) perform HD access procedures in their current practice. 44%
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(17/39) have operated on less than five patients in the past 10 years (Table VI). There was no
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consensus on type of operation including homograft, PTFE/Dacron, and Bovine (Table IV).
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Two respondents were uncomfortable with their procedure of choice, homograft.
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3.3.4 Patient Transfer
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Respondents were asked if they would perform the operation or transfer the pediatric patient when the main vascular surgeon was not available. The majority of vascular surgeons
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would transfer the patient for both renal artery stenosis and middle aortic syndrome and near
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equal proportion for performing the operation and transferring for hemodialysis (Table V).
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3.3.5 Comfort level
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The number of cases performed over the past 10 years was associated with an increased
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comfort level for both RAS (P=0.0422) and MAS (p=0.0177). No association with the number
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of cases performed was found for HD (p=0.1547) (Table VI).
171 172
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3.4 Trauma Vignettes
Five vignettes for pediatric vascular trauma cases were surveyed. 24% of the respondents
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stated they were not comfortable with the pre-operative, post-operative, and medical
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management of pediatric vascular trauma.
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175 176
3.4.1 Brachial Artery 91% of the respondents said if they were on call, they would operate on the pediatric patient. 11% were uncomfortable with performing the identified procedure of choice and would
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call the main pediatric vascular surgeon in division for advice even if he/she was not on call.
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93% of the respondents would perform interposition vein graph (Table VII).
180
3.4.2 Superficial femoral artery
99% of the respondents said if they were on call, they would operate on the patient. 7%
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were uncomfortable with performing the identified procedure of choice and would call the main
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pediatric vascular surgeon in division for advice even if he or she was not on call. 95% of the
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respondents would perform vein bypass (Table VIII).
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3.4.3 Popliteal artery
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82% of the respondents said if they were on call, they would operate on the patient. 80%
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responded that they would perform additional imaging prior to going to the operating room with
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52% performing and on table arteriogram and 48% performing a CTA. 4% were uncomfortable
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with performing the identified procedure of choice. 76% would perform vein bypass (Table IX).
190
3.4.4 Carotid artery
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91% of the respondents said if they were on call, they would operate on the patient. 15%
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were uncomfortable with performing the identified procedure of choice and would call the main
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pediatric vascular surgeon in division for advice even if he/she was not on call. 48% would
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perform bypass with vein and 36% would perform patch angioplasty (Table X).
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3.4.5 Aorta
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94% of the respondents said if they were on call, they would operate on the patient. 15%
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were uncomfortable with performing the identified procedure of choice and would call the main
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pediatric vascular surgeon in division for advice even if he/she was not on call (Table XI).
199
3.4.6 Comfort level
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Case numbers over past 10 years and comfort level were compared. For all anatomic locations other than popliteal artery injury there was a statistically significant positive correlation
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between number of cases and comfort level, brachial artery (p=0.02), superficial femoral artery
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(p<0.001), carotid artery (p=0.001), and aorta (p=0.005) (Table XII).
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205
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204 Discussion
The current definition of the Vascular Surgery specialty by the American Board of
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Surgery includes having significant experience with all aspects of treating patients with all types
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of vascular disease [3]. Interestingly, the current definition does not include the care of pediatric
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vascular patients. Moreover, vascular trainee competency includes demonstration of the
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knowledge of the basic principles of vascular surgery which does not include pediatric surgical
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care [4]. Our survey indicates that significant variation exists in the operative management of
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both elective and traumatic injuries as well as vascular surgeon comfort level in caring for
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pediatric patients.
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The elective vascular surgical clinical vignettes included RAS, MAS, and HD. RAS and
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MAS, a common cause of childhood hypertension, has a limited number of studies assessing the
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risk of surgical or endovascular intervention and outcomes [5]. Only 25% of the vascular
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surgeons were trained in and currently care for patients with either RAS or MAS. For those
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performing the operations for RAS and MAS, comfort level in performing the operation of
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choice improved with the number of cases. For RAS and MAS operations without availability of
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the main pediatric vascular surgeon, the majority of respondents would transfer patients to
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another facility. The likelihood of transfer was 79% and 87% for RAS and MAS, respectively.
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In comparison, comfort level and number of cases increased for patients in need of HD
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access. The incidence of end-stage renal disease requiring hemodialysis in the United States is
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approximately 1,000 cases per year [6]. Infants and young children are more frequently
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maintained with PD therapy as compared with older adolescents, who are more likely to receive
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HD [7]. Children older than 10 years and/or weighing >20 kg and will be on HD for more than
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a few months, arteriovenous fistulas or arteriovenous grafts are preferred [8]. Only about half
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the American children receive care at a pediatric center, with the rest receiving dialysis services
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at an adult facility [7]. Since vascular surgeons have experience with adult HD fistula creation,
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they may be more willing to operate on pediatric patients, especially those older than 10 years of
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age. However, no consensus operation was noted from the respondents with either homograft,
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PTFE/Dacron, or Bovine.
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Vascular trauma accounts for less than two percent of injured children admitted to hospitals in the United States [9,10]. Pediatric vascular injuries can present difficult challenges
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to the surgeons providing care [1]. Vascular surgeons were more comfortable caring for
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pediatric vascular trauma in comparison to elective pediatric vascular disease cases as vascular
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surgical principles can be applied from the adult [11]. Yet, 24% of the respondents were
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uncomfortable managing pediatric vascular trauma. Traumatic arterial injury operative
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intervention comfort level improved as the number of cases increased for all injuries except
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popliteal artery injury. For all the vignettes, between 88 to 99% of respondents would operate
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on the pediatric patient if on call and less than 15% of the respondents were uncomfortable
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performing the procedure of choice. Traumatic vascular injuries are emergent procedures and
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unlikely to permit transfer to a regionalized center of care without risk of life or limb. One or
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more vascular surgeons within the division could be identified as the primary or expert vascular
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surgeon for the care of pediatric patients and help advise and assist their partners in emergent
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cases.
247
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Care of pediatric vascular disease and injuries encompasses an undefined space in the vascular surgery practice. Vascular surgeons are neither required to complete a pediatric surgery
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rotation nor do they have dedicated time allotted to managing pediatric vascular patients during
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vascular residency or fellowship [4]. Our results show a limited number of training fellowships
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with a dedicated service for pediatric vascular surgery. Based on the responses, there are a
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limited number of vascular surgeons operating on pediatric patients for both elective and
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traumatic cases. Comfort level in caring for pediatric vascular disease improves as the case
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volume increases. Yet, even those who are comfortable performing the cases and without main
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pediatric surgeon availability, the majority would transfer patients to another facility. These
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finding may suggest a centralized care strategy for pediatric vascular disease. For vascular
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surgery trainees, a pediatric surgery rotation may benefit the trainee as far as increasing the
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comfort level with taking care of pediatric patients. However, few centers have a large enough
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pediatric vascular surgery volume; thus, comfort level caring for and treating these pediatric
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vascular issues may stay the same.
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There is a potential for a lack resources in caring for children at CHs as the vascular
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surgeons were less satisfied with operating room equipment, support staff, and vascular lab
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capabilities in comparison to AH. This discomfort with caring for vascular pediatric patients at
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free-standing hospitals rather than their primary adult hospital may stem from unfamiliarity with
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the staff, and differences of stocking, given lack of vascular pediatric vascular surgery volume. Limitations do exist for this study. First, there are limitations primarily due to the survey
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nature of the study. With a response rate of 18%, bias may exist. Specifically, there was a large
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variation in the training and current practice of the respondents. This may skew the results to
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favor those with pediatric vascular training or those with interest in caring for pediatric patients.
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Another limitation is the bias introduced by the wording of the clinical vignettes. For comfort in
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the peri-operative care of these patients, they could be managed by a different pediatric service;
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thus, comfort level would not be a valuable tool as care for by the vascular surgery service in the
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perioperative period may be limited. At some institutions, a multi-disciplinary team may care for
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these patients. Additionally, surgical specialists who may be caring for these pediatric trauma
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patients including pediatric surgeons, pediatric transplant surgeons, pediatric cardiovascular
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surgeons, or others were not included in the survey.
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In summary, this survey describes the current practice of vascular surgeons who are members of the VESS caring for children for both elective vascular procedures and vascular
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trauma. These data may be used to inform future decisions on pediatric vascular care of
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potentially change discussion about education and clinical training for vascular surgeons [1].
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The results should encourage institutions caring for children to develop and maintain plans for
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the comprehensive and definitive management of pediatric vascular disease and vascular trauma
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[1].
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Conclusion
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Most centers do not have a dedicated team for pediatric vascular cases, and many
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vascular fellows do not rotate on a pediatric vascular surgery service. Adequate vascular
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resources within a FSCH including equipment, support staff, and vascular lab technologists are
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not available to vascular surgeons. A significant portion of vascular surgeons do not feel
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comfortable in the management of pediatric vascular disease. Centralized care of this patient
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population may be warranted.
292 Acknowledgements
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No additional acknowledgements to address.
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Appendix: Survey Questions
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Research data for this article
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Due to the sensitive nature of the questions asked in this study, survey respondents were assured
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raw data would remain confidential and would not be shared
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References
1. American College of Surgeons. A Guide to Surgical Specialists. Available at: https://www.facs.org/education/patient-education/patient-resources/specialists; [accessed
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January 2018].
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2. The American Board of Surgery. Training and Certification: Vascular Surgery.
http://www.absurgery.org/default.jsp?aboutvascularsurgerydefined; [accessed January 2018].
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3. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate medical Education in Vascular Surgery.
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https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/450_vascular_surgery_2017
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-07-01.pdf?ver=2017-10-24-143917-207; [accessed January 2018].
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4. Rumman RK, Matsuda-Abedini, M, Langlois V, Radhakrishnan S, Lorenzo AJ, Amaral J, Mertens L, Parekh RS. Management and Outcomes of Childhood Renal Artery
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Stenosis and Middle Aortic Syndrome. Am J of Hypertension 2018;
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doi.org/10.1093/ajh/hpy014
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5. Saran R, Li Y, Robinson B, et al. US Renal Data System 2015 Annual Data Report: epidemionlogy of kidney disease in the United States. Am J Kidney Dis 2016; 67: S1-
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S434.
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6. Chand DH, Swartz S, Tuchman S, Valentini RP, Somers MJG. Dialysis in Children and
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Adolescents: The Pediatric Nephrology Perspective. Am J of Kidney Dis 2017; 69: 278-
320 321 322
286.
7. National Kidney Foundation. DOQI clinical practice guidelines for vascular access. Am J Kidney Dis 1997; 30: S150-S191.
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8. Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, Green D, Demetriades D.
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Pediatric vs. adult vascular trauma: a National Trauma Databank review. J Pediatr Surg.
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2010; 45:1404-1412.
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9. Tepas JJ, Walsh DS. Vascular Injury. In: Coran AG, ed. Pediatric Surgery. 7th ed. Philadelphia, PA: Elsevier Saunders; 2012, p. 361-368.
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10. Bonasso PC, Gurien LA, Smith SD, Saylors ME, Dassinger MS. Pediatric Vascular
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Trauma Practice Patterns and Resource Availability: A Survey of ACS-Designated
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Pediatric Trauma Centers. J of Trauma Acute Care Surg 2018; Jan 12. [Epub ahead of
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print]
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11. Sciarretta JD, Macedo FI, Chung EL, Otero CA, Pizano LR, Namias N. Management of
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lower extremity vascular injuries in pediatric trauma patients: a single Level I trauma
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center experience. J of Trauma Acute Care Surg 2014; 76: 1386-9.
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Appendix As a potential participant in the study as a member of the Vascular and Endovascular Surgery Society (VESS), you are receiving this link and being asked to participate in a research project. Participation in this project will involve completion of a brief 23-27 question survey that should take 10 minutes. Participation is voluntary and neither the decision to participate nor the survey responses will have any bearing on professional status, and indicate that responses are anonymous.
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Wide variation and level of comfort in pediatric vascular operations appears to exist across the United States. The aims of this survey are to: 1) determine variations in practice patterns for the management of pediatric vascular procedures; 2) determine number of vascular surgeons caring for pediatric patients in the United States; and 3) evaluate the operation of choice for management of pediatric vascular diseases and pediatric vascular trauma
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Pediatric Vascular Practice Patterns 1) What program are you associated with? All members of the Vascular and Endovascular Surgery Society. 2) What year did you complete your vascular surgery fellowship?
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3) What type of fellowship did you participate in? a. 2 year post general surgery fellowship i. Please select the choice that best describes your experience regarding operative pediatric vascular surgery procedures during your general surgery training. 1. Observe in OR 2. Operate with vascular surgeon 3. Operate with pediatric surgeon ii. Did you spend dedicated time on a pediatric surgery rotation during your vascular fellowship training? 1. Yes 2. No b. Integrated Program (0/5) i. Please select the choice that best describes your experience regarding operative pediatric vascular surgery procedures during your vascular fellowship. 1. Observe in OR 2. Operate with vascular surgeon 3. Operate with pediatric surgeon ii. Did you spend dedicated time on a pediatric surgery rotation during your residency? 1. Yes 2. No
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336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377
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4) Do you train vascular fellows or vascular residents on a daily basis? a. Yes i. 2 year post general surgery fellowship ii. Integrated Program (0/5) iii. Both b. No
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5) Does your current institution have an affiliation with a Pediatric Hospital? a. No b. Yes i. What is the setting of your pediatric hospital? 1. Free-standing children’s hospital (FSCH) a. Do you have privileges at the FSCH? i. Yes ii. No b. If FSCH, how many times in 3 month period do you operate there? i. 0 ii. 1-2 iii. 3-5 iv. 6-10 v. > 10 c. On a scale of 1-5 (1 being the worst), how would you rate your satisfaction with the following at the FSCH: i. Available equipment in OR: ii. Support staff in OR for endovascular procedure: iii. Vascular lab technologist available: 2. Pediatric hospital within a general adult hospital a. On a scale of 1-5, how would you rate your satisfaction with the following: i. Available equipment in OR: ____ ii. Support staff in OR for endovascular procedure: _____ iii. Vascular lab technologist available: ____
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378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417
6) How many partners are within your vascular division, including yourself? 7) How many partners operate on pediatric patients, including yourself? 17
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8) How many partners will operate but only under emergent situations on pediatric patients, including yourself?
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9) How many partners will not operate on pediatric patients, including yourself?
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10) Are you the main vascular surgeon in your division operating on pediatric patients? a. Yes i. If yes, are you the only vascular surgeon in your division operating on pediatric patients? 1. Yes 2. No a. If No, write in how many other vascular surgeons in your division would you consider main surgeons caring for pediatric patients? ________ b. No i. If no, do you operate on pediatric patients? 1. Yes a. Do you call themain pediatric vascular surgeon when performing procedures on pediatric patients? i. Yes 1. Call them to discuss the case. 2. Call them for standby. 3. Call them to take over the case. ii. No 2. No Clinical Vignettes Pediatric Vascular
11) How would you describe your level of comfort in pre-operative, post-operative, and medical management of pediatric vascular disease? a. Very comfortable. b. Comfortable. c. Uncomfortable.
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418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457
12) Did you operate on pediatric patients with renal artery stenosis during your training? a. Yes b. No 13) Do you care for pediatric patients with renal artery stenosis in your current clinical practice? 18
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a. Yes
b. No
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i. A nine year old male has uncontrolled hypertension despite three drug therapy and CTA shows left renal artery stenosis. What is your procedure of choice? 1. Unilateral Balloon angioplasty and stenting 2. Renal autotransplantation 3. Patch angioplasty 4. Splenorenal bypass 5. Reimplantation 6. Bypass a. autogenous hypogastric artery b. saphenous vein 7. Other ii. What is the number of cases/your experience with pediatric patients with renal artery stenosis over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable
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i. A nine year old male with failed triple medication uncontrolled hypertension and CTA shows left renal artery stenosis. Would you refer this patient to the main pediatric vascular surgeon in your division? 1. Yes a. If the main surgeon was not available, would you perform the operation or transfer the patient to another facility? i. Perform operation ii. Transfer 2. No ii. Would you be willing to operate on this patient? 1. Yes 2. No
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458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497
14) Did you operate on pediatric patients with Middle Aortic Syndrome during your training? a. Yes 19
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b. No
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15) Do you care for pediatric patients with Middle Aortic Syndrome in your current clinical practice? a. Yes i. A twelve year old female complains of bilateral lower-limb claudication. CTA shows stenosis from the mid descending aorta to the aortic bifurcation without concomitant stenosis of the renal or visceral arteries. What is your procedure of choice? 1. Balloon angioplasty 2. Patch aortoplasty 3. Homograft 4. Thoraco-to-infrarenal aortic bypass ii. What is the number of cases/your experience with pediatric patients with Middle Aortic Syndrome over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. A twelve year old female complains of bilateral lower-limb claudication. CTA shows stenosis from the mid descending aorta to the aortic bifurcation without concomitant stenosis of the renal or visceral arteries. Would you refer this patient to the main pediatric vascular surgeon in your division? 1. Yes a. If the main surgeon was not available, would you perform the operation or transfer the patient to another facility? i. Perform operation ii. Transfer 2. No ii. Would you be willing to operate on this patient? 1. Yes 2. No
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498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537
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16) Did operate for pediatric patients needing long-term hemodialysis access during your training? a. Yes b. No
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17) Do you care for pediatric patients requiring hemodialysis access in your current clinical practice? a. Yes i. An 8-year-old male will require long-term hemodialysis and you are consulted for upper extremity vascular access. You do not have an autologous vein available for fistula creation. What is your conduit of choice? 1. Homograft 2. PTFE/Dacron 3. Bovine ii. What is the number of cases/your experience with pediatric patients with need for hemodialysis over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. An 8-year-old male will require long-term hemodialysis and you are consulted for upper extremity vascular access. You do not have an autologous vein available for fistula creation. Would you refer this patient to the main pediatric vascular surgeon in your division? 1. Yes a. If the main surgeon was not available, would you perform the operation or transfer the patient to another facility? i. Perform operation ii. Transfer 2. No ii. Would you be willing to operate this patient? 1. Yes
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538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577
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2. No
Clinical Vignettes Trauma
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18) How would you describe your level of comfort in pre-operative, post-operative, and medical management of pediatric vascular trauma? a. Very comfortable. b. Comfortable. c. Uncomfortable.
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19) A 12 year old sustains a brachial artery transection secondary to supracondylar humerus fracture with 5 centimeter segment of artery transected and not amenable to primary repair. If you were on call and consulted, would you operate on this patient? a. Yes i. How would you perform the arterial repair? a. Autogenous arterial autograph b. Interposition vein graph c. PTFE/Dacron d. Ligation and evaluation of hand perfusion ii. What is the number of cases/your experience with pediatric patients with traumatic brachial artery injury over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. Would you call the main vascular surgeon in your division if he/she was not on call? 1. Yes 2. No a. Who would perform the repair? _____
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578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616
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20) A 16 year old sustains a gunshot wound to the left thigh. A CTA demonstrates an injury to the superficial femoral artery that is too extensive to repair primarily. If you were on call and consulted, would you operate on this patient? a. Yes i. How would you perform the arterial repair? 1. Patch angioplasty 2. Autogenous arterial autograph 3. Endovascular stent 4. Bypass a. Vein b. Artery 5. Other ii. What is the number of cases/your experience with pediatric patients with traumatic superficial femoral artery injury over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. Would you call the main vascular surgeon in your division if he/she was not on call? 1. Yes 2. No a. Who would perform the repair? _____
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617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656
21) An 8 year old sustains a posterior knee dislocation without palpable dorsalis pedis and posterior tibial pulses. If you were on call and consulted, would you operate on this patient? a. Yes i. Would you perform additional imaging prior to going to the operating room? 1. Yes a. CTA b. On table arteriogram 2. No 23
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ii. How would you perform the arterial repair? 1. Patch angioplasty 2. Autogenous arterial autograph 3. Endovascular 4. Bypass a. Vein b. Artery iii. What is the number of cases/your experience with pediatric patients with traumatic popliteal artery injury over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iv. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No
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i. Would you call the main vascular surgeon in your division if he/she was not on call? 1. Yes 2. No a. Who would perform the repair? _____
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22) A 6 year old arrives to the ED with a gunshot wound to zone II of the neck with an expanding hematoma. You are called by pediatric surgeon during emergent neck exploration who found a 2 cm common carotid injury. If you were on call and consulted, would you operate on this patient? a. Yes i. How would you perform the arterial repair? 1. Patch angioplasty 2. Bypass with PTFE/Dacron 3. Bypass with vein 4. Bypass with artery. ii. What is the number of cases/your experience with pediatric patients with traumatic carotid artery injury over past 10 years as an attending surgeon? 1. 0 2. 1-2
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657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696
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3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No
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i. Would you call the main vascular surgeon in your division? 1. Yes 2. No a. Who would perform the repair? _____
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23) A 10 year old sustains a gunshot wound to the abdomen. The pediatric surgeon performs emergent exploratory laparotomy and found an expanding hematoma from an injury to the infrarenal aorta. There is no associated bowel injury. If you were on call and consulted, would you operate on this patient? a. Yes i. How would you perform the arterial repair? 1. Patch angioplasty 2. Bypass a. Vein b. Artery 3. PTFE/ Dacron ii. What is the number of cases/your experience with pediatric patients with traumatic aortic injury over past 10 years as an attending surgeon? 1. 0 2. 1-2 3. 3-5 4. 6-10 5. >10 iii. What is your comfort level in performing your procedure of choice? 1. Very comfortable 2. Comfortable 3. Uncomfortable b. No i. Would you call the main vascular surgeon in your division if he/she was not on call? 1. Yes 2. No
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697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736
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a. Who would perform the repair? _____
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1) Are you the program director of the vascular program at your institution? a) Yes b) No (If no answered, will skip this portion of survey)
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2) Does your institution have a fellowship trained vascular surgeon available at all times, including emergencies, for operative management of pediatric patients? a) Yes b) No c) Unsure
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3) Does your institution have a fellowship trained vascular surgeon listed on a circulated call schedule at all times? a) Yes b) No c) Unsure 4) Do your fellows rotate on a pediatric vascular surgery service? a) Yes b) No
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5) Is there a dedicated team for pediatric vascular at your institution? a) Yes b) No
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739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764
Vascular Program Directors Survey
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Table I Satisfaction rating on scale of 1 to 5 with available equipment OR, support staff, and availability of vascular laboratory technologist by pediatric hospital setting. Adult Hospital
p-value*
Rating of available equipment in OR
3;3;4
4;5;5
0.002*
Rating of support staff for endovascular procedure
1;2;4
Rating of vascular lab technologist available
2;2;4
4;5;5
<0.001*
3;5;5
0.010*
AC C
EP
TE D
M AN U
SC
*Indicated statistical significance using Wilcoxon rank-sum tests.
RI PT
Children’s Hospital
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
A nine year old male has uncontrolled hypertension despite three drug therapy and CTA shows left renal artery stenosis. What is your procedure of choice? Unilateral Balloon Angioplasty and Stenting 18% (5) Renal Autotransplantation 0% (0) Patch Angioplasty 7% (2) Splenorenal Bypass 4% (1) Reimplantation 14% (4) Bypass - Autogenous Hypogastric Artery 32% (9) Bypass - Saphenous Vein 7% (2) Other 18% (5)
RI PT
Table II Operation of choice and number of cases for Renal Artery Stenosis clinical vignette.
ACCEPTED MANUSCRIPT
Table III Operation of choice and number of cases for Middle Aortic Syndrome clinical vignette.
10% ( 3) 41% (12) 0% ( 0) 48% (14)
AC C
EP
TE D
M AN U
SC
Balloon Angioplasty Patch Aortoplasty Homograft Thoraco-to-infrarenal Aortic Bypass
RI PT
A twelve year old female complains of bilateral lower-limb claudication. CTA shows stenosis from the mid descending aorta to the aortic bifurcation without concomitant stenosis of the renal or visceral arteries. What is your procedure of choice?
ACCEPTED MANUSCRIPT
Table IV Operation of choice and number of cases for Hemodialysis clinical vignette.
32% (11) 41% (14) 26% ( 9)
AC C
EP
TE D
M AN U
SC
Homograft PTFE/Dacron Bovine
RI PT
An 8-year-old male will require long-term hemodialysis and you are consulted for upper extremity vascular access. You do not have an autologous vein available for fistula creation. What is your conduit of choice?
ACCEPTED MANUSCRIPT
Table V Patient transfer decision for clinical vignettes when main vascular surgeon is not available. p-value
27 27
0.210 0.156
Hemodialysis
13
17
0.119
AC C
EP
TE D
M AN U
SC
RI PT
Transfer
Renal Artery Stenosis Middle Aortic Syndrome
Perform Operation 7 4
ACCEPTED MANUSCRIPT
Table VI Association of number of cases performed in past 10 years and comfort level for operative management of RAS, MAS, HD. Comfortable
Uncomfortable
RAS 0 1-2 3-5 6-10 >10
0% (0) 0% (0) 44% (4) 33% (3) 22% (2)
6% (1) 44% (8) 28% (5) 22% (4) 0% (0)
0% (0) 0% (0) 100% (2) 0% (0) 0% (0)
MAS 0 1-2 3-5 6-10 >10
0% (0) 29% (2) 43% (3) 0% (0) 29% (2)
5% (1) 67% (14) 19% (4) 10% (2) 0% (0)
100% (1) 0% (0) 0% (0) 0% (0) 0% (0)
HD 0 1-2 3-5 6-10 >10
0% (0) 0% (0) 27% (4) 47% (7) 27% (4)
18% (3) 6% (1) 41% (7) 29% (5) 6% (1)
p-value 0.0422
RI PT
Very comfortable
AC C
EP
M AN U
TE D
P-values calculated using Fisher’s exact tests
SC
0.0177
50% (1) 0% (0) 50% (1) 0% (0) 0% (0)
0.1547
ACCEPTED MANUSCRIPT
Table VII Operation of choice for brachial artery trauma vignette.
4% ( 3) 93% (78) 0% ( 0) 4% ( 3)
AC C
EP
TE D
M AN U
SC
Autogenous arterial autograph Interposition vein graph PTFE/Dacron Ligation and evaluation of hand perfusion
RI PT
A 12 year old sustains a brachial artery transection secondary to supracondylar humerus fracture with 5 centimeter segment of artery transected and not amenable to primary repair. How would you perform the arterial repair?
ACCEPTED MANUSCRIPT
Table VIII Operation of choice for superficial femoral artery trauma vignette.
4% ( 4) 0% ( 0) 0% ( 0) 95% (87) 0% ( 0) 1% ( 1)
AC C
EP
TE D
M AN U
SC
Patch Angioplasty Autogenous Arterial Autograph Endovascular Stent Bypass - Vein Bypass - Artery Other
RI PT
A 16 year old sustains a gunshot wound to the left thigh. A CTA demonstrates an injury to the superficial femoral artery that is too extensive to repair primarily. What is your procedure of choice?
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
An 8 year old sustains a posterior knee dislocation without palpable dorsalis pedis and posterior tibial pulses. What is your procedure of choice? Patch angioplasty 14% (11) Autogenous arterial autograph 4% ( 3) Endovascular 4% ( 3) Bypass - Vein 76% (58) Bypass - Artery 1% ( 1)
RI PT
Table IX Operation of choice for popliteal artery trauma vignette.
ACCEPTED MANUSCRIPT
Table X Operation of choice for carotid artery trauma vignette.
RI PT
A 6 year old arrives to the ED with a gunshot wound to zone II of the neck with an expanding hematoma. You are called by pediatric surgeon during emergent neck exploration who found a 2 cm common carotid injury. What is your procedure of choice? 36% (30) 5% ( 4) 48% (40) 11% ( 9)
AC C
EP
TE D
M AN U
SC
Patch angioplasty Bypass with PTFE/Dacron Bypass with vein Bypass with artery.
ACCEPTED MANUSCRIPT
Table XI Operation of choice for Aorta trauma vignette. A 10 year old sustains a gunshot wound to the abdomen. The pediatric surgeon performs emergent exploratory laparotomy and found an expanding hematoma from an injury to the infrarenal aorta. There is no associated bowel injury. What is your procedure of choice? 45% (39) 7% ( 6) 6% ( 5) 43% (37)
AC C
EP
TE D
M AN U
SC
RI PT
Patch angioplasty Bypass - Vein Bypass - Artery PTFE/ Dacron
ACCEPTED MANUSCRIPT
Table XII Association of number of cases performed in past 10 years and comfort level for operative traumatic arterial injury. Comfortable
Uncomfortable
p-value
Brachial Artery 0 1-2 3-5 6-10 >10
16% (5) 12% (4) 38% (12) 19% (6) 16% (5)
14% (6) 44% (19) 30% (13) 7% (3) 5% (2)
33% (3) 56% (5) 11% (1) 0% (0) 0% (0)
0.0213
Superficial femoral artery 0 1-2 3-5 6-10 >10
16% (7) 12% (5) 37% (16) 16% (7) 19% (8)
14% (6) 58% (25) 16% (7) 2% (1) 9% (4)
50% (3) 50% (3) 0% (0) 0% (0) 0% (0)
<0.0001
Popliteal artery 0 1-2 3-5 6-10 >10
19% (5) 37% (10) 19% (5) 22% (6) 4% (1)
28% (13) 57% (26) 11% (5) 2% (1) 2% (1)
33% (1) 33% (1) 33% (1) 0% (0) 0% (0)
0.0729
Carotid artery 0 1-2 3-5 6-10 >10
21% (4) 42% (8) 32% (6) 0% (0) 5% (1)
69% (35) 29% (15) 2% (1) 0% (0) 0% (0)
83% (10) 8% (1) 8% (1) 0% (0) 0% (0)
0.0001
57% (30) 36% (19) 8% (4) 0% (0) 0% (0)
92% (12) 0% (0) 8% (1) 0% (0) 0% (0)
0.0055
SC
M AN U
TE D 38% (8) 33% (7) 24% (5) 0% (0) 5% (1)
EP AC C
Aorta 0 1-2 3-5 6-10 >10
RI PT
Very comfortable