搜索结果：Seminars in vascular surgery

Simulation-based training (SBT) has become essential in vascular surgery education, providing a risk-free environment for skill development. This scoping review evaluates the current state of vascular surgery simulation, highlighting validated models, educational impact, and areas for improvement. A systematic literature search was conducted in PubMed, Embase, and Scopus, following PRISMA-ScR guidelines. Studies assessing validated simulation models for open and endovascular procedures, vascular anastomosis, carotid interventions, peripheral vascular interventions, and nontechnical skills training were included. Data extraction focused on fidelity, skill acquisition, procedural efficiency, and accessibility. Validated high-fidelity models, including 3D-printed, virtual reality (VR), and pulsatile cadaveric systems, significantly enhance technical proficiency and confidence. Bench and porcine models improve vascular anastomosis training, while VR-based simulators enhance catheter manipulation and decision-making. However, simulation remains limited by high costs, accessibility challenges, and lack of standardized nontechnical skills training. Simulation improves competency in vascular surgery but requires further integration into training curricula. AI-driven assessments, hybrid simulation models, and expanded cost-effective solutions are needed to bridge existing gaps. Standardization and broader adoption of simulation will enhance competency-based training and improve patient outcomes.

The decline in diversity in medical education, following the Supreme Court's 2023 ruling against race-based affirmative action, exacerbates existing health disparities. With decreasing enrollment of underrepresented groups in medical schools, residency attrition, and gaps in diversity, equity and inclusion (DEI) standards, urgent efforts are needed to address systemic inequities in medical training and patient care. Vascular surgery has made important progress in increasing diversity within its training programs, but there is still much work to be done to create a truly inclusive environment. While there has been growth in the representation of women within vascular surgery, the proportion of underrepresented in medicine (UriM) physicians has not kept pace. Addressing the lack of diversity in vascular surgery requires a multi-pronged approach focused on recruitment, retention, and the creation of an inclusive learning and work environment. Establishing an inclusive environment goes beyond recruitment; it requires fostering a culture where all trainees and faculty feel valued and heard. Through targeted initiatives, commitment to transparency, and systemic changes to academic and clinical environments, the field can make substantial strides in workforce diversity and in turn addressing disparities.

Vascular specialists are increasingly confronted with clinical dilemmas surrounding the optimal role for carotid revascularization in an elderly patient population. Specifically, while carotid revascularization has been demonstrated to reduce the risk of ischemic stroke in appropriately selected patients, its application in elderly patients, particularly those who are asymptomatic, remains a focus of debate. This controversy stems largely from the exclusion of such older patients from the seminal trials that established the efficacy of revascularization over medical management. Furthermore, early studies have also highlighted concerns regarding elevated perioperative risk, prevalence of competing comorbidities, and limited life expectancy in this patient population, calling into question the marginal benefit of a revascularization procedure. However, more recent evidence suggests that with careful patient selection, elderly individuals can experience comparable outcomes to their younger counterparts. In particular, both carotid endarterectomy and transcarotid artery revascularization have demonstrated favorable safety and effectiveness profiles in octogenarians, and both appear to outperform transfemoral carotid artery stenting in terms of perioperative stroke/death risk. Importantly, contemporary risk assessment tools, including those incorporating frailty and anatomical complexity, highlight that age alone should likely not preclude intervention. Instead, these tools can be utilized to aid in performing an individualized and comprehensive risk assessment to inform shared decision making. In this review article, we will explore current controversies, supporting evidence, and important considerations when caring for older patients, specifically those over the age of 80 who are considering carotid revascularization.

Clinical equipoise-genuine uncertainty within the expert community regarding the relative merits of competing treatments-forms the ethical and scientific foundation of randomized controlled trials. The growing adoption of thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (uTBAD) has increasingly challenged the principle of clinical equipoise in the treatment algorithm of uTBAD. Optimal medical therapy remains the accepted standard in the treatment of uTBAD. However, the expanding role of TEVAR has led some clinicians and institutions to view early intervention as beneficial, despite the lack of definitive comparative data. Randomized controlled trials, such as INSTEAD, INSTEAD-XL, and ADSORB, have demonstrated that TEVAR promotes false-lumen thrombosis and remodeling, but have not shown a clear survival benefit over optimal medical therapy. Retrospective studies frequently suggest favorable aortic remodeling and improved survival with TEVAR, yet these associative findings cannot establish causality and fall short of the evidentiary strength required to resolve treatment uncertainty. Contemporary guidelines reflect this ambiguity by endorsing aggressive medical therapy with selective TEVAR for anatomically high-risk patients. In the absence of definitive data, practice patterns have been shaped by institutional culture. Persistent uncertainties underscore the need for a definitive randomized trial. These unresolved questions underscore the persistence of clinical equipoise and the ethical necessity for a definitive randomized trial. Equipoise is challenged by institutional culture, specialty bias, referral patterns, patient expectations, and device marketing. Clinical equipoise in uTBAD will be resolved by adequately powered trials demonstrating improvement in patient-centered outcomes. Surrogate measures of aortic remodeling are insufficient.

Transcarotid artery revascularization is increasingly prevalent, but relies on fluoroscopic guidance for placement of carotid stents. With increasing awareness about the hazards of radiation exposure, we aimed to explore the prior literature regarding alternative and adjunct imaging methods in carotid stenting. These have included fusion with preoperative computed tomography angiography, fully contrast-sparing procedures with preoperative magnetic resonance angiography and fusion using plain fluoroscopy, and ultrasound-assisted transfemoral carotid stenting. All methods demonstrated excellent technical results but have achieved very limited adoption. We also reviewed literature on the use of ultrasound-guided stent and device deployment in other vascular beds, including inferior vena cava (IVC) filter placement, endovascular aneurysm repair, and peripheral arterial stenting, suggesting that ultrasound is a feasible method for intraoperative guidance. However, with lack of widespread adoption, further modifications may be required to improve usability in the operative setting. Finally, our group explored a novel frontier in ultrasound-guided transcarotid stenting, using preoperative computed tomography angiography imaging in conjunction with live ultrasound imaging. Fusion of the live and preoperative imaging allows the user to see the exact location of their ultrasound imaging plane superimposed on a 3-dimensional model of the carotid, taking significant uncertainty out of real-time ultrasound imaging. This novel registration technology may significantly improve the ability of surgeons to use ultrasound in the deployment of carotid stents, thereby reducing radiation exposure in the procedure. In addition, the same technology may be extrapolated to other areas of vascular pathology in the future.

Traditional carotid revascularization outcome measures often overlook meaningful changes in outcomes important to patients. Patient-reported outcomes are being used more often to assess how diseases and treatments affect these outcomes, with these insights gathered through patient-reported outcome measures (PROMs). This narrative review summarizes the PROM instruments applied in carotid revascularization studies, highlights key findings regarding quality of life (QoL) before and after intervention, and examines methodological challenges inherent to PROM implementation. Generic PROMs are most often used in carotid revascularization research, with most studies describing QoL changes after carotid endarterectomy in symptomatic patients using the generic 36-Item Short Form Survey PROM. Symptomatic patients can expect a return to baseline QoL by 1 year after intervention. Trial data suggest carotid artery stenting confers a short-term QoL benefit with equivalency to carotid endarterectomy by 1 year. There is insufficient high-quality data to evaluate QoL and revascularization for asymptomatic patients, compare best medical therapy with intervention, or compare the effect of surgical technique on QoL. Interpretation of PROM and QoL data in carotid revascularization research to date is limited by heterogeneity in study methodology and PROM choice and validation. Most PROMs used in carotid revascularization are not validated and lack consensus for testing intervals, patient stratification, and the type of PROM that best reflects patient perceptions. Future work should emphasize the development of carotid disease-specific PROMs to best capture patient-reported outcomes and guide clinical decision making.

Training surgeons poses many unique challenges. In addition to the clinical acumen that must be learned, a minimum threshold of technical competency is a requisite for independent practice. The trends of endovascular interventions and open surgical procedures add another layer of complexity to vascular surgery training. Simulation can provide a solution for both technical skills training and evaluating proficiency. The Education Committee of the Association of Program Directors of Vascular Surgery (APDVS) developed the Fundamentals of Vascular and Endovascular Surgery platform to provide an opportunity for more uniform basic technical skill teaching and assessment across all vascular training programs. Evaluation by experts with standardized scoring of Objective Structured Assessment of Technical Skills (OSATS) Global Rating Score and Global Summary grading systems have demonstrated correlation with participant ability when completing the end-to-side anastomosis, patch angioplasty, and clockface suturing models. Future research should be directed toward developing autonomous and objective methods for technical assessments on these models.

Nonhealing wounds are increasingly prevalent, present in 1% to 2% of the global population, with higher incidence in geriatric patients. These chronic wounds pose challenges to older adult patients owing to physiologic changes that hinder healing, common medical comorbidities that promote inflammation and damage microcirculation, poor nutritional status and mobility, and psychosocial barriers to receiving care. In this literature review, the epidemiology, pathophysiology, systems costs, and management of chronic venous leg ulcers, arterial ulcers, and diabetic foot wounds in older adult patients are investigated. Evolving skin structure, pro-inflammatory cellular changes, and propensity for infection place the geriatric population at risk for all wound types. Strategies to differentiate between nonhealing wounds through physical examination, standardized tools, and patient-specific characteristics are outlined. Optimal wound care management principles for each wound type, including wound bed debridement, moisture optimization, biofilm control, and management of edema are addressed. Venous leg ulcers secondary to venous insufficiency are particularly common in older adults and often recur, requiring innovative techniques in compression and tissue substitutes. Emerging therapies, including skin grafts, hyperbaric and topical oxygen, and bedside imaging devices, are discussed. Finally, older adult patients are susceptible to social circumstances that place them at risk for suboptimal wound care and poor healing. The combination of access gaps to regular caretakers, immobility, nociceptive and neuropathic pain, and frailty must be acknowledged and addressed in older adult patients with wounds. The aims of this literature review were to clarify these factors to consolidate awareness and to advocate for a multidisciplinary approach to wound care management.

The interventional management of symptomatic carotid disease (ie, endarterectomy, angioplasty/stenting, or transcarotid artery revascularization) has traditionally involved correcting the area of arterial narrowing, guided by stenosis severity combined with medical therapy, and has been recommended by the 2021 American Heart Association Secondary Stroke Prevention Guidelines. Despite this traditional practice, advances in medical therapy show promise in reducing recurrent stroke without the need for interventional procedures in the setting of low-to-intermediate-risk carotid lesions. We review current evidence for the nonoperative management of symptomatic carotid disease, focusing on markers of plaque vulnerability, risk calculators, and the efficacy of intensive medical therapy. The objective of this review was to illustrate that medical management of symptomatic carotid disease may be a reasonable alternative to surgical intervention in select patients. High-risk features such as intraplaque hemorrhage, a large lipid-rich necrotic core, a thin fibrous cap, plaque ulceration, vessel wall enhancement, and microembolic activity found on transcranial Doppler ultrasound strongly predict recurrent ischemic events and favor revascularization. In contrast, their absence supports medical management. Risk stratification tools such as the Carotid Artery Risk score and PLAQUE Radiology Scoring system have demonstrated potential utility for identifying low-risk patients who are good candidates for medical therapy. Guideline-directed medical therapy uses antiplatelet agents, intensive lipid-lowering therapy, blood pressure control, diabetes management, and structured lifestyle interventions. Contemporary clinical trials such as the Second European Carotid Surgery Trial and CASCOM are evaluating the comparative effectiveness of revascularization versus intensive medical therapy, with interim data suggesting comparable outcomes in appropriately selected patients. In the modern era, medical management of symptomatic carotid stenosis is safe and effective for patients lacking high-risk plaque features. Integration of imaging biomarkers, validated risk calculators, and structured risk factor modification programs offers a precision-medicine approach that may redefine treatment algorithms and aid in patient management.

Multidisciplinary aortic teams (MAT) are integral to the management of aortic pathology. This study quantifies the effects of MAT implementation on aortic case volumes, practice patterns and surgical productivity at a single academic institution. Patients receiving aortic procedures were identified using CPT codes. Three time periods were defined: 2 years prior to MAT (2018), the first year with MAT (2020), and 2 years post implementation of MAT (2022). Full MAT was defined as having aortic-focused providers from cardiothoracic surgery, vascular surgery, cardiology and genetics. Total aortic case volume increased over 300 over the study period. Increased volume was seen for both cardiothoracic and vascular cases with a significant increase in the proportion of ascending aortic replacements as well as thoracic endografting (P&#x202f;<&#x202f;.01). Patients receiving multiple procedures significantly increased from 2018 to 2020 (70.3%&#x202f;vs. 84.9%) as well as mean number of procedures per patient (1.98&#x202f;vs. 2.42, both P&#x202f;<&#x202f;.05). While the number of patients receiving genetic testing and followed by the institutional cardiology team remained constant during the study period, the number of patients receiving joint cardiothoracic and vascular evaluation increased significantly (23.8% 2018&#x202f;vs 41.1% 2020, P&#x202f;=&#x202f;.02). Overall procedural RVUs increased from 6.8k in 2018 to 21.1k in 2022 (310% increase). Implementation of MAT correlated with increased aortic case volumes for cardiothoracic and vascular surgeons as well as increased overall productivity. These data suggest that robust multidisciplinary involvement is crucial to expand complex aortic volume and develop comprehensive treatment plans for patients with thoracoabdominal pathology.

Claudication from peripheral artery disease is a common mobility-limiting condition in older adults. Exercise therapy, whether delivered through supervised programs or structured home-based programs, plays a central role in claudication care for older adults, offering substantial functional gains with minimal risk, and should be the cornerstone of management alongside optimized medical therapy. This review examines contemporary management of claudication in the aging population, with emphasis on exercise therapy. Treatment modalities, including best medical therapy, supervised exercise therapy, home-based exercise programs, and invasive interventions (endovascular and open surgery) are critically evaluated. Pharmacotherapy (eg, cilostazol) can modestly improve walking distance, and aggressive risk factor control (eg, smoking cessation and statins) is imperative for all patients. Invasive revascularization is reserved for select individuals with lifestyle-limiting claudication unresponsive to conservative measures, given procedural risks and the potential for repeated interventions. Recent society guidelines (American College of Cardiology and the American Heart Association 2016 and European Society for Vascular Surgery 2024) and the Society for Vascular Surgery's 2025 focused update uniformly endorse exercise and medical therapy as initial management, restricting revascularization to severe claudication after conservative therapy trials and emphasizing individualized shared decision-making approaches. Claudication outcomes (ankle-brachial index changes, 6-minute walk improvements, and patient-reported outcomes) across treatments are reviewed alongside indications, contraindications, and benefits of each strategy.

Patient and stakeholder engagement is increasingly emphasized in clinical research, yet practical guidance on how to operationalize engagement in high-acuity, multicenter surgical trials remains limited. We describe the design and early implementation of a structured engagement strategy within the IMPROVE-AD (Improving Outcomes in Vascular Disease-Aortic Dissection) trial. IMPROVE-AD is a pragmatic, multicenter randomized trial comparing optimal medical therapy alone with optimal medical therapy plus thoracic endovascular aortic repair for uncomplicated type B aortic dissection. A formal patient engagement committee, supported by a stakeholder engagement core, was established to integrate patient perspectives into trial design and conduct. Engagement activities included inputs on trial design, recruitment strategies, participant-facing materials, and communication approaches. Observations were derived from the early implementation of these activities. Stakeholder engagement informed several aspects of trial development and implementation. Early engagement contributed to the refinement of trial design elements, including the prioritization of clinical endpoints over surrogate measures. During trial implementation, patient engagement committee input supported the revision of informed consent language, development of public-facing materials, and refinement of recruitment messaging, with an emphasis on clarity, transparency, and clinical equipoise. Access to aggregated screening and enrollment data enabled the identification of potential barriers to recruitment and underrepresentation. These observations are descriptive. A formal evaluation of the impact of engagement on enrollment, retention, or other trial outcomes has not yet been conducted. Structured stakeholder engagement can be incorporated into the design and conduct of a high-acuity, multicenter randomized trial and may inform communication, recruitment, and implementation strategies. Although the full model described here is resource intensive, selected elements may be adaptable across diverse research settings. Further work is needed to evaluate the impact of engagement and to identify scalable approaches.

Cocaine and amphetamine use is strongly associated with Type B aortic dissection (TBAD). This disproportionately affects younger patients, who are more likely to present with complicated disease and experience greater postoperative morbidity. Stimulant-positive patients are often underrepresented or excluded from prospective trials evaluating optimal medical therapy, thoracic endovascular aortic repair, and perioperative management. Ethical concerns, medicolegal risk, stigma, and barriers to follow-up have further constrained trial participation, resulting in reliance on retrospective data and an absence of standardized management guidance. A literature review was conducted investigating the clinical presentation, medical and surgical management of stimulant-positive patients presenting with uncomplicated TBAD. We focused on anesthetic and ethical challenges unique to this population and explored the role of multidisciplinary care teams in perioperative care. Stimulant use precipitates acute sympathetic activation, labile hypertension, and increased aortic wall stress, complicating medical and procedural management. Routine stimulant screening may improve risk stratification and guide antihypertensive selection. Perioperative management should be guided by clinical evidence of intoxication rather than toxicology results. Nonurgent procedures should be deferred only in cases of active intoxication. Early multidisciplinary involvement-including addiction medicine, social work, and case management-may address barriers to medication adherence, reduce recurrence risk, and improve continuity of care. Stimulant-associated TBAD represents a distinct clinical entity requiring tailored medical, surgical, anesthetic, and psychosocial strategies. Standardized screening practices, evidence-based perioperative management, and integrated multidisciplinary care pathways may improve outcomes. Prospective studies and professional society guidance are needed to define best practices for this high-risk population.

Since the first carotid endarterectomy (CEA) in 1953 by Dr. Michael DeBakey, the management of carotid stenosis has evolved tremendously, with the introduction of transfemoral carotid artery stenting (tfCAS) in the 1990s and transcarotid artery revascularization (TCAR), introduced by Dr. Juan Parodi in 1998 and available commercially in 2015, as well as improved medical management. Society guidelines endorse revascularization for symptomatic patients with high-grade stenosis and acceptable procedural risk. Introduced as a minimally invasive alternative to CEA, tfCAS has been consistently associated with higher perioperative stroke risk compared with CEA. As such, guidelines recommend CEA for patients older than 70 years, although stenting may be considered for younger patients or those with high surgical risk. TCAR has increased in volume since its introduction in 2015, with continued growth after its coverage expansion in April 2022. Although no trials have directly compared TCAR with the other techniques, registry data have indicated its safety and equivocal outcomes compared with CEA, and guidelines show a preference for TCAR over tfCAS and CEA in patients with high surgical risk. Management of asymptomatic disease remains controversial, with advancements in medical therapy. The recent CREST-2 trial found a lower risk of perioperative stroke or death and ipsilateral stroke within 4 years after tfCAS and intensive medical therapy compared with intensive medical therapy alone; CEA and intensive medical therapy also had a lower risk but the difference did not reach statistical significance. As such, patient selection should continue to be individualized.

As the world's elderly population continues to grow, the proportion of people living with chronic medical conditions is also increasing. Cardiovascular diseases including hypertension, diabetes, and atherosclerosis are among the most common, and as a result peripheral artery disease (PAD) is increasingly prevalent in this population. It is estimated that 15% to 20% of the elderly population has been diagnosed with PAD, and consequentially there is also a large proportion who have progressed to chronic limb threatening ischemia (CLTI). The management of this end stage of PAD is complex regardless of age, as there is high variability in current practice patterns and a lack of consensus on endovascular or surgical bypass as the initial treatment modality. The treatment paradigm becomes even more complicated in the elderly population, and special considerations must be given to treatment including the decision to offer revascularization (surgical or endovascular) vs primary amputation. This article explores the risks and benefits of the 2 approaches in the context of mortality, quality of life, and cost in the elderly population. Although there is good evidence that revascularization confers benefits in mortality, quality of life, and cost, there are also data that indicate that this approach should only be offered to fully independent individuals as outcomes in those with a nonambulatory status preoperatively are poor. Overall, the authors advocate for a patient-centered, multidisciplinary approach to treating CLTI in this population that focuses first and foremost on patient goals.

It has been established that there is a shortage of vascular surgeons nationwide. This is attributed partially to an imbalance between the number of vascular trainees, and consequently the number of newly graduated vascular surgeons entering the workforce, and the number of clinically active vascular surgeons approaching retirement age. Concurrently, a "silver tsunami" of an aging population in the United States, and increasing prevalence of morbid obesity, diabetes, and peripheral vascular disease portends a marked increase in the patient population in need of vascular care. This anticipated lack of appropriate vascular care may disproportionately affect specific populations. It is our aim to explore the role community training can serve in addressing this issue.

As medicine evolves and life expectancy increases, octogenarians and nonagenarians represent growing populations that are at increased risk of ischemic stroke from asymptomatic carotid stenosis (ACS). Despite the significant disability and mortality that results from stroke in older adults, there are few data on the management of ACS in this population to inform clinical practice guidelines. The authors sought to assess the current body of literature on the management and outcomes of ACS in older adults. Prior landmark randomized controlled trials comparing carotid endarterectomy with best medical therapy alone have been questioned, as modern best medical therapy strategies have significantly evolved since their conception. These studies either do not include octogenarians and nonagenarians or involve a limited sample size, making it challenging to apply these findings to older adult population. Two particular areas of interest in our review are the potential benefits of carotid revascularization and risk stratification. Retrospective studies suggest that carotid endarterectomy may improve cognitive functioning in older adults. Frailty is shown to be associated with worse postoperative outcomes of carotid revascularization in the general population, although few data exist on the impact of frailty on outcomes in octogenarians and nonagenarians. Overall, there is a limited body of literature informing the clinical management of ACS in octogenarians and nonagenarians, and future randomized controlled trials are needed to compare outcomes of carotid revascularization with best medical therapy alone in this population.

Psychological safety is a critical component of the medical learning environment. While multiple synthesis studies exist for psychological safety within broader medical education, few have focused specifically on surgical training paradigms. This narrative review evaluates psychological safety for surgical trainees. A literature search of PubMed was conducted to identify studies discussing psychological safety within the surgical learning environment. Studies were included if psychological safety was a primary outcome, predictor, or theme. Studies were excluded if surgical trainees were not included or specifically discussed. A total of 53 articles were screened. Of these, 36 were excluded for relevance, and the remaining 17 full texts were reviewed. Reasons for exclusion include: study was conducted internationally; psychological safety was not a critical outcome, predictor, or theme; study focused on nonsurgical medical specialties (ie, anesthesia or psychiatry); and psychological safety of surgical trainees was not discussed despite surgical trainees being within the study cohort. A total of 11 studies were included for comparison. Four studies evaluated the positive impact of psychological safety within care teams that included surgical trainees. Two discussed the importance of building psychological safety as a surgical educator. Five studies evaluated learning environment factors or interventions that predicted psychological safety. Existing literature on psychological safety within the surgical learning environment focuses on educators, surgical teams, and specific aspects of the learning environment. While these studies offer valuable insight, additional studies are needed to identify effective interventions and operationalization of previous recommendations.

As life expectancy increases, the prevalence of ruptured abdominal aortic aneurysms (rAAA) poses a significant challenge for our healthcare system. Aging induces biochemical changes, including degradation of the extracellular matrix and loss of vascular smooth muscle cells, which increase the propensity for the development of aneurysms and subsequent rupture due to compromised integrity of the aortic wall. The mortality rate for elderly patients presenting with rAAA is high, ranging from 80 to 90%. Both open and endovascular repair come with substantial risk for elderly patients. While EVAR has been shown to have lower perioperative mortality in this population, elderly patients face significant post-operative recovery challenges related to age and frailty. In determining who should be offered surgery for rAAA, patient selection is crucial. Frailty and existing comorbidities should be factored into whether or not patients are offered surgery. A tailored approach that is individualized to patient specific goals and accounts for pre-existing comorbidities and functional status is essential to improving outcomes for elderly patients presenting with rAAA.