How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia.

Objective: Although multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team.

Revascularization Outcomes Stratified by Glycemic Control in Patients with Diabetes Mellitus and Chronic Limb-Threatening Ischemia.

Background: The prevalence of chronic limb-threatening ischemia (CLTI) has increased alongside rising rates of diabetes mellitus (DM). While diabetic patients with CLTI have worse outcomes compared to patients without diabetes, conflicting data exist on the relationship between the severity of DM and CLTI outcomes. Close inspection of the relationship between DM severity and outcomes in CLTI may benefit surgical decision-making and patient education.

Physician Reimbursement for Vascular Surgery Procedures and Vascular Laboratory Studies Before and After the Affordable Care Act.

Objectives: The Patient Protection and Affordable Care Act (ACA), fully implemented by 2015, has significantly increased the number of Americans with health insurance. However, its impact on physician reimbursement (PR) is not well studied. Our objective was to determine the ACA's impact on the professional component of PR for selected vascular surgery (VS) procedures and vascular laboratory (VL) studies at our institution.

Addition of Efficiency Measures to Current Accuracy Measures in the Vascular Laboratory Can Be Used for Future Accreditation and Payment Models.

Background: The Medicare Access and CHIP Reauthorization Act (MACRA) brings with it increased regulatory requirements not traditionally addressed by standard vascular laboratory accreditation, which is based on accuracy. The new quality improvement project of the Intersocietal Accreditation Commission (IAC) may satisfy an improvement activity (IA) of the MACRA. We hypothesize that other IAs in the MACRA such as timeliness of test results or patient care quality performance requirements can be met by analyzing data already being collected by the vascular laboratory.

Four-extremity venous duplex ultrasound for suspected deep venous thrombosis is an anachronism.

Background: Duplex ultrasound is the "gold standard" for diagnosis of acute deep venous thrombosis (DVT) because of its high specificity, sensitivity, safety, and portability. However, unnecessary testing epitomizes inefficient use of scarce health care resources. Here we hypothesize that the majority of simultaneous four-extremity duplex ultrasound (FED) examinations are unnecessary.

A Case of Acute Iliocaval Thrombosis in the Setting of a Suprarenal Inferior Vena Cava Saccular Aneurysm.

Inferior vena cava (IVC) aneurysms are a rare finding, whose management and outcomes remain uncertain due to their low incidence and long-term follow-up. As IVC aneurysms remain a poorly understood clinical entity, it is important to expand upon our existing knowledge base as new cases arise. We present a patient with a suprarenal IVC saccular aneurysm and an overview of the current literature regarding IVC aneurysm classification, presentation, and management.

Presence and degree of residual venous obstruction on serial duplex imaging is associated with increased risk of recurrence and progression of infrainguinal lower extremity deep venous thrombosis.

Objective: The role of follow-up venous duplex ultrasound (DUS) after acute lower extremity deep vein thrombosis (DVT) remains unclear, yet it is commonly performed. We aimed to clarify the role of follow-up DUS. Our primary objective was to determine the association between the presence of residual venous obstruction (RVO) on DUS and DVT recurrence or propagation (rDVT).

Ultrasound-Guided Thrombin Injection Is a Safe and Effective Treatment for Femoral Artery Pseudoaneurysm in the Morbidly Obese.

Introduction: Ultrasound-guided thrombin injection (UGTI) is a well-established practice for the treatment of femoral artery pseudoaneurysm. This procedure is highly successful but dependent on appropriate pseudoaneurysm anatomy and adequate ultrasound visualization. Morbid obesity can present a significant technical challenge due to increased groin adiposity, resulting in poor visualization of critical structures needed to safely perform the procedure.

Common carotid artery end-diastolic velocity and acceleration time can predict degree of internal carotid artery stenosis.

Objective: Whereas duplex ultrasound parameters for predicting internal carotid artery (ICA) stenosis are well defined, the use of common carotid artery (CCA) Doppler characteristics to predict ICA stenosis when the ICA cannot be insonated directly or accurately because of anatomy, calcification, or tortuosity has not been studied. The objective of this study was to identify CCA Doppler parameters that may predict ICA stenosis.

Methods: We reviewed all patients at our institution who underwent carotid duplex ultrasound (CDU) from 2008 to 2015 and also had a comparison computed tomography, magnetic resonance, or catheter angiogram.

Comparison of time utilization in an academic inpatient versus an outpatient vascular laboratory.

Purpose: Efficient, cost-effective services in vascular laboratories (VLs) will be required in tomorrow's health care environment. Inpatient VLs (IPVL) are burdened with complex patients, excessive workload, and a high percentage of bedside tests. Outpatient VLs (OPVL) are therefore presumed to be more productive and efficient.

Elimination of medically unnecessary duplex venous scanning based on an established algorithm can result in significant cost savings under Medicare for the institution and the taxpayer.

Objective: The utility of duplex venous scanning (DVS) for suspected deep venous thrombosis in the emergency department (ED) remains controversial. We aimed to measure potential cost savings and economic impact in our institution and nationally for unnecessary DVS in Medicare patients seen in the ED.

Methods: We have previously calculated that 15.

Complete "in situ" avulsion of the radial artery complicating transradial coronary rotational atherectomy.

Background: Transradial percutaneous access (TR) is promoted because of increased patient comfort and convenience as well as a lower risk of access site and cardiac complications in the literature. Increased use of the TR purports a new set of possible complications for which the vascular surgeon must be capable to recognize and manage.

Methods: A 48-year-old, devout Jehovah's Witness, woman with a history of coronary artery bypass surgery presented with a non-ST-segment elevation acute myocardial infarction.

Endovascular intervention for pelvic congestion syndrome is justified for chronic pelvic pain relief and patient satisfaction.

Objective: Pelvic congestion syndrome (PCS) is difficult to diagnose, poorly understood, and often confused with other causes of chronic pelvic pain. Thus, gonadal vein reflux, its relation to lower extremity venous insufficiency (LEVI), and treatment remains controversial to physicians and payors. We present our experience with endovascular PCS treatment and hypothesize that properly selected patients can realize significant improvement.

Aortic arch replacement through a left thoracotomy for right-sided aortic arch aneurysm with complete vascular ring.

Right-sided aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum is the second most common vascular ring. Aneurysms of the arch in its retroesophageal portion are rare. The surgical repair of a retroesophageal arch aneurysm poses a significant challenge because no single approach provides access to the whole arch and all of its branches.

Delayed presentation and management of blunt traumatic inferior gluteal artery pseudoaneurysm with associated arteriovenous fistula.

Disruption of arterial wall integrity as a result of trauma, iatrogeny, inflammation, or infection may result in pseudoaneurysm formation. Gluteal artery aneurysms are rare and represent less than 1% of all arterial aneurysms. Pseudoaneurysms of the inferior gluteal artery (IGA) following blunt trauma are exceptionally rare with only 6 reported cases in the English literature.

Clinical evaluation of suspected deep vein thrombosis guides the decision to anticoagulate prophylactically but does not impact the decision to perform after hours duplex venous scanning or increase its yield.

Objective: The utility of after-hours duplex venous scanning (DVS) for suspected deep vein thrombosis (DVT) in emergency department (ED) patients has been debated. Availability of safe prophylactic low molecular weight heparin, cost containment efforts, and retention of scarce sonographers have to be balanced against 24/7 demand for services. We determined the incidence of DVT in DVS ordered after-hours, correlation between Wells' score and prophylactic anticoagulation as well as urgently performed DVS, and complications of delaying DVS until regular hours.

Differential effect of zoledronic acid on human vascular smooth muscle cells.

Introduction: The activation of human vascular smooth muscle cell proliferation, adhesion and migration is essential for intimal hyperplasia formation. These experiments were designed to test whether zoledronic acid (ZA) would modulate indices of human smooth muscle cell activation, exert differential effects on proliferating versus quiescent cells, and determine whether these effects were dependent on GTPase binding proteins prenylation. ZA was chosen for testing in these experiments because it is clinically used in humans with cancer, and has been shown to modulate rat smooth muscle cell proliferation and migration.

Adventitia-derived hydrogen peroxide impairs relaxation of the rat carotid artery via smooth muscle cell p38 mitogen-activated protein kinase.

The role of adventitia-derived reactive oxygen species (ROS) in vascular disease and impaired vascular relaxation is not clear. Based on robust adventitial ROS generation and effects on MAPK involvement in vascular dysfunction, we hypothesized that adventitia-derived ROS hydrogen peroxide (H(2)O(2)) impairs vascular relaxation through activation of medial smooth muscle p38 MAPK. By using a novel in vivo model, the adventitial surface of rat carotid arteries was bathed in situ for 90 min with vehicle, angiotensin II (AngII; 500 nM), AngII+H(2)O(2)-scavenger catalase (3,000 U/ml), AngII+p38 MAPK inhibitor SB203580 (10 μM), or AngII+superoxide dismutase (SOD; 150 U/ml).

Lack of glutathione peroxidase 1 accelerates cardiac-specific hypertrophy and dysfunction in angiotensin II hypertension.

Glutathione peroxidase 1 (Gpx1) plays an important role in cellular defense by converting hydrogen peroxide and organic hydroperoxides to nonreactive products, and Gpx1(-/-) mice, which are characterized by reduced tissue glutathione peroxidase activity, are known to exhibit enhanced oxidative stress. Peroxides participate in tissue injury, as well as the hypertrophy of cultured cells, yet the role of Gpx1 to prevent end organ damage in cardiovascular tissue is not clear. We postulated that Gpx1 deletion would potentiate both aortic and cardiac hypertrophy, as well as mean arterial blood pressure, in response to angiotensin II (AngII).

5-Fluorouracil treatment of problematic scars.

Background: Keloids and hypertrophic scars can be uncomfortable, disfiguring, and aesthetically undesirable. Anecdotal reports suggest that low-dose intralesional fluorouracil can be used to treat these undesirable scars.

Methods: Using a prospective case series protocol, both keloid and hypertrophic scar patients were included.

Nox4 oxidase overexpression specifically decreases endogenous Nox4 mRNA and inhibits angiotensin II-induced adventitial myofibroblast migration.

The vascular adventitia is emerging as an important modulator of vessel remodeling. Adventitial myofibroblasts migrate to the neointima after balloon angioplasty, contributing to restenosis. We postulated that angiotensin II (Ang II) enhances adventitial myofibroblast migration in vitro via reduced nicotinamide-adenine dinucleotide phosphate oxidase-derived H(2)O(2) and that Nox4-based oxidase promotes migration.

Are the communication and professionalism competencies the new critical values in a resident's global evaluation process?

Background: The ACGME requires the assessment of resident competency in 6 domains. Global evaluations covering all 6 competencies are routinely used. Evaluators may be overly influenced by resident affability and availability, thereby resulting in a halo effect.

Adventitial fibroblast reactive oxygen species as autacrine and paracrine mediators of remodeling: bellwether for vascular disease?

The importance of the vascular adventitia is increasingly being recognized not only in vascular disease but also in normal maintenance and homeostasis of vessels. Activation of the adventitia and its resident fibrocytic cells in response to injury, stretch, cytokines, and hormones has been shown to stimulate differentiation, collagen deposition, migration, and proliferation. Importantly, the effects of adventitial fibroblasts are increasingly being ascribed to reactive oxygen species (ROS) produced by adventitial fibroblast NAD(P)H oxidases.