BACKGROUND: The first 2 integrated vascular residents in the United States graduated in 2012, and in 2013, 11 more entered the job market. The purpose of this study was to compare the job search experiences of the first cohort of integrated 0 + 5 graduates to their counterparts completing traditional 5 + 2 fellowship programs. METHODS: An anonymous, Web-based, 15-question survey was sent to all 11 graduating integrated residents in 2013 and to the 25 corresponding 5 + 2 graduating fellows within the same institution. Questions focused on the following domains: training experience, job search timelines and outcomes, and overall satisfaction with each training paradigm. RESULTS: Survey response was nearly 81% for the 0 + 5 graduates and 64% for the 5 + 2 graduates. Overall, there was no significant difference between residents and fellows in the operative experience obtained as measured by the number of open and endovascular cases logged. Dedicated research time during the entire training period was similar between residents and fellows. Nearly all graduates were extremely satisfied with their training and had positive experiences during their job searches with respect to starting salaries, numbers of offers, and desired practice type. More 0 + 5 residents chose academic and mixed practices over private practices compared with 5 + 2 fellowship graduates. CONCLUSIONS: Although longer term data are needed to understand the impact of the addition of 0 + 5 graduating residents to the vascular surgery work force, preliminary survey results suggest that both training paradigms (0 + 5 and 5 + 2) provide positive training experiences that result in excellent job search experiences. Based on the current and future need for vascular surgeons in the work force, the continued growth and expansion of integrated 0 + 5 vascular surgery residency positions as an alternative to traditional fellowship training is thus far justified.

BACKGROUND: Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement. METHODS: This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy. RESULTS: During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding. CONCLUSIONS: Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

OBJECTIVE: The degree of carotid artery stenosis, as calculated by catheter-based angiography using NASCET methodology, has been shown to predict stroke risk in several large randomized controlled trials. In the current era, patients are increasingly being evaluated with CT-angiography (CTA) prior to carotid artery revascularization, especially as transcarotid artery revascularization (TCAR) adoption grows. Interpretation of CTA for degree of carotid stenosis has not been standardized, with both NASCET methodology and area stenosis being used. We performed a single-institution, blinded, retrospective analysis of CTAs using both NASCET methodology and CT-derived area stenosis to assess concordance/discordance between the two methods when evaluating > /=70% and > /=80% stenosis. METHODS: The UMass Memorial Medical Center vascular lab database was queried for all carotid duplex ultrasounds performed from 2008-2017. The dataset was winnowed to patients with duplex-defined > /=70% stenosis (defined as peak systolic velocity (PSV) > /=125 cm/s and an internal carotid-to-common carotid (ICA:CCA) ratio > /=4), and a correlative CTA performed < 1 year from duplex. A blinded review of all correlative CTA, using centerline measurements on a 3D workstation (Aquarius iNtuition Viewer, Terarecon, Durham, NC) was performed to characterize the degree of carotid stenosis by NASCET methodology and by area stenosis. Patients were excluded if revascularization was performed between the two imaging studies. RESULTS: Of 37,204 carotid duplex ultrasounds reviewed (2008-2017), 3,480 arteries met criteria for duplex defined > /=70% stenosis. A correlative CTA within 1 year of the duplex was identified in 460 arteries, of which 320 were adequate quality for blinded review. The median days between duplex and CTA was 9.5 days. Concordance between area and NASCET methodologies were poor for both > /=70% (kappa = 0.32) and > /=80% stenosis (kappa = 0.25). Of 247 arteries considered to have > /=70% area stenosis, 127 (51.4%) were considered to have > /=70% NASCET stenosis. Of 169 arteries considered to have > /=80% area stenosis, 44 (26.0%) were considered to have > /=80% NASCET stenosis. CONCLUSIONS: Area stenosis CTA calculations of carotid artery stenoses dramatically overestimate the degree of carotid stenosis compared to that calculated by NASCET methodology. Given that stroke risk estimates are based on trials that used NASCET methodology, area stenosis likely overestimates the risk of stroke. Therefore, area stenosis calculations may lead to unnecessary carotid revascularization procedures. This model highlights the need for standardized utilization of NASCET methodology when utilizing CTA as the imaging modality to determine threshold for carotid revascularization.

In 2008, the top priority in our division's 5-year strategic plan was "to become an internationally recognized center of excellence for the endovascular treatment of complex aortic pathology extending from the aortic valve to the external iliac artery." Five components were identified as "most critical" to achieve this strategic priority: (1) training at centers of excellence in complex endovascular repair; (2) industry partnership to improve access to developing technologies; (3) a fully integrated team approach with one leader involved in all steps of all cases; (4) prospective data collection; and (5) development and implementation of a physician-sponsored investigational device exemption for juxtarenal, pararenal, and thoracoabdominal aneurysms. We have now performed 49 repairs (16 commercially manufactured devices, 33 physician-modified devices) for 3 common iliac, 20 juxtarenal, 9 pararenal, and 17 thoracoabdominal aneurysms, using 142 fenestrations, branches, and scallops. All patients had complete 30-day follow-up for calculation of 30-day events. Kaplan-Meier analysis was used to calculate 1-year events. In 5 years, we developed a successful complex endovascular aortic program that uses fenestrated/branched repair techniques. A focused team strategic planning approach to program development is an effective way for vascular surgery divisions to gain experience and expertise with new complex technologies while ensuring acceptable patient outcomes.

Background Pulmonary embolism (PE) has been cited as the most common preventable cause of death in hospitalized patients. The objectives of this study were to determine recent trends in clinical outcomes and resource utilization for hospitalized patients with a clinically recognized episode of acute PE. Methods Patients discharged from United States acute care hospitals with a primary or secondary diagnosis of PE were identified from the Nationwide Inpatient Sample during the 8-year period between 1998 and 2005. Major clinical outcomes assessed included hospital mortality and length of hospitalization. To assess resource utilization for the treatment of PE, average hospital charges for these admissions were assessed, normalized to 2005 United States dollars and adjusted to reflect the United States Consumer Price Index. Results Between 1998 and 2005, the number of hospitalized patients with a primary or secondary discharge diagnosis of PE increased from 126,546 to 229,637; hospital case-fatality rates for these patients decreased from 12.3% to 8.2% (p < 0.001); length of hospital stay decreased from 9.4 days to 8.6 days (p < 0.001); and total hospital charges increased from $25,293 to $43,740 (p < 0.001). Conclusions Between 1998 and 2005, significant improvements were observed in outcomes for patients hospitalized with clinically recognized PE, including decreases in mortality and length of hospital stay. Charges for this hospital care increased during this time period.

RATIONALE: Mitochondria, although required for cellular ATP production, are also known to have other important functions that may include modulating cellular responses to environmental stimuli. However, the mechanisms whereby mitochondria impact cellular phenotype are not yet clear. OBJECTIVE: To determine how mitochondria impact endothelial cell function. METHODS AND RESULTS: We report here that stimuli for endothelial cell proliferation evoke strong upregulation of mitochondrial uncoupling protein 2 (UCP2). Analysis in silico indicated increased UCP2 expression is common in highly proliferative cell types, including cancer cells. Upregulation of UCP2 was critical for controlling mitochondrial membrane potential (Deltapsi) and superoxide production. In the absence of UCP2, endothelial growth stimulation provoked mitochondrial network fragmentation and premature senescence via a mechanism involving superoxide-mediated p53 activation. Mitochondrial network fragmentation was both necessary and sufficient for the impact of UCP2 on endothelial cell phenotype. CONCLUSIONS: These data identify a novel mechanism whereby mitochondria preserve normal network integrity and impact cell phenotype via dynamic regulation of UCP2.