219 vascular fellows' perception of the future of vascular surgery

In an attempt to identify the fellows' concerns about the future of the field of vascular surgery, we conducted a survey consisting of 22 questions at an annual national meeting in March from 2004 to 2007. In order to obtain accurate data, all surveys were kept anonymous. The fellows were asked (1) what type of practice they anticipated they would be in, (2) what the new training paradigm for fellows should be, (3) to assess their expectation of the needed manpower with respect to the demand for vascular surgeons, (4) what were major threats to the future of vascular surgery, (5) whether they had heard of and were in favor of the American Board of Vascular Surgery (ABVS), (6) who should be able to obtain vascular privileges, and (7) about their interest in an association for vascular surgical trainees. Of 273 attendees, 219 (80%) completed the survey. Males made up 87% of those surveyed, and 60% were between the ages of 31 and 35 years. Second-year fellows made up 82% of those surveyed. Those expecting to join a private, academic, or mixed practice made up 35%, 28%, and 20% of the respondents, respectively, with 71% anticipating entering a 100% vascular practice. Forty percent felt that 5 years of general surgery with 2 years of vascular surgery should be the training paradigm, while 45% suggested 3 and 3 years, respectively. A majority, 79%, felt that future demand would exceed the available manpower, while 17% suggested that manpower would meet demand. The major challenges to the future of vascular surgery were felt to be competition from cardiology (82%) or radiology (30%) and lack of an independent board (29%). Seventeen percent were not aware of the ABVS, and only 2% were against it; 71% suggested that vascular privileges be restricted to board-certified vascular surgeons. Seventy-six percent were interested in forming an association for vascular trainees to address the issues of the future job market (67%), endovascular training during fellowship (56%), increasing focus on the vascular fellows at national meetings (49%), and representation for the fellows on the national councils (37%). This survey suggests that several significant issues exist in the minds of vascular trainees that have not been addressed and may present opportunities for further dialogue.     

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral

OBJECTIVE: Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report. METHODS: An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed). RESULTS: There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis. CONCLUSIONS: Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.     

人工血管在血管外科中的应用

人工血管的诞生，是血管外科发展的重要里程碑，其临床应用已十分广泛，有关研究也一直方兴未艾。按材质而言，人工血管分为合成血管、生物血管、表面改性人工血管和支架型人工血管。     

L-arginine protects the mesenteric vascular circulation against cardiopulmonary bypass-induced vascular dysfunction

BACKGROUND: The aim of our study was to determine whether addition of the nitric oxide donor l-arginine at reperfusion may prevent the cardiopulmonary bypass (CPB)-induced vascular alterations in the intestine. METHODS: Twelve dogs underwent 90-minute hypothermic CPB. After 60 minutes, the cardiac arrest-treated group (n = 6) received 40 mg/kg intravenous bolus l-arginine, followed by 3 mg/kg/min infusion for 20 minutes. Hemodynamic parameters, blood gases, lactate, and glucose were monitored. Reactive hyperemia (RH) in response to superior mesenteric artery ischemia and vasorelaxation to systemically administered vasoactive drugs (acetylcholine [ACH] and sodium nitroprusside) were assessed before and after CPB and defined as percent change of vascular resistance. RESULTS: In the control group, CPB reduced reactive hyperemia (RH) (-26 +/- 15% vs -53 +/- 5%), and the response to ACH (-30 +/- 3% vs -42 +/- 7%). In the treated group, the post-CPB endothelial dysfunction was reversed (-37 +/- 1%, P <.05 vs control group) and RH partially recovered (-34 +/- 4%, P <.05). Administration of l-arginine resulted in a higher mesenteric oxygen delivery, increased nitrite/nitrate production, and lower lactate release from the mesenteric vascular circulation after reperfusion. CONCLUSIONS: CPB disrupts some of the regulatory functions of the endothelial cell in the mesenterium and these are mostly related to nitric oxide unavailability. Systemic supplementation of l-arginine at reperfusion prevents the CPB-induced mesenteric endothelial dysfunction in association with an increased blood distribution and a reduced metabolic impairment.     

Diabetic vascular disease: characteristics of vascular disease unique to the diabetic patient

Diabetes is a cardiovascular disease affecting almost every arterial vascular bed with significant consequences. Vascular disease is one part of a triopathy of complications that singularly but most commonly in combination makes the Diabetic patient uniquely susceptible to lower extremity complications. The other two conditions are Neuropathy and an altered response to Infection. Diabetic peripheral arterial disease has a predilection for the smaller below knee tibial/peroneal arteries and there is no microvascular occlusive arterial disease affecting the diabetic foot. Microvascular dysfunction is not an occlusive phenomenon and supports an aggressive approach to treating existing macrovascular atherogenic occlusive disease complicating diabetic wounds of all extremities. Individualized, patient-centered treatment utilizing all available endovascular and open revascularization options best ensures the highest quality outcomes at a cost our healthcare system can afford.     

腰椎毗邻血管的应用解剖及血管损伤并发症

下腰椎前入路手术,在治疗腰椎疾病方面扮演着非常重要的角色,其手术区域相关的临床解剖学研究也日益深入。腰椎局部区域的血管、神经对于术中的显露有着直接影响,熟悉这些结构不仅能减少术中创伤和术后并发症,也能为新的手术入路和技术的发展提供新思路。该文对腰椎前方血管的特点和减少血管并发症的研究现状进行综述。     

Reducing the risk of vascular surgery

Vascular surgery is associated with high rates of cardiopulmonary morbidity and mortality compared with other types of major non-cardiac surgery. Anaesthetists need to carefully evaluate the patient and consider strategies to reduce risk. Attention to detail is of paramount importance. In emergencies, risk can be minimised by rapid but appropriate correction of hypotension and coagulopathy. In elective cases strategies include identifying those patients most at risk and then using medication and other medical therapies to optimise medical co-morbidity prior to operation. Risks for the newer surgical techniques for vascular surgery are also discussed.     

Preoperative evaluation of the vascular patient

Periferal vascular disease usually results from a systemic entity in which atherothrombosis develops in different vascular territories, having common risk factors. It is hence usual to find coexistent, often subclinical, coronary artery disease, which is responsible for most of perioperatory morbidity and mortality in patients submitted to vascular surgery. An adequate preoperatory risk stratification must be accomplished, having in mind the clinical manifestations, risk factors, comorbidities, functional capacity and global left ventricular systolic function of the patient. He should be included in one of three different subgroups: low, high or intermediate risk, which might reinforce the need for further testing, most often aiming at the detection of coronary artery disease and foresee the short, medium and long term outcome. This strategy is very important and it is in part due to it and to better medical/surgical and anesthetic care that the surgical results have markedly improved in recent years. In this paper a state of the art is done of the guidelines to follow and the results of several studies performed on this subject. The role of methods to detect coronary ischemia is remarked, using either nuclear or echocardiographic techniques for this purpose.     

Malignant vascular tumor of the hallux

A rare case of a malignant hemangioma of the great toe is reported. The etiology, incidence, clinical presentation, differential diagnosis, and pathology of an hemangioendothelioma is presented. The basis for surgical treatment and medical management to rule out metastases was discussed. Amputation remains the treatment of choice for hemangioendothelioma.     

血管外科的现状及发展趋势--第四届国际血管外科学术会议述评

由中华医学会主办的第四届国际血管外科和腔内血管外科学术会议暨第四届国际布加综合征学术会议于2 0 0 2年 10月 17～ 2 0日在北京召开。来自 18个国家和国内 40 0余名代表出席会议。大会收到论文 3 5 2篇 ,大会报告 42篇 ,分会交流 14 4篇。通过卫星转播现场演示腹主动脉瘤腔内人工血管植入术 2例 ,还转播了激光治疗下肢静脉曲张多例和肺栓塞治疗的全程录像。1　布加综合征 (BCS)中华医学会外科学会血管学组组长、大会主席汪忠镐首先回顾了国际BCS学会诞生和历史。 1987年在北京国际血管学会上报告了BCS研究工作 ,引起了各国学者的兴…