The role of the vascular surgeon as a consultant, providing intraoperative assistance in both elective and emergent circumstances, is well defined. Previous studies have characterized the nature of these consultations, highlighting the important role that the vascular surgeon plays in assisting in exposure, reconstruction, and hemorrhage control, in a variety of surgeries, especially oncologic, spine, and orthopedic procedures [1 -9].
Although planned consultations often occur in the preoperative setting, emergency consultations are common and frequently require immediate vascular intervention [2].
Although these studies have collectively shown a wide variety in the indications, times, and specialties requesting these consultations, few studies have evaluated the role of the vascular surgeon in the management of the trauma patient, and none have looked exclusively at intraoperative vascular consultations in the setting. trauma population.
Furthermore, no study has attempted to characterize changing trends in intraoperative vascular consultation over time. It is unclear what role, if any, vascular surgeons play in the intraoperative management of vascular emergencies in trauma.
The primary objectives of this study included determining the incidence of intraoperative vascular surgery consultation in trauma, characterizing how these consultations have changed over time, and defining their outcomes.
It was hypothesized that vascular surgeons have become increasingly involved in the management of trauma patients over the past two decades, due – in part – to increasing endovascular capabilities.
| Methods |
A retrospective review was conducted of all emergent intraoperative vascular consultations at a level I trauma center from 2002 to 2017. Cases were identified using Horizon Surgical Manager , a documentation system used in the operating room, to perform a monitoring of personnel present, type of surgery performed and use.
All surgical cases in which a vascular surgeon was involved were included, while all cases that included vascular surgery as a primary service, elective cases, and consultations obtained preoperatively were excluded.
The specialties that required consultation, the reasons for consultation, interventions performed, and results achieved, including mean operative time for vascular surgery, successful revascularization rate, hemorrhage control rate, amputation rate, and mortality, were recorded for each case, using a direct review of the medical record.
Data abstraction was performed by four independent reviewers and compared for consistency. Continuous variables were expressed as medians and interquartile ranges, and categorical variables were expressed as percentages. This study was conducted with the approval of the University of Washington Institutional Review Board , and patient consent was waived.
| Results |
Between 2002 and 2017, 256 cases involving vascular surgery as a consultative service were identified. Of these, 22 cases were excluded due to the elective or joint nature of the procedure, resulting in 234 cases that met the inclusion criteria.
Over the 15-year study period, a 529% increase in the number of consultations per year was seen, with 65% (n = 152) requiring an immediate intraoperative response. Baseline data show a 73% male predominance, mean age of 38 years, and low rates of hypertension (39%), diabetes (29%), and peripheral arterial disease (26%).
The majority of visits were for trauma (n = 189 [81%]), with 14% (n = 32) resulting from iatrogenic injuries, and 5% (n = 13) related to pathology or difficult patient anatomy.
The specialties that most frequently required consultations were general/trauma surgery (44%), orthopedic surgery (40%), spinal surgery (6%), and neurosurgery (2%), with other specialties requiring consultation, including hand surgery (2 %), otorhinolaryngology (2%), urology (1%), gynecology (1%), maxillofacial surgery (1%), and plastic surgery (1%).
Common indications for consultation included: poor limb perfusion (37%), uncontrollable bleeding (26%), arterial injury (20%), and assistance with exposure (6%), with rarer indications such as placement of a filter in the inferior vena cava (5%), and visceral ischemia (3%), among others. The lower extremities were the most commonly involved region (45%), followed by the upper extremities (17%), head and neck (15%), inferior vena cava and iliac arteries (14%), and aorta (9%).
Although increases were seen in the number of consultations received per year for both general surgery/trauma and orthopedics, the increase in total consultations received appears to be driven more by an increase in the number of general surgery/trauma consultations during the year. study period.
During that 15-year period, there was a greater than 1,400% increase in the number of visits ordered for general surgery/trauma, compared to approximately 220% in the number of orthopedic visits. No other service demonstrated a clear trend in the number of consultations requested over time.
Operations performed included primary repair with or without patch angioplasty (34%), bypass (17%), noninterventional diagnostic angiography (14%), ligation (8%), exposure assistance (6%), fasciotomy (6 %), stent placement or hemorrhage control (5%), inferior vena cava filter placement (4%), thrombectomy (2%), and amputation (1%), among others (3%).
Across the study period, the proportion of visits treated using endovascular techniques did not increase over time. Of the patients who presented with ischemia, 94% were successfully revascularized, and hemorrhage was controlled in 99% of cases. Limb salvage was high, with an overall amputation rate of 1.7%, and in-hospital mortality was low (7.3%). The average operative time for the vascular portion of the surgery was 2.4 hours.
Among the 103 general surgery consultations received during the study period, 110 vascular operations were performed, which included primary repair (n = 44 [40%]), vessel ligation (n = 14 [12.7%]), evaluation intraoperative with or without diagnostic angiography (n = 13 [11.8%]), autologous bypass (n = 11 [10.0%]), endovascular hemorrhage control (n = 6 [5.5%]), fasciotomy (n = 4 [3.6%]), stent placement (n = 3 [2.7%]), prosthetic bypass (n = 2 [1.8%]), and thrombectomy (n = 2 [ 1.8%]), among others (n = 11 [10.0%]).
Reasons for presentation included poor limb perfusion (20%), arterial injuries (25%), and hemorrhage (43%), with 12% due to other causes (including inferior vena cava filter placement and visceral ischemia). ).
| Discussion |
Although previous studies have evaluated the important role that vascular surgeons play as intraoperative consultants in a variety of specialties, these studies frequently exclude emergency intraoperative consultations, and rarely examine the role of vascular surgeons in the management of trauma patients [ 1-9]. Likewise, how that role has changed over time, as well as the reasons for the trends, have not been previously explored.
In the management of the trauma patient, at the level I trauma center where the authors practice, vascular surgeons are increasingly being called upon to assist with a variety of issues, including ischemia, uncontrollable hemorrhage, and difficult exposures.
Vascular surgeons provide effective and efficient care, with low average operative times, and high rates of revascularization and hemostasis control. Despite this increasing role in trauma, vascular surgeons are not included in the list of specialties that are considered essential in a level I trauma center [10].
Although several studies have demonstrated the increasing role of endovascular techniques in the management of various vascular pathological processes over the past two decades [11,12], endovascular capabilities, and the changing landscape from a general vascular practice towards an endovascular approach intense, cannot entirely explain the trends seen in this study, because the proportion of procedures performed using endovascular techniques remained stable over the 15-year study period. Importantly, the balance between open and endovascular approaches in this study may be explained, in part, by another trend seen at the authors’ institution, in which vascular surgery is increasingly the primary service in the management of isolated vascular injuries. .
The current methodology may not have captured those cases, which may involve a higher proportion of endovascular techniques that, when combined with the cases included in the present study, may result in endovascular numbers consistent with the increasing trends observed nationwide. Regardless of the actual volume of endovascular cases, the reasons underlying this shift toward greater vascular involvement in the treatment of a trauma patient are likely multifactorial, and may be influenced by the trauma surgeon’s decreased familiarity with vascular repair, as demonstrate multiple studies describing the decline in vascular experience of general surgery residents over time [13,14].
Drake et al. [13], for example, found a 50% decrease in the mean number of vascular procedures performed by general surgery chief residents between 1989 (59.2 procedures) and 2007 (29.6 procedures). Additionally, Krafcok et al. [14] demonstrated significant decreases in the number of multiple vascular surgery procedures performed by general surgery residents between 1999 and 2013, with a greater than 50% decrease in the number of endarterectomies, aortic aneurysm repairs, and bypasses performed. the lower extremity.
This hypothesis is supported by the findings of the present study, that the increase in the trend of vascular consultation in the institution where they work is largely driven by a greater number of general surgery consultations, given the increase of 1400 % observed.
Regardless of the reasons for the increase in the number of consultations, it is important to recognize the changing role of vascular surgeons in the management of trauma patients, and the financial implications of those trends.
As vascular surgeons become increasingly essential team members at a Level I trauma center, it can be argued that 24-hour in-house availability of vascular surgeons at those centers should be mandatory, similar to the of other required specialties, such as plastic, oral and maxillofacial surgery [10].
Furthermore, the recognition that vascular surgeons play an essential role in the management of trauma patients may result in the recognition of previously unappreciated output that cannot be adequately captured through traditional value unit analyses. relative (UVR).
In this study, urgent intraoperative consultations requiring immediate evaluation involved a primary repair, with or without vein patch angioplasty, or a bypass in more than 50% of cases .
According to the Center for Medicare and Medicaid Services 2020 Physician Fee Schedule , those procedures pay $872.29 or 15.30 UVR labor (UVRt) for primary repair, with or without patch angioplasty (CPT code [ Current Procedural Terminology ] 35226), yu$s 1,469.93 or 26.75 UVRt for a bypass with vein graft (CPT code 35556) [15].
With those cases averaging 2.2 and 3.9 hours, respectively, those payments result in US$396.50 per hour or 6.95 UVRt per hour, for a primary repair, and US$376.91 per hour or 6 .86 UVRt per hour, for a bypass .
Although these estimates do not include the substantial time required for postoperative care and patient follow-up, they demonstrate the mismatch between the amount of time and energy required for those cases, and the low reimbursements received. Additionally, those estimates do not consider the workflow disruptions that occur when these queries are received during the day, or the productivity impacts from sleep disruption when they are received during the night.
If current trends continue, such that vascular surgeons are increasingly called upon for intraoperative assistance with the trauma patient, hospitals will need to address the relatively low reimbursements provided for time-consuming work that requires the vascular surgeon is immediately available at all times.
Given its retrospective nature, this analysis has several limitations. In addition to those inherent to retrospective reviews, such as the possibility of loss or incorrectness of the data reviewed, others include the inability to determine individual surgeon factors driving vascular consultation, as well as non-medical factors (medico-legal factors). and systems policy), which can influence these trends. Based on the information available, although hypotheses can be made, it is less clear why the observed trends exist.
Going forward, it will be important to quantify the financial implications of those changing trends, to demonstrate the value that vascular surgeons bring to a Level I trauma center, outside of standard clinical practice. Understanding these financial contributions will ensure that vascular surgeons, and divisions of vascular surgery, are adequately compensated for these currently undervalued services.
Additionally, understanding individual surgeon factors that drive vascular consultation in trauma may reveal why these trends exist.
Ultimately, understanding these trends will allow Level I trauma centers to predict future needs and ensure the availability of adequate vascular coverage. Finally, determining the medicolegal and political factors that influence these trends will allow vascular surgeons to influence these changing practice patterns.
| Conclusions |
Vascular surgeons are essential members of the team in a Level I trauma center, with increasing involvement in the treatment of the trauma patient over time.
These trends are not explained by endovascular capabilities but may be explained by the trauma surgeon’s decreased familiarity with vascular repairs, based on changes in the experience provided by a general surgery residency over time. Despite these trends, vascular surgeons continue to provide timely and effective care.
