Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3711_Библиотеки_им_академика_М_И_Перельмана

will provide vital information about the form that the aortic center should take, along with what services it should con­sider providing. Identifying current awareness and diagnosis of aortic pathologies, along with identifying existing local clinics and facilities, can inform outreach and inter- facility cooperation and education efforts, along with facilitating future referrals. Such information regarding geography and possible patient volume will allow identication of a need in the community, but should not be the only thing informing the creation of an aortic center. Internally, institutional invento­ries can anticipate barriers and provide information about the current state of the organization, including individual and team perceptions and expectations. An institution should con­sider its capacity to provide needed services in all stages of a patient’s care and its ability to engage patients. Evaluating the existing institutional strategies and goals will encourage buy­in and support, as it allows for the creation of a business plan and care delivery model that aligns with the system’s vision and strategy, providing clear benets to the system along with positive patient impact and clinical benets. Further planning will address the center’s structure, the extent and range of involvement of clinical specialists, the support staff required, equipment and technology needs, and points of access to the center.

It is important to elevate credentialing standards for vascu­lar involvement in order to promote quality improvement. Physicians are leaders in aortic centers, with their clinical, surgical, and academic expertise allowing them to direct the development of the center and collaborate with the health care team, referring physicians, industry partners, and administration. Raising standards for physicians ensures that these leaders are highly qualied in vascular initiatives and interventions. Board certication is one essential step to ensuring high standards in vascular involvement. Currently, board certication in the United States is the responsibility of the American Board of Surgery, with certication in vascular surgery overseen by the Vascular Surgery Board and certication in cardiotho­racic surgery overseen by the American Board of Thoracic Surgery. Currently, surgeons seeking certication must rst complete an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency pro­gram in both general surgery and vascular or thoracic sur­gery. However, board certication paradigms may be shifting to provide several alternatives to the traditional training courses, providing a shorter and more specialized program for both cardiothoracic and vascular surgeons [16]. Further options to consider include certication by the American Board of Internal Medicine and the American Board of Vascular Medicine, both of which assure exper­tise in medical specialties, thereby raising standards and elevating credentials. Fellowship training is another important consideration for an aortic center. A meta-anal­ysis of 23 studies exploring the structural and surgeon­specic characteristics of fellowship training on patient outcomes found that fellowship training appears to have a positive impact on patient outcomes, with rates of mortal­ity, conversion to open surgery, and complications all reduced in centers with an afliated fellowship training program [17]. Other strategies to elevate credentials may include case review participation, complex case consulta­tion, and procedure- specic privileging. All these methods increase quality of care by increasing the expertise offered

While all physicians in an aortic center should be creden­tialed and capable of performing surgeries according to their specialization, planning for equitable case distribution is necessary to assure timely, high-quality patient care. Patients requiring uncomplicated standard procedures should be seen in an aortic clinic. If no specic referrals have been made by primary care providers, these cases may be distributed equally to physicians, based on the availability and ease of getting into the clinic. More complex cases may be referred initially to a particular surgeon, or they may be discovered to be more complicated upon complete workup in the clinic. In these situations, aortic case conferences may provide support internally for surgeons to plan complex interventions, while also providing the opportunity for internal referrals to physi­cians with more expertise.

Streamlining diagnosis of aortic disease is urgent, as some pathologies involving aortic disease have high morbidity and mortality rates if left untreated [21]. Imaging teams should work closely with vascular teams to identify existence of, location, and severity of the patient’s presenting pathology, enabling timely planning of care and treatment. They should be especially adept at distinguishing types of dissections and identifying ruptures and should be able to provide informa­tion essential for endovascular planning, such as feasibility of arterial access, landing zones for graft placement, and necessity of debranching. Radiology teams should base their appropriateness criteria on current and relevant data, consid­ering cost, risks, and other factors to determine the proper

Integrating cardiology and vascular medicine into the ser­vice line should also be addressed in the creation of a mul­tidisciplinary aortic center, as early diagnosis, risk factor modication, and medical management may provide proce­dural alternatives. Cardiologists and vascular medicine spe­cialists provide cardiac clearance, blood pressure control, cholesterol control, and ongoing surveillance of contribut­ing risk factors, preventing further disease progression along with stabilizing patients to ensure the success of interventions. Medical management is the recommended rst line of treatment for some aortic pathologies, further increasing the importance of having vascular medicine and cardiology integrated into the care provided by the aortic center [23].

Nephrology specialists should be intimately involved in the multidisciplinary center, as risk for aortic disease is highly associated with complications involving the renin­angiotensin system such as hypertension and kidney disease [25]. Renal insufciency and kidney disease may also come about secondary to aortic disease causing stenosis or malper­fusion, or secondary to complications from aortic interven­tion, such as coverage of renal arteries or thromboemboli.

In order to be successful, a multidisciplinary aortic center should put effort into early patient identication. Marketing and outreach efforts, screening, and education opportunities for physicians and communities can improve disease aware­ness and identify at-risk patients. This early identication provides an opportunity to educate at-risk populations in order to slow or prevent disease progression through self­management. Not only is this benecial for patients who may be able to prevent vascular disease, it is likely to lead to improved outcomes because of the potential for early diag­nosis. As late diagnosis is associated with decreased effec­tiveness of medical management, a greater need for procedures, higher complication rates, and increased total cost of care, ensuring early diagnosis, may provide higher patient satisfaction as outcomes improve [27].

center will take advantage of the opportunity to educate at­risk populations in clinics, community screenings, and every patient interaction.

Early identication not only allows prevention of aortic dis­ease, but it also allows patients to receive proper preoperative care. Preoperative care in a multidisciplinary center should allow effective stabilization and preparation of patients pre­paring to undergo surgical intervention. This care may include imaging and laboratories to provide accurate diagno­ses and characterization of a patient’s condition, blood pres­sure management, and blood/uid initiation. Such involvement provides necessary information to physicians about whether intervention is needed and the urgency of such intervention and prepares patients for potential intervention by initiating preoperative procedures, consults, and stabiliza­tion. Preoperative care may also include a presurgical path­way for elective repair, addressing behavioral risk factors, improving tness, and reducing frailty. This type of preop­erative care may include physical and medical rehabilitation, pulmonary medicine, and physical and occupational therapy, increasing exercise capacity and improving health to reduce the risk of complications and improve procedural outcomes. Preoperative planning and care should also address initial interactions in emergency situations. ED protocols should be implemented for patients arriving directly to the emergency department or for referrals made from other emergency department facilities. Proper protocols ensure that the aortic team is notied of vascular patients in a timely manner and that the OR team can be activated and prepared for emergent interventions. Planning should be done to implement proto­cols for nursing and intensive care unit staff to ensure that the appropriate preoperative services are provided to all patients.

reducing the risk of complications. As part of a multidisci­plinary aortic center, the hybrid suite is signicant because it allows interdisciplinary efforts to occur in the same room, as specialists are able to collaborate in a patient’s care. While costs for a full range of capabilities and technologies in a hybrid suite may be prohibitive, the advantages may lead to improved outcomes and reduced costs per case, resulting in a signicant long-term benet [36–38]. Initial capital investment may be high, but the investment in appropriate technology ensures the high quality of intraoperative care that distinguishes high-vol­ume aortic centers.

Long-term follow-up and care should be an integral part of a multidisciplinary aortic center. An aortic center should pro­vide ongoing outpatient education to patients and caregivers and maintain communication with primary care providers and referring physicians. Depending on the condition, follow-up may include imaging to determine sizing changes or progres­sion of disease. Post-intervention imaging should identify pos­sible endoleaks, graft migration, and aneurysmal degeneration, along with any ischemic complications. Follow-up labs may also be useful in determining any complications secondary to the intervention. Surveillance of hypertension and high choles­terol, both as contributing factors for aortic disease, should be consistent and include medical management. Other team con­tributions to long-term care may include coordinating with rehabilitation facilities [39], advising pain management, and encouraging mental health support [40]. Consistent follow-up not only contributes to a true cross-continuum of care but also provides longitudinal data useful for quality control and out­come studies. Postoperative imaging and laboratory evaluation, along with ongoing surveillance and support, will result in improved long-term care, improving outcomes.

Coordination of clinical specialists is one of the most chal­lenging and integral parts of developing a multidisciplinary aortic center. Communication between specialists may be