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PubMed2004

Minimally invasive surgical practice: a survey of general surgeons in Ontario.

INTRODUCTION: With the rapidly evolving techniques for minimally invasive surgery (MIS), general surgeons are challenged to incorporate advanced procedures into their practices. We therefore carried out a study to assess the state of MIS practice in Ontario. METHODS: A questionnaire was mailed to 390 general surgeons in Ontario. It addressed the surgeon's practice demographics, performance of both basic and advanced MIS procedures, the factors influencing this practice and the means of obtaining MIS training. RESULTS: Of the 390 general surgeons surveyed, 309 (79%) responded. Thirty-six of these were retired and were excluded from the analysis, leaving 273 available for study. The average age in the study group was 49.7 years; 247 (90%) were men. Of 272 who responded to the question, 116 (43%) had subspecialty training. The average surgeon's operating room (OR) time was 1.5 d/wk and the average waiting time for elective procedures was 4 weeks. We found that 257 (94%) respondents performed basic laparoscopic procedures, and 164 (60%) performed appendectomy; 135 (49%) performed at least 1 advanced laparoscopic procedure in their practice, although only 30 (22%) of these performed inguinal hernia repair. Using a Likert scale, we found that the most important factors influencing the incorporation of advanced laparoscopic procedures into surgical practice were a lack of OR time (median 4), lack of OR financial resources (median 4) and lack of training opportunities (median 4). Of surgeons responding to questions, 161 (64%) of 251 felt that the present medical environment did not allow them to meet standard-of-care requirements; they felt that it was the responsibility of academic surgical departments (214 [80%] of 268), the Canadian Association of General Surgeons (177 [68%] of 262) and the Ontario Association of General Surgeons (141 [53%] of 264) to provide continuing medical education courses for MIS training. CONCLUSION: The ability of practising general surgeons to incorporate advanced MIS procedures into their surgical practice remains a complex issue.

Adult↗
PubMed2004

[To be a good expert surgeon].

The clinical and scientific level of Japanese surgeons leads the world needless to say, in the field of early gastric cancer, supported by double-contrast roentgenogram, endoscopy and surgical procedure including lymph node dissection with good outcomes. Surgical skills of Japanese surgeons have been improved by watching of cine or videotaped programs at the academic assemblies, breaking through apprenticeship. Ambitious young surgeons could freely learned excellent technical procedure from the pictures. Young surgeon must be an ever-thinking surgeon to get any hint on the film. Even though medical examinations and treatments including surgical procedures are on the way of standardization through EBM, manuals, guidelines and DPC payment system, medical doctors including surgeons must critically continue to think and seek for better treatment for the patients. Since the every patient differs in terms of age. sex, stage of disease, complicated conditions and social background, the treatment should be different, patient to patient, as tailor made fashion. Unless any progress is made, science and arts of medicine will decline. As another advice for a young surgeon from my experience you should write an operation protocol of every procedure by your self, even if that operation is the first experience or you joined as an assistant. After you wrote, you read the protocol by your instructor. Then you learn many knowledge and surgical know-how. Certainly, the book of the protocols will be your valuable treasure. Furthermore, you should not aim to be a skillful surgeon, but to be a good surgeon performing reliable and gentle operations for the patients.

Attitude of Health Personnel↗
PubMed1995

Increased flight surgeon role in military aeromedical evacuation.

BACKGROUND: Physicians were involved in the development of aeromedical evacuation (medevac) and flight surgeons flew as crewmembers on the first U.S. military medevac flights. However, since World War II flight surgeons have not been routinely assigned to operational medevac units. The aeromedical literature addressing the role of physicians in medevac is controversial. Recent contingencies involving the U.S. Air Force (USAF) have required the augmentation of medevac units with flight surgeons. RECENT CHANGES IN THE EUROPEAN THEATER: Beginning in 1992, the United States Air Forces Europe (USAFE) assigned three flight surgeons to the medevac squadron. Between 2 February 1993 and 24 March 1994 USAFE moved 241 patients on 29 missions out of the former Yugoslavia--most of these missions had a flight surgeon on the crew. Because advance medical information on the status of these patients is often nonexistent, the presence of a physician on the crew proved life-saving in some instances. In peacetime operations, there has been a recent trend in the European theater for the USAF to move more unstable patients. OBSERVED BENEFITS OF PHYSICIANS IN MEDEVAC: Dedicated medevac flight surgeons have proven to have the specific experience and training to perform effectively in the role of in-flight medical attendant. In addition, they are effective in negotiating with referring physicians about the urgency of movement, required equipment, the need for medical attendants, etc. These flight surgeons also provide medical coverage of transiting patients in the Aeromedical Staging Flight (ASF), thus providing needed continuity in the medevac system. CONCLUSION: Dedicated medevac flight surgeons fill a unique and valuable role in medevac systems. Agencies with medevac units should consider assigning flight surgeons to these units.

Aerospace Medicine↗
PubMed1997

Characteristics of surgeons with high and low malpractice claims rates.

We studied the relationship of malpractice claims and the personal, educational, and practice characteristics of a sample of surgeons (n = 427). The surgeons were members of a physician-owned malpractice trust and represented all those who had fewer than 0.13 malpractice claims per year and those with more than 0.54 claims per year. Data are reported separately for orthopedic surgeons (148), obstetrician-gynecologists (115), and a mixed group of other surgeons (164). The last group included otolaryngologists, neurosurgeons, and general, vascular, thoracic, and plastic surgeons. We studied the relationship between the number of malpractice claims (ranging from no history of claims to those terminated from the trust because of high rates of claims) and the surgeon's personal, educational, and practice characteristics. The major differences were between the surgeons who were terminated because of a high number of claims and those with few or no claims. Terminated surgeons were less likely to have completed a fellowship, belong to a clinical faculty, be members of professional societies, be graduates of an American or Canadian medical school, have specialty board certification, or be in a group practice. The data also suggest that orthopedists with high numbers of claims may be less likely to have a religious affiliation or to have a registered nurse working in their office practice. These findings suggest that surgeons with lower claim rates may be more likely to manifest exemplary modes of professional peer relationships and responsible clinical behavior.

Certification↗
PubMed2005

Mortality data in adult cardiac surgery for named surgeons: retrospective examination of prospectively collected data on coronary artery surgery and aortic valve replacement.

OBJECTIVES: To present named surgeon mortality for isolated first time coronary artery surgery and aortic valve surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: All NHS hospitals undertaking adult cardiac surgery in north west England. PARTICIPANTS: 25 consultant surgeons carrying out coronary artery surgery and aortic valve replacement between April 2001 and March 2004. MAIN OUTCOME MEASURES: Mortality for both operations according to surgeon. EuroSCORE to stratify patients into low and high risk. RESULTS: 10,163 patients underwent surgery under 25 surgeons. The average number of patients per surgeon was 363 for coronary artery surgery and 44 for aortic valve replacement. Seventeen per cent of the patients undergoing coronary artery surgery and half of those undergoing aortic valve surgery were considered high risk. The average mortality was 1.8% (range 0-3.8%) for coronary surgery and 1.9% (0-12.5%) for aortic valve surgery. Mortality for all surgeons fell below 99% control limits of the national mean for both operations. CONCLUSIONS: The presented mortality figures for the two cardiac operations fell within accepted limits for all surgeons. The division of outcomes according to low and high risk patients is imperfect but may help to inform the public about the complexities of this type of analysis and prevent surgeons avoiding high risk patents who may benefit from an operation.

Adult↗
PubMed1980

Self-perception of the elective surgeon and some patient perception correlates.

This study investigated the personality characteristics of the elective surgeon, the realism of the surgeon's role concept, and the relationships between these variables and the occurrence of litigation. Data obtained from 125 surgeons and 65 of these surgeons' patients were computer analyzed to answer three specific questions. The surgeon's personality needs were found to differ significantly from those of the general population. Both the surgeons and the patients viewed the surgeon's role unrealistically. No specific physician-patient interaction variable was found to be related significantly to the occurrence of litigation. Findings showed that the elective surgeon is aware of the documented causes for litigation but unaware of how his own personality may affect his vulnerability to litigation.

Adult↗
PubMed2002

The performance of master surgeons on the Advanced Dundee Endoscopic Psychomotor Tester: contrast validity study.

HYPOTHESIS: The contrast validity of the Advanced Dundee Endoscopic Psychomotor Tester (ADEPT) was determined by comparing the performance of "master surgeons" with that of surgical trainees (also called junior surgeons) on the system. DESIGN: Twenty master surgeons and 20 junior surgeons were tested on the ADEPT system. The master surgeons, all of consultant grade, were recruited as established experts of national or international standing in laparoscopic surgery. The junior surgeons were participants of essential laparoscopic courses at the start of their higher surgical training. The ADEPT end points used in the study were instrument error, execution time, and task completion. An analysis of variance was used for the data analysis, with statistical significance set at.05. RESULTS: Master surgeons incurred a significantly lower instrument error rate than surgical trainees (P =.007), with no significant difference in execution time and the task completion score (P =.42 and P =.40, respectively). CONCLUSION: The ADEPT system has contrast validity because master surgeons completed the tasks more accurately without sacrificing execution time.

Adult↗
PubMed2007

Surgeon characteristics and variations in treatment for early-stage breast cancer.

HYPOTHESIS: Adherence to National Institutes of Health consensus statement recommendations for early-stage breast cancer will vary by surgeon characteristics. DESIGN: Secondary data analysis using the Surveillance, Epidemiology, and End Results national tumor registry linked with Medicare claims data. Logistic regression was used to analyze data on a cohort of 1045 surgeons who operated on 9449 Medicare patients with early-stage breast cancer. MAIN OUTCOME MEASURE: Care adherent to the 1990 National Institutes of Health consensus statement recommendations. RESULTS: Surgeon age and specialty were not associated with adherent care overall, nor among breast-conserving surgery or mastectomy subgroups. Patients of higher-volume surgeons were significantly more likely to undergo adherent care overall because of greater use of lymph node dissection among women who received either breast-conserving surgery or mastectomy. Patients of female surgeons and surgeons with a medical school affiliation were less likely to undergo adherent care overall, which was related to greater use of breast-conserving surgery and lesser use of lymph node dissection among patients who underwent breast-conserving surgery. CONCLUSIONS: Several surgeon characteristics are significantly associated with variations in breast cancer treatment received. These results warrant further investigation into the association between these surgeon characteristics and cancer care outcomes.

Aged↗
PubMed1984

The barber-surgeons of London.

The Company of the Barber-Surgeons of London was formed by the union of the Company of Barbers and the Fellowship of Surgeons in 1540. It marked one of the great milestones in English surgery. The barbers had carried out minor surgery such as bleeding and lancing of abscesses, while the more erudite surgeons attempted to evolve some principles in surgery, and were involved in the mutilating surgery of warfare. The Barber-Surgeons became responsible for instigating teaching programs and the licensing of men to practice the art of surgery; they also appointed surgeons to the armed forces. An inevitable rift between these two different types of people occurred in 1745. The surgeons broke away and formed the Company of Surgeons, which, in 1800, became the Royal College of Surgeons.

Barbering↗
PubMed2003

Association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery.

OBJECTIVE: To evaluate whether hospital volume and surgeon volume of total hip replacements (THRs) are associated with patient-reported functional status and satisfaction with surgery 3 years postoperatively. METHODS: We performed a population-based cohort study of a stratified random sample of Medicare beneficiaries who underwent elective primary or revision THR in Ohio, Pennsylvania, or Colorado in 1995. The primary outcomes were the self-reported Harris hip score and a validated scale measuring satisfaction with the results of surgery. Both outcomes were assessed 3 years postoperatively. Hospital volume was defined as the aggregate number of elective primary and revision THRs performed on Medicare beneficiaries in the hospital in 1995. High-volume hospitals were defined as those in which >100 such procedures are performed annually, and low-volume centers were defined as those in which </=12 procedures (primary THR cohort) or </=30 procedures (revision cohort) are performed annually. RESULTS: In unadjusted analyses, patients who underwent surgery in low-volume centers had worse functional status 3 years following primary and revision THR compared with patients whose surgery was performed in higher-volume centers. Patients whose revision THR was performed by a low-volume surgeon also had worse function. After adjustment for sociodemographic and clinical variables, however, the association between higher hospital volume and better functional status following primary THR was weak and statistically nonsignificant, and no statistically significant or clinically important associations between hospital or surgeon volume and functional status following revision THR was observed. Patients who underwent elective primary THR in low-volume centers were more likely to be dissatisfied with the results of surgery compared with patients whose surgeries were performed in high-volume centers. Similarly, patients whose surgeons performed </=12 procedures per year were more likely to be dissatisfied with the results of revision THR than were patients whose surgeons performed >12 procedures per year. CONCLUSION: Hospital volume and surgeon volume have little effect on 3-year functional outcome following THR, after adjusting for patient sociodemographic and select clinical characteristics. However, satisfaction with primary THR is greater among patients who underwent surgery in high-volume centers, and satisfaction with revisions is greater among patients whose operations were performed by higher-volume surgeons. Referring clinicians should incorporate these findings into their discussion of referral choices with patients considering THR. Conclusions regarding the effect of volume on longevity of the implants must await longer-term followup studies. Finally, further research is warranted to better understand the association between hospital and surgeon procedure volume and patient satisfaction with surgery.

Aged↗
PubMed2006

Anonymous pilot study of hepatitis C virus prevalence in liver transplant surgeons.

The risk of hepatitis C virus (HCV) transmission to surgeons is related to the HCV prevalence in the surgical patient population. As HCV-related cirrhosis is the commonest indication for liver transplantation in Europe and North America, liver transplant surgeons are at particular risk. The prevalence of HCV infection in liver transplant surgeons is unknown. The aim of this study was to estimate the prevalence of HCV infection in liver transplant surgeons attending the 9th Congress of the International Liver Transplantation Society using unlinked anonymous testing for HCV. Surgeons attending the conference were invited to complete an anonymised questionnaire regarding their surgical and transplant practice and provide an unlinked anonymised blood spot sample by finger prick. Samples were screened for antibodies to HCV (enzyme-linked immunosorbent assay III, Ortho Diagnostics, Raritan, NJ). Polymerase chain reaction testing for HCV RNA was performed on reactive samples.A total of 117 liver transplant surgeons (79 European, 16 North American, 10 Asian, 9 South American, 3 Australasian) provided a blood spot sample. Two (1.7%) surgeons had antibodies to HCV, 1 (0.8%) had detectable HCV RNA (genotype 1a). Assuming that both infections were acquired during surgery, the estimated maximum rate of HCV transmission is 1 per 743 to 1,045 years of surgical (0.96 to 1.35 HCV transmissions per 1,000 years of general surgical practice) and 449 to 683 years of liver transplant practice (1.46 to 2.23 HCV transmissions per 1,000 years of liver transplantation practice). In conclusion, risk of HCV transmission to liver transplant surgeons appears to be low despite the particular risks associated with frequently operating on HCV infected patients.

Hepacivirus↗
PubMed2005

Learning curve: the surgeon as a prognostic factor in colorectal cancer surgery.

The individual surgeon is an independent prognostic factor for outcome in colorectal cancer surgery. The surgeon's learning curve is therefore directly related to the patient's outcome. The exact shape of the learning curve, however, is unknown. The present study reviewed supervision, training/teaching, specialization, surgeon's caseload, and hospital's caseload as the five main surgeon- and hospital-related confounding factors for outcome, and examined their influence on the learning curve as well as their interactions and prognostic significance. All five confounding factors were related to outcome. The highest degree of evidence, however, was found for training/teaching (introduction of total mesorectal excision), specialization in colorectal surgery (special interest, board-certification, specialized colorectal cancer units), and the surgeon's caseload. Five surgeon- and hospital-related factors directly influence the surgeon's learning curve and are therefore rightly considered predictors of outcome in colorectal cancer surgery. Improvements in supervision, training/teaching, specialization, the surgeon's caseload, and the hospital's caseload will therefore translate into enhanced patient outcome.

Certification↗
PubMed1996

Canadian attitudes toward use of primary repair in management of colon trauma. A survey of 317 members of the Canadian Association of General Surgeons.

PURPOSE: The majority of recent American articles on management of colon trauma promote liberal use of primary repair. The extent to which Canadian surgeons have embraced such recommendations is unknown. METHOD: To determine the current attitude of Canadian surgeons toward the use of primary repair, we surveyed the members of The Canadian Association of General Surgeons regarding their management of three fictitious cases of penetrating and blunt colon trauma. RESULTS: Three hundred seventeen members of the Canadian Association of General Surgeons responded. Ninety-two percent managed a fictitious case of early, uncontaminated stab wounds by primary repair. Delay in treatment or fecal contamination was associated with a significantly reduced number of respondents choosing primary repair (P < 0.001). Surgeons were less likely to choose primary repair for management of a case of blunt colon injury (35 percent; P <0.001), and only 25 percent considered primary repair an option for a case of low velocity bullet wounds; 2 percent chose it for high velocity bullet wounds. Overall, the most common response to colon trauma scenarios was colostomy. However, 96 percent of respondents selected primary repair as the treatment of choice for at least one clinical situation depicted in the questionnaire. The likelihood of choosing primary repair was independent of surgeons' experiences or the level of the surgeons' trauma center. CONCLUSIONS: Although there are still settings in which many Canadian surgeons consider colostomy the appropriate treatment for colon injuries, primary repair has definitely established a foothold in all levels of Canadian general surgery practice.

Adult↗
PubMed2000

Effect of surgeon specialty interest on patient outcome after potentially curative colorectal cancer surgery.

OBJECTIVE: There are significant differences in patient outcome after potentially curative surgery for colorectal cancer that relate to the surgeon performing the procedure. The reasons for these differences remain obscure. The aim of this study was to examine the effect of the surgeon's specialty on patient outcome after potentially curative colorectal cancer surgery and to identify factors that may help explain differences in outcome among specialty groups. METHODS: Between 1990 and 1993, 378 patients underwent potentially curative surgery for colorectal cancer by surgeons with different specialty interests, vascular or transplant, general, and colorectal surgeons, in a large teaching hospital. Information on operative details, including the length of the resection specimen, resection margins, whether the tumor was removed with en bloc resection of adjacent clinically involved organs, number of lymph nodes removed, and stage was collected. Factors affecting both local and overall recurrence rates were analyzed using logistic regression analysis at both univariate and multivariate levels. RESULTS: At a median follow-up of 45 months the only factors associated with a significantly reduced local recurrence rate were the length of the resection specimen (odds ratio, 0.56; 95 percent confidence interval, 0.31-0.99) and colorectal specialty (P = 0.04). Patients operated on by a general surgeon were 3.42 times (95 percent confidence interval, 1.32-8.9) more likely to develop a local recurrence than those operated on by a colorectal surgeon. For overall recurrence, early stage disease (P < 0.0001), absence of vascular invasion (0.005), and colorectal specialty (0.025) were the only factors associated with significantly improved outcome at multivariate analysis. CONCLUSIONS: These data show that surgeons with an interest in colorectal cancer achieve lower local and overall recurrence rates compared with vascular or transplant or general surgeons. Differences in local recurrence rates seem to be predominantly related to the extent of resection performed and demonstrate the need to remove an adequate specimen when performing potentially curative colorectal cancer surgery.

Aged↗
PubMed1987

Accuracy of suture techniques of surgeons with different surgical experience.

The pinpoint accuracy in the suturing techniques of 35 surgeons was measured by the distance deviated from an expected needle exit. The grip of the needle holder used by the surgeons was their habitual one. Accuracy was tested using two ways of suturing; namely with, and without wavering a needle to aim at an exit after suturing began. Where the surgeons did not waver the needle, accuracy improved both when the surgical experience was greater than one year (p less than 0.05) and again when the experience exceeded 10-15 years (not significant). Difference of the accuracy between individual surgeons disappeared in those surgeons with 15 to 20 years experience. Where the surgeons wavered the needle, improvement was more marked in the former period and less in the latter. Wavering improved the accuracy in each group (p less than 0.01), but with the possible danger of injuring tissue. In conclusion, accuracy was not as precise as most surgeons' confidence believed. A significant improvement was observed with 1-year experience, but the improvement thereafter was poor. Fifteen to 20 years experience was not enough to acquire a suturing technique not necessitating needle wavering in the tissue, still yielding a 1.7 mm deviation in a 2 cm suture-stride. It was however enough to eliminate surgeons' individual differences in accuracy.

General Surgery↗
PubMed2000

Laparoscopic cholecystectomy performed by a single surgeon using a visual field tracking camera: early experience.

BACKGROUND: This report describes a visual field tracking camera for laparoscopic surgery that allows the visual field to be changed without moving the laparoscope. We also report on our early experience with this camera for single-surgeon laparoscopic cholecystectomy. METHODS: The visual field tracking camera has a tracking mechanism (composed of a zoom lens and a charge-coupled device [CCD] slide mechanism) built into the camera head. The 80 degrees visual field observed with the laparoscope can be expanded using the zoom lens, and the field can be shifted by changing the size of the area being viewed by the CCD. This is accomplished by pushing a switch on the forceps or by verbal command. Cholecystectomy was carried out on 12 patients with gallstones using this camera. The operations were performed by either a single surgeon or two surgeons. Forceps held with a forceps holder were inserted through the right port to lift the fundus of the gallbladder. The single surgeon used the other two ports to resect the gallbladder by the two-handed technique. RESULTS: In all cases, cholecystectomy was completed without any need to move the laparoscope at any point during the operation. Seven operations were performed by a single surgeon. Mainly for education purposes, five other operations were performed by a pair of surgeons. The mean time required for surgery was 76 +/- 17 min. This time did not differ from that of laparoscopic cholecystectomy performed during the same period on 22 patients by teams of three surgeons using conventional cameras. CONCLUSIONS: Using the visual field tracking camera, laparoscopic cholecystectomy can be performed without any need to touch the laparoscope. This camera allowed laparoscopic cholecystectomy to be performed by a single surgeon.

Cholecystectomy, Laparoscopic↗
PubMed2004

A randomized prospective study of complications between general surgery residents and attending surgeons in near-total thyroidectomies.

PURPOSE: Recurrent laryngeal nerve palsy and hypoparathyroidism are the most common and serious complications after thyroid operations. Surgeon experience has been defined as a significant factor in the number of complications occurring in thyroid surgery. There has so far been no prospective randomized study that compares the complication rates between residents and the attending surgeon in statistically similar patient groups in which all of the patients undergo the same type of thyroid surgery by the same surgical team. In this prospective study the performances of residents and attending surgeons were evaluated and compared according to the complication rates in near-total thyroidectomies. METHODS: One hundred and fifty-two patients underwent near-total thyroidectomies between April 2001 and May 2003. The number of randomly selected patients operated on by residents at the level of postgraduate year two, under the direct supervision of an attending surgeon, and the number of patients operated on by attending surgeons were 78 and 74, respectively. All patients had preoperative and postoperative videolaryngostroboscopic examinations of the vocal cords and serum calcium level evaluation. RESULTS: The rates of temporary vocal cord paralysis with respect to the nerves at risk for residents and attending surgeons were 3.7% and 2.7%, respectively. The temporary hypoparathyroidism rate was 8.1% for attending surgeons, whereas it was found to be 6.4% for residents. Neither any cases of permanent vocal cord paralysis nor permanent hypoparathyroidism were detected. CONCLUSION: Our results indicate that the complication rates in near-total thyroidectomies performed by residents and attending surgeons are similar. Thyroid surgery can therefore be safely and effectively performed by residents under close supervision.

Adult↗
PubMed2006

Perceptions of Canadian vascular surgeons toward pharmacological risk reduction in patients with peripheral arterial disease.

Patients with peripheral arterial disease (PAD) are at a markedly higher risk of cardiovascular morbidity and mortality, with evidence indicating that risk-reduction pharmacotherapy can serve to attenuate cardiovascular events in these patients. Given the central role of vascular surgeons in the treatment of patients with PAD, we sought to determine their perceptions and knowledge of risk-reduction pharmacotherapy in patients with PAD. We conducted a cross-sectional survey of 79 Canadian vascular surgeons who attended the 2004 annual meeting of the Canadian Society for Vascular Surgery, the largest and most representative meeting of its kind in Canada. The recommended targets of low-density lipoprotein cholesterol, blood glucose, and blood pressure were known to 53.8%, 40.4%, and 57.7% of vascular surgeons, respectively. The majority of vascular surgeons (65.4%) reported screening for risk factors in <50% of cases. Although 90.4% of vascular surgeons would recommend antiplatelet therapy for PAD, only 5.8% would recommend angiotensin converting enzyme (ACE) inhibitors and 19.2% would recommend lipid-lowering therapy with statins. Eighty-four percent of Canadian vascular surgeons indicated that their self-assessment of risk reduction in PAD was average to below average, yet 90.4% of them believed that risk-reduction therapy should be recommended or initiated by vascular surgeons. Canadian vascular surgeons' perceptions toward risk reduction in PAD identify knowledge and action gaps, despite the recognition that recommending and instituting therapy is important to patient care. Given the heightened risk of cardiovascular disease in patients with PAD, these data have important implications.

Angiotensin-Converting Enzyme Inhibitors↗