Vascular Specialist September 2018

13

2

Veterans served at AAA screening event.

Dr. Sheahan pens a letter to a paid consultant.

8 News From SVS Don't forget disability insurance in your fiscal health checkup.

Proposed changes to E/M impact vascular surgeons

BY FRANCESCO A. AIELLO, MD, AND MATTHEW J. SIDEMAN, MD

C

MS has published its proposed rule changes for the physician fee schedule and Medicare Part B payment policies. We would like to focus on E/M services. While note writing isn’t a skill vascular surgeons aspire to master, it constitutes a large portion of our reimbursement, and any Medicare changes to these services warrant a closer look.

The current Medicare proposal would create a single reimbursement for level II-V new office visits ($135) and another single payment for level II-V established office visits ($93).

These would coincide with a single work RVU value for new (1.90 wRVU) See CMS · page 4

Predicting stent failure in the treatment of May-Thurner syndrome Steven D. Abramowitz, MD

BY MARK S. LESNEY MDEDGE NEWS R E P OR T I N G F RO M T HE VA S C U L A R A N N U AL M EET I N G

BOSTON – The use of an intravascular ultrasound (IVUS)–based scoring system could predict stent failure at 2 years in the treatment of May-Thurner syndrome, according to Steven D. Abramowitz, MD, of the MedStar Washington Hospital Center, Washington, and his colleagues.

Dr. Abramowitz presented their research in the Vas-

NEWS

Briefs NEW COLUMN

cular and Endovascular Surgery Society (VESS) sessions held at the Vascular Annual Meeting.

“IVUS has become an important adjuvant diagnostic tool in the treatment of deep venous disease, and as such may provide a useful assessment and predictive tool for treatment success in stenting of May-Thurner syndrome,” said Dr. Abramowitz.

In their study, 118 consecutive patients with May-Thurner syndrome underwent IVUS-guided stent placement from April 2009 through May 2015 at two See May-Thurner · page 3

APDVS PROPOSAL A proposal has been put forth to the RRC Surgery by the APDVS to recommend 20 venous cases and 15 hemodialysis access cases be added to the vascular surgery case requirements for independent and integrated vascular training programs. It is anticipated that this will be on the Sept. 2018 RRC Surgery meeting agenda.

See Column on page 3

Martin allred/nationwide PhotograPhers

VOL. 14 • NO. 9 • SEPTEMBER 2018

Vascular specialist 10255 W Higgins Road, Suite 280 Rosemont, IL 60018

CHANGE SERVICE REQUESTED

Presorted Standard U.S. Postage PAID Permit No. 384 Lebanon Jct. KY

FROM THE EDITOR

An open letter to our hospital consultants

BY MALACHI G. SHEAHAN III, MD MEDICAL EDITOR, VASCULAR SPECIALIST

Dear <redacted>,

J

ust thought I would write and give you a quick update on our situation, not that you asked. As you recall, a few years ago we spent many hours discussing and planning the Heart and Vascular Service Line that you encouraged us to set up in our new hospital. These conversations were filled with the greatest hits of health care administrators. “Institutional silos,” “layers of integration,” and “financial dashboards” were crowd favorites. Personally, I enjoyed the endless timelines, flow charts to nowhere, and of course the countless hours spent crafting a vision statement.

It’s a wonder we got any work done! At least one of us was getting paid by the hour.

When I asked you to provide concrete examples of fully integrated, functional Heart and Vascular Service Lines you initially deferred. Finally, you listed three examples. Of course, when I reached out to them, two had disbanded, and the third had no idea what I was talking about. Nevertheless, I pressed on.

I tried to figure out how this would all work. What keeps the service line synchronous? My research kept turning up lines like: “alignment across departments and specialists is imperative for addressing the care delivery and business challenges facing cardiovascular providers.” OK sure, but huh?

The purpose of a Heart and Vascular Service Line is purportedly to improve the quality of care of cardiovascular patients. The concept of the service line has been in place for over 20 years, so where is the literature demonstrating the quality benefits? The improved outcomes? As far as I can

VASCULAR SPECIALIST Medical Editor Malachi G. Sheahan III, MD Associate Medical Editors Mark A. Adelman MD, Bernadette Aulivola, MD, O. William Brown, MD, Elliot L. Chaikof, MD, PhD, Carlo Dall’Olmo, MD, Alan M. Dietzek, MD, RPVI, FACS, Professor Hans-Henning Eckstein, MD, John F. Eidt, MD, Robert Fitridge, MD, Dennis R. Gable, MD, Linda Harris, MD, Krishna Jain, MD, Larry Kraiss, MD, Joann Lohr, MD, James McKinsey, MD, Joseph Mills, MD, Erica L. Mitchell, MD, MEd, FACS, Leila Mureebe, MD, Frank Pomposelli, MD, David Rigberg, MD, Clifford Sales, MD, Bhagwan Satiani, MD., Larry Scher, MD, Marc Schermerhorn, MD, Murray L. Shames, MD, Niten Singh, MD, Frank J. Veith, MD, Robert Eugene Zierler, MD Resident/Fellow Editor Laura Drudi, MD. Executive Director SVS Kenneth M. Slaw, PhD. Interim Director of Membership, Marketing and Communications Angela Taylor Managing Editor SVS Beth Bales Vascular Specialist is the official newspaper of the Society for Vascular Surgery and provides the vascular specialist with timely and relevant news and commentary about clinical developments and about the impact of health care policy. Content for Vascular Specialist is provided by Frontline Medical Communications Inc. Content for the News From the Society is provided by the Society for Vascular Surgery.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher.

The Society for Vascular Surgery and Frontline Medical Communications Inc. will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.

2 • VASCULAR SPECIALIST

Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, division of vascular and endovascular surgery, Louisiana State University Health Sciences Center, New Orleans.

tell it does not exist. So maybe that was never really the primary goal. Based on the vigor and financial capital hospitals pour into the creation of these lines, there must be a different game afoot.

Looking deeper into the health care administration literature it seems the true benefit of a service line is that it keeps patients within the system. Once a patient is brought in by one specialty, the other specialties can converge to offer their services. It soon becomes an assembly line of atherosclerotic delights. The patient enjoys the theoretical advantage of having all of his or her specialists together, and the hospital enjoys the profits.

I would have been comfortable fighting the concept of the service line on the basis of access, practicality, or quality. The truth is, it isn’t about any of these things. If the service line were really about patient convenience, we would have put a vascular lab in the clinic as I requested. But that wouldn’t have been convenient for radiology or cardiology. In your model, which specialty does the work doesn’t matter because the hospital profits regardless. So without a financial map to describe how this all plays out, you just threw us into the same cage Thunderdome-style.

Two specialists enter, one specialist leaves. The prob-

POSTMASTER Send changes of address (with old mailing label) to Vascular Specialist, Subscription Services, 10255 W Higgins Road, Suite 280, Rosemont, IL 60018-9914.

RECIPIENT: To change your address, contact Subscription Services at 1-800-430-5450. For paid subscriptions, single issue purchases, and missing issue claims, call Customer Service at 1-833-836-2705 or e-mail custsvc.vasc@fulcoinc.com.

The Society for Vascular Surgery headquarters is located at 633 N. St. Clair St., 22th Floor, Chicago, IL 60611.

Vascular Specialist (ISSN 1558-0148) is published monthly for the Society for Vascular Surgery by Frontline Medical Communications Inc., 7 Century Drive, Suite 302, Parsippany, NJ 07054-4609.

Phone 973-206-3434, fax 973-206-9378 Subscription price is $230.00 per year.

National Account Manager Valerie Bednarz, 973-206-8954, cell 973-907-0230, vbednarz@mdedge.com Digital Account Manager Rey Valdivia 973-206-8094 rvaldivia@mdedge.com Classified Sales Representative Drew Endy 215-657-2319 cell 267-481-0133 dendy@mdedge.com Senior Director of Classified Sales Tim LePella, 484-921-5001, cell 610-506-3474, tlapella@mdedge.com Advertising Offices 7 Century Drive, Suite 302, Parsippany, NJ 07054-4609 973-206-3434, fax 973-206-9378 Letters to the Editor: VascularSpecialist@vascularsociety.org Editorial Offices: 2275 Research Blvd, Suite 400, Rockville, MD 20850, 240-221-2400, fax 240-221-2548 ©Copyright 2018, by the Society for Vascular Surgery Scan this QR Code to visit vascularspecialistonline.com

lem is that CMS is already looking at the volume of diagnostic studies as a factor in total cost. You helped us build a system that enables and encourages more testing. Cue Tina Turner, “We don’t need another ECHO…” The turning point in our relationship should have come when you sent me the list of CPT codes for the procedures expected to be performed by vascular surgery. You got a few right. Lower extremity bypass, amputations, and even aneurysms were there. You seemed surprised, though, that we would be doing other leg interventions and thought the carotid endarterectomies would be done by neurosurgery. Here the problem was laid out. You were describing in detail the mechanisms for our new service line, but you didn’t really know what a vascular surgeon was. It’s a little late, but let me help you.

When I sent back the CPT list, even I forgot a few. Like 35251 (repair of intra-abdominal blood vessel), 27364 (radical resection of thigh sarcoma), or 35141 (repair of femoral pseudoaneurysm). You see, vascular surgeons are the great facilitators.

Our expertise enables other specialties to perform at their highest levels. Comprehensive programs in orthopedics, neurosurgery, cardiology, cardiac surgery, surgical oncology, trauma, and urology would be essentially impossible without vascular surgery.

A study conducted at Northwestern showed that 7% of their total volume of vascular surgeries were cases providing intraoperative assistance to other specialties.1 And this excluded trauma. While the hospital greatly benefits from this relationship, the vascular surgeons often do not. Emergently helping other physicians requires canceling our responsibilities, both at work and at home. CPT codes often Editor continued on following page

FRONTLINE MEDICAL COMMUNICATIONS SOCIETY PARTNERS Director, FMC Society Partners Mark Branca Editor in Chief Mary Jo M. Dales Executive Editors Denise Fulton, Kathy Scarbeck Managing Editor Mark S. Lesney Creative Director Louise A. Koenig Director, Production/Manufacturing Rebecca Slebodnik

FRONTLINE MEDICAL COMMUNICATIONS Corporate President/CEO Alan J. Imhoff CFO Douglas E. Grose SVP, Finance Steven J. Resnick VP, Operations Jim Chicca VP, Sales Mike Guire VP, Society Partners Mark Branca VP, Editor in Chief Mary Jo M. Dales VP, Editorial Director, Clinical Content Karen Clemments Chief Digital Officer Lee Schweizer VP, Digital Content & Strategy Amy Pfeiffer President, Custom Solutions JoAnn Wahl VP, Custom Solutions Wendy Raupers VP, Marketing & Customer Advocacy Jim McDonough

VP, Human Resources & Facility Operations Carolyn Caccavelli Data Management Director Mike Fritz Circulation Director Jared Sonners Corporate Director, Research & Comms.

Lori Raskin Director, Custom Programs Patrick Finnegan AllMedx President Douglas E. Grose Executive Vice President, Sales John Maillard Editorial Director/COO Carol Nathan In affiliation with Global Academy for Medical Education, LLC President David J. Small, MBA

SEPTEMBER 2018

Editor continued from previous page

severely undervalue our time spent assisting with large resections or waiting “on standby.”

The overall financial contributions of vascular surgeons to hospital systems are often overlooked. In a study performed at a tertiary care hospital in New Jersey, vascular surgeons were found to have the leading gross margin per FTE of any specialty, 66% more than cardiology. (And these were academic vascular surgeons, a famously lazy breed!)2 In 2002, Merritt, Hawkins & Associates found that the average vascular surgeon provides over $2 million in revenue to his or her hospital, third highest of any specialty.3 With the widespread adoption of endovascular procedures, this number is likely to be higher today.

So now, an update on our great experiment. Run by cardiology our service line treats heart disease, heart attacks, heart failure, and high blood pressure. At least according to the website. If you want to find vascular surgery, it is listed last, under “other services.” And no, sadly the list is not alphabetical. Around the country, there is a great shortage of vascular surgeons. There are two to three job openings for every graduate annually. Remarkably, our service line boasts 10 board-certified vascular surgeons. But people always seem to want what they don’t have. In our service line director’s case, that was a TAVR program. So there was great effort and expense in creating one. When it came time to start our FEVAR program, I simply took my friend Andy Schanzer out to dinner and asked him how he did it at UMass. Then we

just started doing cases. No fanfare, no press releases. No expensive hires. The dinner cost about $100 (Andy is a cheap date, but I ordered multiple apps).

Today, our service line is disintegrating. There is no animosity. It just didn’t work out. It never really made sense.

Yes, our patients have heart disease. They also have lung cancer, diabetes, prostate disease, and spinal stenosis. They would benefit from wound care, smoking cessation, and certainly a comprehensive vascular lab. None of which were offered in our service line. We didn’t belong in the same silo as cardiology, and I certainly never believed they should be in one that treats PVD. I guess it is quaint to expect that a specialty’s scope of practice matches their ACGME and ABMS training requirements. Maybe I’m old-fashioned.

So <redacted>, looking back on our meetings you often took the tone of an adult explaining a difficult, but necessary thing to a child. Maybe the biggest lie we tell children is that adults know what they’re doing. Vascular surgery is an incredibly valuable asset to a health care system: one threatened by physician scarcity and one deserving of promotion and growth. It seems remarkably shortsighted to bury this asset on a service line under the direction of cardiology.

In the end, I have only one request. The next time you are in a meeting with a vascular surgeon who asks for an example of a successful Heart and Vascular Service Line don’t use us. It didn’t work. I don’t think it ever truly works. ■ References

1. JAMA Surg. 2016;151(11):1032-8.

2. J Vasc Surg. 2012;55(1):281-5.

3. Merritt, Hawkins & Associates, 2002 Physician Inpatient/Outpatient Revenue Survey.

IVUS for prediction May-Thurner from page 1

collaborating institutions. Patients had a mean age of 46 years and included 86 (73%) women. At the time of treatment, 45, 30, 25, and 18 patients had Clinical Etiology Anatomy Pathophysiology disease 3, 4, 5, and 6, respectively.

Dr. Abramowitz described how he and his colleagues derived an IVUS-driven scoring system to assess the following categories of May-Thurner syndrome (nonocclusive or occlusive), disease chronicity (nonthrombotic, acute, or chronic), venous disease length (less than 180 mm or greater than 181 mm), venous inflow compliance (presence or absence of respiratory variation), iliocaval confluence disease involvement (present or absent), iliocaval confluence stenting obligation (stented or spared), and presence of perivenous collaterals before and after stenting (none or resolved).

Six of the categories were scored with 0 or 1 and one category was scored with 0, 1, or 2. Scores were tabulated for each patient at the time of initial intervention.

All 118 (100%) patients received anticoagulation and 78 (66%) were SEPTEMBER 2018

on an antiplatelet agent. Thirty-eight (32%) developed moderate in-stent stenosis, required thrombolysis, or underwent additional stenting procedures and were considered treatment failures during the observed period.

“This data is hopefully the first step in allowing us to guide intra-operative decision making.”

Eighty patients (68%) required no additional intervention and were considered treatment successes. The mean IVUS score for all patients was 5.22. The mean IVUS score in the treatment failure cohort was 5.64 compared with a score of 4.67 in the treatment success group, a significant difference. Patients with a score above 4 on this 7-point scale had an increased relative risk (1.6) of stent failure at 2 years.

“An IVUS-driven scoring system score of 4 or greater during initial intervention for May-Thurner syndrome predicts failure at 2 years. Additional treatment modalities should be considered at implantation to prevent failure,” said Dr. Abramowitz.

In an interview, Dr. Abramowitz added: “There is an emerging body of research regarding outcomes of deep venous intervention. However, we are still looking to generate clinically relevant data that will help guide interventionists to achieve durable technical success and long-term positive clinical outcomes for our patients.

“At this time, there is very little data to help correlate what physicians see on venography and IVUS during the treatment of May-Thurner lesions. This data is hopefully the first step in allowing us to guide intra-operative decision making. IVUS is an excellent tool that has been proven by other studies to aid in the diagnosis and management of venous disease. With this data we also hope that it becomes a drive of patient management as well. Ideally, this data will transition into also guiding anticoagulation management, postoperative surveillance strategies and outcomes stratification for patients,” Dr. Abramowitz concluded.

NEWS

Briefs

American Board of Surgery

In June 2018, the ABS unanimously approved the following motion: Directors of the ABS are required to hold a primary certificate of the ABS, either in general surgery or in vascular surgery. This clears the way for graduates of integrated vascular residencies, or other vascular surgeons who do not hold a current general surgery certificate, to serve on the ABS. As part of the new Continuous Certification Program, vascular surgeons with lapsed general surgery certificates may regain certification. This will take 5 years to complete, and surgeons who choose to enroll may regain their certification within the first year of participation. Entry will only be offered for a brief period – surgeons may enter in 2018, 2019, or 2020.

Upon successful completion of the first assessment, participants will regain ABS certification in general surgery. They will then be required to take and pass the assessment each year for 4 additional consecutive years (5 consecutive years total). For surgeons who choose to enroll in 2018, registration will be open from Aug. 1 through Oct. 15. www.absurgery.org September is PAD Awareness Month

Help SVS spread the news about peripheral arterial disease. It’s easy – SVS has updated its online resources for physicians (vascular. org/news-advocacy/pad-resources-physicians) and for patients (vascular.org/news-advocacy/peripheral-arterial-disease-resources). Both web pages have videos, web links, scholarly articles, and more, appropriate for each audience.

mlesney@mdedge.com MDEDGE.COM/VASCULARSPECIALISTONLINE • 3

RESIDENTS AND TRAINING

Vascular training for general surgery resident continues downward trend

BY MARK S. LESNEY MDEDGE NEWS FROM ANNA LS O F S U RG ERY

O

perative experience in open arterial vascular surgery procedures for general surgery residents has significantly declined, according to the results of a study of the Accreditation Council for Graduate Medical Education (ACGME) national case log reports, which lists the mean numbers of operations performed.

“Because fundamental vascular surgery skills are necessary for operative general surgery, vascular surgery should remain an essential content area. However, programs cannot solely depend on operative experience to teach fundamental vascular surgery skills,” John R. Potts III, MD, FACS, and R. James Valentine, MD, FACS, stated in their report published online in Annals of Surgery.

The number of individuals completing ACGME-accredited general surgery and vascular surgery training each year of the study was obtained from public reports of the ACGME as well as the available summary national data regarding the reported operative experience of residents completing general surgery programs.

The researchers found that over 15 years (academic year 2001-2002 through AY 2016-2017), the total vascular operations performed by

general surgery residents significantly declined as did the total open arterial vascular procedures, including those in seven of nine categories (P less than .0001).

The issue of adequate exposure to vascular procedures for general surgery residents is complex. “The number of individuals completing general surgery residency annually has increased by approximately 20% since AY 2001-2002. During the same period, the number of open arterial operations reported by general surgery residents decreased by approximately 38%. Thus, the declining experience is clearly not simply a matter of distributing the same number of operations to a larger number of individuals,” the investigators reported.

The ACGME-designated “essential content areas” have increased in recent years for general surgery trainees to now encompass alimentary tract, abdomen, breast, head and neck, endocrine system, the surgical management of trauma, soft tissues, pediatric surgery, surgical critical care, surgical oncology, and vascular surgery. The essential content areas compete to varying degrees for the trainee’s time, potentially cutting into not just vascular cases but other areas as well. It is also the case that general surgery trainees are often in an institutional setting where they are competing with vascular surgery

Changes to E/M CMS from page 1

and established visits (1.22 wRVU). The proposal would also make these services subject to the multiple procedure payment reduction (MPPR: 50% reduction if billed with another service by the same practice). To obtain this single reimbursement, you must achieve at least a level 2 visit through one of four methods: the current 1995 or 1997 guidelines, time or medical decision making. While CMS has not created a special code to track these visits, they are willing to create a G-codes to ensure additional reimbursement for primary care and specialists reliant on higher level codes: vascular surgery isn't on the list.

CMS claims analysis based on 5-year aggregate data for 2017 shows vascular surgeons receiving a total increase in reimbursement of 7% for E/M. Our analysis, using the single reimbursement and CMS rate of effect for MPPR (1.4%) for 2016, yielded a 9% increase. This increase is largely carried by the additional reimbursement for level II & 4 • VASCULAR SPECIALIST

P E R SPEC T IVE by Malachi Sheahan III, MD

Can general surgery residents get that much experience?

R

ecently I was asked to give a talk on techniques for the open repair of abdominal aortic aneurysms. This was received like a historian discussing medieval medical treatments.

“After the renal vein is retracted, place a clamp across the aortic neck and occlude it. (Audience gasps!)

With an #11 blade incise the aorta, taking care to preserve the IMA. (Young student shrieks from the back row.) When you remove the thrombus, the lumbar vessels may bleed briskly, requiring sutures.”

residents for the same pool of vascular surgery patients.

During those last 5 years, significant declines occurred in five categories: aneurysm, cerebrovascular disease, arteriovenous dialysis access, peripheral vascular disease, and extra-anatomic bypass, according to the authors.

“Knowledge of arterial anatomy, approaches, control, and repair are crucial to the practice of operative general surgery. In the face of declining experience for their resident as surgeon in open arterial operations,

III established patient visits, while all level IV and V will see a reduction. Despite this improvement, we question the individual practice impact and are concerned the benefits may not be equitable across vascular surgery practices. Basically, those who document and bill at a higher level will see a marked reduction in reimbursement (level IV & V will see a 15-37% reduction), while those who automatically apply lower codes will see an increase (level II and III has potential 23-107% increase).

From a work RVU standpoint, Level II and III visits will see a 26-154% increase while level IV and V will suffer a 19-40% reduction. This pattern may be largely based on practice location, group practice compensation and confidence in coding. The new proposed system raises other concerns. Without third-party agreement or a specific G-code, it will be difficult to implement, ensure non-CMS reimbursement, and monitor as even CMS agrees that “many practitioners would continue and report level of E/M as appropriate under CPT”.

While appealing based on financial analysis, this proposal lacks infrastructure, means for application,

(Resident in second row passes out.)

There are 297 approved general surgery programs in the country; only 54 of them have an associated integrated vascular residency in the upcoming match. We are not taking their cases. These cases no longer exist. General surgery graduates can no longer be considered qualified to perform vascular surgery. We are a different specialty with different training requirements and different skills. The future of vascular care in this country will depend on our understanding of and adaption to this new reality. general surgery programs must augment resident education in the principles of vascular surgery through other means,” the authors concluded.

Portions of this study were presented at the2018 meeting of the American Surgical Association.

Dr. Potts and Dr. Valentine reported that they had no conflicts of interest. mlesney@mdedge.com

SOURCE: Potts JR et al. Ann Surg. 2018 Jul 24. doi: 10.1097/ SLA.0000000000002951.

stakeholder approval, or safeguard for participating clinicians. The additional reimbursement for specialists, which would get a G-code, excludes vascular surgeons and is not only unfair and without merit, but goes against CMS policy prohibiting different reimbursement for a code based on specialty. For a proposal that has a potential start date of January 2019, we feel that due diligence and thorough vetting is mandatory prior to any implementation.

The current system for E/M services is outdated and susceptible to subjective interpretation, and a new system must be developed. The current proposal relies heavily on unsupported and unacceptable methodology placing our members at significant financial risk. Therefore, while we certainly endorse changes that would decrease our administrative and documentation burden, we must ensure it is done in a manner conducive to corrective actions and with stakeholder participation.

Dr. Aiello is from the University of Massachusetts Medical School, Boston. Dr. Sideman is from the University of Texas, San Antonio.

SEPTEMBER 2018

THIS CHANGES EVERYTHING ACCESS

TARGET

CLOSE

INTERVENE

From the leaders in radial access…discover what’s next in peripheral intervention.

Ask your TERUMO representative about R2Pª today.

©2018 Terumo Medical Corporation. All rights reserved. All brand names are trademarks or registered trademarks of Terumo. PM-00375

VAS_5

5/24/18 1:53 PM

NEWS FROM SVS

Welcome to our New SVS Members

T

he Society for Vascular Surgery welcomes the following new members, who joined during the first six months of 2018.

Active members

United States Mohammed Abdallah, DO; Deerfield Beach, FL Steven Abramowitz, MD; Washington, D.C. Brian Adams, MD; Ogden, UT Rana Afifi, MD; Houston, TX Chad Ammar, MD; Wichita, KS Ruosu An, MD; Rowlett, TX Ahmad Bhatti, MD; Port Jefferson, NY Mark Brennan, DO, FACOS; Johnson City, NY Emilio Calabrese, MD; Niceville, FL Young Erben, MD; New Haven, CT Yana Etkin, MD; New York, NY Grant Fankhauser, MD, MBA; Galveston, TX Ziad Fayad, MD, RPVI; South Bend, IN Lindsay Gates, MD; Spokane, WA John Hovorka, MD; McAllen, TX Kamran Jafree, MD; Dayton, OH Arjun Jayaraj, MD; Jackson, MS Joseph Karam, MD; Minneapolis, MN Hannah Kim, DO; Winchester, VA Matthew Koopmann, MD; Portland, OR Steven Levin, MD; Bay City, MI Jerry Light, MD; Bedford, TX Lamar Mack, MD; Visalia, CA Rajesh Malik, MD; Washington, DC Tareq Massimi, MD; Washington, DC Ryan McEnaney, MD; Pittsburgh, PA Derek Nathan, MD, RPVI; Seattle, WA Kristine Orion, MD; New Haven, CT Nathan Orr, MD; Lexington, KY David Paolini, MD; Toledo, OH R. Michael Patton, MD; Wilmington, NC Cherie Phillips, MD; Flint, MI Brian Rapp, MD; Richmond, VA Marcus Semel, MD, MPH; Weymouth, MA Todd Simon, DO; Augusta, GA Denise Smith, MD, PhD; Tallahassee, FL Bjoern Suckow, MD, MS; Lebanon, NH Xiaoyi Teng, MD; Minneapolis, MN Tadaki Tomita, MD; Chicago, IL Areck Ucuzian, MD, PhD; Baltimore, MD Marie Unruh, MD; New Orleans, LA Edward Villella, MD, RPVI; Beaver, PA Dimitrios Virvilis, MD; Gulfport, MS Natalie Weger, DO; Pueblo, CO Michael Williams Jr., MD; St. Louis, MO 6 • VASCULAR SPECIALIST

Canada Patrice Nault, MD, FRCSC; Gatineau, Quebec Santosh Pudupakkam, MD; Sudbury, ON Associate Members

Majed Nounou, MD, Lapeer, MI International

Argentina Javier Ferrari Ayarragaray, MD; Caba Elvio Demicheli, MD; Mar del Plata Samuel Fernandez, MD; Olivos Luis Mariano Ferreira, MD; Caba Guillermo Garelli, MD; Cordoba Ramon Elias Gimenez, MD; Libertador San Martin Antonio Ricardo La Mura, MD; Buenos Aires, Buenos Aires Alexis Lezcano, MD; San Juan Enrique Miranda, MD; San Luis Juan Rinaldi, MD; Alta Gracia Javier Rodriguez Asensio, MD; General Rodriguez, Mecca Javier Hernan Rodriguez Asensio, MD; General Rodríguez, Buenos Aires Cesar Manuel Salvado, MD; Martinez Jorge Enrique Valdecantos, Sr., MD; San Miguel de Tucumán Brazil Luiz Henrique Dias Gonçalves de Sousa, MD; San Paulo Martin Geiger, MD, MSc; Campinas, SP Aline Goulart, MD; Brasilia, DF Rodrigo Lago, MD; Belo Horizonte, Minas Gerais Rodolfo Mansano, MD; Campo Mourao, Parana Paulo Moutella, MD; Asa Sul, Brasilia China Jia Wan, MD; Kunming, Yunnan Italy Pasqualino Sirignano, MD; Rome Japan Kazunori Hashimoto, MD; Saitama City, Saitama Jordan Kristi Janho, MD; Om Alsomaq, Amman Mexico Javier Anaya-Ayala, MD; Mexico City The Netherlands Hence Verhagen, MD, PhD; Rotterdam Kak Khee Yeung, MD, PhD; Amsterdam, Noord-Holland Portugal José Vidoedo, MD; Maia Saudi Arabia Ahmed Sakr, MD; Jeddah, Mecca United Kingdom Michael Guant, MD, FRCS; Impington, Cambridge

Affiliate Members, PA Section

Lisa Bartlow, PA-C; Athens, GA Mary Ashely Behm, PA-C; Virginia Beach, VA Gary Bissonette, PA-C; Grand Rapids, MI Sarah Bruns, PA; Hartford, CT Kenneth Bush, MPAS, PA-C, ATC; Winston Salem, NC Jonathan Carroll, PA-C; Gainesville, FL Dana Clark, PA-C; Virginia Beach, VA Alexandra Cotter, PA-C; Raleigh, NC Stephanie Curtis, PA-C, MPAS; Kansas City, MO Maysoon Dayoub, PA-C, MPAS; Drexel Hill, PA Damien De Collibus, PA-C; New York, NY Maria Difiore, PA-C; Franklin Square, NY Rita DiTommaso, PA-C; Gainesville, FL Athena Drosos, PA; Salem, NH Olga Fatakhova, PA; New York, NY Karl Felsheim, PA-C; Hershey, PA Jessica Fernandes, PA-C; Boston, MA Colin Flynn, PA-C; Boston, MA Ryan Forsyth, MPAS, PA-C; Spokane, WA Carlee Genung, PA-C; Reston, VA Jennifer Gonzalez, PA-C; Needham, MA Holly Grunebach, PA-C, MSPH; Baltimore, MD Rachel Gurr, PA-C; Bountiful, UT Elana Hacker, PA-C; Sylvania, OH Peggy Hall Curci, PA-C; Nashville, TN Erin Hanlon, PA-C; Annapolis, MD Monica Hatch, PA-C; Salt Lake City, UT Julie Hinzman, PA-C; Albuquerque, NM Elizabeth House, PA-C; Grand Rapids, MI Travis Householder, PA-C; Albuquerque, NM Alison Jackson, PA-C; Bayport, NY Marylee Jackson, PA-C; Piedmont, SC Joseph Jacot, PA-C; Flint, MI Blessen John, PA-C; Astoria, NY Emily Johnson, PA-C; Marietta, GA Thomas Jones, PA-C; , MI Lauren Kendall, PA-C; Springfield, OR John Klein, PA-C; Ann Arbor, MI George Litz, PA-C; Everett, WA Kristen Long, PA-C; Chester, PA Albaro Lopez Perez, PA-C; Orlando, FL Kenia Lynn, PA-C; Miami, FL Mary Masayda, PA-C; Watertown, CT

Apply by Dec. 1 The final membership application deadline for 2018 is Dec. 1. For more information on SVS membership, see vsweb.org/JoinSVS. Dena Mathew, PA-C; New Hyde Park, NY Kristin Maurer, PA-C; Boston, MA Nicole Meregian, PA-C; Auburndale, MA Viktoriya Mirkin, PA; New York, NY Shira Mohammed, PA-C; Baltimore, MD Danielle Moses, PA-C; Charlottesville, VA Arica Navaie, PA; Rochester, NY Meghan Nilan, PA-C; Morristown, NJ Melissa Nolan, PA-C; Cleveland, OH Jon Peckham, PA-C; Phoenix, AZ April Pena, PA-C; Tyler, TX Brittany Perron, PA-C; Manchester, NH Laura Pride, PA-C; Atlanta, GA Kerry Reilly, PA-C; Clifton Park, NY Caitlin Reynolds, PA-C; West Hartford, CT Stephen Robischon, PA-C; Milwaukee, WI Robin Rose, PA-C; New Haven, CT Erin Rotter, PA-C; Somerville, MA Morgan Rudnick, PA; Boston, MA Jeffrey Sabido, PA-C; Fairfield, CA Saurab Sainju, PA-C; Salt Lake City, UT Candice Salvas, PA-C; Lebanon, NH Sarah Schoonover, PA-C; Denver, CO Melissa Sedor, PA-C; Bloomsburg, PA Jeanelle Shaver, RPA-C; Glens Falls, NY Laura Skanse, PA-C, RVT; Kirkland, WA Robert Skasko Jr, PA-C; Dallas, PA Olivia Snodgrass, PA-C; Tyler, TX Matthew Spicer, PA-C; Annapolis, MD Kristen Tobash, PA-C; Walnutport, PA Claire Tomlinson, PA-C; Franklin, TN Ashley Volles, RPA-C; Fayetteville, NY Emose Voltaire Piou, PA; Boston, MA Heather Warren, PA-C; Temple, TX Cheryl Weinstein Shama, RPA-C; Brooklyn, NY John Westfall, PA-C; Boston, MA Danielle Wiley, PA-C; Bellingham, WA Savannah Wills, PA-C; Roanoke, VA Daniel Yee, PA-C; Pleasanton, CA Erin Zahorujko, MS, PA-C; Blacklick, OH Suzanne Zayan, PA-C; Ypsilanti, MI New Members continued next page SEPTEMBER 2018

NEWS FROM SVS

SVS Working Hard to Protect Vascular Surgeons, Medicine in CMS Proposals Proposed Rules Include Substantial Cuts to Vascular Labs

A

fter reviewing proposals from the Centers for Medicare and Medicaid Services (CMS), the Society for Vascular Surgery has drafted comments to mitigate potentially substantial negative effects on SVS members.

CMS released the 2019 Hospital Outpatient Prospective Payment System (HOPPS) and the combined Medicare Physician Fee Schedule (PFS) /Quality Payment Program (QPP) proposed rules in July and is accepting comments into September. Of particular concern to the SVS are the flattening of Evaluation and Management (E/M) codes (see story on page 1), loss of value in Relative Value Units (RVU) for indirect expenses and substantial

cuts to vascular labs and other vascular procedures as a result of repricing.

Payments under the Medicare Physician Fee Schedule are based on three relative value scales, representing the relative amounts of physician work, practice expense (PE) and malpractice (MP) expenses) required to provide each service. The proposed PFS rule includes a compression of E/M codes, reducing levels two through five to a single level, averaging payments and paperwork requirements. SVS is particularly concerned that this proposal neglects the complexity of vascular cases, resulting in a net deficit exceeding

New Members

BC; San Antonio, TX Kimberly Guest, RN; Durham, NC Karen Hanrahan, BSN, RN; Boston, MA Tina Marino, AG-ACNP; Sun City West, AZ Deborah Nealon, FACHE; Germantown, MD Thad Neidrick, CRNP; Danville, PA BreAwn Rizzuto, NP; Murray, UT Marie Rossi, RN, BS, CVN; Albany, NY ■

continued from previous page Affiliate Members

Ana Contreras, BSN, BA, RN, CVRNBC; Boston, MA Nancy Crandall, NP; Providence, NJ Kate Dell, MSN, AGACNP-BC; Lafeyette, IN Mini George, NP-C; Houston, TX Phyllis Gordon, MSN, APRN, ACNS-

May 13, 2019

Vascular Research Initiatives Conference Boston, Massachusetts

CMS continued on following page

IN MEMORIAM

D

r. Frank C. Spencer, former president of the American Association of Vascular Surgery (pre-merger), who revolutionized surgical repair of battlefield vascular injuries during the Korean War, also known for his training of hundreds of surgeons. To see an interview with Dr. Spencer, visit vsweb.org/HistoryProject.

He discusses the Korean War and changes in vascular surgery in the Era II SVS history video, on the same page, at approximately the 5-minute, 5-second point. ■

SEPTEMBER 2018

SAVE THE DATE:

A Day of Emerging Vascular Science With Abstracts, Posters, Panel of Experts, The Alexander W. Clowes Distinguished Lecture and Interacting With Researchers and Physicians

Submit Abstracts:

Oct. 30, 2018 – Jan. 15, 2019

MDEDGE.COM/VASCULARSPECIALISTONLINE • 7

NEWS FROM SVS

FISCAL HEALTH CHECKUP: Be Sure To Assess Disability Insurance

as well.

SVS members might want to do such an assessment of their disability insurance coverage: Are plans paid for with pre-tax or after-tax dollars? Is the rate locked in? Members just might be significantly under-insured.

SVS offers individual disability plans with three companies – Principal Life Insurance Company, Standard Life and Lloyd’s – through its Affinity Program of expanded benefits.

Important considerations include taxes, annual premium rate increases, guaranteed renewability and, significantly, whether the plan recognizes and covers the subspecialty of vascular surgery Group plans are taxable when the employer or group pays the premiums. In contrast, SVS plans are paid with after-tax dollars. “You

premiums paid after taxes provides a $300,000 annual tax-free benefit.

Subspecialty recognition is also important. “It’s vital to make sure that your policy clearly defines and covers you as a vascular surgeon. No surgeon I know wants to be forced into a career as a GP,” Blocker said.

G eckophotos /Getty I maGes

W

ellness checks aren’t just for physical health.

They’re for fiscal health

may need 100 percent of the pretax benefit to live on,” explained Mark Blocker, of the SVS Affinity Program. “This is the biggest issue members face, in deciding on a disability insurance plan.”

The impact can be substantial: A $300,000 annual benefit through a group or employer-paid plan will

CMS continued from page 7

CMS estimates of -1 percent for vascular surgery factoring in an estimated 51 hours of paperwork reductions per year. SVS has joined other medical organizations in a request to CMS that seeks to adopt changes to this proposal, including: 1. Changing the required documentation of the patient’s history to focus only on the interval history since the previous visit 2. Eliminating the requirement for physicians to re-document information that has already been documented in the patient’s record by practice staff or by the patient

8 • VASCULAR SPECIALIST

provide taxable benefits. At a 40 percent rate, the annual benefit becomes $180,000. “If the state income tax is 8 percent, or $24,000, that $300,000 benefit under a group plan reduces the benefit to just $156,000, or $13,050 a month,” Blocker said.

In contrast, the SVS plan with

3. Removing the need to justify providing a home visit instead of an office visit.

SVS is preparing a significant Congressional lobbying effort to educate members on unintended consequences of prematurely flattening E/M codes and is prepared to work on a legislative fix should the PFS final rule not reflect our concerns.

SVS is also very concerned about the unintended consequence of altering the current practice expense methodology to accommodate the E/M proposal on vascular surgery services. Many vascular surgery CPT codes are experiencing inappropriate decreases in the indirect practice expenses (administrative labor, office supplies and other expenses) due to these alterations in the CMS PE methodology.

SVS is further advocating against potential significant reimbursement reductions for physician-owned vascular lab and other vascular/endovascular procedures as a result of repricing initiatives. CMS is proposing updated pricing for 2,017 supply and equipment items based on a recently awarded market research contract. SVS has serious concerns about the sources used by the CMS contractor and has submitted documentation to combat the proposed reductions.

SVS has been working tirelessly to advocate on behalf of vascular surgery and will be providing extensive comments and guidance to CMS and lawmakers to ensure the best possible outcomes during the regulatory and legislative process. ■

SVS plans also: • Are portable so a move to another practice doesn’t affect coverage.

• Are guaranteed renewable, while group plans can be canceled by the insurer.

• Have rates locked at enrollment.

Group plans can raise rates annually.

• Are discounted 10 percent for SVS members with a possible additional 10 percent discount.

• Contact Blocker at mark@ nationalaffinity.net or 312-291-4472 (Purchasing a product through the expanded SVS affinity program benefits not only you and your practice, but also SVS itself.) ■

AAA Guideline Translated into Spanish T

he Society for Vascular Surgery has translated the updated guidelines on abdominal aortic aneurysms into Spanish, aimed at the large population of Spanish-speaking vascular surgeons.

The translated guideline — a pilot project to gauge interest in such work — already is available. The SVS International Relations and Document Oversight committees collaborated on the translation.

“Our committee thought we could contribute internationally by sharing the work that’s already been done,” Dr. Ascher said of the guideline translation. SVS hired a professional translator who is also a medical doctor to do the overall translation, which was then painstakingly reviewed, line by line, by committee volunteers.

The translated guideline, with 112 recommendations and 774 references, is aimed primarily at surgeons in Latin America and Europe.

Translations to other languages could follow, said Dr. Ascher, citing Chinese, Mandarin, Hindu and Russian as possibilities. The International Relations and Document Oversight committees want members who find this first effort beneficial to let committee members know, and also suggest other guidelines and materials to translate. One possibility is translating the Vascular Educational Self-Assessment Program (VESAP) into another language.

To obtain a copy of the guideline in Spanish, visit vsweb.org/SVSGuidelines. People will be asked to submit some information, including where they learned of the translation, before accessing the guideline. For more information, email guidelines@vascularsociety.org. ■ SEPTEMBER 2018

NEWS FROM SVS

Course Focuses on Reimbursement, Risk and Red Tape

W

hy should vascular surgeons or their coding staff attend the SVS Coding and Reimbursement Workshop? The short answer is: reimbursement, risk and red tape. Or, as workshop instructor Sean Roddy, MD, puts it: “Maximize your appropriate reimbursement, limit your risk of audit and avoid red tape.”

It’s generally accepted, he said, that correct coding lessens the chances for an audit. “No one wants the IRS knocking on the door,” he said. Even if the audit turns up nothing inappropriate, preparDR. RODDY ing for it costs a surgeon time and money. Doing it right the first time also pays off monetarily, because a denied claim has a “precipitously” reduced chance of ever being paid. “It’s best to do it right the first time. It has the best odds for payment and it avoids staff re-work,” Dr. Roddy said.

Thus, the 1 ½-day course on Oct. 19 and 20 in Chicago emphasizes teaching the right way to do appropriate coding to avoid an audit.

Vascular surgery coding is complicated because vascular surgery has a great many codes and procedures compared to other surgical specialties.

“We do percutaneous procedures, we do open procedures and we do them in all areas of the body

FROM JVS:

besides the heart and the brain,” said Dr. Roddy.

Understanding the differences between codes is important information covered in the course.

Dictation is another significant topic. In a complicated procedure, surgeons may need to use additional codes, which are reimbursable if supported by the surgeon’s accompanying dictation. “It’s necessary and legal,” said Dr. Roddy. “We talk about what to put in the dictation to justify the appropriate level of coding.”

The SVS course is also the only one that includes information on the vascular lab, “an integral part of all vascular practices,” said Dr. Roddy. “We teach how to avoid inappropriate payment denials for all vascular lab studies.”

He called 95 percent of vascular claims fairly straightforward. “It’s the extra 5 percent. We spend a good portion of the time talking about the complicated things, trying to get you that last bit and prevent an audit.”

The course audience typically is approximately one-third physicians and two-thirds coders. “Coding is important enough that if you don’t want to attend, or a partner doesn’t want to, have your coder attend the course in Chicago,” said Dr. Roddy. “We have some coders who come every year to keep up to date.”

Dr. Roddy himself once was in the “don’t care” category. “I wanted to operate,” he said. He began taking an interest in the reimbursement process

SPOTLIGHT ON LEADERSHIP:

Developing Ronald L. Dalman, MD Preoperative Risk Score for rAAA I R

BY VENITA CHANDRA, MD MEMBER OF THE LEADERSHIP DEVELOPMENT & DIVERSITY COMMITTEE

uptured abdominal aortic aneurysms risk scores, based on four variables, allows accurate prediction of 30-day mortality after repair, according to a study published in October’s Journal of Vascular Surgery. The risk factors, which authors say can be readily assessed in the emergency room, include age of 76-plus; confidence interval of 1.47-4.97; P=.011); creatinine concentration of more than 2.0 mg/dl; and systolic blood pressure ever less than 70 mm Hf. Researchers wanted to develop a preoperative risk score to predict mortality after repair of a ruptured AAA. The article is open source through Oct. 31 at vsweb.org/ JVS-RiskScore. ■

SEPTEMBER 2018

had the honor of interviewing Dr. Ronald Dalman, the Walter C. and Elsa R. Chidester Professor and Chief of Vascular Surgery at Stanford University. We focused on one of the five “practices” routinely embraced by successful leaders described by Kouzes and Posner in their book “The Leadership Challenge”: “challenging the process” and the courage to question the status quo and thoughtfully test new paradigms.

VC: Tell me about your leadership style when it comes to implementing change. How do you prepare yourself for the potential risks associated with such change?

RLD: A lot of people in leadership roles talk about “how do you get people to do what you want?” I believe

Coding and Reimbursement Workshop Friday, Oct. 19 (1 to 5 p.m.) and Saturday, Oct. 20 (8 a.m. to 4:45 p.m.)

Renaissance Hotel, downtown Chicago Cost: $880 for members; $955 for non-members; $25 for residents and trainees Optional Evaluation & Management Coding session, Oct. 19 (9 a.m. to noon) Cost: $100, $125, $50 per respective category See vsweb.org/Coding18 for more information and to register. because he “wanted to KNOW how we got paid,” he said. “I’m a mathematical, logical person.”

He took a course, conducted research and developed a zeal for proper coding that maximizes appropriate reimbursement. At national meetings, he “annoyed Bob Zwolak” (known for his coding and reimbursement expertise) so much that Dr. Zwolak put Dr. Roddy on the SVS Coding and Reimbursement Committee. Dr. Roddy is now in charge of the coding course. ■

Interview with

that approach focuses on the wrong question. The key way to look at implementing change in an organization/program is to align it to everyone’s goals. I make it a practice to try to become intimately familiar with the goals of the organization at all levels.

Then, from the perspective of the stakeholder, you can help them understand why the changes you are trying to implement are in their best interest.

Another key component is being as transparent as possible. I believe in being open with the information that I work hard to acquire in order to understand the need for change, and then I share it. I want them to see what I’m seeing, then allow them to draw their own conclusions. Nine times out of 10, when presenting the data in this clear way, informed team members will come to the same conclusions. If you think about the peer group we are working with, they are all extremely well-educated, conscientious and ambitious individuals who

don’t need to be encouraged to do the right thing, they just need the information to see where that path lies.

VC: I would say another style that you encompass (since I work with you) is that you are almost always the first person to throw yourself into the mix. For example, we opened a new clinic in a new location and you personally went there first, even though you were hiring people to cover that location. Is this an intentional approach?

RLD: Well, yes, that is my style. I had a colleague who liked to say, “Beware the courage of the non-combatant.”

This all falls into understanding the situation. By personally putting myself in the situation, when possible, I get first-hand knowledge about whether this is a worthwhile endeavor and what may be the key issues, challenges, etc. Integrity and transparency require doing what you say is Spotlight continued on following page

MDEDGE.COM/VASCULARSPECIALISTONLINE • 9

Spotlight continued from previous page

best and saying what you are actually doing and why.

VC: What are other leadership skills critical to your day-to-day success?

RLD: There are several: 1) Be responsive. While you may not solve the problem or have the correct answer right away, it is imperative to ensure that people’s concerns have been heard and are being addressed. 2) Leverage all the assets on your team in order to get the best out of everyone. For example, in my role today, having an administrative dyad that can make decisions on my behalf, decisions that reflect what my priorities are and vice versa, is incredibly helpful to the success of our program and my goals as a leader. 3) Reset sometimes. Sometimes there are bad ideas, or decisions or feelings that have been lingering and are difficult to work around or through. The natural tendency is to avoid these sticky/difficult areas; however, these are like bad areas on a hard drive and you need to address these problematic areas head on. You must reset the hard drive, so to speak. If you don’t, it can be impossible to move forward. 4) Prioritize the

good of the group. It is well known that one gets the opportunity for leadership roles because of individual performance, but then overnight you have to completely change your perspective and reset your focus on the success of the group rather than your

In addition, you need to be mature enough in your practice and career.

Just because an opportunity is offered now doesn’t mean it is the right time for you. While there is never a perfect time, you really have to know yourself, and know what your

DR. DALMAN

DR. CHANDRA

own personal priorities. This is imperative but not necessarily intuitive to the new leader.

strengths, weakness and personal goals are, to make the right decision.

If you are able to think concretely about these things you can then determine if they are aligned with what your goals would need to be as a leader and what you will want the group to accomplish.

VC: What a good point. What advice do you have for people making such a transition?

RLD: It’s really about self-awareness.

SAVE THE DATE! June 12–15, 2019 National Harbor, Md. (Outside Washington, D.C.)

10 • VASCULAR SPECIALIST

Scientific Sessions: June 13–15 Exhibits: June 13–14

Many of us are over-achievers and believe that we need to keep striving for the next accomplishment/opportunity. But it is important to stop and think about what it is that will ultimately make you happy. What it is about this leadership position that truly resonates with you? If you don’t think this through, you may not be ready for a leadership transition, as there are major tradeoffs when taking on such roles. Often you must be prepared to pay less attention on your personal career so as to focus on the broader goal of group or program that you may be leading.

VC: In conclusion what parting advice do you have for younger vascular surgeons?

RLD: Think big. Look outside your immediate circle of acquaintances and colleagues for collaborative opportunities. When you look outside your comfort zone (academic discipline, specialty focus, age, training background, institutional affiliation, nationality, etc.) to build broader collaboration networks, you create novel opportunities and insights which will be incredibly transformational for your own career and professional future. They certainly have been for me! ■

2019 VASCULAR ANNUAL MEETING AN WASHINGTON, D.C.

SEPTEMBER 2018

PERIOPERATIVE CARE

Nearly one-quarter of presurgery patients already using opioids

P

SEPTEMBER 2018

taking opioids, and among those having orthopedic spine surgery, 65.1% were taking opioids. General surgery patients were not among those mostly likely to be using opioids (gastrointestinal surgery, 19.3% and endocrine surgery 14.3%). “Certain surgical services may be more likely to encoun-

“All surgeons should take a preop pain history .... They should also ask about a history of substance use disorder.”

DR. ENGLESBE

exclusion of patients admitted to surgery from the ED could mean that 23.1% is a conservative estimate, he noted.

Patient characteristics included in the study (tobacco use, alcohol use, sleep apnea, pain, life satisfaction, depression, anxiety) were self-reported and validated using tools such as the Brief Pain Inventory, the Fibromyalgia Survey, and the Hospital Anxiety and Depression Scale. Procedural data were derived from patient records and ICD-10 data and rated via the ASA score and Charlson Comorbidity Index.

A multivariate analysis of patient characteristics found that age between 31 and 40, tobacco use, heavy alcohol use, pain score, depression, comorbidities reflected in a higher ASA score, and Charlson Comorbidity Score were all significant risk factors for presurgical opiate use.

Patients who were scheduled for surgical procedures involving lower extremities (adjusted odds ratio 3.61; 95% confidence interval, 2.81-4.64) were at the highest risk for opioid use, followed by pelvis surgery, excluding hip (aOR, 3.09; 95% CI, 1.88-5.08), upper arm or elbow (aOR, 3.07; 95% CI, 2.12-4.45), and spine surgery (aOR, 2.68; 95% CI, 2.15-3.32).

The study also broke out the data by presurgery opioid usage and surgery service. Of patients having spine neurosurgery, 55.1% were already

ter patients with high comorbidities for opioid use, and more targeted opioid education strategies aimed at those services may help to mitigate risk in the postoperative period,” the authors wrote.

“All surgeons should take a preop pain history. They should ask about current pain and previous pain experiences. They should also ask about a history of substance use disorder.

This should lead into a discussion of the pain expectations from the procedure. Patients should expect to be in pain; that is normal. Painfree surgery is rare. If a patient has a complex pain history or takes chronic opioids, the surgeon should consider referring them to anesthesia

for formal preop pain management planning and potentially weaning of opioid dose prior to elective surgery,” noted Dr. Englesbe, the Cyrenus G. Darling Sr., MD and Cyrenus G Darling Jr., MD Professor of Surgery, and faculty at the Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.

Surgeons are likely to see patients with a past history of opioid dependence or who are recovering from substance abuse. “Every effort should be made to avoid opioids in these patients. We have developed a Pain Optimization Pathway which facilitates no postoperative opioids for these and other patients. These patients are at high risk to relapse and surgeons must know who these patients are so they can provide optimal care,” Dr. Englesbe added.

The limitations of this study as reported by the authors include the single-center design, the nondiverse racial makeup of the sample, and the difficulty of ascertaining the dosing and duration of opioid use, both prescription and illegal.

The investigators reported no disclosures relevant to this study. This study was supported by the National Institute on Drug Abuse, National Institutes of Health, the American College of Surgeons, and other noncommercial sources. tborden@mdedge.com

SOURCE: Hilliard PE et al. JAMA Surg. 2018 Jul 11. doi: 10.1001/jamasurg.2018.2102.

Pre-existing condition?

23.1% of patients were already taking opioids of various BackyardProduction/Thinkstock

reoperative opioid use was prevalent in nearly one-quarter of patients undergoing surgery at a large academic medical center, a cross-sectional observational study has determined.

Prescription or illegal opioid use can have profound implications for surgical outcomes and continued postoperative medication abuse.

“Preoperative opioid use was associated with a greater burden of comorbid disease and multiple risk factors for poor recovery. ... Opioid-tolerant patients are at risk for opioid-associated adverse events and are less likely to discontinue opioid-based therapy after their surgery,” wrote Paul E. Hilliard, MD, and a team of researchers at the University of Michigan Health System. Although the question of preoperative opioid use has been examined and the Michigan findings are consistent with earlier estimates of prevalence (Ann Surg. 2017;265[4]:695-701), this study sought a more detailed profile of both the characteristics of these patients and the types of procedures correlated with opioid use.

Patient data were derived primarily from two ongoing institutional registries, the Michigan Genomics Initiative and the Analgesic Outcomes Study. Each of these projects involved recruiting nonemergency surgery patients to participate and self-report on pain and affect issues.

Opioid use data were extracted from the preop anesthesia history and from physical examination. A total of 34,186 patients were recruited for this study; 54.2% were women, 89.1% were white, and the mean age was 53.1 years. Overall, 23.1% of these patients were taking opioids of various kinds, mostly by prescription along with nonprescription opioids and illegal drugs of other kinds.

The most common opioids found in this patient sample were hydrocodone bitartrate (59.4%), tramadol hydrochloride (21.2%) and oxycodone hydrochloride (18.5%), although the duration or frequency of use was not determined.

“In our experience, in surveys like this patients are pretty honest. [The data do not] track to their medical

record, but was done privately for research. That having been said, I am sure there is significant underreporting,” study coauthor Michael J. Englesbe, MD, FACS, said in an interview. In addition to some nondisclosure by study participants, the

kinds when they had nonemergency surgery.

MDeDge News

BY THERESE BORDEN MDEDGE NEWS FROM J AMA SURG E RY

Source: Hilliard PE et al. JAMA Surg. 2018 Jul 11. doi: 10.1001/jamasurg.2018.2102.

MDEDGE.COM/VASCULARSPECIALISTONLINE • 11

ANEURYSMS

Open aortic aneurysm, peripheral bypass patients among highest users of post-acute care

BY MARK S. LESNEY MDEDGE NEWS FROM T HE JO U RN A L OF SURGI CAL R E SEA RC H

T

he wide disparity among hospitals in their rates of postsurgery discharge to post-acute care (PAC) could be an area of focus for cost containment in Medicare spending, according to the findings of a study that used data from the National Inpatient Sample (NIS) and the Veterans Affairs health system (VA) regarding surgical patients.

PAC, including skilled nursing facilities and inpatient rehabilitation, accounts for 73% of regional variation in Medicare spending, and studies on hospital variation in this area have typically focused on nonsurgical patients or been limited to Medicare data. However, a high degree of variation also appears to hold for surgical patients, according to the

authors of this large database study of more than 4 million patients who had aortic aneurysm repair, peripheral vascular bypass, colorectal surgery, hepatectomy, pancreatectomy, or coronary bypass.

“We found that there is significant variation in use of PAC and rates of home discharge following complex cardiac, abdominal, and vascular surgery,” Courtney J. Balentine, MD, of the University of Alabama at Birmingham and his colleagues wrote in their report in the Journal of Surgical Research.

To explore hospital variation in post-surgery PAC, they evaluated 3,487,365 patients from the NIS (39% were aged 70 years or older, and 60% were men) and 60,666 from the VA (32% were aged 70 years or older, and 98% were men) who had surgery during 2008-2011.

Within the NIS, 631,199 patients (18%) were discharged to PAC facili-

ties, and among the 60,666 veterans, 4744 (7.8%) were discharged to PAC facilities. In addition, hospital rates of discharge to PAC facilities varied from 1% to 36% for VA hospitals and from 1% to 59% for non-VA hospitals, according to the researchers.

They found that some VA hospitals were four times more likely to discharge patients to PAC facilities than would be expected from their patients’ characteristics, while others were 90% more likely to send patients home than would be expected, according to Dr. Balentine and his colleagues.

Procedure-specific rates of discharge to PAC facilities from VA hospitals ranged from 2% following endovascular aneurysm repair to 10% after pancreatectomy and peripheral vascular bypass. Among the NIS hospitals, in contrast, rates of discharge to PAC facilities ranged from 6% following hepatectomy to as high as

44% following open aneurysm repair.

“These data could be used to characterize practices that promote more effective recovery from surgery and minimize the need for PAC,” the authors wrote. “Given that skilled nursing facilities and inpatient rehabilitation cost [$5,000]-$24,000 more than treatment at home, even minor reductions in the need for PAC facilities could result in substantial cost savings,” they stated.

“Our findings suggest that there is considerable room for improvement in the use of PAC after surgery and that we still have a long way to go in terms of using PAC to help patients recover and regain their independence,” the researchers concluded.

The authors reported that they had no conflicts of interest. mlesney@mdedge.com

SOURCE: Balentine CJ et al. J Surg Res. 2018 Oct;230:61-70.

Little adverse event overlap of M&M and AHRQ

BY MADHU RAJARAMAN MDEDGE NEWS FROM T HE JO U RN A L OF THE A M E R ICA N COL LEGE OF SU R G EON S

L

imited overlap in adverse events identified by surgical morbidity and mortality (M&M) conferences and by Agency for Healthcare Research and Quality patient safety indicators (PSIs) demonstrates that the two processes capture different measures, as reported by Jamie E. Anderson, MD, of UC Davis Medical Center in Sacramento and her colleagues.

Just 18 of 149 (12.1%) PSI-defined events were identified by both processes in a retrospective, observational study of complications at the UC Davis Medical Center’s department of surgery. Most events (62.4%) were identified by only the M&M review, while 25.5% were identified by only the PSIs, reported The study authors identified 6,563 surgical hospitalizations in the year 2016, of which 647 (9.9%) had at least one event that was either submitted for review for a departmental M&M conference, identified as a PSI event from administrative data, or both.

Hospital administrative data were reported using ICD-10 CM/PCS codes. Investigators identified all PSI cases, which included pressure ulcer, retained surgical item, central venous catheter–related blood stream infection, perioperative hematoma or hemorrhage requiring a procedure, postoperative acute kidney injury requiring dialysis, postoperative respiratory failure, perioperative pulmonary embolism 12 • VASCULAR SPECIALIST

or deep venous thrombosis, postoperative sepsis, postop wound dehiscence, and unrecognized abdominopelvic accidental puncture or laceration.

Complications submitted to the M&M conference were reviewed for PSI-defined events, and included events from vascular, general surgery, cardiothoracic, colorectal, surgical oncology, plastic, transplant, and trauma. PSI-defined events were reviewed to verify whether they were “true” PSI events and further classified as a documentation error, intentional exclusion, or inherent limitation of the PSI. Of 6,563 surgical hospitalizations, 647 had at least one complication identified by M&M, PSI, or both. Of these, 116 had at least one PSI-defined event identified by either M&M or PSI. The remaining hospitalizations had unrelated complications and were excluded from analysis.

Of the 116 hospitalizations, there were 149 PSI-defined events, of which 18 (12.1%) were identified by both methods. Most events (62.4%) were identified by only the M&M review, and 25.5% were identified by only the PSIs. Perioperative hemorrhage/hematoma and postoperative sepsis were most likely to be identified by both. Of the 93 PSI-defined events captured by only M&M, 11 (11.8%) met AHRQ criteria and were considered “true” events, or “false negatives.” All 38 events identified by PSI alone were correctly identified as true PSI events.

The findings indicate that the AHRQ PSI and surgical M&M conference “should be considered complementary approaches for identifying complications,” Dr. Anderson and her coauthors wrote.

The PSI data captured central venous catheter–related blood stream infection and pressure ulcers, but the M&M conferences did not include these outcomes. The M&M reviewed more cases of postoperative sepsis, abdominopelvic accidental laceration, and the one case of retained surgical item.

“These two processes of identifying complications have different purposes, and each approach captured different events,” they added.

The M&M conference “balances clinician education and quality improvement with an underlying theme of accountability,” they said, with increased emphasis on examining adverse events in the context of systems-based practices. PSI, on the other hand, is intended as a “resource-nonintensive means” to help hospitals identify preventable events and facilitate quality improvement, they said.

“We believe that our center’s existing M&M case-finding process is fundamentally sound, but it could be improved by including all PSI-flagged hospitalizations in our M&M process. This may result in review of some false-positive records, but it will enable our department to address certain potentially preventable complications that are currently overlooked.”

Two of the study coauthors received salary support from the AHRQ and one serves on the agency’s Quality Indicators Expert Workgroup. No other disclosures were reported.

SOURCE: Anderson JE et al. J Am Coll Surg. 2018 Jul 5. doi: 10.1016/j.jamcollsurg.2018.06.008.

SEPTEMBER 2018

FROM THE VASCULAR COMMUNITY

VFW screening a success

Courtesy

of the

sVs

M

ore than 600 military veterans participated in the 2nd annual free mass screening event for abdominal aortic aneurysms at the VFW convention in Kansas City July 21-24.

Conducted as part of the national conventions of Veterans of Foreign Wars and VFW Auxiliary, the 2nd annual free AAA screening for veterans resulted in 11 aneurysms being discovered that required medical attention.

The event was coordinated by New Orleans–based non–profit AAAneurysm Outreach. The SVS Foundation served as a sponsor along with W. L. Gore & Associates, Philips ultrasound medical equipment company, the Society for Vascular Ultrasound, and others. Other sponsors for the screening event were the VFW and Massage Envy. St. Luke’s Mid-America Heart Institute provided physicians and staff volunteers.

“We are deeply grateful to those who have served our nation, and are privileged to provide this risk awareness education and lifesaving screen-

The recent AAAneuurysm Outreach event screened 600 veterans.

ing,” said Don Lanman, U.S. Army Veteran and member of the AAAneurysm Outreach board of directors, at the Kansas City event.

SVS members Keith Allen, MD

and Karthik Vamanan, MD provided medical expertise for the screening event. “Our members know all too well how under-diagnosed this problem is and how a ruptured AAA can be fatal,” said Dr. Allen.

“Dr. Vamanan and I found it incredibly rewarding to help screen hundreds of veterans, be able to tell the vast majority of them that they are fine, and be pro-active about those who need to see a vascular surgeon. We feel like we got to have a really positive impact.”

AAAneurysm Outreach kicked off this annual program with a similar screening at the 2017 VFW Convention in New Orleans. Medical support was provided by the attending staff and residents of the LSU Vascular Surgery training programs. That year, 1,003 military veterans participated in the free screening event – likely the largest single-site screening for abdominal aortic aneurysms ever performed in the United States.

According to Executive Director J. B. Hunt, AAAneurysm Outreach plans to continue this successful mass

A cure for billing headaches... g& The 2018 SVS Codin p o h s k r o W t n e m e s r Reimbu 18 0 2 , 0 -2 9 1 r e b to c O : WHEN nois li Il , o g a ic h C : E R E H W Renaissance Hotel

SEPTEMBER 2018

screening event at the 2019 VFW convention, scheduled for Orlando, Fla. Vascular surgeons interested in this or other screening events should

“We are deeply grateful to those who have served our nation, and are privileged to provide this ... lifesaving screening.” contact the organization at jbhunt@ aoutreach.org The SVS Foundation participated as part of its expanded mission that includes an emphasis on members in community practice, prevention, patient education, and, ultimately, the public’s vascular health. To learn more about the SVS Foundation visit vascular.org/about-svs/svs-foundation.

– Malachi G. Sheahan III, MD

in the experts for Avoid costly errors! Jo y workshop on this intensive two-da ment issues that coding and reimburse line. Topics include impact YOUR bottom ntials but also 2019 not only coding esse rgical package, updates, the global su edures as specifics for such proc , wound care and hemodialysis access information on aneurysm repair; and ment regulations.

Medicare reimburse

g18

odin Details: vsweb.org/C

MDEDGE.COM/VASCULARSPECIALISTONLINE • 13

PRACTICE MANAGEMENT

5 HIPAA myths in the digital age

BY ALICIA GALLEGOS MDEDGE NEWS

T

he nexus of new technology and privacy rules springing from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) leads to a lot of stress and trepidation for health care professionals. Lucia Savage, chief privacy and regulatory officer for Omada Health, and Matthew Fisher, a health law attorney based in Worcester, Mass., who specializes in compliance issues, dispel common HIPAA myths and offer advice on how to protect yourself and your practice.

MYTH: You should not send emails to patients if their emails are unsecured.

Truth: Physicians are not responsible for email security flaws from patient servers, said Ms. Savage, who served as chief privacy officer for the Office of the National Coordinator for Health IT under President Obama.

HIPAA requires only that health providers send emails from a secure system that protects a doctor’s message from their end, she said.

“There’s this myth out there that you cannot send an electronic message to a patient’s email box if that email is unsecured, and that’s not true,” Ms. Savage said at a recent American Bar Association meeting.

“The obligation is to secure what you send, not to secure what an unregulated, private person receives.”

Just remember to warn patients that they’re responsible for the safe storage of an email message once it arrives.

MYTH: Expect a big OCR fine if an email meant for one doctor lands in the wrong physician’s inbox.

Truth: An email with protected health information (PHI) accidentally sent to the wrong health provider is not likely to get doctors in trouble with the Office for Civil Rights. In the last 12 years, there have been 184,000 HIPAA-related complaints to OCR and only 55 resulted in financial settlements, according to research Ms. Savage conducted through the Department of Health & Human Services website. Of the 55 settlements, none were associated with PHI accidentally sent from one health provider to another, she said in an interview. “[The OCR] tends to seek fines for really eye-poppingly bad behavior,” Ms. Savage said, not small-scale accidents. For example, OCR fined one hospital for including the name of a patient in a press release without patient permission. Another health professional was fined for repeated failures to encrypt their computer system.

If a document with PHI does end up in the wrong inbox, Ms. Savage advises calling the receiver and asking that they immediately delete the email.

MYTH: Notifying OCR of a data breach results in an automatic fine.

Truth: Breaches alone are not the reason most fines are levied, nor do breach notifications mean an instant penalty, Mr. Fisher said in an interview. Fines by OCR are more often tied to further noncompliance found when the agency begins investigating the entity after the breach report.

“Most breach reports will result in OCR conducting a follow-up investigation, usually with paper-based requests,” he said. “If responses to those requests reveal widespread or

14 • VASCULAR SPECIALIST

consistent noncompliance, then OCR may latch on and dig in order to impose a fine.”

For example, a breach could be the result of a lost USB drive or laptop, but OCR’s investigation might ultimately find that the practice failed to conduct an adequate risk analysis. Because a risk analysis is a fundamental component of HIPAA compliance, the inadequate risk analysis becomes the basis for a fine, Mr. Fisher said.

The best way to avoid an OCR fine is to ensure that proper HIPAA protocols are in place to assess security risks, prevent breaches, and mitigate breaches should they occur.

“Part of good compliance is constant review and revision of policies as well,” Mr. Fisher said. “It is not sufficient to put the policies into place and then never revisit those policies. Circumstances change all of the time and policies need to keep up.”

MYTH: Providing patients electronic copies of their health information is optional.

Truth: Health professionals are obligated to provide copies of health information to patients and that includes electronic copies if practices have such technology. The electronic copy requirement was adopted in 2009 as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Despite the electronic amendment’s existence for nearly 10 years, Ms. Savage said she frequently hears from patients about the difficulty of obtaining health information and the extended time and high cost that come with requests. “[Providing health information to patients] is an obligation,” Ms. Savage stressed. “A 21st-century physician might want to be thinking about how to build on that obligation to really engage their patients in a partnership of care. If you give the patient the data, they can actually become a more valuable [participant] with you and engage in self-management.”

More information on HITECH and giving patients access to protected

health information can be found online.

MYTH: HIPAA is a barrier to innovation and slows digital solutions in health care settings.

Truth: HIPAA is flexible and can adapt to newer technology more easily than many people think, Mr. Fisher says. “[There is the perception] that HIPAA is archaic and does not fit with modern technology,” he said. “There are a lot of misplaced fears that digital tools cannot satisfy security requirements or will place data where they should not go.”

In actuality, many health care applications enable doctors to satisfy HIPAA requirements, while using updated technology. Secure email to send patients messages is one example, he said, as well as secure text messaging between providers.

At the same time, new techMS. SAVAGE nology can often assist health care privacy and advance security, Mr. Fisher noted.

Technology solutions frequently automate routine tasks, such as auditing.

Tools like maMR. FISHER chine learning and artificial intelligence can enhance security and catch up with attacker intelligence, he added.

“Technology should be viewed as a means of enhancing and expanding capabilities,” he said. “Using the auditing example, an individual really cannot adequately review all records or access points, but a program may be able to do so and begin to identify small trends that represent a security concern. From this perspective, the technology, as indicated, is about enhancing what can be done.”■ SEPTEMBER 2018

PAD AND CLAUDICATION

Fewer groin infections with negative pressure

BY MARK S. LESNEY MDEDGE NEWS

C

losed incision negative pressure therapy (ciNPT) reduced surgical site infections (SSI) in vascular surgery, according to the results of a prospective, randomized, industry-sponsored trial of patients who underwent vascular surgery for peripheral artery disease (PAD).

The investigator-initiated Reduction of Groin Wound Infections After Vascular Surgery by Using an Incision Management System trial (NCT02395159) included 204 patients who underwent vascular surgery with longitudinal groin incision to treat the

lower extremity or the iliac arteries.

At 30 minutes preincision, patients received intravenous antibiotic treatment (1.5 g cefuroxime or 600 mg clindamycin, if allergic to penicillin).

After closure, the incision and surrounding skin area was cleaned and dried using sterile gauze. In the control group, a sterile adhesive wound dressing was applied to the wound, which was changed daily. In the treatment group, ciNPT was applied under sterile conditions in the operating room using the Prevena device, which exerts a continuous negative pressure of 125 mm Hg on the closed incision during the time of application. The device was removed at 5-7 days postoperatively, and no further wound

dressings were used in the treatment group unless an SSI occurred.

The control group experienced more frequent SSIs (33.3%) than the intervention group (13.2%) (P =.0015), a difference was based on an increased rate of Szilagyi grade I SSI in the control group (24.6% vs. 8.1%, P = .0012), wrote Alexander Gombert, MD, of the University Hospital Aachen (Germany), and his colleagues. The absolute risk difference based on the Szilagyi classification was –20.1 per 100 (95% confidence interval, –31.9 to –8.2).

In addition, there was a statistically significantly lower rate of SSI when using ciNPT within the subgroups at greater risk of infection, compared with controls: PAD stage greater than

or equal to 3 (P less than .001), body mass index greater than 25 kg/m2 (P less than .001), and previous groin incision (P = .016).

“The use of ciNPT rather than standard wound dressing after groin incision as access for vascular surgery was associated with a reduced rate of superficial SSI classified by Szilagyi, suggesting that ciNPT may be useful for reducing the SSI rate among high-risk patients,” the researchers concluded.

Acelity funded the trial. Dr. Gombert received travel grants from Acelity. mlesney@mdedge.com

SOURCE: Gombert A et al. Eur J Vasc Surg. 2018 Jul 2. doi: 10.1016/j. ejvs.2018.05.018.

ADVERTISING

INDUSTRY INFO TERUMO MAXIMIZE RADIAL SOLUTIONS TO PERIPHERAL CHALLENGES – INTRODUCING RADIAL TO PERIPHERAL (R2P™) by TERUMO

From the leaders in radial access, Radial to Peripheral (R2PTM) is the first and only portfolio of longer-length radial devices specifically designed for peripheral procedures, including Above-the-Knee (ATK) and PAD/CLI vascular interventions.

SPONSORED PRODUCTS AND INDUSTRY NEWS

• R2P™ DESTINATION SLENDER® Guiding Sheath o 6 Fr Size o 119 cm and 149 cm lengths • R2P™ SLENGUIDE® Guiding Catheter o 7 Fr Size o 120 cm and 150 cm lengths • GLIDEWIRE® Hydrophilic Coated Guidewire o Straight, Angled, 1.5 mm and 3 mm J Tip o 350 cm, 400 cm, and 450 cm lengths • GLIDECATH® Hydrophilic Coated Catheter o 4 Fr Size o 150 cm length • NAVICROSS® Support Catheters o Straight, Angled o 135 cm and 150 cm lengths

With the introduction of R2P™, TERUMO continues to advance procedural solutions, enabling physicians to utilize a comprehensive radial to peripheral approach to perform more peripheral procedures for more patients: • Optimize entry site management with Slender Technology™ • Enable the potential for quicker ambulation, improved patient comfort, and satisfaction • May increase cath lab efficiencies and decrease overall costs per procedure The R2P™ portfolio is comprised of: • GLIDESHEATH SLENDER® Hydrophilic Coated Introducer Sheath o 7/6 Fr Size o 10 cm and 16 cm lengths SEPTEMBER 2018

• R2P™ METACROSS® RX PTA Balloon Dilatation Catheter o 3-8 mm diameter x 20-200 mm length o 200 cm shaft length MISAGO®

RX Self-expanding

• R2P™ Peripheral Stent o 6-8 mm diameter x 40-150 mm length o 200 cm shaft length o Coming in 2018—contact a TERUMO representative for availability Indications The MISAGO® RX Self-expanding Peripheral Stent is indicated to improve luminal diameter in symptomatic patients with de novo or restenotic lesions or occlusions of the Superficial Femoral Artery (SFA) and/or proximal popliteal

artery with reference vessel diameters ranging from 4 to 7 mm and lesion length up to 150 mm.

Important Safety Information Do not use this device in pregnant patients or patients who may be pregnant, patients who exhibit angiographic evidence of severe thrombus in the target vessel or lesion site before/ after undergoing Percutaneous Transluminal Angioplasty (PTA) procedure, patients with contraindication to antiplatelet and/or anticoagulation therapy, patients with known allergy to nickel-titanium alloy, gold or contrast media, vessels in which there may be a residual stenosis of 50% diameter or larger in the target vessel after the planned intervention, a lesion that is within an aneurysm or an aneurysm with a proximal or distal segment to the lesion, a lesion through which a guide wire cannot pass. This device should only be used by a physician who is familiar with, and well trained in, Percutaneous Transluminal Angioplasty (PTA) techniques and stent implantation.

• TR BAND® Radial Compression Device o Regular 24 cm and Long 29 cm Discover what’s next in peripheral intervention--learn more at www.terumois.com/r2p.

RX ONLY. Refer to the product labels and package insert for complete warnings, precautions, potential complications, and instructions for use. ©2018 Terumo Medical Corporation. All rights reserved. All brand names are trademarks or registered trademarks of Terumo. PM-00531 MDEDGE.COM/VASCULARSPECIALISTONLINE • 15

COMPLE T E COVER AGE FOR COMPLE X C A SE S.

AV Access Intervention

Complex SFA

Complex Iliac

In-Stent Restenosis

The GORE® VIABAHN® Endoprosthesis delivers proven safety, durable outcomes, and unmatched versatility demonstrated in over a half million patients worldwide.

Get the complete story at goremedical.com/viabahn/indications

W. L. Gore & Associates, Inc. | Flagstaff, AZ 86004 | goremedical.com INTENDED USE / INDICATIONS: The GORE® VIABAHN® Endoprosthesis is indicated for improving blood flow in patients with symptomatic peripheral arterial disease in superficial femoral artery de novo and restenotic lesions up to 270 mm in length with reference vessel diameters ranging from 4.0 – 7.5 mm, in superficial femoral artery in-stent restenotic lesions up to 270 mm in length with reference vessel diameters ranging from 4.0 – 6.5 mm, and in iliac artery lesions up to 80 mm in length with reference vessel diameters ranging from 4.0 – 12 mm. The GORE® VIABAHN® Endoprosthesis is also indicated for the treatment of stenosis or thrombotic occlusion at the venous anastomosis of synthetic arteriovenous (AV) access grafts. CONTRAINDICATIONS: The GORE® VIABAHN® Endoprosthesis with Heparin Bioactive Surface is contraindicated for noncompliant lesions where full expansion of an angioplasty balloon catheter was not achieved during pre-dilatation, or where lesions cannot be dilated sufficiently to allow passage of the delivery system. Do not use the GORE® VIABAHN® Endoprosthesis with Heparin Bioactive Surface in patients with known hypersensitivity to heparin, including those patients who have had a previous incidence of HeparinInduced Thrombocytopenia (HIT) type II. Refer to Instructions for Use at goremedical.com for a complete description of all warnings, precautions and adverse events.

Products listed may not be available in all markets. GORE®, VIABAHN®, and designs are trademarks of W. L. Gore & Associates. © 2018 W. L. Gore & Associates, Inc. AX0721-EN1 JUNE 2018

VAS_16.indd 1

9/5/2018 4:34:17 PM