Vascular Specialist@VAM–Conference Edition 2

CURTAIN RAISER

OPENING CEREMONY HERALDS ‘POWER’ OF VAM ATTENDANCE

SVS PRESIDENT MICHAEL DALSING, MD, OFFICIALLY opened the 2023 Vascular Annual Meeting (VAM) yesterday morning, telling attendees at the early morning Opening Ceremony: “For 76 years, vascular surgeons have been developing and integrating ideas, tenacity and collaboration across this meeting— and unless this is your very first VAM, you understand first-hand the power that comes with attending VAM.”

For those for whom VAM 2023 is their first meeting, the current moment is a wonderful one within the specialty, Dalsing said—“full of innovation, friendship and scholarship.” He hailed a bustling program of new science and special sessions, including the Frank J. Veith Distinguished Lecture, which takes place today (9:30–10 a.m.) in Potomac A/B.

Dalsing was followed at the podium by Andres Schanzer, MD, SVS Program Committee chair, who highlighted the “radical departure” from the meeting’s historical approach to postgraduate education content. “We have moved away from invited sessions to a submission of education proposals,” he said. The move, led by William Robinson, MD, Postgraduate Education Committee chair, is no longer “friends inviting friends to give talks with many of the same faces on the podium all week long,” but “entirely created by you and your peers.”

LONG-TERM OVERALL SURVIVAL (OS) and amputation-free survival (AFS) are outcomes that rebound in claudicants who quit smoking prior to elective surgery—and they mirror those of never smokers. But patients who don’t kick the habit have significantly worse outcomes, lighting up the question: should stubbing out for good be

“a requirement” before intervention?

bypass. The findings were published simultaneously in the Journal of Vascular Surgery (JVS).

SPOT LIGHT

DAY TWO HIGHLIGHTS

DAY ONE OF VAM 2023 is in the books and it’s on to a jam-packed day two of educational and scientific sessions, presentations for specific member groups and plenty of chances to see friends and colleagues.

Some Thursday highlights: The International Chapter Forum (6:30–8 a.m.), with presentations from eight international chapters on a range of topics, including if continuing medical education needs for Millennials differ.

In the inaugural Frank J. Veith Distinguished Lecture, at 9:30 a.m., Matthew Menard, MD, and Alik Farber, MD, will discuss, “BEST-CLI: The Journey to Evidence and Beyond.” Immediately following that attendees will learn the recipient of the prestigious SVS Lifetime Achievement Award

By Urmila Kerslake and Will Date

That was the message from Rohini J. Patel, MD, who presented data during yesterday’s William J. von Liebig Forum on long-term outcomes in the smoking claudicant after elective lower extremity

Patel, a general surgery resident physician at the University of California, San Diego (UCSD), San Diego, noted that patients and vascular specialists must grasp that structured smoking cessation should be a more prominent part of vascular office visits before and after lower extremity bypass and can “even be considered a requirement prior to elective procedures in claudicants,” a group that

See page 2

In the afternoon, three special membership sections feature, along with the “How I Do It” video session, and educational sessions covering a range of topics. These include “My Worst Cases,” modern management and device evolution for CLTI patients, the role of vascular surgeons in oncology cases, and “Optimizing the Clinical Environment: Learning and Practicing with Intent and Inclusion.”

Then comes the Opening Reception in the Exhibit Hall from 5–6:30 p.m., in conjunction with the International Poster Competition and the Interactive Poster Session, followed by the Celebration of Diversity Reception from 6:30–7:30 p.m.

Vascular.org/OnlinePlanner23

SIGNIFICANT LIFE AND LIMB GAINS FOR CLAUDICANTS WHO STOP SMOKING BEFORE LOWER EXTREMITY BYPASS

VON LIEBIG FORUM

FROM THE COVER: SIGNIFICANT LIFE AND LIMB GAINS FOR CLAUDICANTS WHO STOP SMOKING BEFORE LOWER EXTREMITY BYPASS continued

from page

1

Medical Editor Malachi Sheahan III, MD

Associate Medical Editors

Bernadette Aulivola, MD | O. William

Brown, MD | Elliot L. Chaikof, MD, PhD

| Carlo Dall’Olmo, MD | Alan M. Dietzek

MD, RPVI, FACS | Professor HansHenning 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

Christopher Audu, MD

Executive Director SVS

Kenneth M. Slaw, PhD

Director of Marketing & Communications Bill Maloney

Managing Editor SVS Beth Bales

Marketing & Social Media Manager

Kristin Crowe

Communications Specialist

Marlén Gomez

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Publisher Roger Greenhalgh

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Editorial contribution

Jocelyn Hudson, Will Date, Jamie Bell, Clare Tierney, Éva Malpass, Adam

Pearce and Benjamin Roche

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Letters to the editor vascularspecialist@vascularsociety.org

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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 healthcare policy. Content for Vascular Specialist is provided by BIBA News. Content for the news from SVS 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 BIBA News 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, or the quality or endorsement of advertised products or services, mentioned herein. | The Society for Vascular Surgery headquarters is located at 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018. | POSTMASTER: Send changes of address (with old mailing label) to Vascular Specialist, Subscription Services, 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018. | RECIPIENT: To change your address, e-mail subscriptions@bibamedical.com | For missing issue claims, e-mail subscriptions@bibamedical. com. | Vascular Specialist (ISSN 1558-0148) is published monthly for the Society for Vascular Surgery by BIBA News. | Printed by Ironmark | ©Copyright 2023 by the Society for Vascular Surgery

represents a unique non-emergent vascular patient population that can require lower extremity bypass.

Smoking is known to increase complications, including poor wound healing and coagulation abnormalities, and have cardiac and pulmonary ramifications, said Patel. “Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is in general surgery,” she explained.

The research team queried the Vascular Quality Initiative VISION database over a 16-year period to tackle the question of how actively smoking claudicants fare after elective lower extremity bypass. They then carried out two separate propensity score matches on patient records that included 609 (10%) never smokers, 3,388 (55.3%) former smokers, and 2,123 (34.7%) current smokers who underwent bypass for claudication. One analysis examined the outcomes of former smokers and compared these to outcomes achieved in patients who had never smoked. The second analysis contrasted outcomes between current smokers and former smokers. The primary outcome measures included five-year OS, limb salvage (LS), freedom from target lesion reintervention (FTR) and AFS.

Health gains don’t shift unless claudicants quit smoking

There were no differences recorded with respect to any of these measures between 497 well-matched pairs of former smokers and those who had never smoked.

The second analysis, which focused on ascertaining outcome differences between 1,451 well-matched pairs of current and former smokers, found that there was no difference in LS or FTR, but revealed “a significant increase in OS and AFS” in former smokers compared with current smokers, suggesting that giving up smoking reaps rewards in terms of both limb and life preservation.

“Our study found that former smokers have better OS and AFS when compared to current smokers, while former smokers mimic never smokers at five-year outcomes for OS, LS, FTR and AFS,” Patel averred.

Patel stated: “This study emphasizes that we as providers must spend more time and effort working with patients to quit smoking prior to elective lower extremity bypass in claudicants.”

Limitations of the study include that the database contained no information on the duration or intensity of smoking among the study population, and there were no available data on the rate of recidivism or the cause of death among those studied.

According to senior author Mahmoud Malas, MD, chief of Vascular and Endovascular Surgery at UCSD: “We have found through this Medicare-linked VQI VISION analysis that even quitting smoking at least one month prior to surgical intervention can change long-term outcomes. Former smokers do better than current smokers and mimic the results of patients who have never smoked. As vascular surgeons, we need to play a more active role in these discussions with our patients in the clinic and in referring patients to smoking cessation programs.”

In discussion that followed the presentation, Patel was asked to comment on whether she felt that the length of time from smoking cessation could be an additional avenue of study, in particular if that information could be conveyed to patients to arrive at a specific length of time that may confer a benefit.

“We just looked at the actual smoking status,” responded Patel, adding that if this could be linked to variables such as days since patients have quit smoking “that would be a great next step to see if there are some intervals such as six or eight weeks that provide the best drop off.”

Sex-related disparities in lower-extremity revascularization outcomes brought into focus

PAD By Clare Tierney

Women are more likely to undergo reintervention after lower-extremity revascularization for peripheral arterial disease (PAD) compared to male patients with similar limb salvage and survival outcomes despite having fewer comorbidities, findings of a retrospective analysis presented during yesterday’s William J. von Liebig Forum indicate.

Keyuree K. Satam, MD, an incoming vascular surgery intern at Stanford Hospital presented the findings of the analysis, outlining that prior research has suggested that women are more likely to undergo these repeat procedures than men. The current study analyzed patients who had a revascularization procedure for PAD between 2013 and 2020 at a tertiary care center. The study team carried out Kaplan- Meier analyses for major adverse limb event (MALE)free survival.

The study included

1,987 patients, of whom 37% (n=736) were female. The female patients included were more likely to be older (70.5 years vs. 69.2, p=0.015) and Black (18% vs. 12.3%, p=0.003). Male participants were more likely to have a higher prevalence of comorbidities including coronary artery disease (59.3% vs. 45.6%, p<0.0001), diabetes (60.2% vs. 51.9%, p=0.0003), and chronic renal insufficiency (20.1% vs. 15.8%, p=0.016). The speaker shared that patients in the study had a total of 2,647 reinterventions, with females having a significantly higher rate of ipsilateral reinterventions compared to males (2.0±1.5 vs. 1.7±1.4, p=0.05) and a higher proportion of ≥3 reinterventions (9.5% vs. 6.6%, p=0.035). Kaplan-Meier curves showed no difference between males and females regarding MALE-free survival.

Satam noted that perioperative complications were similar for male and female patients, except for those resulting in a return to the operating room, which was higher among males (17.7% vs. 13.9%, p=0.029). After mean follow-up of three years, there was no difference in major amputation, reintervention rate, MALE, or mortality.

Rohini J. Patel

“This study emphasizes that we as providers must spend more time and effort working with patients to quit smoking prior to elective lower extremity bypass in claudicants”

The Only AV DCB IDE Trial in which a Majority of Patients had Upper

Arm Fistulas

61.7% OF PATIENTS TREATED WITH A DCB HAD UPPER ARM FISTULAS

31.3%

FEWER REINTERVENTIONS THAN PTA ALONE AT 6 MONTHS

In the In.Pact AV Access Trial, 46.5% of patients in the DCB arm (n=170) and 45.7% of patients in the PTA arm (n=160) had brachiocephalic or brachiobasilic fistulas. See clinicaltrials.gov NCT03041467 for more details on the In.Pact AV Access Trial. Lutonix AV IDE Trial. Data on file. BD. Tempe, AZ. In the Lutonix AV IDE Trial, 61.7% of patients in the DCB arm (n=141) and 73.4% of patients in the PTA arm (n=143) had upper arm fistulas. At 6 months, treatment with Lutonix™ 035 DCB resulted in a target lesion patency rate of 71.4% versus 63.0% with standard PTA alone. Target lesion primary patency defined as freedom from a clinically driven re-intervention of the target lesion or access thrombosis. The primary effectiveness analysis for superiority of DCB vs. PTA was not met with a one-sided p-value of p = 0.0562. Number of interventions required to maintain TLPP at 6 months were 44 in DCB arm versus 64 in the PTA arm-meaning the DCB arm required 31.3% fewer interventions. At 30 days, treatment with Lutonix™ 035 DCB resulted in a freedom from primary safety event rate of 95.0% versus 95.8% with PTA alone. Primary safety defined as freedom from localized or systemic serious adverse events through 30 days that reasonably suggests the involvement of the AV access circuit. The primary safety endpoint for non-inferiority for DCB vs. PTA was met with one-sided p-value of p = 0.0019. Percentages reported are derived from Kaplan-Meier analyses.

Indications for Use: The Lutonix™ Catheter is indicated for percutaneous transluminal angioplasty (PTA), after pre-dilatation, for treatment of stenotic lesions of dysfunctional native arteriovenous dialysis fistulae that are 4 mm to 12 mm in diameter and up to 80 mm in length.

Contraindications:

1) Women who are breastfeeding, pregnant or are intending to become pregnant or men intending to father children over the next 2 years. It is unknown whether paclitaxel will be excreted in human milk and there is a potential for adverse reaction in nursing infants from paclitaxel exposure.

2) Patients judged to have a lesion that prevents complete inflation of an angioplasty balloon or proper placement of the delivery system.

Warnings: A signal for increased risk of late mortality has been identified following the use of paclitaxel-coated balloons and paclitaxel-eluting stents for femoropopliteal arterial disease beginning approximately 2-3 years post-treatment compared with the use of non-drug coated devices. There is uncertainty regarding the magnitude and mechanism for the increased late mortality risk, including the impact of repeat paclitaxel device exposure. Inadequate information is available to evaluate the potential mortality risk associated with the use of paclitaxel-coated devices for the treatment of other diseases/conditions, including this device indicated for use in arteriovenous dialysis fistulae. Physicians should discuss this late mortality signal and the benefits and risks of available treatment options with their patients.

Potential Adverse Events Potential adverse events which may be associated with a PTA balloon dilation procedure include, but are not limited to, the following: · Additional intervention · Allergic reaction to drugs or contrast medium · Aneurysm or pseudoaneurysm Arrhythmias · Embolization Hematoma · Hemorrhage, including bleeding at the puncture site Hypotension/hypertension Inflammation · Loss of permanent access · Occlusion Pain or tenderness · Sepsis/infection Shock Steal Syndrome · Stroke · Thrombosis Vessel dissection, perforation, rupture, or spasm.

Although systemic effects are not anticipated, refer to the Physicians’ Desk Reference for more information on the potential adverse events observed with paclitaxel.

Potential adverse events, not described in the above source, which may be unique to the paclitaxel drug coating include, but are not limited to, the following: Allergic/immunologic reaction to the drug coating (paclitaxel) · Alopecia Anemia · Blood product transfusion Gastrointestinal symptoms · Hematologic dyscrasia (including leukopenia, neutropenia, thrombocytopenia) · Hepatic enzyme changes Histologic changes in vessel wall, including inflammation, cellular damage, or necrosis Myalgia/Arthralgia ·Myelosuppression · Peripheral neuropathy

Please consult product labels and instructions for use for indications, contraindications, hazards, warnings, and precautions. BD, the BD Logo, and Lutonix are trademarks of Becton, Dickinson and Company or its affiliates. © 2023 BD. All rights reserved. © 2023 Illustration by Mike Austin. BD-77311

CRITICAL ISSUES FORUM CRAWFORD PANEL FOCUSES MINDS ON CHALLENGES FACING VASCULAR SURGERY WORKFORCE NUMBERS

YESTERDAY’S E. STANLEY CRAWFORD

Critical Issues Forum, which looked at ways to address the pipeline of sources feeding the vascular surgery pool of talent, yielded an illuminating perspective on the looming workforce crisis currently occupying leaders in the field. Speaking from the audience after the six-strong panel concluded their talks, Rana Afifi, MD, from McGovern Medical School, University of Texas Health Houston, introduced herself to the panel of experts assembled by organizer President-Elect Joseph Mills, MD, as a non-Board-certified vascular surgeon—and as someone not eligible for the U.S. Board. “I graduated from my residency-fellowship outside of the U.S., and came for super-fellowship in the U.S.,” she told them, describing the many “obstacles and problems” she has encountered on her path toward Board eligibility. “I was told after PGY-11 years: Repeat. Repeat your residency.”

Despite the challenges, Afifi continued, she found a way forward and is now practicing, but pointed out she is not represented in the statistics produced by former SVS

President Michel S. Makaroun, MD, from the University of Pittsburgh Medical Center, whose talk honed in on the question of insufficient supply or maldistribution in the workforce pipeline.

“I’m pretty sure there are a lot of others who are struggling—who either leave, are frustrated, are broken because they feel inadequate, or they compete for spots for people in the U.S.,” Afifi elaborated.

She addressed a need for “more creative” solutions in efforts aimed at finding an alternative pathway for people who graduated from residency outside of the U.S. “Have we reached out as a vascular society to other societies to see if they have found solutions that can create more spots?”

Responding, Makaroun said he completely agreed with the need for creativity in the search for more surgeons to bolster the workforce. “I believe you are a member of the SVS and you are counted in the group that is called ‘early-active,’” he continued. “The people who are not Board-eligible are still part of those statistics, so we are not ignoring you. But I totally agree with you that

MEMBERSHIP Slew of special SVS section sessions set for Thursday

THE SVS INCLUDES FIVE SPECIAL SECTIONS FOR different member groups, including physician assistants, women, young surgeons, surgeons in community practice and the Subsection on Outpatient and Office Vascular Care (SOOVC). With each section session quite popular during the 2022 VAM, all sections will hold dedicated educational sessions during this year as well. SOOVC and the Women and PA sections take place from 1:30–3 p.m. Thursday. PAs continue from 3:30–5 p.m.

SOOVC

SOOVC will concentrate on the “Business of Running an OBL (office-based lab),” as well as comparing costs of OBLs vs. ambulatory surgery centers (ACSs), financial viability, daily management, and maintaining an OBL with decreased payments.

Section leaders also will present the recipients of the section’s first-ever awards. The SOOVC Presentation Award recipients are:

◆ Michael A. Curi, MD; “Arteriovenous fistula creation and care in a dedicated office-based practice is superior to hospital-based care”

we need to look for other opportunities to have support for our workforce.”

The Crawford Forum is developed by the incoming SVS president to address longrange issues deemed critical to the specialty, with Mills focusing the theme on the complexity of the issues contained within the workforce pipeline. He titled the forum, “The State and Future of Our Specialty— Extending, Repairing and Maintaining the Vascular Surgery Pipeline.”

Mills deems the challenges multifaceted, saying: “The pipeline is not one line. It has multiple connections that come from multiple places and go to multiple places.”

The panel captured three main areas of focus: the root sources of future vascular surgeons, the existing workforce, and the

◆ Keerthi Harish, MD; “Prior authorization processes in the office-based laboratory setting are administratively inefficient and threaten timeliness of care”

◆ Pavel Kibrik, MD; “Success rate and factors predictive of redo endothermal ablation of small saphenous veins”

The SOOVC Research Seed Grant recipients are:

◆ Michael Curi, for the award above

◆ Robert Molnar, MD; “Assessing the currently accepted indications for outpatient fistulogram performance and developing a quality improvement plan to establish a treatment algorithm for patients with hemodialysis (HD) dysfunction”

◆ Heather Waldrop, MD, and Christina Cui, MD; “Potential cost savings by moving appropriate cases to an office-based angiography suite”

Women’s Section

The Women’s Section will concentrate on “Financial Literacy for the Vascular Surgeon.” Talks include “It’s never too soon: Early planning for your financial future”; “Navigating business plans for vascular surgery practice”; “Understanding your contract”; “Financial planning for mid- and late-career surgeons: An advisor perspective”; “Consulting with industry: Collaboration or conflict?”; and “Negotiating salary: Tips to minimize the pay gap.”

distribution of that workforce. Lee Kirksey, MD, from the Cleveland Clinic in Ohio looked at outreach to high school and college students and Malachi Sheahan III, MD, from Louisiana State University in New Orleans, dealt with efforts to attract medical students and residents in training. Dawn M. Coleman, MD, from Duke University Medical Center in Durham, North Carolina, addressed vascular surgeon wellness, followed by Laura Marie Drudi, MD, from Centre Hospitalier de l’Universite de Montreal in Canada, on burnout solutions. The panel was rounded out by former SVS President Makaroun, on workforce supply or maldistribution, and Peter R. Nelson, MD, from the University of Oklahoma in Tulsa, on prophylactic measures to improve the workforce crisis.

Physician Assistants Section

Following a rousing session of “Jeopardy Cases over Cocktails” on Wednesday, the PAs continue their collaboration with the Society for Vascular Nursing today. From 12–1 p.m., the two groups will hold a lunchtime panel discussion with PAs Ricardo Morales, Erin Hanlon and Abby Keen, and nurses Katherine Hays, Gabriell Grayson and Stacy Hosenfeld. Audience members should bring their questions.

“This will focus on discussing our different roles and responsibilities,” said Holly Grunebach, PA-C, section chair. “We function very similarly within the vascular team. Our training is different but our interactions with the patient are the same. There is a lot of collaboration.”

PAs then have an afternoon of education, with sessions from 1:30–3 and 3:30–5 p.m. in Maryland A. The line-up includes a review and discussion of vascular oddities and vascular imaging. Participants will view comparisons of ultrasound images highlighting the area of disease both before and after repair with such tools as a patch, stent, bypass and more.

SVS members will lead three hands-on simulations, highlighting the use of two closure devices to close arteriotomy sites after angiograms. The third will offer hands-on learning of performing an ultrasound of the carotid artery, plus discussion of the results.

“We think we’ve planned a fantastic afternoon of learning for our members,” said Grunebach. “We started out our planning with thinking about what we really found useful from last year and went from there.”

This is the only PA group that is for PAs in vascular surgery, Grunebach pointed out. “It’s hard to find something this specialized and it’s what I really like about it. We’re of like minds and function in similar practices. The section is very valuable.”

“It’s hard to find something this specialized and it’s what I really like about it. We’re of like minds and function in similar practices”

Michel S. Makaroun, right, and Laura Marie Drudi

Patients have spoken.

TCAR is preferred over CEA.

The Less Invasive Standard in Stroke Prevention

Designed to give the vascular specialist more options when treating carotid artery disease, TCAR is a less invasive treatment option that takes less time to perform and results in significantly less risk of CNI and in-hospital MI in comparison to CEA.* All while protecting the patient from surgery-related stroke with freedom from stroke rates as high as 99.4%.** With indisputable clinical and patient benefit

Come see the new ENROUTE Enflate® RX Balloon

Specifically designed for TCAR

RISK ASSESSMENT MODELS “NO BETTER THAN A COIN TOSS” FOR PREDICTING BLEEDING IN PATIENTS CONSIDERED FOR VTE PHARMACOLOGIC PROPHYLAXIS

A STUDY OF TWO RISK ASSESSMENT models (RAMs) for predicting the bleeding risk in patients considered for pharmacologic prophylaxis to prevent venous thromboembolism (VTE) has found that though an increasing risk score correlated with higher bleeding rates, both models had a low predictive ability for major bleeding post-admission.

This was the conclusion of Hilary Hayssen, MD, who presented the findings of the analysis of more than 1.2 million patients undergoing both surgical and non-surgical interventions during Wednesday’s William J. von Liebig Forum in Potomac A/B.

Half of all VTE events are associated with hospitalization, Hayssen told delegates, explaining that hospital-associated pulmonary embolism (PE) is a leading preventable cause of death. Pharmacologic prophylaxis reduces the incidence of PE but can cause bleeding, meaning that there is a need to balance the risk of VTE against the risk of bleeding when considering this avenue of treatment.

There are two current risk assessment models to evaluate bleeding risk in those being considered for pharmacologic prophylaxis, the IMPROVE and Consensus models. Hayssen and colleagues assessed the predictive ability of each model for bleeding within 30, 60 and 90 days post-admission, comparing the performance of the two models in patients admitted at all 1,298 Veterans Health Administration (VHA) facilities nationwide between January 2016 and December 2021.

In total, data were analysed from 1,228,448 patients, 26.5% (n=324,959) of whom underwent surgical procedures, and 73.5% (n=903,489) non-surgical interventions. To review the two scores, researchers calculated the IMPROVE and Consensus scores using medical record data, which enabled them to assess the predictive ability of the models for bleeding at 90 days in both surgical and non-surgical patients.

A total of 5.6% of patients had major bleeding, as defined by the International Society on Thrombosis and Hemostasis (ISTH),

within 90 days post-admission, occurring in 5% of the surgical patients, and 5.8% of non-surgical patients. A total of 68,372 bleeding events occurred within 90 days of admission, and 29% of events occurred between 31 and 90 days, Hayssen reported.

In terms of the performance of the two models, Hayssen reported that higher scores were associated with higher bleeding rates. Results showed that the IMPROVE scores ranged from 0 to 22, while Consensus scores ranged from -5.60 to -1.21.

However, she reported that the ability of either RAM to predict 90-day bleeding, calculated by computing the areas under the respective receiver operating-characteristic curves (AUC) was “no better than a coin toss” (AUCs: IMPROVE 0.61, Consensus 0.59), a finding that was similarly low at 30 and 60 days post-admission. The predictive ability for either score was consistent across both surgical and non-surgical patients.

“In this validation study evaluating these two bleeding RAMs for patients being considered for pharmacoprophylaxis, we found that increasing scores were associated with increasing bleeding rates, but that the scores actually had low predictive ability for 90-day bleeding in a general hospitalized setting,” Hayssen offered in her concluding remarks.

“The bleeding RAMs possibly are not ready for general implementation in a hospital setting. More validation studies and more evaluation of the components of these models is needed to improve predictive ability to evaluate these models in conjunction with our more commonly used VTE risk as-

sessment models.” In the discussion that followed the presentation, Hayssen was asked by session moderator Michael Dalsing, MD, what factors could improve the two scores.

“It is a combination of adding risk factors that are not included,” she commented, noting that one of the risk models has 11 risk factors and the other has seven. It could be possible, she said, to include risk factors that are related but also possibly removing risk factors that are not related.

“When we looked at the prevalence of the factors in the bleeding group and the non-bleeding group, there were [factors] that were possibly, in isolation, considered more protective based upon their incidence in the two groups. So, while we haven’t evaluated which risk factors may be more important, that is definitely an aim of future research that we have.”

Vascular Quality Initiative launches national smoking cessation drive

The SVS Patient Safety Organization (SVS PSO) has launched a national smoking cessation initiative. By Beth Bales

SVS PSO Associate Medical Director Gary Lemmon, MD, and SVS PSO Director of Quality Betsy Wymer introduced the program during SVS PSO’s Vascular Quality Initiative’s (VQI) Annual Meeting Wednesday.

CAN-DO (Choosing Against Combustible Nicotine

Despite Obstacles) joins two existing national initiatives on discharge medications and sac diameter reporting, with imaging, in connection with endovascular aneurysm repair (EVAR).

“Smoking is the leading cause of preventable death and disability, 10 times more than the premature deaths from all wars fought by the U.S,” said Lemmon. It’s a major cause of cardiovascular disease and more than 90% of cancer of the lungs and other organs. Moreover, secondhand smoke increases the risk of death and disability to those who do not smoke themselves.

CAN-DO includes three components to increase smoking quit rates: including smoking cessation variables (preop smoking in elective procedures only, and smoking cessative for elective, urgent and emergent cases) in VQI’s arterial registries; physician and patient toolkits; and revising the smoking cessation section on the SVS website, to make it more patient-centered and increase its visibility.

VQI currently captures some variables, but the new initiative expands upon them to include smoking status, history and demographics prior to surgery and in postop care and long-term follow-up. Simplicity is stressed. “We’re trying to minimize the burden” on VQI members

in terms of the additional variables, Wymer said.

The physician toolkit includes many elements physicians and surgeons will find useful, including results and efficacy from a clinical trial of a brief smoking cessation intervention, a “visual dictionary” on electronic cigarettes and vaping products, an educational library of useful resource documents, the patient-facing document housed on the SVS site and, importantly in a billable world, billable smoking cessation codes.

“We can receive reimbursement for talking to patients about quitting smoking,” said Lemmon. He discussed key phrases and elements to be included to meet the threshold for reimbursement.

The patient toolkit, meanwhile, includes links to many resources on quitting smoking.

Patient education is another important component, said Wymer. In the U.S., 30.8 million adults smoke cigarettes, 3.08 million middle and high school students use tobacco products, one in four people who don’t smoke are exposed to second-hand smoke and more than $240 billion a year goes to treat smoking-related diseases.

Moreover, tobacco companies target specific populations, including people of lower income, and spend $9.1 billion in marketing annually in the U.S. “There are nearly five times more tobacco retailers per square mile in neighborhoods with the lowest income compared to neighborhoods with the highest income,” she said.

Lemmon also noted that simply asking a patient, “Do

you smoke?” is insufficient. Surgeons and doctors should instead extend the conversation to the “3 As”: ask if the patient wants to quit and when the patient smokes that first cigarette of the day; assist by offering liberal use of nicotine replacement therapy and medications but also add that the patient should not combine e-cigarettes as a crutch while also smoking; and give advice by referring patients to professional counseling, apps and other tools.

Other useful information includes a quick guide to treatment options, including nicotine patches, lozenges, nasal spray, gum and inhaler, and the use of counseling via text messaging, smartphone apps and web-based services. Wymer and Lemmon also stressed the deleterious effects of smoking on health: increased risk for peripheral artery disease, plaque building in arteries. Smoking narrows, and thus damages, blood vessel walls, it increases blood pressure and heart rate; affects cholesterol and increases triglyceride levels, a type of fat found in the blood. Both SVS and the American Heart Association advice patients to quit smoking before surgery.

Learn more at www.vqi.org/smoking-cessation

“Increasing scores were associated with increasing bleeding rates, but the scores actually had low predictive ability for 90-day bleeding in a general hospitalized setting”

Betsy Wymer and Gary Lemmon

Analyses offer a deeper dive into BEST-CLI trial data

As the vascular community continues to digest key insights from the BEST-CLI randomized controlled trial (RCT), attendees of Plenary Session 3, taking place 8:00–9:30 a.m. Thursday morning in Potomac A/B, will be offered a deep dive into the trial’s vast dataset in the form of two new secondary analyses. By Will Date

BEST-CLI is the largest trial to date comparing revascularization treatment strategies in patients with chronic limb-threatening ischemia (CLTI). The primary results, reported to great interest by investigators in late 2022, showed that both surgical bypass and endovascular strategies are safe and effective, but in those with adequate single-segment great saphenous vein (GSV), it was found that surgery is likely to be the more effective revascularization strategy for a patient who is suitable for either of these approaches.

The two latest analyses, presented here at VAM, come from Matthew Menard, MD, comparing rates of clinical and hemodynamic failure as well as resolution of initial and prevention of recurrent CLTI following endovascular or open revascularization, and from Michael Conte, MD, focusing on reintervention-related endpoints.

“On Thursday, Dr. Menard and I are presenting two of the pre-planned secondary endpoint analyses from the trial, which are important for the vascular community to further digest the impact of initial treatment selection on key clinical outcomes in CLTI patients,” Conte tells VS@VAM in an interview prior to taking to the podium.

“As with any large trial, primary publication can only get so much of the message across, and there is a lot more still planned in the coming months—including looking at subgroups of patients and other important secondary endpoints like these.”

Menard comments that the CLTI patient population is “complicated,” and each individual patient represents a unique treatment challenge, adding that there has been a great need for high-quality data to guide treatment decisions in the space.

“I think the vascular community has appreciated the effort it took to complete the trial and has welcomed the information,” he says.

“As we further unroll the many secondary analyses and additional outcomes, as well as the salient details on the patients that were enrolled into the trial and their anatomic profiles, I think the full impact of BEST-CLI will only continue to grow.”

In the analysis presented by Menard, clinical failure is defined as a composite of all-cause death, above ankle amputation,

major reintervention, and degradation of wound, ischemia, and foot infection (WIfI), while hemodynamic failure comprises a composite of above-ankle amputation, major and minor reintervention to maintain index limb patency, failure to initially increase or a subsequent decrease in ankle brachial index of 0.15 or toe brachial index of 0.10, and radiographic evidence of treat-

Multivariate analysis also reveals that assignment to open surgery was associated with significantly lower risk of clinical and hemodynamic failure in both cohorts, and a significantly higher likelihood of resolving initial and preventing recurrent CLTI symptoms in cohort 1, including after adjustment for key baseline patient covariates.

“My own belief is that there is much more to the story than how technically successful our initial revascularization effort is at restoring adequate perfusion to the ischemic foot,” Menard tells VS@ VAM, placing the findings firmly into context. “CLTI is quite analogous to cancer, and a hallmark of the disease is lingering wounds, persistent pain, and unfortunately, frequent recurrent symptoms.

“The current presentation suggests that for patients who were considered candidates for both open and endovascular treatment options, open surgical bypass is more effective at providing a sustained level of clinical and hemodynamic benefit. This result was seen in both patients that had a single segment of saphenous vein, which is

did not.

“For those that did have optimal vein, the initial CLTI symptoms resolved more quickly, and the rate of recurrent symptoms over the course of the follow-up period was significantly lower.”

Conte, meanwhile, focuses his presentation on the reintervention-related study endpoints, looking at rates of both major reintervention, any reintervention and the composite of any reintervention, amputation or death, by intention-to-treat (ITT) assignment in both trial cohorts. The analysis also makes a comparison between treatment arms in each cohort using a stratified Cox model adjusted for prespecified baseline covariates.

“This analysis is really a deeper dive into the overall burden of reinterventions experienced by patients in the trial, and beyond the primary ITT comparisons we delve into what some of the predictive factors are for patients needing reinterventions,” says Conte of the aims of the study.

“We do not have anything quite like this existing in the literature—prospectively collected data in over 1,800 CLTI patients who were revascularized and followed for several years,” he comments.

“There are key observations that need to be brought to the forefront in terms of the nature of reinterventions, the cumulative number of reinterventions that were required, the timings of those reinterventions and how they differed between endo and open. This is important information for how to inform and follow CLTI patients in everyday practice, no matter what [approach] you pick.”

In the study’s abstract, the investigators report that in the trial’s cohort 1, assignment to initial open treatment was associated with a significantly reduced incidence of major limb reintervention, any reintervention, or the composite of any reintervention, amputation or death. The findings are similar in cohort 2 for major reintervention or any reintervention. In both cohorts, limb reinterventions were notably higher for patients assigned to endovascular treatment, as opposed to open surgery.

ment stenosis or occlusion.

The study’s time-to-event analyses were by intention-to-treat assignment in both trial cohorts—those with suitable single-segment GSV, and those lacking suitable single-segment GSV—using multivariate stratified Cox regression models.

Multivariate analysis

In the abstract published ahead of the presentation, it is reported that in the cohort of patients with suitable single-segment GSV there was a significant difference in time to clinical failure, hemodynamic failure, and resolution of presenting symptoms in favor of the open surgical approach.

Among those lacking suitable single-segment GSV, there was a significantly lower rate of hemodynamic failure, also favouring the open approach, and no significant difference in time to clinical failure or resolution of presenting symptoms.

the ideal surgical scenario, and those that

“Secondary reinterventions in CLTI are common—and are more common with endovascular strategies compared to bypass with a good vein,” says Conte of the results. “Despite more than double the total number of major reinterventions, patients randomized to endo in BEST-CLI still experienced 27% more major amputations compared to those in the open arm with good vein.

“Thus, there are real downstream costs to these treatment failures, and not all limbs are recoverable by a secondary attempt. We should use the available evidence on patient risk, anatomic complexity, and severity of limb threat to select the best revascularization treatment up-front, and inform CLTI patients about these inherent trade-offs.

“It’s past time to end the tiresome “open-versus-endo” debate and embrace the complementary nature of these options for each individual patient.”

“As with any large trial, primary publication can only get so much of the message across, and there is a lot more still planned in the coming months, including looking at key subgroups of patients and important secondary endpoints like this”

MICHEAL CONTE

Matthew Menard Michael Conte

Thursday, June 15, 2023

6 a.m. to 6 p.m. Registration

6:30 to 8 a.m. International Chapter Forum

6:45 to 8 a.m. Industry Breakfast Symposia (not eligible for CME credit)

B1: BEST-CLI in Light of Modern Peripheral DE Technologies: What Conclusions Can We Draw?, Sponsored by Boston Scientific

B2: Translating the IVUS Expert Consensus to Real World Procedural Use, Sponsored by Philips

B3: Clinical Insights in PAD: Reducing the Risk of Major Thrombotic Vascular Events, Sponsored by Janssen Pharmaceutical

6:45 to 8 a.m.

Student Program (MS1-2): Introduction to Vascular Surgery

Medical Student Program (MS3-4): How to Succeed as a Vascular Surgery Residency Applicant

Surgery Resident Program: How to Succeed as a Vascular Surgery

THURSDAY SCHEDULE AT-A-GLANCE

J. Veith Distinguished Lecture: BEST-CLI: The Journey to Evidence and Beyond

OBL Section: The Business of Running an OBL 1:30

1:30 to

The OncoVascular Surgeon: Case Reviews and Strategies to Guide to Optimize Vascular Reconstruction in Oncology 3:30

EARLY CAREER FOCUS Trainees and students anticipate VAM experience

VAM brings together not only vascular surgeons but also residents, fellows and medical students keen to glean as much vascular education as possible. VS@VAM caught up with a selection of aspiring surgeons to find out how their conference was going so far—and what they hope to gain from it.

◆ “I’m looking forward to meeting the leaders in the field, getting to see and learn about interesting research, new technology and learning more about vascular surgery outside of the limited clinical setting that I had during rotations this past year.” Jordan George, third-year medical student at Meharry Medical College, Nashville, Tennessee.

◆ “Internships and sponsorships are the two key things that have helped me … so I really look to my mentors and sponsors I’ve met at VAM to guide me in my next steps.” Jessica Rea, MD, resident at Baylor College of Medicine, Houston.

◆ “I’m looking forward to networking and getting to know more vascular surgeons and, all in all, getting more vascular exposure through some of the topics presented at VAM.” Marinna Tadros, MD, applying for vascular surgery residency at the University of Arkansas at Little Rock, Little Rock, Arkansas.

◆ “I come from a school that doesn’t have a vascular program so just getting exposed to that is what I’m really looking forward to.” Daemar Jones, scholarship recipient, fourth-year medical student at Texas Tech University Health Sciences Center, Lubbock, Texas.

◆ “I hope to meet people with similar interests and background in vascular surgery and to connect with mentors in

the field, while getting advice on how someone very early in his or her career can proceed.” Kundanika Lakkadi, medical student at University of Queensland-Ochsner Clinical School, New Orleans.

◆ “As a Canadian trainee, to be able to get a sense of the broader vascular surgery landscape and being able to network with our colleagues is what I most look forward to.

I’m looking forward to the “Emerging Issues and Controversies in Vascular Trauma” session; I think it will be very interesting.” Arshia Javidan, MD, resident, University of Toronto, Toronto, Canada.

ACS-SVS VASCULAR VERIFICATION PROGRAM

THE AMERICAN COLLEGE OF SURGEONS (ACS) will have representatives on hand at VAM to provide more information on the Vascular Verification Program, an ACS quality program developed by the SVS. The program helps participating hospitals improve outcomes and deliver the best treatment for patients receiving vascular surgical and interventional care in an inpatient setting.

It provides an evidence-driven, standardized pathway for instituting and growing a quality improvement and clinical care infrastructure within a hospital’s vascular program.

ACS representatives will be available at SVS Central, the Society’s information center outside the Exhibit Hall on the lower level of the Gaylord National Resort and Convention Center.

CPVI COURSE EARLY-BIRD PRICING DEADLINE

THOSE VASCULAR SURGEONS WHO WANT to learn more about treating peripheral arterial disease (PAD) at the Complex Peripheral Interventions Course in October will be able to do so at a discount during VAM.

The SVS will return to early-bird pricing for the course until midnight Friday.

The course will support attendees to become familiar with the latest innovations and techniques in treating patients with PAD. This two-day course includes didactics, case-based learning and extensive hands-on training that gives vascular surgeons the opportunity to practice the latest procedures on cadavers and benchtop models during small-group simulations.

Learn more at vascular.org/CPVI23

Corporation, Cook Medical, Cordis®, Medtronic and W L Gore & Associates, Inc

From the top Arshia Javidan, Daema Jones, Jessica Rea, Kundanika Lakkadi, Marinna Tadros and Jordan George

SVS descends on Capitol Hill

By Beth Bales and Marlén Gomez

NEARLY 50 SVS MEMBERS TOOK ADVANTAGE OF VAM’s

location near Washington, D.C., visiting Capitol Hill Tuesday to discuss legislation related to vascular surgery with members of Congress and their staffs. The meetings were constituent-driven, with members talking with elected officials (and their staffs) from their home districts/states.

“The primary purpose of our trip to the Hill was to establish relationships that help the Society and its members become resources for lawmakers and help educate them on the issues important to the specialty and the patients we serve,” said incoming SVS Advocacy Council Chair Margaret Tracci, MD. “We want them to ask, ‘What do the vascular surgeons think?’”

Progress in advocacy is made through the development of key relationships with members of Congress and their staffs, particularly those who work on healthcare legislation, said Executive Director Kenneth Slaw, PhD.

“The presence of 50 vascular surgeons and staff on the Hill could not be more timely or meaningful in that relationship-building process,” he said. “During the nearly 100 meetings, participants talked about the need to ensure that there is a viable and vibrant workforce of vascular surgeons.”

The day ended “with great momentum, and on a particularly positive note when several influential members of Congress who have been key allies for surgeons visited, offering encouragement and a pledge to

continue to work with the SVS to address issues critical to vascular surgeons and patients,” said Tracci.

Slaw concurred. “It was a very successful and productive day and reinforces that SVS and members have a regular presence on Capitol Hill going forward,” he added.

Advocacy at VAM

During Wednesday’s advocacy session, “Member Perspectives on Advocacy—Myths, Facts and Reasons

Why all SVS Members Should Engage,” SVS panelists delved into the changing trends in advocacy across different generations and shared ways to make a lasting impact at all levels of engagement.

Leading the interactive session were Margaret Tracci, MD, current vice chair and incoming chair of the SVS Advocacy Council, and Matthew Sideman, MD, current council chair.

Tracci’s presentation on “Elements of effective advocacy” highlighted advocacy’s role in shaping the future of vascular surgery. She emphasized the importance of active member participation, dispelled common myths surrounding advocacy and provided reasons why every SVS member should engage in advocacy efforts.

Sideman provided an overview of SVS’ advocacy and policy priorities. He emphasized the need to advocate for policies that ensure optimal patient care, access to innovative treatments and adequate resources for vascular surgeons.

Sideman will soon pass the torch to Tracci as council chair and offered remarks on his time on the council.

“I’m most encouraged by our increased participation and awareness among the Society. One specific issue we’ve been able to address was the clinical labor update that resulted in a $3.5 billion shift in significant hardships for people who run their own practices. We’ve worked

tirelessly on that and, leading a coalition, we have focused on legislation to provide relief. I would’ve liked to have seen that passed into law before my time ends, but I’ll pass the reins to Tracci,” said Sideman.

The panel discussion used the Slido live Q&A platform to allow attendees to share their thoughts, concerns and suggestions about advocating for vascular surgery. Many questions and comments focused on the Capitol Hill visit nearly 50 SVS members had attended the day before.

All the presenters emphasized the need for collective action and urged attendees to become active advocates for the specialty of vascular surgery.

VAM will feature a Friday breakfast educational session from 6:45–8 a.m., highlighting more of SVS’ advocacyrelated efforts. It will give participants an overview of the foundations of SVS’ advocacy and policy work, “SVS Advocacy in Action: Work Being Done, Issues on the Horizon and How to Become Involved.”

Above: SVS members attend Congress during VAM 2023

VAM THROUGH THE LENS »

A snapshot of opening day at VAM 2023, when delegates gathered fro across the globe for a series of program highlights—the World Federation of Vascular Societies Educational Session, the Opening Ceremony, and the William J. von Liebig Forum, to name but a few.

“I used to tell my colleagues that I’m the plumber of the body, but now I have to learn how to be the electrician as well”

CASSIUS IYAD OCHOA CHAAR

This year the Gaylord National Convention Center welcomed VAM back through its doors, once again offering a scenic, waterfront setting for the educational offerings of this highlight event in the vascular calendar.

COMMENT& ANALYSIS

EDUCATIONAL OPPORTUNITIES ABOUND AT VAM 2023

By Christopher Audu

OK, SO DAY ONE HAS LIVED UP TO the hype. From hearing about amazing research endeavors to listening to lively discussions on the latest treatment options for vascular patients, it has been very invigorating.

Day two is equally packed. One of the advantages of an internationally recognized meeting, such as VAM, is the opportunity to interact with, and learn from, international colleagues on the advances in and challenges to vascular surgery in their respective environments. These can range from coffee break conversations to the formal sessions organized by the society. Check out the International Educational Forum today, where there’ll be opportu-

PLENARY 4

nities to learn about vascular surgery in various geographical contexts.

One of the reasons the vascular field is so fascinating is that we can treat even young patients who need vascular care. Look for the Pediatric Vascular Surgery development group session in the afternoon. I anticipate there’ll be presentations on the surgical treatment of renovascular hypertension in the pediatric population, in addition to novel approaches and considerations for mid-aortic syndrome.

Another vascular surgical area that is exciting to see develop is vascular oncology. Tomorrow afternoon there’ll be an exciting session on the onco-vascular surgeon. What does this mean? How do we aid our

Study weighs up total transfemoral and upper extremity approaches for F/BEVAR

surgical oncology colleagues when malignancies need to be removed? How should we think about vascular reconstruction in the setting of tumor burden? These are questions on my mind, and as a trainee, this, and the pediatrics sessions, present a valuable opportunity to learn about conditions whose treatment may not be available at every training institution.

I hope you are able to take full advantage of the chances to fill knowledge gaps, meet new friends and see old ones at SVS VAM 2023. Thanks to the organizers for putting together a stellar program.

Endothelial cell granted superhero status in invited research presentation

“The endothelial cell is the superhero of the vascular system,” Kathryn L. Howe, MD, PhD, FRSCS, a vascular surgeonscientist at the University of Toronto in Toronto, Canada, argued yesterday in Plenary Session 2.

Howe put forward the case that there is a parallel between Superman and the superpowers that can be seen of the endothelial cell. Both, she averred, are considered guardians, that are “more than they appear,” and have crucial roles in the sense that they can respond to their environment and shift identity.

Just like Superman, however, Howe pointed out that endothelial cells have a kryptonite. Smoking, sleep habits, diet, sedentary activity, diabetes, obesity, dyslipidemia and hypertension are “all factors that undermine the power of the endothelial cell,” the presenter stressed.

So, what can vascular surgeons do? To this question, Howe had a clear answer: “We can deliver exceptional vascular care by promoting endothelial health for all.”

IN A PROSPECTIVE, NON-RANDOMIZED STUDY, RESEARCHERS FOUND THAT A total transfemoral approach was associated with lower rates of cerebrovascular events and improved outcomes compared to an upper extremity approach during fenestrated/branched endovascular aneurysm repair (F/BEVAR).

Thomas Mesnard, MD, research fellow at the University of Texas Health Science Center at Houston, is due to share this finding with the VAM audience this morning (11:45–11:52 a.m.) during Plenary Session 4, which takes place in Potomac A/B.

The authors detail in their abstract that this study was conducted over the course of nine years, from 2013–2022, and included 541 patients (70% male; mean age, 74±8 years) treated with F/BEVAR. They specify that an upper extremity approach was used in 366 (68%) patients and transfemoral access in 177 (33%) patients.

Mesnard will report that the use of a transfemoral approach was associated with lower fluoroscopy time (p=0.001), lower operative time (p<0.001), similar cumulative air kerma (p=0.2), and similar technical success (p=0.96) as compared to an upper extremity approach. Mortality occurred in 1% of all patients, with no significant difference between groups (p=0.67).

Furthermore, he will share that patients treated by an upper extremity approach had significantly higher rates of major adverse events (18% vs. 8%, p=0.006) and more cerebrovascular events (3% vs. 0%, p=0.035).

Mesnard will present these findings on behalf of Gustavo S. Oderich, MD, professor of surgery and chair of vascular and endovascular surgery at the University of Texas Health Science Center at Houston, and colleagues.

Speaking to VS@VAM ahead of the presentation, Oderich comment ed on what procedures in this space might look like in the future: “Transfemoral access allowed us to reduce the risk of stroke and complications. This has been possible with the development of steerable sheaths. It is likely that, with the introduction of smallerprofile stents and better sheaths, the procedure will be simplified even further.”

SOCIAL MEDIA HELPS PROMOTE SAFE TECHNIQUE, STUDY FINDS TREATMENT PARADIGM

A SOCIAL MEDIA CAMPAIGN promoting educational videos proved efficient and cost-effective, and similar campaigns will be useful for quality improvement projects directed toward medical trainees.

That’s the message from “A social media campaign to promote safe technique in femoral access,” presented during the Vascular Quality Initiative (VQI) annual meeting from 11:05–11:15 a.m. Wednesday in National Harbor 2/3.

Cassius I. Ochoa Chaar, MD, MS, Yale University School of Medicine, New Haven, Connecticut, and Joshua J. Huttler, BA, and MD candidate, also of Yale University School of Medicine

will present the campaign and its conclusions.

The effort grew out of an objective to “standardize access protocol and reduce access-relating bleeding complications,” according to the authors. Issues included department differences in femoral access technique and a cadaveric groin dissection study that showed significant anatomic variation.

The team created the “No Guess with Access” quality improvement campaign, which included surveys, posters, teaching sessions, the Yale School of Medicine newsletter, an instructional video on “optimal femoral access corrects anatomical error” and the social media campaign on Twitter and YouTube.

The “No Guess with Access” training video was posted on YouTube; links on social media publicized it, calling the video “an essential training video for all endovascular specialists for safe femoral access techniques.” The social media campaign included 16 weeks of paid advertising on Twitter, targeting healthcare professionals, specifically medical trainees. —Beth Bales

“I hope you are able to take full advantage of the chances to fill knowledge gaps, meet new friends and see old ones at SVS VAM 2023”

CHRISTOPHER AUDU is the Vascular Specialist resident/fellow editor.

Gustavo Oderich

VESS SESSION 2

Physical pain a risk factor for vascular surgery trainee burnout, survey reveals

Arecent survey has indicated that physical pain is “prevalent” among vascular surgery trainees and represents a risk factor for burnout. Eric Pillado, MD, MBA, a vascular surgery resident at Northwestern University Feinberg School of Medicine in Chicago, shared this conclusion during yesterday afternoon’s second SVS-VESS Scientific Session.

Pillado detailed that 527 trainees completed a confidential, voluntary survey, administered after the Vascular Surgery In-Training Examination (VSITE), representing an 82.2% response rate. He revealed that 38% reported moderate-tosevere discomfort/pain after a full day of working, among whom 73.6% reported using ergonomic adjustments and 67% over-the-counter medications. Pillado also communicated that more women tended to report moderate-to-severe pain than men (44.3% vs. 34.5%, p<0.01).

After adjusting for gender, training level,

study addresses

race/ethnicity, mistreatment, and lack of operative autonomy—which the authors describe in their abstract as a proxy for loss of meaning in work— moderate-to-severe pain (odds ratio [OR] 2.52, 95% confidence interval [CI] 1.48–4.26) and using physiotherapy as pain management (OR 3.06, 95% CI 1.02–9.14) were determined to be risk factors for burnout.

In light of these findings, the presenter suggested in his conclusion that programs “should provide ergonomic education and adjuncts, such as posture awareness and microbreaks during surgery, early and throughout training”.

Pillado presented this work on behalf of senior author Dawn M. Coleman, MD, chief of the division of vascular and endovascular surgery at Duke University Medical Center in Durham, North Carolina, and the Vascular Surgery

SECOND trial steering committee.

Jocelyn Hudson

asymptomatic carotid patients

Alessandro Gregio, MD, a vascular surgery trainee at the University of Bologna in Bologna, Italy, presented midterm results from the Carotid asymptomatic stenosis observational study during the first of two SVS-VESS (Vascular and Endovascular Surgery Society) Scientific Sessions yesterday afternoon.

“Whether to intervene or to follow [asymptomatic] patients with best medical therapy is an ongoing matter of debate,” said Gregio, noting that he and colleagues performed a prospective observational cohort study to add data to the discussion. Out of 366 patients enrolled in the study, 306 completed follow-up.

Gregio, who was presenting the study results on behalf of senior author Mauro Gargiulo, MD, and colleagues, concluded that the 48-month risk of ipsilateral transient ischemic attack or stroke was 6% in a real-world scenario. He added that adherence to best medical therapy is high in this population, and also that plaque progression and contralateral stenosis are risk factors for neurological events during follow-up.

The researchers will follow patients out to five years, the presenter noted.

VASCULAR ONCOLOGY ONCO-VASCULAR SESSION SET TO OFFER

IN

SURGERY

RANDALL DEMARTINO, MD, IS DIVISION CHAIR OF VASCULAR AND Endovascular Surgery at the Mayo Clinic in Rochester, Minnesota, and a co-moderator of a session dedicated to onco-vascular surgery, taking place today from 3:30–5 p.m. in National Harbor 12/13. A series of presentations will feature case reviews as well as discussion of how to achieve the best outcomes in vascular reconstruction for oncology patients. DeMartino previewed the session for VS@VAM ahead of time.

“The goal of the session is to describe the landscape of cases that aren’t as typical in vascular training,” DeMartino begins, outlining how in recent years, vascular surgeons have been taking on increasing numbers of cases from oncology colleagues for tumors involving vascular structures and performing reconstruction post-resection. “We want to be able to help” in affording patients the better chance at survival that resection can provide, he emphasizes, while noting how this is a “new” field for many vascular surgeons. The growing case numbers he and other vascular surgeons have been seeing is what prompted his interest in holding the session at this year’s VAM, DeMartino adds.

There is a significant need for multidisciplinary collaboration in order to deal with these complex cancer cases, he continues, citing urology and orthopedics as among the departments he works with. “We find ourselves [working] all over the body,” he summarizes, pointing out that vascular surgeons “are the experts in helping the patients maintain limb or organ function through the vasculature.”

The session will cover multidisciplinary collaboration and the importance of good communication among the specialties involved in a particular case; which imaging modalities to use; how to approach patients who have had previous surgeries or whose tumor has been irradiated; how to set up and prepare mentally for emergency cases; and how best to follow up with different patients.

‘CLINICAL PEARLS’

‘NEW’ AREA OF VASCULAR

Observational

‘ongoing debate’ around intervention in

THE GLOBAL BURDEN OF CLTI: ESVS PRESIDENT POINTS TOWARD NEED FOR NEW GLOBAL VASCULAR GUIDELINES

Early-bird VAM 2023 attendees yesterday gained broad insight into the issues facing vascular surgeons around the world, with the tone set from the opening talk on the World Federation of Vascular Societies (WFVS) Educational Session docket.

Looking at the global burden of chronic limb-threatening ischemia (CLTI) and the joint guidelines that steer practice, Philippe Kolh, MD, from the University Hospital of Liege in Belgium and current president of both the European Society for Vascular Surgery (ESVS) and the WFVS, told attendees: “We need a new version of these guidelines.”

Kolh was talking through the global burden, patterns and management of CLTI patients across the globe. He set the scene for the core argument behind his message on what the latest survey data show. “The caseload is highly variable,” he said.

“The proportion of CLTI patients needing primary amputation was very large across centers, with the lowest proportion in the U.S. and the highest in India and South Africa—that probably also reflects the type of care that we can provide to our patients with CLTI.

“In Asia and South Africa, the majority use the GLASS [the Global Limb Anatomic Staging System] rating; in other regions, the minority of the reporting centers use GLASS.

“A similar pattern (and discrepancy) was seen with the risk calculator: the majority in Asia and South Africa use it. The WIfI (Wound, ischemia and foot infection) system is used by the majority in most countries except, quite strangely, the U.S., where 50% of centers reported no use of WIfI.”

Assessing how much is this snapshot representative of the global picture, Kolh proffered. “We’ll see in the next survey,” he said.

“Endovascular-first strategy was the most common strategy in India and South Africa. In other countries, the majority reported that endovascular-first is not their approach for CLTI.

“For bypass surgery, in addition to great saphenous vein [GSV], synthetic graft is the preferred conduit in many centers, while for below-the-knee bypass with a GSV is preferred.

When there was no GSV, the contralateral vein was the preferred conduit in all countries when above-the-knee bypass is in question. When below-the-knee bypass is needed in cases of no conduit, surprisingly [an] endovascular approach is the most preferred alternative. No center reported arm veins as an option.”

Further, said Kolh, drug-eluting technology is accepted in both femoropopliteal

and crural artery segments, and arm veins are used in about 40% of centers.

He then turned to costs. “There was a huge variation in procedural cost across countries and centers,” Kolh reported.

“The percentage of patients who bear outof-pocket [costs] is quite different. It varies from less than 10% [in the majority of centers] to up to 80% [in India/Asia].”

Meanwhile, Kolh provided feedback based upon the impact of the BEST-CLI (Best endovascular vs. best surgical therapy in patients with critical limb ischemia) trial, and how it had altered surgeon practice.

“About half of replies indicate that the BEST-CLI trial has changed their practice,” he revealed. “If the answer was ‘no,’ the reason most often given was that they already were doing their practice according to the results.”

Concluding, Kolh said there was “huge variation” in patterns of CLTI treatment across the globe.

The WFVS session—the second to be hosted at VAM—saw each member society

of the organization represented in person, said moderator Palma Shaw, MD, the WFVS secretary-general.

One of those—the Vascular Society of Southern Africa (VASSA)—produced an insight on the state of vascular surgery training in Africa, and the challenges faced on the continent.

Asha Malan, MD, a VASSA executive committee member, provided stark data.

The South African population of approximately 60 million is currently served by nearly 65 [vascular surgeons]—“even though this does reflect an approximate 50% increase over the last decade.”

This compares to France, with a similar population of 67 million, where there are

10 times this number of vascular surgeons, she said. “To make matters worse,” Malan went on, of that 65 number, “only 13 of us are currently employed in the public sector, carrying 80% of the burden of disease.”

Because of the shortage of general surgeons in South Africa, vascular surgery is still considered a subspecialty of general surgery, she said, with the consequence that vascular surgery training requires a further two years after five years of general

surgery training completion.

Training is offered at seven centers, Malan added, with a currently enrolled rate of 14 trainees. “However, due to the lack of funding for training programs,” just two-to-four vascular surgeons qualify annually, resulting in a net loss, she pointed out.

“South Africa needs to re-evaluate the need for revision of specialized vascular surgical care,” Malan concluded.

“Endovascular-first strategy was the most common strategy in India and South Africa. In other countries, the majority reported that endovascularfirst is not”

PHILIPPE KOLH

Palma Shaw

Asha Malan

Philippe Kolh