Vascular Specialist@VAM–Conference Edition 3

2 International Forum Generational training needs in specialty

4 Novel drug First-in-human AAA study findings

6 Lifetime Award

Pair of former SVS presidents gain accolade

PRESIDENTIAL

By Jocelyn Hudson

FRIDAY MORNING

will see Michael C. Dalsing, MD, MBA, deliver what is an annual hallmark of the VAM program—the SVS Presidential Address.

From 11:00 a.m.–12:15 p.m. in Potomac A/B, Dalsing will chart his personal journey from “small-town boy with some big dreams” to president of the SVS, as well as the history of the Society and that of the vascular surgery specialty in general, all the while delivering the salient message that “the Annual Meeting is only part of our story.”

Rural America will be the opening scene for Dalsing’s address. This is where he grew up, with parents who were “deeply affected by World War II and the Depression,” his mother— who, Dalsing will say, would have travelled widely given the chance—“convinced that education would open doors to the world.”

Against this backdrop, Dalsing moved away to attend college, majoring in

See page 3

BEST-CLI INVESTIGATORS IMPLORE A MOVE BEYOND ENDO VS. OPEN ‘BATTLE’ IN THE NAME OF SCIENTIFIC ADVANCE

The principal investigators behind the BESTCLI trial struck a conciliatory tone during the inaugural Frank J. Veith Distinguished Lecture yesterday morning in which they laid bare the blood, sweat and tears shed on their journey to complete the landmark study.

The headline findings that emerged out of the trial—that both open and endovascular procedures were equally safe, and that chronic limb-threatening ischemia (CLTI) patients deemed suitable for either approach who had an adequate great saphenous vein experienced better overall clinical outcomes after open bypass surgery— sparked rancor in the interventional surgical communities.

Yet, Alik Farber, MD, and Matthew Menard, MD, used the maiden Veith Lecture to shine a light

down a path toward further advances in end-stage peripheral arterial disease (PAD) care.

The pair used the platform to tell the story of their journey in order that others might take the leap of faith they did to tackle “impactful questions in science,” Farber told VAM 2023 attendees.

They first got together to develop the idea for a trial to compare open vs. endo treatment for CLTI in 2007. “It really was the blind leading the just as blind,” quipped Menard. As Farber described, personally he had very little experience in clinical trials at the time. “There was a lot of insecurity,” he said. “Were we really the right people to do this?” he recalled thinking back then.

See page 2

10 Trauma bypass ‘Excellent’ limb salvage rates

13 CLTI Frailty status beats WIfI in all-comers

13 Word on the street VAM attendees chime in on CLTI trials

www.vascularspecialistonline.com

SPOT LIGHT

UP TODAY AND TOMORROW

FRIDAY KICKS OFF WITH

the International Fast Talk Scientific Session at 6:30 a.m. Three breakfast sessions will cover developing a successful and funded clinical research program to improve patient care, fundamentals and advances in managing pulmonary embolism and advocacy work.

Another international session, the International Forum Scientific Session, takes place from 7:15–8 a.m., also in Maryland A.

From 11 a.m.–12:15 p.m., the spotlight belongs to outgoing President Michael C. Dalsing, MD, and his Presidential Address

The Community Practice Section holds its special session for its members from 1:30–3 p.m. At 2:45 p.m. section leaders will announce this year’s recipients of the Excellence in Community Practice Award

From 3:30–5 p.m., the Young Surgeons Section will hear topics relevant to their career stage.

The Exhibit Hall remains open from 9:30 a.m.–5 p.m. The Career Fair (9 a.m.–3 p.m.) and Residency Fair (1:30–3 p.m.) round out the day. SVS Central is open from 9:30 a.m.–5:30 p.m.

Then it’s time to visit the Roaring Twenties, at the SVS Foundation “Great Gatsby Gala” (7–11 p.m.). An After Party takes place 11 p.m.–1 a.m. Saturday.

Saturday, meanwhile, will feature the final two plenaries, the Poster Competition championship, and the Roy Greenberg Distinguished Lecture

ADDRESS: “THE ANNUAL MEETING IS ONLY PART OF OUR STORY”

VEITH LECTURE

2

INTERNATIONAL CHAPTER

Generational divide:

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

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Kristin Crowe

Communications Specialist

Marlén Gomez

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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.

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OLDER-GENERATION VASCULAR SURGEONS ARE KEEN

TO hone their endovascular skills, while the younger generation are looking to develop their capacity to treat aortic pathologies—but surgeons at all stages in their career favour hands-on learning to continue their development.

These are among the key findings of a multi-generational survey of Mexican vascular surgeons, intended to gain a greater understanding of the training and developmental needs of the country’s growing vascular community.

“We are a facing a change in Mexico, where an increase in the number of vascular surgeons is needed, so the response has been to open more hospital programs and more available positions,” Rodrigo Garza-Herrera, MD, representing the Mexican Society for Vascular Surgery, told delegates at yesterday morning’s International Chapter Forum Educational Session.

Garza-Herrera explained that the number of vascular surgeons practicing in Mexico is expected to expand rapidly in the coming years, from around 1,100 now to more than 1,600 by 2026. Consequently, the millennial generation—those born between 1980–1996—will make up a greater proportion of the workforce by the end of the decade, in creasing from 43% at the current count, to an estimated 63% in 2026.

To understand whether these demographic changes will impact the training needs of its vascular community, the Mexican Society has surveyed all of the vascular surgeons practicing within the country, and the results of the survey have informed the development of new training initiatives and programs. The work has also shone a light on some important differences—and similarities—spanning the generational divide.

In total, 356 individuals took part in the survey, pre-

continued from page 1

biology and expecting to be a scientist, before making “potentially one of the most consequential decisions of [his] life” and taking the Medical College Admissions Test (MCAT), thus launching a long and celebrated career in vascular surgery.

Alongside his personal and professional journey to SVS president, Dalsing will deliver a sweeping history of vascular surgery, and outline how the twists and turns of certain decades were pivotal in defining vascular surgery as the distinct specialty that it is today, as well as some of the challenges that it presently faces.

In the 1940s, he will say, vascular surgery was “coming of age.” In the 1970s and early 1980s, training, certification, and defining the specialty took “center stage,” and the endovascular revolution of the 1990s and 2000s, he will continue, saw a vascular surgery field that was “changing fast.”

The president, who is professor emeritus in the Division of Vascular Surgery at Indiana University School of Medicine in Indianapolis, will reflect on his current position within the vascular surgery field, paying honorable mention a “long list” of individuals who have influenced his career over the years. He will

dominantly male (74%) and mainly from the millennial generation (46%), followed by generation X (34%) and those from the baby boomer generation (20%).

The survey suggests that there is a far greater proportion of women entering Mexico’s vascular surgery field, with men outnumbering women 8:1 in the boomer generation, compared to 1.6:1 in among the millennials, a trend that Garza-Herrera said he “hopes to see continuing.”

Surgeons were also polled on their academic needs, with seven key fields identified for them to prioritize their areas of strength and weakness, including: venous pathology, open arterial surgery, endovascular therapy, vascular access, aortic disease, vascular anomalies and advanced wound care.

Venous pathology was reported as the biggest strength in 41% of participants, whereas the greatest weakness was vascular malformation, chosen by 52% of respondents—an area that was particularly pronounced among millennials, 63% of whom selected this criteria. The survey asked participants to identify the areas where they felt the greatest need for improvement, to which 54% felt that they need to improve their endovascular skills, and 32% felt that an increased competence in treating vascular malformations is needed.

“Baby boomers showed the highest need for improving endovascular skills and millennials showed the highest need to improve their capacities in the treatment of aortic pathology,” Garza-Herrera commented, pointing out a generational difference highlighted through the survey responses.

Results from the survey, which was conducted in 2020, have already shaped training initiatives being put into practice in Mexico.

also describe the “immense joy” at seeing the next generation of vascular surgery residents and fellows serve their communities as “compassionate and skilled vascular surgeons,” in addition to being “exceptional people.”

Dalsing’s talk will argue that vascular surgery is “unique” as a specialty, in that it involves the care of a patient from initial contact to the end of their life. As a result, specialists “must master several dissimilar skillsets requiring years of training.”

The specialty is, however, a “hidden gem,” Dalsing will say, which he highlights as a problem.

“In general, people do not know what we do,” meaning the specialty risks being “overlooked as a needed partner in discussions about our patients’ care.”

And this is all in the context of an aging population and its “increasing demands,” being served by a “finite” number of providers.

This is where the SVS comes in, Dalsing will state, with its role extending far beyond the calendar highlight that is VAM. “SVS is literally reinventing itself as it evolves and moves forward to integrate dozens of new innovative ideas currently under

consideration for implementation. This process happens year over year. We are coming of age as a mature organization,” he will tell attendees.

And who but the SVS will advocate for the interests of vascular surgeons? Dalsing will ask. “No one!” He will stress that the SVS is a small group that “must speak with a strong and unified voice to be heard,” all in the interest of vascular patients, as well as members’ wellbeing.

“We are the champions of quality vascular care. We must embrace this role and encourage those who want to be on the vascular team,” Dalsing will say.

He will express his belief in the need to market to the general population—a seemingly “unattainable” goal by his own admission, but one he feels is the “endgame” if there is a desire to be recognized as the “undisputed champions of quality vascular care.”

He will define the scope, the added value the specialty brings, and a general impression of the players involved. The next steps? According to Dalsing, “defining the rules of engagement and tactics to be used for success” with education as a “centrepiece” of this effort.

Do baby boomers and millennials see eye-toeye on vascular surgery training needs?

“We are a facing a change in Mexico, where an increase in the number of vascular surgeons is needed, so the response has been to open more hospital programs and more available positions”

RODRIGO GARZA-HERRERA

SPECIAL SESSION UNDERSCORES ‘COMPLEMENTARY’ NATURE OF OPEN AND ENDOVASCULAR STRATEGIES IN CLTI PATIENTS

A dedicated session yesterday afternoon saw speakers and delegates gather to debate, analyse and consider the implementation of the BEST-CLI and BASIL-2 randomizedcontrolled trials (RCTs). There was general agreement that the strategies are complementary, and that “picking the right thing for the right patient at the right time” should take precedence.

By Jocelyn Hudson

irst to speak were Alik Farber, MD, MBA, professor of surgery and radiology at Boston University, and Matthew T. Menard, MD, associate professor of surgery at Brigham and Women’s Hospital in Boston, who shared key findings from the BEST-CLI trial.

They concluded that the BEST-CLI trial “supports a complementary role for open and endovascular revascularization strategies and highlights the need for expertise in both for optimal care of these patients.”

The next step? According to Farber and Menard, this will be to figure out which patients are best treated with surgery and which with endovascular therapy.

The focus then moved to BASIL-2, with Andrew Bradbury, MD, MBA, professor of vascular surgery at the University of Birmingham in Solihull, England, sharing main findings from this trial. He addressed the question, will BASIL-2 change practice

in the UK? To this he said that in around 50% of patients it is not “obvious” that infrapopliteal vein bypass or best endovascular therapy is preferable and so there is “no strong [multidisciplinary team meeting] recommendation” on the subject.

Next on the agenda was a debate, during which Michael S. Conte, MD, professor and chief of the division of vascular and endovascular surgery at the University of California San Francisco was tasked with arguing that patients with chronic limb-threatening ischemia (CLTI) who have adequate saphenous vein should be treated with bypass.

Before getting started, he modified the debate question to read: “Patients with CLTI who are acceptable surgical candidates, and who have adequate great saphenous vein, should be offered bypass surgery as an initial treatment strategy.” His closing message was in line with that

posed before him, that endovascular and open are complementary therapies. “It’s time for our field to mature and develop an evidence-based framework akin to [coronary artery disease],” he stressed, urging delegates to “stop the simple-minded ‘open vs. endo’ debate.” The important thing is “picking the right thing for the right patient at the right time,” he said.

Delivering the counterview, Brian G. DeRubertis, MD, of Weill Cornell Medicine in New York, contended that “almost all” patients with CLTI who have adequate saphenous vein should be treated with bypass. He argued that this was an “easier stance” as—he put forward—an endovascular-first treatment strategy “has become the standard of care for the majority of patients with CLTI over the last 15 years.” He underlined the fact that recent randomized controlled trials “demonstrate an important and preferred role for surgical bypass in some patients with CLTI,” noting however that trial results “do not suggest this is true for most patients.”

“We have yet to determine exactly which patients warrant a bypass-first approach.”

Following the debate, Vincent L. Rowe, MD, professor of clinical surgery at the University of Southern California Los Angeles, spoke on “how best to capture meaning” from the two trials.

One of the points Rowe made in his conclusion was that the death rates in both trials were “very high” and that a deeper dive on what was causing these deaths is warranted. “Is there some type of risk factor that we can find that’s causing all of these deaths to occur in these patients?”

Addressing the question “what is BEST for CLTI?” Misty D. Humphries, MD, MS, associated professor of surgery at the University of California-Davis in Sacramento, weighed up the pros and cons of both an administrative database and a randomized trial. Concluding, she argued that observational studies are “not going anywhere,”

Some of that rancor seen in the aftermath of the release of their findings late last year emerged back then over trial design too. But eventually, the specialties united, and they got NIH grant approval.

They had many difficulties along the way. “This trial was extremely difficult to enroll,” said Farber. “There were multiple curveballs.” The Katsanos meta-analysis. COVID-19. Running out of money.

continued from page 1

Upon receiving positive feedback from within the vascular surgery ranks, Farber related, they began the National Institutes of Health (NIH) application portion of their journey.

At first blush, as they prepared to go down the NIH route, they thought vascular surgeons should do the trial owing to the fact they carry out both procedural modalities.

Despite their arguments, the application failed. Yet, they persevered. They responded to the criticisms. Other specialties were included. More funding was secured.

They got there, presenting at the American Heart Association and publishing the results in the New England Journal of Medicine. “We hope our story encourages others to pursue their research ambitions, even in the face of

but stressed that there “may be saturation without changes in data fields.” Randomized trials, on the other hand, cost “lots of money, but eliminate bias.” Alongside these concluding thoughts, Humphries included a picture on the slide, highlighting a question that was in keeping with one of the overarching themes of the session: “Can’t we all just get along?”

Finally, Kristina A. Giles, MD, division chief of the department of surgery at Main Medical Center in Scarborough, Maine, addressed the topic of implementing BESTCLI and BASIL-2, sharing “what will be easy and what will not.”

Scrutinizing the data, realizing that the trials are complementary, and realizing that open and endovascular methods are complementary will be “easy,” she said, while noting that one of the harder aspects of implementation will include the challenges associated with vein mapping everyone before an angiogram, among others.

Moderator Joseph L. Mills Sr., MD, of the Baylor College of Medicine in Houston, opened the discussion with a question on bias. Conte remarked here that “bias comes in lots of forms” and brought up a “major bias” in real-world practice that is the economic and workflow bias. “A lot of people are working in places where doing surgery is inconvenient for their workflow and potentially forgotten.”

Various panel and audience members brought up coronary disease in CLTI patients. Touching on a point he made during his presentation, Rowe averred that “death was most likely caused by a coronary event,” with Mills also stating that “we need to pay more attention to coronary disease.”

In this vein, Menard commented that one of the tasks ahead for the trial investigators is to look at both trials closely, stressing that “shockingly, we don’t know what our patients are dying from, that’s step one.”

obstacles, self-doubt and judgment of others,” said Farber.

Menard paid tribute to the man for whom the new VAM lecture is named: Frank Veith, MD. “It is impossible to [over]estimate how much of a maverick Frank has been, and the enormity of what he has contributed to the field,” he said. Menard sees a kindred spirit in Veith in the sense of how the limb-salvage pioneer looks at the foot. Menard, too, likes to try the less conventional. “But one thing I haven’t done, and Frank did it a long time ago: he did a prosthetic bypass to the foot,” said Menard. “It worked. Here’s another thing that Frank did: 13 prior failed procedures—he did a bypass from the common iliac artery to the peroneal artery. And it worked.”

Veith was also an endovascular believer before most had cottoned on to its potential, he said. Menard’s point was centered on progress in CLTI made over the decades. That extends to turf battles—endo vs. open. “Hopefully, never more,” he said. “Turf battles in the vascular community have been, and still are distracting, destructive, highly counter-productive and of very little service to our patients. I charge the audience to sincerely bring to their part to fight an entirely new battle: that is to move beyond this 25-year-old paradigm of endo vs. open.”

“Turf battles in the vascular community have been and still are distracting, destructive, highly counter-productive and of very little service to our patients” MATTHEW MENARD

FROM THE COVER: BEST-CLI INVESTIGATORS IMPLORE A MOVE BEYOND ENDO VS. OPEN “BATTLE” IN THE NAME OF SCIENTIFIC ADVANCE

INTERVENTIONS ‘CRUCIAL’ FOLLOWING RESCUE OF PRIOR EVAR WITH PMEG

The findings of a recent study on reinterventions and sac dynamics after fenestrated endovascular aneurysm repair (FEVAR) with a physician-modified endograft (PMEG) for index aneurysm repair and following prior EVAR led researchers to conclude that “vigilant” surveillance and a low threshold for further interventions are “crucial” following PMEG for rescue of prior EVAR with loss of proximal seal.

NICHOLAS J. SWERDLOW, MD, A vascular surgery fellow at Beth Israel Deaconess Medical Center in Boston, shared these findings during yesterday morning’s Plenary Session 4 on behalf of senior author Marc L. Schermerhorn, MD, chief of vascular and endovascular surgery at Beth Israel Deaconess Medical Center, and colleagues.

Swerdlow et al note in their study abstract that, while the high frequency of reinterventions after FEVAR with a PMEG has been well-studied, the impact of prior EVAR on reinterventions and sac behaviour following these procedures remains unknown. In the present study, therefore, the researchers analyzed three-year rates of reinterventions and sac dynamics following PMEG for index

PATIENT SAFETY

aneurysm repair compared with PMEG for prior EVAR with loss of proximal seal.

The investigators analyzed 122 consecutive FEVARs with PMEGs at a tertiary care center that was submitted to the Food and Drug Administration (FDA) in support of an investigational device exemption (IDE) trial. They excluded patients with aortic dissection, type I–III thoracoabdominal aneurysms, non-elective procedures and prior aortic surgery other than EVAR, for a final cohort of 92 patients.

Patients were divided into those who underwent PMEG for index aneurysm repair (index-PMEG) and those who underwent PMEG for rescue of prior EVAR with loss of proximal seal (rescue-PMEG).

Novel drug candidate for slowing AAA growth demonstrates safety in humans

The local delivery of a glucose-derived compound in small- and medium-sized abdominal aortic aneurysms (AAAs) has been deemed safe, with “promising” early efficacy data indicating its potential in stabilising or slowing AAA sac growth.

According to Stephen Cheng, MBBS, MS, chair of the Department of Surgery at the University of Hong Kong, these first-inhuman study findings—which he will present today at VAM 2023 during Plenary session 6 (10–11 a.m.) in Potomac A/B—merit further evaluations within randomized controlled trials.

Swerdlow shared with the audience that, of the 92 patients included in the analysis, 55 (60%) underwent index-PMEG and 37 (40%) underwent rescue-PMEG. He added that rescue-PMEG patients were older—78 years (interquartile range [IQR] 75–83) vs. 73 years (69–78), p<0.001. Otherwise, there were no statistically significant differences in baseline demographics and procedural characteristics.

The presenter reported that perioperative mortality was 1.8% for index-PMEG and 2.7% for rescue-PMEG (p=0.8) and that, at three years, overall survival was 83% for index-PMEG and 72% for rescue-PMEG (p=0.08).

In addition, he noted that freedom from reintervention was significantly higher for index-PMEG than rescue-PMEG, specifically 79% vs. 45% at three years (p<0.001).

Swerdlow then shared sac dynamic findings. He revealed that, at three years following index-PMEG, aneurysm diameter was stable in 58% of patients and decreased in 42% of patients, with no cases of sac expansion.

At three years following rescue-PMEG, however, he noted that aneurysm diameter was stable in 31% of patients, decreased in 31% of patients and increased in 38% of patients (p=0.05).

The presenter stated in his conclusion that FEVAR with PMEGs for index aortic repair and rescue of prior EVAR with loss of proximal seal are “two distinctly different entities.” He summarized that, following FEVAR with a PMEG for index aneurysm repair, less than a quarter of patients had undergone reintervention at three years and sac expansion was “rare.”

“THE MAIN MESSAGE IS THAT THIS IS A GROUP of patients where, currently, there are no effective treatments to slow the growth of [abdominal aortic] aneurysms,” Cheng tells VS@VAM. “And, therefore, the idea of using a drug that is delivered only once inside the aneurysm sac sounds attractive— especially if it leaves nothing behind and all the future treatment options are left open.”

The multicenter study in question saw patients with an AAA (diameter <5.5cm) recruited to receive a one-time, local administration of 25ml of 1,2,3,4,6-pentagalloyl glucose (PGG) solution via transfemoral access. The study’s primary endpoints were technical success and safety—determined by the occurrence of major adverse events at 30 days. Cheng et al have reported a 100% rate of technical success, and found that the only safety-related concern was that four of the 21 enrolled patients showed a transient elevation of liver enzyme levels. However, these levels returned to normal within 30 days and triggered no clinical symptoms.

“When we talked to the pharma scientists, who are really looking at the molecular aspects of why these drugs work, the answer was that PGG is largely metabolized in the liver,” Cheng adds. “This is a way that the liver responds to any [raised level] of glucose in the metabolism pathway. That is the explanation that has been given to us, but we have seen no adverse effects in the patients. It will certainly be an area we will be closely monitoring as to how patients behave afterwards but, so far, they are all

At three years following PMEG rescue of prior EVAR with loss of proximal seal, however, it was observed that over half of patients had undergone reintervention and over a third had ongoing sac expansion, which led Swerdlow to underscore the importance of “vigilant” surveillance and a low threshold for further interventions in this group of patients.

Ahead of Swerdlow’s presentation, Schermerhorn shared some thoughts on the study findings with VS@VAM: “I have changed my practice now to reline the entire graft whenever I do a rescue PMEG. I believe that many of these patients have undetected type 3 endoleaks that lead to sac expansion and subsequent loss of the proximal seal.

“Extending the seal proximally fixes the 1a leak but does not address the original cause of sac expansion for the subgroup that had original expansion due to type 2 or 3 endoleak and we need to be alert to this possibility. I have now performed sacotomy on four patients for presumed type 2 endoleak with sac expansion (two of whom had prior rescue PMEG) and found fabric tears that were not detected by [computed tomography angiography], duplex, or angiography.”

fine and the one patient who did have a very high enzyme level returned to normal in about a month’s time.”

With this being a first-in-human study, Cheng is quick to point out that any conclusions drawn from the results regarding efficacy of the PGG solution in slowing AAA growth are preliminary.

Nevertheless, as per their secondary endpoint of freedom from aneurysm sac enlargement, the researchers report average AAA diameter changes from baseline of 0.2mm, 1.1mm, 2mm and 0.8mm at six, 12, 24 and 36 months, respectively. Follow-up computed tomography angiography (CTA) data further indicated average volume changes of 2.5%, 9.6%, 24.3%, and 11.6%, respectively—and, at 12 months, none of the aneurysms had grown by more than 5mm in diameter, while only three had a volume growth >10%.

Prior studies have indicated that the average rate of AAA sac growth is around 3–3.5mm per year, according to Cheng. He states that this figure was used as a target in the present study, adding that the treatment threshold in Caucasians is an aneurysm diameter of 5.5cm and, “if we can slow the growth by 50% [to about 1.7mm], then we can push back the threshold for intervention from five years to 10 years, and that would bring expected benefits”.

“But, I must reiterate that this is a first-in-human study of a relatively small number of patients,” he adds. “The main focus was on patient safety rather than long-term aneurysm sac [growth].”

‘VIGILANT’ SURVEILLANCE AND LOW THRESHOLD FOR FURTHER

“I have changed my practice now to reline the entire graft whenever I do a rescue PMEG”

MARC L. SCHERMERHORN

Stephen Cheng

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VASCULAR TITANS

SVS honors two with Lifetime Achievement Award

The SVS on Thursday honored two surgeons—instead of the traditional one—with its highest honors, the Lifetime Achievement Award. It’s only the third time the Society has done so in the award’s history, said Michael C. Dalsing, MD. He presented the honorees: Enrico Ascher, MD, professor of surgery at NYU Langone School of Medicine, and Julie Freischlag, MD, formerly dean of Wake Forest University School of Medicine and now chief academic officer of Advocate Health. Freischlag was SVS’ first—and still only—woman president. Both Ascher and Freischlag are “exceptionally deserving of this prestigious distinction,” said Dalsing. SVS will profile the two recipients in the July issue Vascular Specialist.

MATURATION

Nephrologist insights for vascular surgeons at hemodialysis access session

FRIDAY AFTERNOON IN POTOMAC D WILL SEE VAM PLAY HOST TO A SERIES of presentations on access for hemodialysis that will offer education on arteriovenous fistulas (AVFs), grafts (AVGs) and maturation—as well as strategies for managing their failure.

The session will be moderated by Maureen Sheehan, MD, of Wake Forest University Medical Center, North Carolina, and Thomas Huber, MD, from the University of Florida in Gainesville, and is titled “Creation and Complications: Current Strategies in Hemodialysis Access.” Split into two sections, the 90-minute program will focus first on access creation, with Vandana Dua Niyyar, MD, President of the American Society of Diagnostic and Interventional Nephrology (ASDIN), offering up an interventional nephrologist’s angle on the creation of dialysis access.

Speaking to VS@VAM, Huber—among those behind the program—said: “The hope was that we could get someone from the outside that could share their perspective. We’ve tasked [Niyyar] with telling us what vascular surgeons need to know from a nephrologist’s perspective.”

Next up will come Theodore Yuo, MD, of the University of Pittsburgh Medical Center, who will explore endovascular AVF (endoAVF), before Libby Weaver from the University of Virginia Health System will talk AVG materials and Yana Etkin, MD, Zucker School of Medicine at Hofstra/Northwell, Long Island, New York, will explore access maturation strategies.

Following a 15-minute panel discussion, the second half of the session will get underway with a talk on the management of failing AVGs and AVFs from Jeffrey J. Siracuse, MD, from the Boston School of Medicine in Boston. Management is the name of the game in this whole second sequence of talks—with management of everything from high-flow AV access the focus of Samuel S. Ahn of TCU & UNTHSC School of Medicine, Fort Worth, to the management of access emergencies rounding out the session in a talk from Huber himself. Detailing his talk, Huber told VS@VAM that he will turn the spotlight on “aneurysms and pseudoaneurysms that are not recognised and treated definitively.” Benjamin Roche

FRIDAY MORNING’S PLENARY

Session 5 (8:00–9:30 a.m.) is set to feature new data on an external support device that may deliver more functional arteriovenous fistulas (AVFs) while also offering an improvement in costeffectiveness. Presenting an abstract on research into the VasQ device will be Ellen D. Dillavou, MD of WakeMed Hospital in Raleigh, North Carolina.

The study explored the support device’s ability to improve functional success in AVF over a 24-month period. Dillavou is set to deliver “the first complete report of the U.S. pivotal comparative study results”, alongside a cost-effectiveness analysis. Over the study, she will detail, 144 patients were enrolled—90% of them receiving a brachiocephalic and 10% a radiocephalic fistula. Some 782 patients treated by

Ellen D. Dillavou

the same surgeons without the VasQ device immediately before enrollment in the trial were identified as a comparative group, with their Medicare claims data utilized for comparison. Statistical comparison was then performed between the groups with regards to primary patency—defined as freedom from intervention—as well as functional success (continuous use for dialysis after 30 days) and post-creation reintervention. Payor cost was taken into consideration alongside each of these outcomes.

“Primary failure of 7.9% for VasQ AVF patients compared favorably to the 22% to 32.2% reported in contemporary U.S. meta-analyses,” the study authors report, while the cumulative patency for the VasQ device of 76.7% (95% confidence interval [CI]: 67.7–83.4%) was found to be “superior to contemporary metaanalyses,” which the authors say report between 53.7% to 63% for standard AVFs. There was a “nearly 50% reduction in access interventions” with the device at six months, which the authors argue led to the annualized cost reduction they found of US$7,764.19 per patient year.

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FRIDAY/SATURDAY SCHEDULE AT-A-GLANCE

Complication: Current Strategies in Hemodialysis Access

ES: Evolution of the Modern JVS

Young Surgeons Section: Welcome to the First Five Years of Practice – Things we Should All Know

Modulating

Diversity celebration

THE SVS CELEBRATED ALL OF ITS members at the inaugural Celebration of Diversity Reception last night.

In previous years, many specific groups held smaller receptions while at VAM, including young surgeons, women and many others, including alumni groups. For this year, SVS organizers decided to instead combine many into one.

“In the past, the Women’s Networking Reception was held as an extension of the ‘Women’s Committee,’ a designation that preceded the current Women’s Section,” said Audra Duncan, MD, one of the founding members and current chair of the Women’s Section.

“The reception became so popular, that it was typically difficult to enter the packed room at the venue. So, the reception evolved into larger and larger rooms, and the invite list became broader to capture the wide audience that was interested in attending,” she said.

“It is breathtaking to see the large audience at this reception compared to the handful of us in a room 20 years ago, and to know we are gathering with so many other VAM members.”

Compiled by Beth Bales and Marlén Gomez

OPTIMIZING THE CLINICAL ENVIRONMENT

AMERICA’S FACE IS CHANGING, BECOMING MORE DIVERSE, AND with more women and immigrants in the country, medicine and the vascular surgery specialty.

Raghu L. Motaganahalli, MD, of the Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, presented both the barriers and pathways to success in “Mitigating Barriers to Inclusion and Advancement in Academic Surgery: International Medical Graduate (IMG) Perspective. His presentation was part of an educational session on “Optimizing the Clinical Environment: Learning & Practicing with Intent and Inclusion” Thursday afternoon.

“I am an immigrant vascular surgeon and believe we add value to our specialty,” he said straightforwardly, at the start of his presentation.

The U.S. includes more than 2.8 million foreign-born healthcare workers from a wide range of countries. Top countries of birth are the Philippines, Mexico, India, Jamaica and Haiti.

In 2021, U.S.-born doctors represented 60.1% of residents and fellows in ACGME-accredited programs; DOs made up 16.9% and international medical graduates made up nearly 23%. IMGs in 2021 represented 17.5% of the vascular surgery workforce.

Some challenges in getting hired include concerns about standardized training, including school reputation and accreditation; perceived language and cultural barriers and visa requirements, he said.

Both systemic intervention and individual actions can help mitigate exclusion. IMGs who want to advance in academics should “choose the right environment, surround yourself with people who want you to succeed and supplement your environment with the necessary resources to succeed.”

Presidential handover

THE ANNUAL BUSINESS MEETING (for members only). The results of the justcompleted SVS election of officers (vice president and treasurer) will be announced at the meeting, which will also feature reports from officers and others, presentation of awards and the passing of the gavel—and the SVS presidency—from Michael C. Dalsing, MD, to Joseph Mills, MD. The meeting, from 12–1:45 p.m. Saturday, closes out VAM 2023.

Last hours to bid on Gala Auction items

A NIGHT OF GRANDEUR, reminiscent of the parties hosted by the fictional character Jay Gatsby, awaits attendees on Friday night at the “Great Gatsby Gala,” benefiting the SVS Foundation. Gala tickets are sold out, but bidding will continue for everyone regardless of VAM or Gala attendance. More than 50 items are available, including weekend excursion packages. The Gala Silent Auction will close at 8 p.m., allowing individuals from around the globe to participate.

TRAUMA ‘Excellent’ limb salvage rates for trauma bypass performed by vascular surgeons

REVASCULARIZATION FOR

extremity trauma can be performed with excellent limb salvage rates, though poor compliance with long-term surveillance raises some cause for concern. These are among the primary messages to be presented from a study detailing the experience and outcomes of a rural, level one, trauma center performing upper- or lower-extremity revascularization in trauma patients over a 20-year timespan, in which investigators sought to identify bypass failure modes and surveillance protocols.

Vascular surgery resident Misak Harutyunyan, MD, will present the analysis during this morning’s Plenary Session 7 (8:00–9:30 a.m.) in Potomac A/B, on behalf of the Albany Medical College vascular team, including senior author Jeffrey Hnath, MD, and submitting author R. Clement Darling, MD. The Albany team posits that long-term outcomes in civilian trauma patients requiring upper- or

TRAINEE PERFORMANCE

lower-extremity revascularization has been poorly studied, secondary to limitations of certain large databases and the nature of the patients in this specific vascular subset.

Their dataset offers up insights from 223 revascularizations performed between January 2002 and June 2022. Of these patients 161 (72%) had lower and 62 (28%) upper extremities. The Albany team reports an operative mortality rate of 4.5% (n=10), all involving lower-extremity revascularization. Thirty-day non-fatal complications included immediate bypass occlusion in 11 patients (4.9%), wound infection in 7 (3.1%), graft infection in 6 (2.7%), and lymphocele/seroma in 5 patients (2.2%).

All major amputations (13, 5.8%) were early and in the lower extremity bypass group, the study’s authors report. Late revisions in the lower- and upper-extremity groups were 14 (8.7%) and 2 (3.2%) respectively.

Although the study’s authors are set to report that revascularization for extremity trauma can be performed with excellent limb salvage rates, demonstrating longterm durability with low limb loss and bypass revision rates, they also sound a note of caution over poor compliance with long-term surveillance.

“The poor compliance with long-term surveillance is concerning and may require adjustment in patient retention protocols,”

A NATIONAL COHORT STUDY OF VASCULAR TRAINEES TAKING THE Vascular Qualifying Examination (VQE) and the Vascular Certifying Examination (VCE) found performance during the former is “not predictive” of first-time pass achievement in the latter—but, the findings highlight the “[necessary]” identification of trainee competency measures that may predict certification examination failure.

Speaking to VS@VAM ahead of her presentation on Saturday, Libby Weaver, MD, from University of Virginia Health System in Charlottesville explained that their results may have stemmed from the two examinations testing distinct competencies.

Given board certification is associated with better quality of care, and that training programs must demonstrate high rates of first-attempt pass by their graduate candidates to maintain accreditation, Weaver noted this result indicates we must “find a marker to better identify candidates at risk [of failure]”.

In a follow-up study looking at Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings—a means of formative assessment of trainees—Weaver et al convey how these are seen to be a “highly predictive” indication of ability to pass board certification examinations. Specifically, medical knowledge and patient care competencies strongly predict performance on VQE, whereas interpersonal communication skills emerge as strongly predictive of VCE performance. This suggests we are “certifying well-rounded vascular surgeons and maintaining a high-quality standard within our specialty”, Weaver noted.

To this end, Weaver intends on furthering this research against a backdrop of the emerging evidence which has found a correlation between board certification and quality of care.

The current study’s senior author Brigette Smith, MD, University of Utah Health, Salt Lake City, is presently researching how Milestone ratings ultimately predict quality of care, ensuring outcomes in practice are reflective of assessment of trainees. “If we are able to make that connection it would be a huge advancement in surgical education,” Weaver commented.

47th ANNUAL

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Libby Weaver

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midwestvascular.org

VAM THROUGH THE LENS » 23

Day two at VAM 2023 saw highlights including the inaugural Frank J. Veith Distinguished Lecture, a packed house for the introduction to vascular surgery for medical students, and lively discussion of two of the biggest trials in vascular surgery of the last 12 months— BEST-CLI and BASIL-2. Away from the educational program, the exhibition opened its doors for the first time, offering an opportunity to learn about the latest developments from industry partners.

“Frank J. Veith’s accomplishments in the vascular surgery community are enormous”

MICHAEL C. DALSING

VAM delegates have had the opportunity to socialize with colleagues and friends over the last few days, including at the SVS Connect@VAM event on Wednesday evening. Taking place outdoors, attendees were able to enjoy the warm June weather and views across the Potomac river.

FRAILTY STATUS BEATS WIFI SCORE AS MORTALITY PREDICTOR IN ALL-COMER CLTI STUDY

A study presented during Thursday’s Plenary Session 3 concluded that the Wound, Ischemia, and Foot Infection (WIfI) stage is predictive of major amputation at one-year follow-up in patients with chronic limb-threatening ischemia (CLTI), while frailty status is a better predictor of mortality. The researchers also found that, at baseline, WIfI classification is associated with both frailty and disability but not quality of life (QoL).

By Jocelyn Hudson

SUBMITTING AND PRESENTING

author John Houghton, MD, a National Institute for Health and Care Research (NIHR) academic clinical lecturer at the University of Leicester in Leicester, England, opened his talk by noting that the WIfI classification system has been widely adopted in CLTI management; however validation has predominantly been among patients undergoing revascularization. The present study, therefore, aimed to investigate the association of WIfI stage with baseline frailty, disability, and QoL, in addition to one-year major amputation and survival, in all-comers with CLTI.

Outlining the study methods, Houghton noted that the research team performed a single-center prospective cohort study of patients aged ≥18 with CLTI, who were enrolled in the study between May 2019 and March 2022. He noted that frailty, disability and QoL assessments were performed at baseline, with an interim analysis of one-

year outcomes performed in January 2023.

The presenter continued that amputation incidence was calculated for WIfI stages, and individual WIfI score combinations with ≥5 patients, and presented as percentages with 95% confidence intervals (CI).

Houghton, who presented this study on behalf of senior author Rob Sayers, professor of vascular surgery at the University of Leicester, and colleagues, detailed that a total of 432 patients were included in the research. He shared that 52 patients (12%) classified as WIfI stage 1, 112 (25.7%) stage 2, 107 (24.8%) stage 3, and 93 (21.5%) stage 4. There were 69 patients (16%) who had incomplete WIfI scores.

Sharing key results with the VAM audience, Houghton reported that increasing WIfI stage was associated with increasing prevalence and severity of frailty (p=0.003), and greater disability (p<0.001). He added that QoL scores, however, were similar for each WIfI stage.

In addition, the presenter revealed that major amputation incidence at one-year follow-up was 2% (95% CI, 0–11) for WIfI stage 1, 7% (95% CI, 4–14) for stage 2, 8% (95% CI, 4–15) for stage 3, 20% (95% CI, 13–30) for stage 4, and 16% (95% CI, 9–27) in those patients with incomplete WIfI scores. It was specified that amputation incidence for individual WIfI scores was largely consistent with stage classification.

Houghton further reported that increasing WIfI stage was independently associated with one-year major amputation (subdistribution hazard ratio [SHR], 1.99; 95% CI, 1.33–2.97, p=0.001), and was also associated with one-year mortality (HR, 1.31; 95% CI, 1.03–1.67; p=0.029). Frailty (clinical frailty score ≥5; HR, 2.18; 95% CI, 1.26–3.76; p=0.005) and non-operative management (HR, 4.42; 95% CI, 2.63–7.41; p<0.001), the presenter stated, were found to be the strongest predictors of mortality at one year.

“These results from the Leg ischemia management collaboration (LIMb) study provide further validation of the utility of the WIfI score in classifying patients with CLTI by risk of major amputation at oneyear,” Houghton told VS@VAM ahead of his presentation. “These data are particularly useful as all not all patients presenting with CLTI require, or are suitable for, revascularization but most of the published data on the WIfI score come from patients undergoing intervention. The LIMb patient cohort is a representative sample of CLTI patients and nearly 25% of patients included were initially managed conservatively. The finding that both frailty and disability were associated with increased WIfI stage highlights both the vulnerability of this patient population and the potential benefits of successful revascularisation, but the lack of association of WIfI score with quality of life is counter-intuitive and warrants further exploration.”

Racial disparities persist in lower-extremity

revascularization

outcomes for Black patients, study finds

Research findings highlight the persistence of unequal treatment outcomes for Black patients with peripheral artery disease (PAD).

Such disparities often are attributed to sociodemographic factors. However, Dana B. Semann, MD, presented research that adjusted for socioeconomic status in a propensity-matched analysis of comorbidities and socioeconomic factors affecting Black patients who have worse outcomes after lower-extremity revascularization.

The research aimed to investigate the impact of socioeconomic status, specifically using the area of deprivation index (ADI), on the outcomes of lower extremity bypass (LEB) and peripheral vascular intervention (PVI) procedures for Black and non-Hispanic white (NHW) patients.

Researchers utilized Vascular Quality Initiative (VQI) datasets from 2016 to 2021, to identify patients who underwent the two procedures. They analyzed 44,968 PVI and 12,006 LEB procedures after matching patients based on comorbidities, ADI, indication, urgency and the number of arteries treated (PVI) or graft target (LEB).

The primary outcome measured was the absence of major adverse limb events (MALE) at one year. The

findings revealed higher rates of MALE at one year for Black patients in both procedure groups. Adjusted analyses indicated that Black patients with chronic limb-threatening ischemia (CLTI) faced a higher risk of MALE at one year for both procedures than their NHW counterparts. “Despite adjusting for socio-economic factors using the validated ADI, Black patients with PAD have worse outcomes following revascularization, especially for CLTI, suggesting that other factors adversely affect outcomes in these patients.,” Semaan concluded. “These unmeasured factors require further exploration to improve PAD outcomes in Black patients.”

Discussant Olamide Alabi, MD, raised concern about the high number of amputations in Black and Brown communities that comorbidities cannot explain and asked the audience to consider the reasons for this.

“In other words, what are we missing, what social and political determinants of amputations have not yet defined and what role does implicit bias play on the Black/white racial disparity that’s seen in major amputation among those with PAD?” asked Alabi.

Semaan said future studies should measure the implicit bias among vascular surgeons and primary care physicians and determine if such bias impacts patient outcomes.

The study’s results underscore the persistent challenges in achieving equitable health care outcomes and highlight the importance of addressing racial disparities in PAD, said Semaan. The findings call for continued efforts to identify and understand the factors contributing to these disparities, intending to develop targeted interventions and strategies to improve PAD outcomes for Black patients.

John Houghton

Dana B. Semann

Young surgeons and surgeons in private practice take the stage Friday for sessions geared specifically to their members’ interests and needs.

The Community Practice Section holds its educational session, “Recognizing, Enhancing and Promoting the Value of the Vascular Surgeon,” will be from 1:30–3 p.m. today in Maryland A. Topics run the gamut of introducing new programs to members’ hospitals, a vascular surgeon’s financial value— always a source of interest and concern for vascular surgeons—and talking with hospital top administrators.

Talks are: “Ancillary value of the vascular surgeon for the healthcare system and hospitals,” “Financial value of the vascular surgeon for the healthcare system and hospitals,” “Introducing TCAR or PERT to your hospital,” followed by a panel discussion.

Final talks of the afternoon are: “Enhancing your practice with advanced practice providers (APPs): Effective strategies to consider,” “Whether to get an MBA” and “Gaining access to C-suite: Talking and negotiating with hospital administration,” followed by a panel discussion of relevant concerns.

Section leaders then will present the Excellence in Community Practice Award, which recognizes an individual’s sustained contributions to patients and his or her community, as well as exemplary professional practice and leadership.

Members of the Young Surgeons Section will host “Welcome to the First Five Years of Practice—Things We Should All Know” from 3:30–5 p.m., also in Maryland A.

Topics cover many issues important to surgeons just starting out after training, including presentations on pursuing research or private practice and how these younger surgeons can make themselves known in the vascular surgery world.

Talks include: “Finding the right practice for you and advice on switching your practice,” “Branding yourself as a vascular surgeon,” and “Managing relationships with industry.”

Also: “The business side of a vascular surgery practice,” “Life planning for a vascular surgery career” and “How to build a clinical research program.” A 30-minute panel discussion will complete the program.

SPECIAL SESSIONS FINANCES Booth No. 527 Booth No. 717 Booth No. 503

“ONE IN FOUR PHYSICIANS IN THEIR SIXTIES HAVE LESS THAN $1 MILLION IN NET worth, and about 12% have less than $500,000, which is pretty pitiful if you think about the amount of immediate salary for physicians, and as vascular surgeons, it can be a little bit higher,” emphasized Danielle C. Sutzko, MD, in her presentation, “It’s Never Too Soon: Early Planning for Your Financial Future.”

Sutzko attributed these figures to the extended duration of physician education, which often delays income. Factors such as student loans and societal expectations of a doctor’s lifestyle further contribute to the financial challenges faced by vascular surgeons. She emphasized the distinction between income and wealth, stressing the need for calculating net worth as a more accurate indicator of financial stability.

The presentation was part of the Women’s Section Educational Session, “Financial Literacy for the Vascular Surgeon.” Moderator, Audra Duncan, MD, began the session by expressing a commitment to providing gender-neutral content applicable throughout a vascular surgeon’s career.

“We’re trying to create topics that will be meaningful to both women and men, and we thought that this year, financial literacy would be a great topic to discuss,” said Duncan.

The session discussions left moderators and attendees wishing for more time to address the audience’s questions. Duncan emphasized the key takeaway of the session was understanding one’s fair market value and the significance of familiarizing oneself with relative value units (RVUs) and their definitions within the specific institution. Duncan also highlighted the importance of negotiating effectively, discerning negotiable aspects and recognizing the

Danielle C. Sutzko takes the VAM podium

Thank You SVS Industry Alliance Partners!

The Society for Vascular Surgery would like to thank the following companies for their support of the 2023 Vascular Annual Meeting and participation in the SVS Industry Alliance Program.

Booth No. 917 Booth No. 517 Booth No. 711 Booth No. 611 Abbott Shockwave Medical Philips Janssen Pharmaceuticals, Inc. 3M Health Care Cook Medical Advanced Oxygen Therapy Inc.

VAM ATTENDEES CHIME IN ON BEST-CLI

AND BASIL-2

VS@VAM journalist Will Date and videographer Jean-Philippe Bensoussan catch some VAM 2023 foot traffic outside the BESTCLI and BASIL 2: Debate, Analysis and Implementation session to get their take on the two trials and how it has impacted their practice.

FIRST UP SVS SECRETARY AND vascular surgeon William Shutze, MD with Texas Vascular Associates in Plano, says he is staying a familiar course.

“These are two really amazing, important trials that just came out this year that have profoundly affected the care of vascular patients. And it’s very exciting that the results have been published. At the same time, even though the overarching conclusions appear to be different, the way that I have interpreted these trials is it’s reinforced a lot of my own personal biases in the care of vascular patients. “I strongly favor bypass surgery for patients that are healthy and have a good quality vein. However, for patients that fall outside of those parameters, it demonstrate the superiority of endovascular techniques and limb salvage.”

Nicolas Mouawad, MD, chief of vascular and endovascular surgery at McLaren Bay Region in Bay City, Michigan, says the two trials offer much food for thought.

“The long-awaited BEST-CLI and then BASIL-2, which I saw when they gave the information at Charing Cross,. I must say it really has confirmed and validated my current practice. We want to keep [intervention] as minimally invasive as possible, but if you have single-segment great saphenous vein in

IMAGING TECHNOLOGIES

complex patients with CLTI, then I generally would offer a bypass.

“BEST-CLI is really an opportunity to compare best surgical therapy versus endovascular care. However, with BASIL-2 coming out, this has given us a little bit of a different perspective from what we saw in BEST-CLI. Unfortunately, I think it keeps the waters a little bit muddied, but for me in my current practice, it really just validates what I currently do.”

Lee Kirksey, MD, vice chair of vascular surgery at Cleveland Clinic in Cleveland, Ohio, peripheral arterial disease (PAD) care is about offering the most appropriate care for the individual patient.

“What BASIL-2 as well as BEST-CLI really highlight is the importance of looking at this heterogeneous group of patients with PAD in a more granular fashion. We know that systemic risk of the operation, the patient’s anatomic complexity, the lesion complexity—all of these things should influence and impact how we manage the patients.

“I really look at BEST-CLI and BASIL-2 as highlighting the importance that we need to tailor therapy to the patient in front of us, using all the best available grading classifications, the GLASS scale for anatomic complexity, the WIfI scale in terms of the patient

presentation, and then select the appropriate therapy. Really, it endorses the need for teambased care so that we have expertise within endovascular therapy, expertise within open surgical bypass. Sometimes there will be some hybrid component of those therapies and we offer the most appropriate therapy for that patient in front of us.

For University of California Los Angeles (UCLA) chief of vascular surgery Vincent Rowe, MD, a BEST-CLI site investigator, diagnosis and screening come to the fore.

“For me, the most important lesson was the outcome the outcome of the patients. I knew that patients with lower extremity disease had a high rate of mortality at four

to five years. I didn’t realize it was this high— and even in those treated with endovascular therapy. So that was shocking to me. And I believe it means we’re going to need to try to diagnose these patients earlier. I think we should start screening these patients. I think it will save lives. And then I also believe that it will really help us be able to combat that low survival rate.

“To know that a patient that I operate on either with a stent or a bypass has a low probability of being there in follow up at five years makes me work even harder because, even though they may not be there in five years, I want them there with their leg until they close their eyes.”

Future research needed to ‘optimize’ use of imaging technologies during aortic procedures

IMAGING TECHNOLOGIES IN THE AORTIC SPACE will be a key feature of Saturday’s Plenary Session 8 (11:15 a.m. to 12:30 p.m.) in Potomac A/B.

Valeria Mejia-Martinez, BS, a medical student at the University of Texas Southwestern Medical Center in Dallas, is due to deliver a presentation on the feasibility and benefits of target vessel catheterization with Philips’ Fiber Optic RealShape (FORS) technology using upper extremity (UE) versus transfemoral (TF) access for fenestrated/branched endovascular aneurysm repair (F/BEVAR).

In order to achieve their study objective, the research team conducted a single-center retrospective study with prospectively collected data.

They included data from 74 patients who underwent F/ BEVAR with FORS guidance for target vessel catheterization during an 11-month period. Among 370 navigation tasks reported, the researchers note that 350 (94.6%) were performed with FORS.

The presenter is due to share at VAM the result that technical success was 90.3% and that mean time required to deem

the catheterization as a failure was 8.4±5 minutes. She will also communicate that UE access, steerable sheath, and FORS catheters were used in 54.3%, 17.7% and 13.7% of cases, respectively.

Mejia-Martinez will conclude that F/BEVAR with FORS technology is feasible using both UE and TF access and facilitates artery catheterization with ac ceptable technical success and potentially reduced radiation. However, she will stress that further experience is required to “optimize the use of FORS during F/BEVAR”.

Later in the session, Nicholas G. Hoell, MD, integrated vascular resident at the Cleveland Clinic in Cleveland, will speak on the use of Centerline Biomedical’s electromagnetic IntraOperative Positioning System (IOPS) as a 3D imaging adjunct in EVAR based on the results of a safety and feasibility study.

Top: Carlos H. Timaran and

On behalf of senior author Francis J. Caputo, MD, associate professor and program director at the Cleveland Clinic,

Hoell will share the results of a study that aimed to demonstrate the safety and efficacy of the electromagnetic-based IOPS in providing guidance for accurate wire and catheter navigation as an adjunct to fluoroscopy during thoracic endovascular aortic repair (TEVAR), FEVAR and EVAR.

Hoell will detail that 30 patients with aortic aneurysms suitable for TEVAR, FEVAR and EVAR were enrolled across two sites in the U.S. from 2020 to 2022.

The presenter is set to conclude that the electromagnetic-based IOPS is safe and effective in providing adjunctive 3D guidance for wire and catheter manipulation in infrarenal and fenestrated endovascular abdominal aortic aneurysm repair.

He will, however, underline the fact that future research is needed to investigate the potential for IOPS to reduce radiation exposure to patient and operator, reduce contrast usage, and reduce operative time while providing better visualization of complex anatomy.

Clockwise from top left: William Shutze, Nicolas Mouawad, Vincent Rowe, Lee Kirksey

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