Vascular Specialist May 2020

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How to be a doctor at the end of the world

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Dispatches from the vascular front: Surgeons in profile

4 Pandemic response SVS leaders respond to pandemic: Remains nimble, pivots to member priorities Vol. 16 • No. 5 • MAY 2020

Aspirin combined with rivaroxaban significantly lowers adverse events in PAD patients after revascularization

SVS Town Halls seek to help steer members out of choppy COVID-19 waters

BY ANGELA O'NEILL

T

See VOYAGER PAD · page 4

BY BRYAN KAY

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he vascular world has gone through a dramatic change. The normal to which vascular surgeons had become accustomed has vanished almost overnight. As the realities of the approaching COVID-19 pandemic have begun to crystalize, the Society for Vascular Surgery (SVS) started to set the stage for what was about to re-arrange the specialty for some time to come.

Among the first SVS maneuvers was to set in motion

Vascular Specialist 9400 W. Higgins Road, Suite 315 Rosemont, IL 60018

reatment with aspirin plus rivaroxaban following lowerextremity revascularization in patients with peripheral arterial disease (PAD) leads to a 15% reduction in the risk of major adverse limb and cardiovascular events when compared with aspirin alone.

The VOYAGER PAD study was presented at the American College of Cardiology/World Congress of Cardiology’s virtual scientific sessions (ACC.20/WCC Virtual)—originally scheduled to take place March 28–30 in Chicago—and simultaneously published in the New England Journal of Medicine (NEJM). It found that a twice daily dose of 2.5mg rivaroxaban plus low dose aspirin is associated with significantly lower incidence of the composite primary efficacy outcome of acute limb ischemia, major vascular amputation,

a series of Town Hall events covering the many implications for vascular specialists. The virtual arena quickly became a platform for meaningful dialogue, dealing with the immediate clinical implications for vascular procedures. Becoming a weekly event, the Town Halls have tackled such issues as impact on education and training, and the safe practice of the vascular lab. As the series details, what awaits vascular surgery on the other side of the pandemic is delicately poised.

See Town Halls · pages 6–7

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FROM THE EDITOR

COVID-19: How to be a doctor at the end of the world

BY MALACHI SHEAHAN III

Malachi Sheahan III is the Claude C. Craighead Jr. professor and chair in the division of vascular and endovascular surgery at Louisiana State University Health Sciences Center in New Orleans. He is the medical editor of Vascular Specialist.

M

y predecessor at Vascular Specialist, Russell Samson, MD, had a gift for writing from experience. Perhaps in fear of being unkindly compared with him, I moved in the opposite direction. My editorials are heavily researched, often for months. I felt that the opinions I’ve earned outweigh those that I simply held. In this piece, however, I will abandon the shelter of research and offer the lessons I have learned from a few unique experiences.

First, a review of my apocalyptic bona fides. In the 1990s, I was a surgery resident in Greenwich Village, the East Coast epicenter of the AIDS crisis.

In 2001, I was part of the early rescue efforts at Ground Zero in New York City. Finally, in 2005, I spent a week in University Hospital after Hurricane Katrina. For about a decade, I felt like the Forrest Gump of American catastrophes. From these experiences, I humbly offer lessons I have learned on how to be a doctor when everything falls apart.

Lesson 1

Family first: On Aug. 27, 2005, my mother-inlaw approached me. In her thick French accent she announced, “Mal, we are leaving.” She and my father-in-law had been staying with us in New Orleans and helping care for our newborn. I turned to the news she was watching intently. A hurricane that had just hit Miami was regaining strength in the Gulf of Mexico. In New Orleans, there had been a few recent false alarms, could this time be different?

I should note here that my mother-in-law is a force of nature, equal parts wondrous and terrifying. As I watched her stare at the strengthening storm, I thought, “Maybe game recognizes game?” I decided to stay and work, and send my wife and child with my in-laws. In retrospect, this was the best thing I could have done for my patients.

In the aftermath of Hurricane Katrina, University

VASCULAR SPECIALIST 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 Hans-Henning Eckstein, MD, John F. Eidt, MD, Robert Fitridge, MD, Dennis R. Gable, MD, Linda Harris, MD, Krishna Jain, MD, Larry Kraiss, MD, Joann Lohr, MD, James McKinsey, MD, Joseph Mills, MD, Erica L. Mitchell, MD, MEd, FACS, Leila Mureebe, MD, Frank Pomposelli, MD, David Rigberg, MD, Clifford Sales, MD, Bhagwan Satiani, MD, Larry Scher, MD, Marc Schermerhorn, MD, Murray L. Shames, MD, Niten Singh, MD, Frank J. Veith, MD, Robert Eugene Zierler, MD Resident/Fellow Editor Laura Drudi, MD Executive Director SVS Kenneth M. Slaw, PhD Director of Membership, Marketing and Communications Angela Taylor Managing Editor SVS Beth Bales

2 • VASCULAR SPECIALIST

–Hospital was in dire condition. No power, no water, no sanitation, no lights. The backup generator was in the basement, now inconveniently under 12ft of water. Caring for the hundreds of patients would require an intense, concerted effort. Ventilator-dependent patients would have to be manually bagged around the clock. The overwhelming majority of the doctors and nurses in the hospital worked tirelessly. For some, though, the pull to leave, find their families and check on their homes was irresistible. Without cell towers or news sources, the only way to confirm their fears was to abandon their post and risk the rising floodwaters.

This same scenario played out in other hospitals around the city. While it would be weeks before I could see my home, at least I had the peace of believing that my wife and child were safe.

Lesson 2

Look for the person in charge; if you can’t find them it’s probably you: The problem with unprecedented disasters is that they are unprecedented (I guess the disaster part isn’t great either). It can be very challenging to figure out who is in charge. People often look to the Federal Emergency Management Agency (FEMA) for guidance. FEMA’s mission statement is “Helping people before, during and after disasters.” In reality,

FEMA is sometimes ill-equipped to carry out early rescue operations after a catastrophe. They would see that as the job of the local authorities. When the local personnel are overwhelmed, next in line is probably the National Guard. Unfortunately, I have seen this process fail in person. Twice.

On Sept. 11, 2001, New York City firefighters, police and first responders began rescue efforts almost immediately after the first plane struck World Trade Center One at 8:46 a.m. By the time the south tower started to unexpectedly collapse at 9:59 a.m., most of the local command team were on-site. A total of 403 police, firefighter and emergency personnel were killed when the towers fell, including most of the people in charge. FEMA set up its control center several miles north and was not present for the early rescue attempts. At the location of the collapsed towers, which we called “The Pile,” different groups tried to reorganize the rescue efforts. Ostensibly, the New York City Fire Department was in charge; but on the scene, it was clusters of medical and emergency personnel without any central leadership.

On Aug. 29, 2005, Hurricane Katrina decimated the infrastructure of New Orleans. The wide swath of destruction meant that aid would have to come from far outside of the storm’s path.

Most of the early rescue efforts were led by the Louisiana Department of Wildlife and Fisheries, as well as private citizens with airboats. Conflict and communication problems between the state and national authorities delayed a coordinated attempt for nearly a week. Michael Brown, then director of FEMA, later admitted it took the federal government days to grasp the scope of the problem.

Lesson 3

Truth, fiction and my wife’s friend who knows someone who works at City Hall: A recent email told me that if I can hold my breath without

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MAY 2020

FROM THE EDITOR coughing for 30 seconds, I don’t have COVID-19.

Reassuring and, of course, nonsense. And this was sent by a physician.

After Katrina, with the city flooded and in complete darkness, anything seemed possible.

Reports of beatings, rapes and murders at the Superdome were rampant. Our own mayor amplified these claims. Similar rumors spread through the hospital. Our junior residents heard from the nurses that a sexual assault had occurred in OR 3. Even after we determined this was a fabrication, the damage already had been done.

People were spooked, and everyone began to look suspicious.

Lies and misinformation spread quickly during disasters, mainly because they seem possible. As doctors and leaders, it is our job to debunk the myths and have a coherent plan for organizing and sharing information. Failure to communicate creates a void easily filled with rumor. Better to share actual bad news. It is often better than what people will come up with on their own.

Interlude A

The Coca-Cola conundrum: When society’s rules crumble, it is important to have a code. There were times after Katrina when it seemed that we might be abandoned. Some of our patients would die slowly and painfully without rescue. Drastic measures may have to be taken. Could euthanasia be considered? But what if help was imminent? No one wants to go full “Lord of the Flies” just as the Navy arrives. Over- or underestimating the severity of a situation can lead to terrible decisions.

The day after the hurricane, our surgical team was in the OR lounge, trying to create an accurate inpatient census. The sub-specialty doctors were gone; we would have to combine all the patients into one surgical service. Temperatures were over 110 degrees in the hospital. Someone mentioned being thirsty. The mid-level surgery resident eyeballed the soda vending machine in the corner, then looked over at me. Electricity had been knocked out long ago. Coins would be of no use.

He wanted to take a crowbar to the machine. No, I said, it had only been 36 hours. We weren’t going to start destroying private property like animals.

Two days later, we were back in the same lounge, our situation now made worse by time and deteriorating conditions. Again, the resident wearily pointed toward the soda machine. As I nodded, he smiled and produced an orthopedic instrument that resembled a Dark Ages nightmare. He made quick work of the machine’s casings, and the entire team enjoyed a round of delicious—albeit quite warm— soda. He had even saved a lime from the cafeteria to cut into wedges. After all, we weren’t animals.

Lesson 4

Be cautious, not afraid: September 1994. The patient was young, younger than me. Maybe 20? His AIDS-defining illnesses were apparent, his vision dimmed from Cytomegalovirus (CMV) retinitis, his breath rasping from the pneumocystis pneumonia— Kaposi’s sarcoma lesions covered his body. That’s why we had been called. The lesions were necrotic and bleeding. I needed to debride and oversew them at bedside. As I approached the wounds with a #10 blade, my hand trembled. I thought the movement MAY 2020

was imperceptible, but my chief resident pulled me back and looked directly into my eyes. “This man has AIDS.” he told me. “Not HIV, AIDS.” He spoke calmly and softly so that only I could hear him. The message was clear: Cutting myself could be fatal. I needed to be careful, not fearful.

Fear is contagious, especially when it comes from authority figures. When I’m flying and we hit a bad patch of turbulence, the flight attendants are my barometer. If they look chill, then I’m not worried.

But if they look a little freaked, then you better believe this $8 mini bottle of chardonnay is about to get crushed.

Patients obviously look to physicians for comfort.

They want to know that we are in this together.

Try to be comforting even when you don’t have any answers. The most common question patients asked me after Katrina was when will they be rescued. I always replied, “I don’t know, but before me.”

Lesson 5

The trainees are vital: University Hospital only lost three patients in the week after Hurricane Katrina, two of whom were terminal. This despite a lack of power and running water. Community hospitals in the region lost 10 times as many. I credit this difference to the residents. While the militaristic nature of our surgical teams may not always be ideal, it is incredibly efficient in times of crisis. After Katrina, patients could be rescued via airboat from the emergency room (ER) ramp or via helicopter from the roof. Rescue personnel were under orders not to enter the hospital. The doctors would have to get the patients out. Many couldn’t walk and would have to be carried up eight or nine flights of stairs. The prevalence of obesity among the non-ambulatory was not trivial. Since everyone on the team had clearly defined roles, difficult tasks were performed expediently. No patients were left behind. And all the doctors got to enjoy a nice hot Coke afterward.

Interlude B

Cloudy—with a chance of extinction: As I prepared to leave our home and head to the hospital before the storm, I decided that I should secure our valuables. I then had the depressing realization that we didn’t actually own any valuables. Maybe my hard drive? Better preserve that minor amputation draft for posterity. Just before unhooking the computer, I decided to check the forecast. I guess I thought it would be “funny.” I visited one of the weather sites, which usually would have said something like, “Highs tomorrow in the 80s with a 30% chance of afternoon thunderstorms.” Well, not this time: “Most of the area will be uninhabitable for weeks… perhaps longer…the majority of industrial buildings will become non-functional. All wood-framed, low-rising apartment buildings will be destroyed. High-rise office and apartment buildings will sway dangerously…a few to the point of total collapse. All windows will blow out…persons…pets…and livestock exposed to the winds will face certain death…power outages will last for weeks…water outages will make human suffering incredible by modern standards…”

Hmm, I thought: So yes to the umbrella?

Lesson 6

Maintain routine: During an emergency, people tend to run around putting out fires. At University Hospital, we tried to continue our routine, even when it seemed absurd. We were low on food, the air was poisonous with sewage, and, worst of all, someone had stolen my deodorant. Still we charted, checked vitals, and continued the mundane. As our ability to care for the patients became compromised, there was a powerful desire to disconnect from them.

One woman developed a gastrointestinal bleed we could not control. We tried to prioritize her rescue. Every night the nurses would seal her chart in plastic so it wouldn’t be ruined in the transfer. No rescue ever came, though. Seemingly unable to face this horror, the nurses just kept her chart sealed, waiting for the escape that would never happen.

Every morning, we would break the seal and resume her charting. It wasn’t right, it wasn’t fair, but we had to force ourselves to face our reality.

Lesson 7

This too shall pass: With the clarity of history, events seem much more self-contained than they were experienced. In the mid-1990s, AIDS seemed uncontainable, and widespread transmission of the virus to the general population appeared to be probable.

After 9/11, another attack seemed imminent.

Working at Ground Zero, when the rare military plane passed, it was terrifying. Rescue workers covered their heads and ducked.

On Aug. 31, 2005, FEMA declared New Orleans unsafe for further rescue operations. The airboats and helicopters stopped coming. The governor called for a day of prayer. We were alone.

At University Hospital, hundreds of people were still left in rapidly deteriorating conditions. Outside, the water continued to rise mysteriously, long after the rain had subsided. Inside, the heat and humidity were overwhelming. Human waste was left unattended in the halls and stairwells. Most of our team started sleeping on the roof, where the air seemed slightly less toxic.

On the morning of Sept. 2, we were awakened by a massive explosion in the southern sky: a chemical plant, I later learned. As the mushroom cloud dissipated, the morning sun began to illuminate the city. Untended fires were burning in buildings throughout the city.

Looking down, the floodwaters—which had once been clear enough that I could see a large catfish swimming in the parking lot—were now black and slick like oil. Finally, I allowed myself to feel the doubt I had seen in the eyes of my patients. Maybe we wouldn’t be getting out. New Orleans had been leveled by wind and drowned in flood. And now it was on fire.

Though the feeling had barely a moment to fester as the sky was soon filled with Chinook helicopters—or double whirlies as I referred to them before I conducted a Google image search while preparing this. The impasse between the state and federal governments had resolved. The National Guard was here. Finally.

We don’t always know when the sun will rise.

To be a good doctor, sometimes you just need to believe it will.

VASCULARSPECIALISTONLINE.COM • 3

NEWS FROM SVS

SVS remains nimble in face of pandemic, pivots to focus on priorities and needs of membership

BY BETH BALES

T

he Society for Vascular Surgery (SVS) started 2020 with plans intensifying for the Vascular Research Initiatives Conference (VRIC) in May, the Vascular Annual Meeting (VAM) in June, the launch of the branding initiative and a host of other SVS priorities.

Within eight weeks, COVID-19 had prompted a rapid, decisive pivot to SVS members’ changing and urgent needs. Members faced an upended practice landscape, with elective surgeries banned and financial concerns growing.

SVS president Kim Hodgson, MD, and executive director Kenneth M. Slaw, PhD, moved swiftly to work with leadership to address members’ pressing needs. Four essential principles are being followed: Listen and communicate: The important first response involved ears.

“We knew that the most important thing was to listen and establish communications with those on the frontlines,” said Hodgson.

In a few days’ time, SVS increased the frequency of the Pulse electronic newsletter to weekly. Through the leadership of SVS secretary Amy

KIM HODGSON

KENNETH M. SLAW

Reed, MD, more immediate critical items were posted to SVSConnect.

A members’ resources page on the SVS website provides important information on a host of topics.

Hodgson instituted a series of Town Halls on topics members deemed critical. The Town Halls incorporate polls that highlight member concerns.

Legislative staff has closely tracked news and responses from Washington, D.C., highlighting the emergency COVID-19 legislation, waivers and the federal financial responses.

Rebalance priorities: The branding initiative has been a top SVS priority.

A launch aimed at referring physicians was planned for the spring with a formal introduction at VAM. That has changed. “We’ve completely shifted our priorities for this project to developing resources for the member toolkit,” said Slaw.

Nothing has been abandoned but simply re-tooled for the time being, added Hodgson.

Members of the Program and Postgraduate Education committees

VOYAGER PAD Continued from page 1

myocardial infarction, ischemic stroke or death from cardiovascular causes than aspirin alone.

On the principal safety outcome of Thrombolysis in Myocardial Infarction (TIMI) major bleeding, there was no significant difference between the therapies. However, rivaroxaban plus aspirin was associated with a significantly higher incidence for the secondary safety outcome of International Society on Thrombosis and Haemostasis (ISTH) major bleeding.

Marc P. Bonaca, MD, a cardiologist at the University of Colorado Anschutz School of Medicine, Aurora, Colorado, outlined the findings as part of a late-breaking session. He explained that the risks of major adverse limb and cardiovascular events are high in patients with PAD who have lower-extremity revascularization, but there is uncertainty about how effective and safe rivaroxaban is in this context.

The double-blind trial randomized 6,564 patients with PAD who had undergone revascularization to receive either rivaroxaban 2.5mg twice daily plus aspirin (n=3,286) or placebo plus aspirin (n=3,278).

Baseline characteristics were well balanced across the two groups, with median age 67 years, and 26% of patients were female. Risk factors were common: 4 • VASCULAR SPECIALIST

40% of patients had diabetes mellitus, 20% had an estimated glomerular filtration rate less than 60ml per minute per 1.73m2 of body-surface area, and 35% were active smokers at randomization. Some 31% had known coronary artery disease and 11% had previous myocardial infarction. The primary efficacy outcome occurred in 508 patients in the rivaroxaban group and 584 patients in the placebo group. Three-year Kaplan-Meier estimates of the incidence were 17.3% in the rivaroxaban arm and 19.9% in the placebo arm (hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.76–0.96, p=0.009).

“In symptomatic peripheral arterial disease after revascularization … in this population and in this setting, rivaroxaban 2.5mg twice daily with aspirin compared to aspirin alone significantly reduces this risk.”—Marc P. Bonaca

already are planning to present some of the canceled VAM material online.

“Our top two priorities are improving the quality of patient care and supporting our members,” he said.

Plan ahead and be nimble: In late 2020, Slaw anticipated that at some point a situation could require the entire staff to work remotely. He took advantage of the holiday calendar and all staff worked away from the office on two separate days. “Our staff was already practiced and disciplined,” he said. “Everyone is functioning well in the virtual world and continuing to meet members’ needs.”

Keep planning for the future: Noting that members are worried about furloughs, Slaw noted: “When the crisis subsides, a crush of patients will come back for delayed procedures. Planning is critical. Organizations need to be conservative and strategic in resource management, but not get into a position where you can’t respond to an opportunity when this crisis is over.”

The same holds true for the Society.

“Our focus over the last several weeks has been to position the Society to come out of this in the best possible shape,” said Hodgson.

The incidences of the first five secondary outcomes in the testing hierarchy were all significantly lower in the rivaroxaban group than in the placebo group, including the incidence of unplanned index limb revascularization for recurrent ischemia (HR 0.88, 95% CI 0.79–0.99, p=0.03). All-cause mortality was not lower in the rivaroxaban group than in the placebo group (HR 1.08, 95% CI 0.92–1.27, p=0.34).

There was no heterogeneity in the efficacy of rivaroxaban plus aspirin as compared with aspirin alone for the primary outcome across major subgroups, including those based on age, sex and cardiovascular risk factors.

TIMI major bleeding occurred in 62 (2.65%) patients in the rivaroxaban group and 44 (1.87%) patients in the placebo group (HR 1.43, 95% CI 0.97-2.1, p=0.07.). Intracranial hemorrhage occurred in 13 patients in the rivaroxaban group and in 17 patients in the placebo group (hazard ratio, 0.78; 95% CI, 0.38 to 1.61). Fatal bleeding occurred in six patients in each group.

Summing up, Bonaca said: “In symptomatic peripheral arterial disease after revascularization … in this population and in this setting, rivaroxaban 2.5mg twice daily with aspirin compared to aspirin alone significantly reduces this risk.”

SOURCE: DOI: 10.1056/NEJMOA2000052 MAY 2020

SVS TOWN HALLS

‘Desperate times require desperate measures,’ maiden SVS Town Hall hears

BY BRYAN KAY

T

he contentious issue of the limited availability of personal protective equipment (PPE), and what this means for performing procedures, was given a robust airing during the first Society for Vascular Surgery (SVS) Town Hall, which focused on the early experiences of COVID-19.

Some of the most forceful arguments were delivered by Benjamin W. Starnes, MD, professor and chief in the division of vascular surgery at the University of Washington, Seattle, who drew on a surgical example to highlight why vascular specialists needed to carefully consider what procedures they were going to perform.

His colleague, professor and associate chief Niten Singh, MD, received a patient with a ruptured aneurysm who required open repair, Starnes explained. Afterward, the patient’s left colon died following which further procedures were required, culminating in a myocardial infarction and the placement of a coronary stent—and now palliative care. Multiple providers were in contact with the patient throughout the hospital, Starnes said.

“We can’t do these types of operations,” he continued. “We’re doing the emergencies the best we can. But we have got to get the picture here, and that is conserve PPE.” The Town Hall panel, convened on March 27, consisted of an experienced group of vascular surgery leaders, and was co-moderated by SVS president Kim Hodgson, chair of the division of vascular surgery at Southern Illinois University School of Medicine in Springfield, Illinois, and Alan Lumsden, MD, the medical director of Houston Methodist DeBakey Heart & Vascular Center in Houston. Starnes has been at the vanguard of the vascular response to COVID-19, operating in, as Hodgson described Washington state, North America’s “ground zero” for the virus.

“We all have this sense of denial,” said Lumsden, responding to the picture painted by Starnes. “Once you’re in the middle of it, you get it. But trying to communicate what you’re communicating right now to people who are on that early phase of the curve— we all hope we’re not going to get where you are—but the reality is you’re right; we need to start conserving [PPE] now.”

In practice

Starnes elaborated on his team’s current practice as part of an answer to a question from Lumsden on what is done when confronted with a case of deep vein thrombosis (DVT), the incidence of which, the DeBakey chief noted, appears to have increased.

“In terms of our hybrid operating room, we’re trying to reserve it unless it’s absolutely needed,” he said. “We will try to use other operating rooms for any of these procedures. Last week, we had an open repair of a ruptured AAA and a gunshot wound 6 • VASCULAR SPECIALIST

to a carotid. Those were easy to do in a different operating room and reserve the hybrid operating room.”

Lumsden asked whether Starnes had been using a portable C-arm in such non-hybrid settings.

“We haven’t been operating,” Starnes said. “We have canceled probably two dozen complex aortic cases in the last month. We are following those cases, by the way—not only the aneurysm cases but the critical limb-threatening ischemia patients.

We’re going to find out who loses a life and who loses a leg. These are desperate times, and desperate times call for desperate measures.”

The panel were posed the question of what vascular-specific complications surgeons were seeing in light of COVID-19. Starnes highlighted DVT: “Some of these patients are hypercoagulable and they’re developing DVTs—and they need to be treated with anticoagulation. But that causes

an issue with all of the ultrasound techs in your lab who are going to be doing these DVT studies.

That’s the only vascular complication of COVID infection that I’m aware of.”

New York

New York soon became the epicenter of COVID-19 in the U.S. Darren B. Schneider, MD, chief of vascular and endovascular surgery at Weill Cornell Medical College and director of the Center for Vascular and Endovascular Surgery at New York Presbyterian Hospital in the city, joined the Town Hall panel to provide a snapshot of the frontlines.

He said his team had implemented much the same protocol as Starnes described in Seattle.

“For more than a week we haven’t done any elective cases, not even so-called urgent elective, and it’s only true emergencies that are life or limb

threatening that we’re doing,” Schneider explained.

“We have completely closed our vascular lab—no inpatient or outpatient vascular lab studies.”

The role of vascular surgeons in his hospital are shifting, Schneider continued. “Because we have to preserve PPE, facilitate physical and social distancing in order to try to the blunt the epidemic, which is out of control in New York.

“Our role is only to provide essential vascular services and now we’re being tapped for other roles. At one of our peripheral hospitals, one of the faculty members is now working in the ICU [intensive care unit] as an intensivist because they have a shortage and all their ICUs are full.”

SVS president Hodgson, meanwhile, highlighted a suggestion from China to limit vascular labs to one room when they can’t be carried out bedside, saying: “What are you doing to clean that room after each case?”

To which Lumsden responded by raising the point of the environmental services responsible for cleaning imaging, hybrid and operating rooms.

“They are really put out to task at the moment— that’s one of the reasons we’re going to try to avoid using our hybrid room if at all possible and switch over to a regular room,” he said.

The panel also included SVS president-elect Ronald L. Dalman, MD, professor and chairman

of vascular surgery at Stanford University School of Medicine in Stanford, California, who addressed the re-usability of N95 masks. “There’s a couple of different proposals,” he said.

“There’s a heat-based proposal and the other is more of a disinfectant … we’re doing some work right now to see if we can validate some of those recommendations. I think the one that is thought to be most effective right now is heat-based. I’m not recommending anybody do this but there is a potential for exposing it to heat or steam or some other form of heating that may allow for reutilization of N95 masks.”

The other panel members were Thomas Forbes, MD, chairman and professor of vascular surgery at the University of Toronto, Canada, and Daniel McDevitt, MD, president and CEO of Peachtree Vascular Specialists in Atlanta.

MAY 2020

SVS TOWN HALLS

Leadership figures ruminate on redeployment of vascular surgeons during viral surge

BY BRYAN KAY

F

or a time, it was an issue increasingly knocking on the door of program directors and section chiefs in hospitals across the country as COVID-19 cases escalated in their areas: the redeployment of vascular surgeons and trainees to other areas of care.

It formed a central plank in a discussion over education, training and wellness during the second in the Society for Vascular Surgery (SVS) virtual Town Hall series (April 3) designed to help the specialty through the worst ravages of the coronavirus crisis.

Amy Reed, MD, professor and chief of the division of vascular surgery at the University of Minnesota in Minneapolis and SVS secretary, made the case that vascular fellows be “last in line” as general surgery residents and trainees are picked off to staff up for coming surges in COVID-19 cases.

“From a faculty standpoint, I’m sure most of you have been asked to say what else can you do besides vascular surgery—if you’re critical care-boarded, or can you staff an ICU [intensive care unit] and be an attending for a period of time," said Reed.

“Many of us have put our names in to be available for that should that come into play. For fellows and trainees, if you have not been asked about this by your institution, your department of surgery and GME [graduate medical education] office, you likely will be. We’ve essentially taken the stance that our fellows are the last in line for this.”

SVS president and moderator Kim Hodgson, MD, chair of the division of vascular surgery at Southern Illinois University School of Medicine in Springfield, Illinois, concurred, adding: “But the interesting thing to me is that the hospitals more or less own the residents and fellows, don’t they? Because they pay their salaries. So is this a hard fight to win?”

Reed responded “last in line” isn’t a position usually adopted, further explaining that general surgery program directors tend to understand the

rationale behind such a designation. “Already our surgical residents were pulled from our service, and we said, ‘Okay, you’re just going to leave us with the fellow and the faculty.’ I think everyone understands that. We can’t have a ruptured aneurysm come in and just be functioning with an APP [advanced practice provider] and a faculty.”

Co-moderating, Alan Lumsden, MD, the medical director of Houston Methodist DeBakey Heart & Vascular Center in Houston, explained how some of his residents had been recruited as scribes for infectious disease consultants—the first instance they had been asked to provide support that was not vascular-related.

Dawn M. Coleman, MD, program director for the integrated vascular residency program and fellowship at the University of Michigan in Ann Arbor, described a situation in her department where residents, faculty and members of the APP force are being primed for side-by-side redeployment “As our hospital prepares for a full surge of COVID care, while the vascular emergencies are

“We've been navigating issues of resident redeployment and where they're going to be strongest suited, and, for some of our trainees, that may be in the critical care unit”—Dawn M. Coleman still continuing to come in—and, to be honest, we have been busier than ever—there’s a pressing need at a hospital level to use our workforce to its fullest capacity,” said Coleman, also a member of the SVS Education Committee.

“We’ve been navigating issues of resident redeployment and where they’re going to be strongest suited, and, for some of our trainees, that may be in the critical care unit. We have surgical residents sitting side by side with the faculty staffing these pop-up ICUs. We also have individuals with COVID-related concerns, who are high risk, or have vulnerable families at home, so we’re really looking for guidance on how to use them most effectively.”

Gilbert R. Upchurch, MD, chair of the

Telemedicine receives shot in arm from events set forth by COVID-19

BY BRYAN KAY

U

nintended consequences of COVID-19 are likely to pop up in an untold number of ways.

Perhaps one of them could be the more widespread use of telemedicine.

That was one of the key messages delivered in the fourth of the SVS Town Halls series titled “Telemedicine MAY 2020

platforms and their use in the COVID-19 era,” held on April 17 (see commentary on page 10).

Outlining the sheer number of people struck by the virus— including thousands upon thousands of healthcare professionals—comoderator of the Judith Lin, MD, chair of the SVS Health Information Technology Task Force, set the tone

department of surgery at the University of Florida College of Medicine in Gainesville and chairman of the Vascular Surgery Board, returned to the original point made by SVS secretary Reed.

“We cohorted our residents about 10 days ago, as well as our fellows,” he said. “I agree with Amy [Reed] that the vascular fellows, the cardiothoracic fellows and the plastic surgery fellows, etc., have a skillset that serves typically on their own service.

A fellow and attending can take on almost any challenge.”

That was a position initially taken up in Houston, but vascular surgeons are “easy pickings”—ripe for being pulled in to provide other modes of care, Lumsden said. “When bodies are needed, all of a sudden they look to the surgery services, and go: ‘We’re not doing any surgery; you’ve got half your residency program sitting at home. Oh, by the way, we need them.’”

Upchurch agreed the day would come when they would be turned into critical care doctors or a line service, but settled on the point of vascular surgeons as acute care surgeons. He ended with a sobering picture of colleagues operating on the frontlines in one of the worst-hit parts of Europe: “Even in Italy, my friends tell me COVID-19 presents with a vasculitis; they’re managing lots of embolic—and thrombolic complications of the lower extremities in particular,” he said.

Financial impact scrutinized

It's the cudgel ominously hanging over vascular surgical practice: that of the prospects for their very survival amid the financial fallout from the pandemic. In that vein, during the third in the SVS Town Hall series on April 10, a panel delved into the widespread economic impacts for vascular practices—particularly those in private practice.

The mood was captured by co-moderator Daniel McDevitt, MD, in his opening remarks. “Up until a few weeks ago, I don’t think any of us would have expected to be here talking about saving our surgical practices from economic disaster, yet here we are,” said the president and CEO of Peachtree Vascular Specialists in Atlanta.

“It’s amazing how much our world has changed in a short time,” added McDevitt, chair of the SVS Community Practice Committee. “How and when will we be able to catch up on the backlog? Many of us are wondering how we can continue to earn a living.”

by saying: “This pandemic is real.

“In Detroit, we have certainly seen the upsurge, the devastation and the demise among patients and healthcare workers. Using telehealth may be a key modality to help fight against COVID-19 while we take care of our patients, conserve PPE [personal protective equipment] and protect healthcare workers to minimize the risk of spread.

“Perhaps the COVID-19 outbreak could finally make telemedicine a mainstream modality of healthcare

delivery in the United States.”

Meanwhile, the Federal Communications Commission COVID-19 Telehealth Program recently announced it would provide $200 million in funding, “appropriated by Congress as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act,” in order to help healthcare entities provide connected care services to patients at their homes or mobile locations in light of the COVID-19 pandemic.

VASCULARSPECIALISTONLINE.COM • 7

COVID-19 IN PROFILE

Dispatches from the vascular surgery frontlines

BY BRYAN KAY

screaming, shouting, playing music and clapping. It’s very moving.”

A

Consequences of COVID-19 for a Florida private practice

lmost overnight, the world changed. Normal life and the globe’s economic engines ground to a halt at the hands of the COVID-19 pandemic.

Vascular surgery quickly followed suit. Outbreaks in hotspots spread across North America saw elective procedures ebb, leaving on the slate emergent cases only. The vascular community was confronted with a new reality: From busy, robust healthcare professionals at the forefront of medical care, across the continent vascular surgeons were largely reduced to threadbare service. Many faced severe financial consequences. Trainees were forced to re-tool for education and training. The specter of re-deployment loomed for others. In response, Vascular Specialist is collecting the stories of those on the vascular front, telling the pandemic stories of surgeons as they lived them.

Here is a snapshot from various points on the pandemic timeline.

A view of COVID19’s impact on hard-hit NYC

Sharif Ellozy, MD, had just about as near to a front row seat as it gets to the part of the United States worst-hit SHARIF by the COVID-19 ELLOZY pandemic—short of operating as an intensive care unit (ICU) or emergency room doctor.

The Weill Cornell Medicine vascular surgeon operates in the heart of New York City, from where he has watched on as the coronavirus wends its way through the population.

Like many colleagues in the vascular specialty, Ellozy has been deployed in support roles, coming closest to the front when providing aspects of care such as line services.

The burden and exposure, of course, is carried by the likes of ICU physicians, says the associate professor of clinical surgery in the division of vascular and endovascular surgery.

“The role of vascular surgeons is to support the people who are really the frontline people,” Ellozy—also a co-founder of the popular vascular surgery podcast, Audible Bleeding— told Vascular Specialist. “The people who are at the front of this are really the intensive care doctors, the 8 • VASCULAR SPECIALIST

NAVY HOSPITAL SHIP USNS COMFORT DOCKED IN NYC

emergency medicine doctors, the anesthesiologists.

“From our standpoint, all of our elective practices have been postponed. What we are doing at my institution, means our main interaction is with the line services. So we are providing things like vascular access for the patients that need it. There are so many patients, the intensivists don’t have the capacity to do all the lines; they’ve got so many other things to do.” Other procedures carried out, noted Ellozy, include instances of acute limb ischemia and ruptured aneurysms.

Some colleagues have been redeployed. “Two of our partners have been re-assigned to ICU; our vascular fellows have not been re-assigned yet; the residents are running on a weekend schedule,” he said.

In any given system across the patchwork of hospitals in the five boroughs, the outbreak is being handled in varying ways, Ellozy explained. “Every hospital has a different set-up. One of my friends is at Mount Sinai [Hospital]. He’s a vascular surgeon but he’s not really working as a vascular surgeon. What happens is they go out and help out where they can throughout the system. He has been working in an ER [emergency room] in Brooklyn.

It’s all hands on deck.”

At Weill Cornell, said Ellozy, there was positive news on the personal protective equipment (PPE) front as his institution did well to preserve precious supplies.

On the other side of the pandemic, as the outbreaks begin to wane and elective procedures re-enter the fray,

he expected to see a deluge of cases.

“A lot of people aren’t coming to the hospital out of a certain amount of fear among the general population because of the possibility of getting sick,” Ellozy said. “We may see a real surge in the amount of cases coming in once this has resolved.”

Meanwhile, he noted, in many instances enterprising trainees took deficits in their education into their own hands. “The one thing I think is really exciting is they’re really working on ways to supplement their education. We started going to remote learning using the Zoom platform.

We’re seeing a lot of places where you have three or four residencies logging on to the same conference— there’s a lot of interaction with these other places—that is really one of the unexpected benefits. And it’s driven in large part by trainees themselves.

Maybe that’s one of the things that comes out of this: collaboration across programs.”

The reinforcement of a vascular adage—that of the resourceful surgeon redolent of the specialty, from veteran to resident—is one of Ellozy’s chief takeaways from the crisis. “Vascular surgeons tend to be for the most part pretty resourceful and anticipatory, and also want to make an impact, and I have been very impressed with how people want to jump in and help out,” he mused. “It’s been very heartening.”

Both that and the public’s support for frontline healthcare professionals: “Every day at 7 p.m. in New York City we have this situation—even though we’re sheltering in place—where people open their windows and start

The impacts of the COVID-19 pandemic landed like a sledgehammer on VASANA vascular surgery, CHEANVECHAI reducing much of practice to a standstill. For those in private practice, the effects have perhaps been even more profound, with practitioners forced to all-but pull down the shutters, reduce staff hours and even let employees go.

No one needs to tell that to Fort Lauderdale, Florida, vascular surgeon Vasana Cheanvechai, MD. For the solo practitioner of Lauderdale Vascular and her team, the knock-on effects were manifold—the timeline brisk.

Based on her strict understanding of the guidelines, Cheanvechai brought her practice to a near close, with the financial implications seeing all but one member of a six-strong staff—an ultrasound tech—let go.

“We had our first positive COVID case reported March 9—at that point there were three people who tested positive in our county,” Cheanvechai—19 years into her practice—explained of the situation as it started to unfold locally in Broward County, which neighbors Miami-Dade County, another of the hardest-hit areas in the United States. “Then by the next week, I had cut down my practice to less than half because, with a vascular population, they tend to be over 60—and we wanted to keep those vulnerable patients over 60 at home. By the 16th, my practice pretty much shut down completely.”

The flow of directives from government authorities accompanied the quickly developing situation felt on the ground at Lauderdale Vascular.

“Starting March 16, it was first suggested that elective procedures be postponed—then Florida’s governor made an executive order March 23 that all non-emergent, or non-life threatening or limb-threatening cases, should be postponed until May 8,” Cheanvechai continued. “This forced a lot of practices to close down or significantly reduce volumes.”

It quickly became apparent just how far-reaching the financial impacts were likely to be as Congress worked MAY 2020

COVID-19 IN PROFILE on legislation to aid the economic devastation. “It’s been difficult to navigate,” Cheanvechai said. “Around the 30th [of March] I heard about the SBA [Small Business Administration] economic injury disaster loan program [EIDL], which was $10,000 as a grant that would go towards payroll and other expenses.”

As that piece of the pie disseminated by the federal authorities wound its way across the country, the sands continued to shift. Cheanvechai received the EIDL grant cash over deep into April—though not at the level initially anticipated.

Other forms of financial aid remained elusive, Cheanvechai noted, describing a chaotic process by which, for instance, the government's Paycheck Protection Program (PPP) could be accessed.

“I was scrambling around trying to find a bank that would take me in case Wells Fargo wasn’t going to be able to provide the PPP,” Cheanvechai explained. “I found one lender in Michigan but I wasn’t sure because I hadn’t heard of the bank before. I found another, a small lender here in town, who originally said they would take me if I opened up an account with them, but then later they emailed me and said they could no longer take anyone who wasn’t a previous account holder. Then, by the Monday, I was able to find another lender where I have some personal accounts, and they said I could apply through them if I opened a business account.”

She added: “It’s hard—it really is a hard thing to go through. Especially as—we as surgeons—we tend to think that there is nothing we can’t do.”

Early steps beyond COVID-19 peak in Seattle

If Seattle and the state of Washington provided the vascular care KIRA NICOLE blueprint for LONG how to proceed once the COVID-19 pandemic started to spread out to other parts of the country, it might also hold clues for what follows as the virus begins to wane.

Kira Nicole Long, MD, watched on as the region became North America’s ground zero for the virus.

And she’s had a front-row seat as the coronavirus peaked in the region, recently giving way to a slowly developing new normal.

MAY 2020

“We really lucked out because I think we were all expecting that, in downtown Seattle where I work, we were going to get hit pretty hard because they were so overwhelmed north of us, which is where Kirkland, Overlake and the hospitals that were really getting pummeled are,” she said. “But we didn’t end up taking as many as we expected. We took all the precautions and saw a lot of positive [patients] but it wasn’t nearly as bad as we had prepared for, which is great.”

A key point: Social distancing appeared to work, continued Long.

“People took that pretty seriously here. And at least at my hospital, they did a pretty good job of conserving PPE [personal protective equipment] appropriately and instituting screening checkpoints at every entry.

I don’t think we’re in the clear but fortunately we’re under control at the moment.”

Nevertheless, a snapshot of Long’s caseload both before the coronavirus registered on the radar of her vascular practice and where her burden sits now seems to capture the moment.

“Normally, I’m doing on average close to 1,000 RVUs [relative value units], and now I would say my numbers have been cut at least in half, if not more,” she explained. “When I’m on call, it feels relatively busy with people coming in with ischemic limbs or urgent dialysis problems.

Obviously, we’re not doing elective surgeries; we’ve had a few more urgent things that we’ve been able to get onto the schedule; but I spend a lot of time doing nothing.”

On another note, Long says her hospital followed a set of guidelines that erred close to those put out by Benjamin W. Starnes and his team at nearby University of Washington Medicine: rupturing or rapid-growth aneurysms, critical limb ischemia, symptomatic carotid disease, urgent dialysis access salvage—or on-call cases such as patients arriving with a cold leg, “which, interestingly, did happen a couple of times.”

Now comes the trickle—perhaps at some point turning into a deluge—of patient cases who have been staying away from healthcare facilities out of fear.

“I’m absolutely seeing that already,” Long said. “Mostly, we’re seeing it in limb salvage, or not being able to do limb salvage. We’ve had a few patients come in who have been sitting at home with worsening gangrene or diabetic foot infections, and it’s progressed now to the point where now it’s going to require an

amputation. I have one patient who had a symptomatic carotid, and I was planning to do it. He was like, ‘I’m absolutely not coming in; I’m too afraid.’ I have not heard back from him about how he’s doing, but I’m nervous.”

Long and her surgical partner, meanwhile, did not have their offer to pitch in either in the intensive care unit (ICU) or in critical care taken up—a consequence perhaps of how things played out for her institution in downtown Seattle. So, Long’s cautious optimism goes on for now.

COVID-19 strikes New Jersey like 'tidal wave'

Operating in the shadow of New York City, Clifford M. Sales, MD, has had his finger CLIFFORD M. on the pulse of SALES North America's two worst-affected regions since the scourge of COVID-19 first started to take hold locally. New York's pandemic plight initially captured much of the national headlines. But for Sales, in the nearby environs of northern New Jersey, the narrative of the second hardest-hit hotspot was developing.

“It crept up on us pretty quickly,” recalled the managing partner of the Cardiovascular Care Group and chief of vascular surgery at Overlook Medical Center in Summit, New Jersey. “We watched what was happening in New York, and we were certainly getting ready. Once it started, the best way to way to describe it was as if we were standing on the beach and watching a tidal wave approach, hoping it broke before it got to us.

And then, in a second, it was over on top of us, swallowing us. That would be the best analogy I could give as to what happened.

“As best we could, we prepared,” continued Sales, also clinical assistant professor of surgery at the Icahn School of Medicine at Mount Sinai across in New York.

What perhaps no one was prepared for, Sales said, was the human price— on patients, their families and the medical professionals.

“I don’t just mean the death toll,” he explains. “When we first started out, we recognized that those patients with comorbidities—diabetes, hypertension or obesity—of those that were older were at greater risk.

“But what we didn't expect was a whole cadre of 30- and 40-year-old healthy patients dying in front of

us. We were not ready to deal with the fact banning all visitors from the hospitals would be so difficult for the families, the patients and, quite frankly, the medical and nursing staffs.

The poor families sitting at home not being able to see their loved ones, knowing they were dying; having to talk to a family over the phone about taking someone off life support because there is no chance of them making it. It is hard enough to do face to face.”

There is also a family dimension on the doctor's side of the equation. Sales illustrated the point: “When you as a doctor and a parent enter a room, fully gowned, to place a catheter in a patient whose deadly disease is known to be contagious, it adds a level of stress we have not witnessed since the beginning of the AIDS crisis in the 1980s—and you have children.

“For us as vascular surgeons, the COVID pandemic has not been physically difficult. We have had to put in a catheter for dialysis, for medicines, for monitoring—that’s been pretty routine for us. We really have not done much surgery. But the mental anguish has been exceedingly difficult.”

The vascular role has varied across the seven hospitals in which Sales and his team operate. “We’re really not involved in managing the patients,” Sales explains. “That’s been the job of the critical care doctors who have done a phenomenal job.

“What they needed from our 15-person vascular surgery group was to be technicians—get catheters in—so they could treat the patients the way they needed to be cared for. Our goal was to facilitate the care these doctors were providing.”

Further down the line, as specific vascular complications popped up, his specialists grew more involved. “For example, being very, very liberal in the use of anticoagulation,” he says.

“There seems to be some type of prothrombotic phase associated with the cytokine release stimulated by the virus.”

Away from the COVID-afflicted population, meanwhile, another wave of patients is emerging. “We’re starting to see the patients who have vascular disease and who were staying away from the medical field because they were just petrified of COVID-19,” says Sales. “I saw two patients [recently] who have advanced disease, probably more advanced than it was six weeks ago. I think we’re going to see more complicated peripheral vascular reconstructions than we saw before.”

VASCULARSPECIALISTONLINE.COM • 9

COMMENTARY

Rise of telemedicine: Embracing new definition of healthcare as digital age confronts holdouts

BY PAULA M. MUTO, MD

T

here is no doubt that the COVID-19 pandemic has challenged our healthcare system like nothing before. We have confronted other diseases like influenza, tuberculosis, AIDS and even the opioid epidemic; but we have never before shut down the world economy or put the citizens of the entire country on quarantine. Whatever the response, the consequences will be far-reaching, especially for physicians who will be expected once again to rapidly adopt new technology. Rather than resist, we should take the opportunity to explore how digital healthcare can restore the primacy of the doctor-patient relationship.

Physicians—and surgeons in particular—are always accused of being old school, set in their ways or late adopters. Granted, by definition, doctors are schooled for years to absorb a significant amount of information derived from years of research and clinical observation. It is only when training is completed that we are allowed to veer off the prescribed path and tailor treatment to better fit a patient’s needs.

It is from the patient who “didn’t read the textbook” that we learn most. Therefore, surgeons are actually programmed from the start to adapt to new situations, guided by years of knowledge and experience. How else would we be able to safely use new devices, learn new procedures or prescribe new therapies?

However, over the past decade, we have seen doctors struggle to enter data, write orders or properly document into electronic medical records.

Despite the many generations of physicians who have now “grown up” with technology, rather than getting better, we seem to have gotten worse and electronic health records are still the number one cause of physician burnout.

Part of the reason is that no one ever bothered to ask the physician—or the “end user”—what would mirror our workflow best. Instead, billers and schedulers were given priority; it’s no wonder many companies built electronic records on top of their existing revenue software. Now, with digital healthcare upon our doorstep, we have the opportunity to not just embrace the technology but also decide for ourselves how best to use it for our patients.

Telehealth is not a new concept. The software for secure video conferencing has been around since astronauts first entered the space station. We have been using digital technology to read images from afar, to render second opinions and to connect intensivists to critical care units.

Until now, the average brick-and-mortar surgeon has not had the chance to use it for their own patients. Granted, surgery is a contact sport, and the physical exam is critical to our decision-making— most of the time.

However, a good history and a review of available data is a significant part of any diagnosis, especially in a nonurgent setting. As long as communication 10 • VASCULAR SPECIALIST

exists directly between both physician and patient, why couldn’t a virtual examining room be as effective under the right circumstances?

There is no doubt that telemedicine visits may be less convenient for the physician, and there are challenges for the patients, too—particularly among the elderly population. The concept also requires a different workflow for follow-up care; you can’t simply tell patients: “Check with the front desk on your way out.” But if we work through these issues as end users, we can adapt the technology to fit our needs rather than the reverse, as was the case with electronic records. Digital technology can streamline access, eliminate wasted steps and connect the patient to the proper point-of-care faster.

The cost of running an office will decrease as some office hours become virtual. Thus, more attention can be given either to new patients or to those who have to be seen in person. On the patient side, many would be grateful not to have to leave work, wait in a crowded waiting room for

Once the smoke clears, and the insurers and the Centers for Medicare and Medicaid Services (CMS) start to pay attention, will telemedicine remain reimbursable on a par with in-person visits?

a five-minute follow-up or take up an appointment slot that can be given to a new patient. In addition, remote specialty care can limit transportation costs and challenges for the elderly in long-term care facilities. In other words, the benefits of telemedicine when incorporated into an existing practice may far outweigh the costs.

Which brings us to the challenge: Once the smoke clears, and the insurers and the Centers for Medicare and Medicaid Services (CMS) start to pay attention, will telemedicine remain reimbursable on a par with in-person visits? Or will claims be adjusted for site-of-service? Will physician licensing extend beyond state lines? All of these issues will need to be worked out, but it is important that we remain actively engaged.

The wait times for specialists will only become worse as treatments become more specialized, and after many years of limiting residency positions, it will take just as many years to train enough doctors to meet the demands of the near future.

Direct-to-consumer models are driving medicine toward lower cost/higher value options, and with expanded health savings accounts and new federal requirements for price transparency, physicians have the opportunity to eliminate obstacles and be directly accessible. Digital healthcare enables a stronger doctor-patient relationship. Together we can reinvent healthcare. It is our responsibility not just to be part of the solution, but to lead the way.

Paula M. Muto is a general and vascular surgeon based in the Boston area. She is also CEO and founder of UBERDOC, a web app that connects specialists and patients.

MAY 2020

RESEARCH

Pandemic lessons for vascular care from military ranks

BY BRYAN KAY

A

n exemplar of how surgery can best perform its role amid a catastrophic event like the COVID-19 pandemic can be found in military medicine’s response to the events that occurred on 9/11, according to an editorial written by Todd E. Rasmussen, MD, and Erin E. Koelling, MD, published in the Journal of Vascular Surgery (JVS).

The vascular surgeon tandem, both serving members of the military, outlined the internationally collaborative nature of how the U.S. armed forces went about caring for injured service members.

“While different in scale, military medicine’s response to 9.11.2001 provides insight as to how the surgical profession can optimize its response to the 2020 pandemic,” wrote Rasmussen and Koelling, respectively professor of surgery and associate dean for research at the Uniformed Services University and attending vascular surgeon at Walter Reed National Military Medical Center in Bethesda, Maryland, and assistant professor of surgery and the chief of vascular surgery at the same institutions. “To rapidly attain a capability to care for thousands of injured service members around the world and to make patient

care decisions in austere, resourcelimited situations, the U.S. military relied on international partnerships, expanded its patient care capacity, and implemented data-driven, performance improvement, including practice guidelines.”

The authors referenced a commentary by Seattle-based Benjamin W. Starnes, MD, and Niten Singh, MD, published by Vascular Specialist, which detailed how North America’s COVID-19 ground zero was handling the outbreak. Starnes et al— vascular surgeons at the University of Washington in Seattle—devised a set of COVID-19 vascular guidelines many institutions adapted or followed.

The authors outlined the work of Jun Jie Ng, FRCS, et al, of the National University of Singapore, who broke down the approach their vascular service had taken in the Southeast Asian city-state in a letter published in the JVS. “In order to optimize our effectiveness in this

pandemic, we must put to use strong international partnerships in vascular surgery,” they state.

Additionally, Rasmussen and Koelling noted the guideline-driven approach for vascular care during the pandemic coordinated between the American College of Surgeons and the Society for Vascular Surgery.

Furthermore, the authors also detailed such elements as triage in resource-limited environments.

“Most mass casualty events occur without notice, providing little time for the healthcare system to respond,”

“In order to optimize our effectiveness in this pandemic, we must put to use strong international partnerships in vascular surgery” —Todd E. Rasmussen and Erin E. Koelling

New COVID-19 vascular registry gains IRB approval soon after launch

BY BRYAN KAY

A

new vascular surgery registry launched to leverage key data gathered in the thick of the COVID-19 pandemic—and aimed at helping prepare for the fallout from future outbreaks—has acquired Institutional Review Board (IRB) approval.

With members spread across 30 different countries and most states in the U.S., the Vascular Surgery COVID-19 Collaborative (VASCC): a retrospectively collected prospective international vascular surgery registry, is now ready to begin enrollment.

VASCC is the work of Robert F. Cuff, MD, assistant professor of surgery and integrated vascular surgery residency and fellowship program director at Michigan State University in Grand Rapids, and Max Wohlauer, MD, assistant professor of surgery-vascular at the University of Colorado in Aurora.

Another key piece of the puzzle saw VASCC team up with the Vascular Low Frequency Disease Consortium (VLFDC) led by director Peter 12 • VASCULAR SPECIALIST

Lawrence, MD, and associate director Karen Woo, MD, out of the UCLA department of surgery, Los Angeles. The VLFDC investigates uncommon vascular diseases.

The idea for VASCC grew out of a new WhatsApp group set up by Wohlauer to provide peer-to-peer support for the vascular surgeon community as the novel coronavirus strain grinds the specialty to a virtual halt. “This pandemic is nothing we have dealt with in our careers and for

“That will be what we hope this registry will be able to do for us—to answer some of the questions that are there now as well as the questions we don’t even know we have yet”—Robert F. Cuff

they wrote. “As such, the most important factor in optimizing team performance and patient survival is to do system-wide planning ahead of time. In our experience, no mass casualty triage scenario ever goes perfectly and they are always chaotic.

However, implementing lessons from those who have been through similar events goes a long way to improving success, if or when healthcare providers are faced with such a daunting task. Unlike most mass casualty events, this pandemic has provided a short-lead time for many providers and healthcare systems not yet affected to prepare.”

Concluding, Rasmussen and Koelling commented: “One of Dr. Norman Rich’s favorite phrases regarding military students, trainees and faculty at the Uniformed Services University and Walter Reed is ‘we teach contingency, we must practice contingency.’ As vascular surgeons we have a knack for responding to conditions that evolve quickly and have life-threatening consequences.

In the case of the 2020 pandemic, we should use the tools we’ve developed to adapt and lead in the whole-ofmedicine response to the virus.”

SOURCE: DOI.ORG/10.1016/J. JVS.2020.03.036

the most part people haven’t seen something like this in their lifetimes,” explained Cuff. “As it spread around the world, we noted in the vascular surgery world, along with the other areas of medicine, we were having to make pretty dramatic changes in our day-to-day function.

“Initially, we started off by thinking about what was going to happen with patients who [have their procedures] canceled and have to be delayed because we didn’t know how long it was going to be; we didn’t know when they would get their surgeries rescheduled. Obviously, they were being scheduled for surgery because it was felt there was something that needed to be done fairly soon. So, as we started canceling these cases in our institution, we started looking at it to see what was going to happen if we delayed someone who had carotid disease and was scheduled to have their carotid fixed: Now, we’ve had to delay them potentially months depending on how long this lasts.”

Cuff elucidates what the registry might yield.

“Once all of the dust is settled,” he said, “we’ll go through and see what worked and what didn’t work. What I thought worked in my hospital with 10 patients may not turn out to be the best option when we look at 1,000 patients from around the world.”

To sign up for VASCC, email robert.cuff@ spectrumhealth.org directly.

MAY 2020

NEWS FROM SVS

Implementing change: How adjustments in communication approach helped BEST-CLI trial register on radar

BY KRISTINA GILES, MD

I

had the privilege of interviewing Alik Farber, MD, the division chief of vascular and endovascular surgery at Boston Medical Center in Boston, where he also is associate chair for clinical operations in the department of surgery. Of course, we all know him as one of the national co-chairs for the BEST-CLI (Best endovascular vs. best surgical therapy in patients with critical limb ischemia) clinical trial.

EMPOWERING ACTION

COMMUNICATING FOR BUY-IN:

Q. How did you communicate your vision for the BEST-CLI trial and how did your strategies for communication change over the course of the trial?

A. Communicating the vision is very important as that is how it gets translated into something that can be operationalized. Matthew Menard, MD, and I had the idea for BEST-CLI over a beer but had no idea what this endeavor would entail. We sought advice from Bob Zwolak, MD, then-SVS president, and Ronald L. Dalman, MD, then chair of the Research Council, and, on their advice, contacted the National Institutes of Health (NIH). We brought together an experienced group of experts for next conversations. We partnered with New England Research Institute, a data coordinating center, and reached out to our community of surgeons to garner further support. These communications were difficult because, at the end of the day, I don’t think people believed the trial would get off the ground. So how do you strategize in that situation? The answer to that is complicated.

We knew we needed to show others that we did not waiver in our own beliefs; we had to press forward. Once we were funded, things changed.

The people surrounding us now actually believed that we could pull it off. As such, the dynamic and subsequent communication changed. We adjusted to communicating a vision that was now about trial execution.

communication accordingly. When talking to BESTCLI site investigators, we had to figure out what the issues were at their site and come up with ways to help them surmount any barriers to enrollment.

Q. How was it different when you were talking to key opinion leaders versus someone in the NIH or a different stakeholder?

A. We had to work hard to get key opinion leaders to believe in our vision and in our ability to carry it out. Talking to the NIH was different. When I “cold-called” the acting head of the cardiovascular branch I was shocked she actually took me seriously. The reality is that the NIH has a process in place for evaluating “pitches” from investigators, be it a Nobel Laureate or a first- timer. When communicating with stakeholders, you have to have a sense for their interests and adjust your

Q. Tell me about a situation in your role as chief of clinical operations in which you had to communicate a changing vision. How did you approach this and how was it received?

A. While a member of our hospital’s Value Analysis Committee I asked our chief medical officer if I could try to standardize vendors for our endovascular platforms (including interventional radiology, interventional cardiology and vascular surgery) to decrease costs. Physicians have their own opinions about devices and had no financial incentive to make changes, making starting the conversation difficult. I called a meeting with all

MAY 2020

physician stakeholders and asked them to consider having a conversation about how standardization might help our medical center. I emphasized the importance of having physicians lead this process, given that physicians often are excluded from such conversations. I emphasized their voices would be heard. We went over bucket lists of all devices and identified as a group what were “must haves”; it turned out that there were very few such items. The rest we agreed to treat as “commodities.” Then, we sent out requests for proposals to the vendors.

When those came back, we as a group discussed them and the changes that would need to occur if we were to go with any given company as primary vendor. During this process one of the physicians asked, “What do I get out of this?” I replied, “Satisfaction of doing what is best for the medical center.” In the end we all came to an agreement and found a cost savings of $1.2 million for the institution.

When talking to BESTCLI site investigators, we had to figure out what the issues were at their site and come up with ways to help surmount any barriers to enrollment­—Alik Farber

Q. “The Heart of Change” authors John Kotter and Dan Cohen use the term “empowerment” to describe removing management, system, mind and/or information barriers. Do you have an example of how you attracted interest from a group?

A. After the above scenario, our CMO asked me to chair the Value Analysis Committee. Getting new products and devices into our hospital has been broken for a decade. My administrative partner and I designed a pathway to bring new devices into the facility and continued to look at other opportunities in the operating room to help standardize and decrease costs. I invited many physicians to directly participate in these teams and working groups, thereby helping empower our physicians to make important administrative decisions. This led to significant buy-in for these processes from the physician community.

Q. How have you used feedback to help empower others for change?

A. Feedback is very important and brings up the importance of leadership style. There are multiple leadership styles, each with its own advantages and disadvantages. I learned in business school that to be a successful leader one has to understand what leadership style(s) you feel most comfortable operating in and what leadership style best fits the individual to whom you are giving feedback, not to mention the associated situation. As such, the leader has to be flexible and comfortable navigating through the various leadership styles based on the issue at hand. In giving feedback, you have to understand what style is needed. For example, I generally use a democratic style in divisional discussions. Recently I used a more autocratic style in developing our division’s strategy surrounding the COVID-19 pandemic.

CREATING SHORT-TERM WINS

Q. The leadership book includes this chapter: In successful change efforts, empowered people create short-term wins—victories that nourish faith in the change effort, emotionally reward the hard workers, keep the critics at bay and build

Change continued on page 14

VASCULARSPECIALISTONLINE.COM • 13

NEWS FROM SVS

Change Continued from page 13

momentum. How did you go about using shortterm wins to help drive the BEST-CLI trial efforts?

A. In its execution phase the trial is like a protracted battle to get it successfully completed. I recently read about a special forces operative who talked about the five-minute rule used in battle: soldiers are taught to think only in five-minute increments.

Looking at BEST-CLI and what was needed to get it accomplished has always been overwhelming.

All along, we have been breaking it down into manageable components. For example, every site visit was a new challenge and we found new ways to make wins at various sites. At one struggling site I encountered a physician, reported to be the site’s busiest, who told me he believed in bypass and therefore did not see a need for BEST-CLI. I told him that the trial presented an opportunity to show

the potential supremacy of bypass and therefore was the very reason why we needed him to enroll his patients. This clicked for him and the site then increased its enrollment. This was one five-minute period in the BEST-CLI battle at that site. Shortterm wins—in aggregate—led to bigger gains. As the trial draws to a close, I appreciate the many five-minute intervals that have led to our current position of starting to see some light at the end of the tunnel.

Q. How do you overcome setbacks that threaten to block progress?

A. With setbacks, you have to take a look at the grand vision. In this vein, you have to take a step back, look at the big picture and then reorganize in order to try to get a win. Specific to BEST-CLI, there were some sites that we could not get to enroll no matter how hard we tried to help them.

However, we helped turn the tide in many other sites.

Q. Any final anecdotes that you feel relates to this process overall?

A. At our hospital, we had a problem with only 40% of our first cases starting on time. I was volunteered to try to fix this problem. The chair of anesthesia showed me a two-page list of surgeons who were late and causing the issue. I told him this was learned behavior, that the surgeons stopped coming on time because cases were seldom ready to go when they were supposed to. We created a working group, crafted staggered starts, identified stakeholders in this process, assigned responsibilities to every group and got buy-in. Ultimately, we improved our first-case starts to 85%. This was a valuable primer for operationalizing an important process for our operating room.

Kristina Giles is assistant professor of surgery in the division of vascular surgery and endovascular therapy in the University of Florida College of Medicine in Gainesville.

Kim Hodgson. “Nothing can ever replace the energy and collegiality of a live VAM, and some education will always be best delivered live, but as we consider the new reality we may be living in, some material lends itself well to virtual delivery.”

Obtain more information about the VAM cancellation at vsweb.org/VAM. Presidential letter

View of Toronto, where VAM 2020 was set to be staged next month

VAM 2020 canceled, summer interactive forums planned

BY BETH BALES AND BRYAN KAY 14 • VASCULAR SPECIALIST

C

iting the health and the safety of SVS members, constituents and their patients as its chief concern, the SVS Executive Board on April 9 canceled the 2020 Vascular Annual meeting in Toronto as a live event.

The decision was made after monitoring the current trajectory and impact of COVID-19 in the United States and Canada, as well as the likely aftermath for SVS members in the months to follow the peak wave.

The SVS Program and Postgraduate Education committees are creating a series of programs built from the meeting’s science and educational offerings. These will be delivered via interactive online forums over the

“Nothing can ever replace the energy and collegiality of a live VAM”­— Kim Hodgson summer. Details on SVS ONLINE (Optimizing Novel Learning In A New Environment) will be available later in the spring.

“While everyone regrets having to cancel VAM this year, this gives us a unique opportunity to explore alternative educational formats and content delivery,” said SVS president

In an early communique, Hodgson had informed members that the uncertainty of the pandemic would ask much of them.

“While vascular surgeons are not, at least initially, on the frontlines of this war, we have to accept that how we respond to this threat may impact the ability of our medical colleagues to both win this war, and do so without compromising their personal safety,” he wrote. “Regardless of the site of service or the approach, our procedures consume resources.

So when you are asked to only do emergencies, as many of us will be, please, make us all proud.”

Hodgson spoke of the troubled waters confronting the specialty. “But vascular surgeons are battle-tested leaders, not just on the frontlines, but in critical supporting roles; wherever we are we lead. We are all in this together and there is no reason to be learning this alone,” he said.

“Take comfort in knowing that your SVS is a solidly built bridge spanning these troubled waters, testimony to the wisdom of those who came before us and the investments that have been made, and that we will continue to advocate for the interests of all vascular surgeons and their patients as we cross over to the postCOVID-19 side.”

MAY 2020

COMMENTARY

COVID-19: Specialists socially distant yet never more close for the sharing of news, articles and meeting other vascular surgeons around the world.

A great advantage of this platform is that it e certainly live in interesting times—times tends not to be too time-consuming yet incredibly in which social distancing has literally helpful in connecting by topic. Facebook has a longbecome the new normal. COVID-19 came standing history of use and continues to serve as a to the United States quietly and then hit like a brick, platform where we can lean on each other in public creating a national emergency. It is almost difficult or private. LinkedIn provides an online professional to remember what it was like to live in the times platform. Newer additions in the time of our new that came before: Politely declined family events normal include conferencing communication tools or get-togethers with friends are but distant and SHERENE SHALHUB NICOLAS MOUAWAD such as Zoom. We have used it in the past for vague memories. As a busy vascular surgeon, one is research meetings—and now for large and small frequently involved in so many roles that barely any for many of the same reasons that preoccupied our social gatherings. time is left for self-reflection or family and friends. past lives. In these times of crisis, maybe you want In addition to SVSConnect, the Society for Then there is the time that we live in now—a to vent, are scared or worried—maybe you know Vascular Surgery (SVS) leadership of president Kim period of crisis that has forced some of the world’s of things that could help others. We should be Hodgson, MD, and executive director Kenneth population to slow down while others have become here for each other—indeed, we are here for each M. Slaw, PhD, along with the SVS Executive busier than ever. other. Peer-to-peer support is essential. More than Committee, rapidly rolled out a program of virtual Social distancing refers primarily to physical ever before, we find ourselves in a position where SVS Town Halls as the COVID-19 pandemic took distancing. The goal of public health during an we need to connect. We realize that even though hold in the U.S. (see cover story). epidemic is to contain any contagion before it we are physically isolated, we don’t have to be The first session, convened on March 27, was progresses rapidly into what we are unfortunately emotionally or socially isolated. entitled, “The impact of COVID-19 on clinical experiencing currently: a pandemic. Even worse, These are difficult times; we don’t have to go practice,” and led by Hodgson and Alan Lumsden, this pandemic is unprecedented in our lifetimes, through this alone. We find ourselves willing to MD, along with Benjamin W. Starnes, MD, continuing to grow exponentially. The president-elect Ronald L. Dalman, MD, public health measures put forth are Daniel McDevitt, MD, and Thomas achieved by aggressively promoting Forbes, MD. social distancing and density reduction The second session followed on in an effort not just to mitigate but April 3 under the theme, “The impact suppress the outbreak. of COVID-19 on education, training And so, in this surreal upside-down and wellness.” This session included now in which we exist, we have hit Hodgson and Lumsden as co-moderators upon a silver lining in amongst our once more, along with Rabih Chaer, MD, new norms in the form of blossoming Dawn M. Coleman, MD, Amy Reed, friendships among our professional MD, and Gilbert R. Upchurch, MD. Both colleagues. of these sessions proved immensely These formal and informal peer-tosuccessful, quickly attracting more than peer connections have created a forum 4,500 viewers across the livestreams of in which to share our institutional the events and then additional views later experiences, celebrate little wins, and across social media platforms such as confront our anxieties and fears.

Facebook, YouTube and Twitter.

It has been remarkable to realize In the times of now, this new normal just how interconnected we have we are currently living through is always been—and also how we are something to which we are all continuing Peer-to-peer support is essential. More not alone. We have learned that to adapt. As vascular surgeons, we are than ever before, we find ourselves in a relying on each other in real time is busy. We have always been busy. We will not only soothing psychologically, but continue to be busy. position where we need to connect translatable to real clinical benefits But this crisis has given us with real-time learning so that we moments for pause amid our usually may continue to serve our patients bustling schedules, allowing time for and communities the best we can. learn how to use new communication platforms. reprioritization of all that is important. As we We have tackled challenges of all shapes and These have quickly proliferated to fill the void tap into our stores of resiliency and experience, sizes: From learning together how to avoid bringing created by social distancing. An example is the and new emotions of grief and anger, we will be the virus back to our families, and designating WhatsApp Vascular Surgeon COVID-19 group traveling through these times together, looking changing spaces in our homes, to sharing largecreated by Max Wohlauer, MD, of the University forward to the future. scale, hospital-applicable protocols such as the of Colorado, in the early days of the pandemic It is our hope that in the times that come after Vascular Surgery Readiness Condition. reaching the United States. Within five days of its COVID-19, we will continue to maintain our peerWe have shared our evolving hospital COVIDinception, 256 vascular surgeons from 24 countries to-peer support networks and remain connected 19-specific practices and kept up in real time with were actively sharing stories, worries, ideas, more than ever. the changes sweeping through our vascular surgery information, guidelines, protocols and techniques. workforce. We have realized that it is safe to show Multiple social media platforms are being used by Sherene Shalhub is associate professor of surgery in the our humanity as we detail our frustrations. We have vascular surgeons, including SVSConnect, Twitter, division of vascular surgery, the department of surgery, seen the constant compassion of our brothers and LinkedIn and Facebook. All of these platforms have at the University of Washington School of Medicine, sisters in vascular surgery on a massive, global scale. provided us with an opportunity to share cases, Seattle. Nicolas Mouawad is the chief of vascular and Perhaps in the times that came before, many of meet others globally and disseminate research endovascular surgery at McLaren Bay Heart & Vascular us were not in peer-to-peer support environments— results. Vascular Twitter has been a great platform in Bay City, Michigan.

BY SHERENE SHALHUB, MD, AND NICOLAS MOUAWAD, MD

W

MAY 2020

VASCULARSPECIALISTONLINE.COM • 15

CORONAVIRUS

Vascular surgeons discuss widespread impacts of COVID-19 on pregnancy, family, career in early virtual roundtable

BY BRYAN KAY

T

he devastating effects of the novel coronavirus pandemic are multifarious and farreaching, touching both life and limb themselves as well as less tangible aspects of daily life like economic vitality and job function.

Each applies unequivocally to vascular surgeons, not least of which the ability of specialists to carry out many of the procedures they otherwise would be busy performing.

That was the focus of an International Society of Endovascular Specialists (ISEVS) seminar that took place April 2 aimed at tackling some of the more personal issues that flow from the new world COVID-19 has helped create.

Difficult decisions often had to be made, the seminar heard.

“We are thinking about ways in our department and hospital system as to how to cut costs: no travel, we’ve given up call pay for a lot of the things that we do,” said Bernadette Aulivola, MD, director of the division of vascular surgery and endovascular therapy at the Loyola University Health System in Chicago.

“We’re starting to look at what staff are critical to the function of our healthcare institution.

“But we’ve also started to have conversations about ways to rebound.

So, being proactive: For example, once we get back to full clinical activity and we have that glut of patients—those non-urgent or emergent procedures that we’ve been putting off—can we commit to staffing clinics on the weekends or nights? Can we commit to doing cases in our ambulatory surgery center on weekends, or extending hours into the night?”

The seminar, which drilled into the impact of the virus on career, pregnancy and family, was moderated

by ISEVS secretary Palma Shaw, MD, and consisted of vascular surgeons Ellen D. Dillavou, MD, Alan Lumsden, MD, and Charudatta S. Bavare, MD, as well as Aulivola. They were joined by obstetrician-gynecologist Patricia H. Bellows, MD. Bellows, assistant professor of obstetrics and gynecology at Houston Methodist Hospital in Houston, elaborated on the nexus of COVID-19 and pregnant physicians—or physicians who may have a pregnant partner at home.

16 • VASCULAR SPECIALIST

ALAN LUMSDEN MODERATES ISEVS COVID-19 SEMINAR

MEMBERS OF SEMINAR PANEL DISCUSS KEY ISSUES

“Once we get back to full clinical activity and we have that glut of patients—those nonurgent or emergent procedures that we’ve been putting off—can we commit to staffing clinics on the weekends or nights?”—Bernadette Aulivola “The most important things are good hand-washing, wiping down surfaces,” she said. “If you are a physician working in a hospital where you are exposed to coronavirus patients and you are coming home to a pregnant spouse, it is going to be important for you to de-contaminate as best as possible.”

Shifting routines

The panelists elucidated how their daily routines had changed, particularly the process by which they avoid cross-contamination between work and home.

“My wife is an intensivist at one of the regional hospitals here [in Houston] and so we’re always worried about carrying something home,” said Houston Methodist DeBakey Heart & Vascular Center surgeon Bavare, who has two young children—a 5 month old and a 6 year old. “Clearly we have to make an effort to keep clothes separate … we have a wipe-down

routine that we do and our nanny helps with. We wipe down every single surface touched by the baby and touched by us.”

For Aulivola, a new normal has formed at the intersection of her career and home life in the crucible of COVID-19. “I have a full-time nanny who typically cares for the kids,” she explains. “My husband is an anesthesiologist so our work hours are quite long. I have decided to have the nanny take on the homeschooling responsibilities, partially because— even though I am not clinically responsible since we’re on a rotation schedule—as the director of my division my administrative tasks have multiplied, so I have to be at work or at home working day-to-day.”

That new routine, Aulivola conceded, required some thought for another, grave reason: The family nanny’s mother is currently fighting cancer. “One of the things that came up was, ‘Do we have her stop coming

because of the potential for us to transmit COVID-19 to our nanny, who brings it home to her family member who is immunocompromised.”

Leadership qualities, too, are of paramount importance amid the crisis, said moderator Shaw, associate professor of surgery at SUNY Upstate University in Syracuse, New York.

“We are leaders for the people who work for us, the people around us— our family,” she said. “They’re looking to us to be strong right now because so many people are very frightened.

Leadership is showing everything is going to be okay—we’re going to handle it.”

In her home life, Dillavou, whose children are 12 and 13 years old, noted a paradox. “My kids have been pretty chill,” she explained. “Interestingly, I find that a couple of times a week, it’s the adults in my life—my sisters, my mom, our billing person—who are having overwhelming anxiety about this, and it bubbles to the surface.”

Dillavou highlighted the emergence of a grassroots initiative started

by Dartmouth College medical students to help healthcare workers handle childcare. “Across the nation, medical students have volunteered to do childcare for their healthcare colleagues who are on the frontlines,” said the associate professor of vascular surgery at Duke University School of Medicine in Durham, North Carolina.

Looking ahead

Back on the theme of departmental finances, Lumsden, chief of Houston Methodist DeBakey Heart & Vascular Center and also ISEVS president, mused on the as yet unknown quantity of the true impact. “I worry the recovery phase of this is going to go on for years,” he said.

“It is clearly having a devastating effect on every hospital and every institution, and I think some of them are not going to survive.

Yet, if there’s a silver lining to the crisis, said Dillavou, it might be the rise of virtual modes of working.

“I think we’re all finding ways to do more things virtually. It will be interesting to see moving forward what we keep.”

Lumsden captured the magnitude of change in an illuminating statistic from his hospital: “A month ago, our institution was doing 40 virtual visits a day,” he said. “The technology was in place. Now, we’re doing 4,000 a day.”

MAY 2020

VASCULAR PRACTICE

Outbreaks see call for older doctors to be protected from COVID-19

BY BRYAN KAY

H

ospitals and government health departments should give careful consideration to the protection of older physicians and nurses in the face of the COVID-19 pandemic, a viewpoint published in the Journal of the American Medical Association (JAMA).

Peter I. Buerhaus, PhD, a nurse and healthcare economist in the Center for Interdisciplinary Health Workforce Studies at Montana State University College of Nursing in Bozeman, Montana, et al asked whether such physicians and nurses should be re-deployed to less risky roles.

“While hospitals and other organizations ramp up their preparations, this is the time to determine whether there may be different roles for older clinicians that will ensure they are able to contribute over the long-term course of the pandemic,” the authors wrote. “This is not to suggest that these

MAY 2020

older nurses and physicians should necessarily be precluded from providing clinical care or should be isolated, but rather to consider if their direct clinician duties can be shifted to emphasize roles with less risk of exposure.”

Buerhaus and colleagues cited Centers for Disease Control and Prevention (CDC) statistics indicating rates of hospitalizations, intensive care unit (ICU) admissions and mortality among reported COVID-19 cases in the United States as being substantially higher among patients older than 45 years compared with younger patients, “with casefatality rates exceeding 1.4% among patients aged 55 to 64 years and exceeding 2.7% among those aged 65 to 74 years.”

Furthermore, they report data from the U.S. Census Bureau American Community Survey 2014–2018 that estimate the physician workforce— approximately 1.2 million in the U.S.— as bearing 230,000 (20%) aged 55–64 years and 106,000 (9%) 65 years or older.

“The recent report of two critically-ill emergency physicians infected by the novel coronavirus disease 2019 (COVID-19) is a sobering reminder of the vulnerability of the nation’s healthcare workforce,” the authors argued. “While all members of the healthcare workforce are vital as the healthcare system faces perhaps its greatest challenge in memory, physicians and nurses are the caregivers who typically have the most direct contact with

patients, whether through advising, triaging or treating those who require hospitalization.”

Buerhaus et al urged healthcare organizations to have foresight of the coming challenges: “Hospitals and other care delivery organizations, including state and local health departments, should carefully consider how best to protect and preserve their workforce, with careful consideration involving older physicians and nurses. Older clinicians are likely to have an even larger role in the months ahead as more regions address workforce shortages by requesting that retired physicians and nurses consider returning to the workforce during the COVID-19 outbreak, as has recently occurred in New York City, the state of Illinois and Great Britain.”

The issue of vascular surgeon contact with COVID-19 patients—specifically regarding those over the age of 65—was raised during the maiden Society for Vascular Surgery (SVS) Town Hall on the pandemic response.

Co-moderator Alan Lumsden, MD, the medical director of Houston Methodist DeBakey Heart & Vascular Center in Houston, put the question to fellow moderator and SVS president Kim Hodgson, MD: Should surgeons in this category be restricted from COVID-19 patients?

“The data we’re hearing is difficult to interpret because we don’t really know what the [number] is, so we don’t really know if the elderly are a more significantly at-risk population,” said Hodgson, also chair of the division of vascular surgery at Southern Illinois University School of Medicine in Springfield, Illinois. “Clearly, I would say that many of my colleagues in a similar age group are probably not up on our intensive care management—certainly not ventilator management, so we can’t provide any value there— but we may be able to provide other supporting roles in the hospital.”

In turn, Hodgson asked Benjamin W. Starnes, MD, professor and chief in the division of vascular surgery at the University of Washington, Seattle, if his hospital had excluded certain surgeon age groups. Washington state, of course, became North America’s epicenter as COVID-19 took root stateside, the first in the U.S. to experience the ravages of the developing pandemic.

Starnes said three physicians over the age of 65 at his institution had not been operating—but posed a corollary. “I would switch that around and say, how do you get a 65-plus-year-old vascular surgeon to stop operating? Say they’re a chief of a division or a chair of a department and they feel as if they have to operate for the betterment of society, and no one is strong enough—or strong-enough-voiced—to keep them from operating. Has anyone had that situation?”

Lumsden, a leadership figure at his institution, concluded the exchange with some context.

“When you’re in a leadership position, you feel like you’ve got to be here and you’ve got to be part of the team,” he said. “You’re heavily involved in not just taking care of the vascular surgery patients, but in the overall management of the hospital, the strategies and looking at how we’re going to handle this going down the line.”

SOURCE: DOI:10.1001/JAMA.2020.4978 VASCULARSPECIALISTONLINE.COM • 17

NEWS FROM SVS

VESAP5 debuting by Aug. 1

BY BETH BALES

Preparing for arrival of CMS Quality Payment Program year 4

BY CHRISTOPHER J. SMOLOCK, MD, PATRICK RYAN, MD, KAREN WOO, MD, AND JILL RATHBURN

I

t’s here: 2020 is year four of the Quality Payment Program (QPP), established by the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) in 2015. QPP requires that most physicians who submit claims to the Centers for Medicare and Medicaid Services (CMS) participate in one of two programs to avoid a reimbursement penalty: the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM).

Physicians who do not participate adequately this year face a 9% penalty in their 2022 Medicare reimbursements. As there currently is no approved vascular condition-specific APM, many vascular surgeons will participate in MIPS if they are not part of a multispecialty APM. Vascular surgeons in independent practices can consider exploring joining such an APM to satisfy QPP participation requirements.

CMS has gradually increased the minimum QPP performance requirements yearly. For MIPS year four, there are four performance categories; weights for each contribute to the final score and are unchanged from year three: Quality (45%), Cost (15%), Promoting Interoperability (25%) and Improvement Activities (15%).

Clinicians must report certain measures from each of the four objectives unless a valid exclusion is claimed. The minimum performance threshold for the 2020 performance period to avoid the 2022 payment penalty is 45 points (increased from 30 in year three). There is a $500 million pool for exceptional performers. The threshold for exceptional performance in year four is 85 points (increased from 70).

These MIPS changes will have a significant impact on vascular surgery and should be considered in a surgeon’s strategy for participating in QPP in 2020. Further details regarding MIPS year four participation can be found online at vsweb.org/MIPS4Participation.

The Nashville Vascular and Vein Institute (NVAVI), a private practice, shared its experience with meeting QPP requirements. The institute planned that reporting would be handled through attestation and utilization of electronic health record functionality via MIPS, and reported the method is not difficult. However, it also transpired NVAVI is included in a local, hospital-associated APM. This emphasizes the importance of checking your QPP participation status at vsweb.org/QPPStatus. Note: This article predates any COVID-19-related deadline alterations.

Christopher J. Smolock, MD, and Patrick Ryan, MD, and Karen Woo, MD, sit on the SVS Quality and Performance Measures Committee. Jill Rathburn is managing partner of Galileo Consulting Group.

18 • VASCULAR SPECIALIST

THE FIFTH EDITION of the Vascular Educational Self-Assessment Program (VESAP) will be available before the beginning of August, when VESAP4 expires.

The online program, with a companion app for off-line use, is designed to meet the requirements of the Vascular Surgery Board of the American Board of Surgery for continuing medical education and Maintenance of Certification selfassessment credits.

It is intended for surgeons preparing for qualifying, certification and recertification exams in vascular surgery; residents and fellows preparing for their exams; and vascular health professionals who want to stay current with the specialty.

Greg Modrall, MD, and Amy Reed, MD, are once again editors-in-chief of the online program, as they were for VESAP4.

All content has been reviewed and updated as necessary, and

the vascular lab section has been expanded considerably.

As in prior editions, VESAP5 will contain 10 modules and more than 500 review questions. Each question includes detailed discussions and references.

The program offers both learning and examination modes and the ability, in examination mode, to earn both CME credits and MOC selfassessment credits.

Pricing is not final. Buyers will be able to purchase the entire package or just the vascular lab module. For more information, see vsweg.org/ VESAP. The fourth edition of VESAP will expire July 31 and no CME credits for it will be awarded after that date.

However, after the July 31 deadline, current VESAP4 users will be able obtain CME certificates for modules successfully completed; log in to the VESAP4 application and choose “print certificate” from the Toolbox Tab. Contact SVS at education@ vascularsociety.org with questions.

SVS journals: Study of interest

BY BETH BALES

ENDOVASCULAR ANEURYSM repair (EVAR) for a ruptured abdominal aortic aneurysm (AAA) proved less hazardous than open repair within 30 days of the procedure, but there were no differences between 30 days and five years, and five to 10 years following repair, according to a study in the June issue of the Journal of Vascular Surgery.

The retrospective study was performed in Ontario, Canada, and involved all ruptured AAA patients (2,692) 40 and older from over a 13-year period. Some 10% underwent EVAR and 90%– 2,431 patients—underwent open repair.

Researchers concluded more work is needed to understand and improve the long-term outcomes of both procedures. The study is one of a number of open-source articles available from the issue: vsweb.org/JVS-OntarioAAA.

Your SVS: Membership deadline is June 1

BY BETH BALES

THE NEXT MEMBERSHIP application deadline for 2020 is June 1. Be part of all SVS has to offer its members, including the online community SVSConnect, which has featured robust resources and conversations on COVID-19, plus free or reduced-rate subscriptions to the Journal of Vascular Surgery. Several new initiatives – including branding and a valuation project to define the value of vascular surgeons and

the vascular surgery service line to institutions – are underway. See all membership benefits at vsweb.org/ MemberBenefits.

Amy Reed, MD, SVS secretary, discusses membership opportunities (plus resources SVS has available to address the COVID-19 pandemic), in an Audible Bleeding podcast Hear it now at vsweb.org/ MembershipPodcast.

Young surgeons currently in their fourth year of Candidate membership now need to apply to become Active members. These specific Candidate memberships will expire on Dec. 31, 2020; transition to Active Membership is not automatic.

Apply today at vsweb.org/Join.

MAY 2020

VENOUS DISEASE

VenaSeal superior for management of chronic venous insufficiency, finds systematic review

BY LIAM DONOVAN

A

ccording to a network meta-analysis, the VenaSeal system by Medtronic is “a promising therapeutic option for anatomic success at six months,” a team of investigators discovered.

The study, published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders, also highlighted the lower number of adverse events with VenaSeal in patients with chronic venous insufficiency (CVI) compared to other interventions studied.

Although “several randomized controlled trials (RCTs) have compared different interventions for CVI management,” as first author Raghu Kolluri, MD, system medical director for vascular medicine and vascular labs at Ohio Health Heart and Vascular in Columbus, Ohio, and colleagues write, there is a lack of studies offering a mixed comparison of these available options.

Summarizing the current landscape of CVI management, Kolluri—also president of the Society for Vascular Medicine and clinical professor of surgery at Ohio University—et al highlight that there are number of strategies being used to treat this kind of disease, including conservative care with compression stockings, surgery, foam sclerotherapy, endovenous laser ablation (EVLA), mechanochemical ablation (MOCA), radiofrequency ablation (RFA) and cyanoacrylate embolization (CAE).

VenaSeal can be used for CAE and is employed globally for the treatment of CVI patients. In order to assess the effectiveness and safety of this system compared with other treatment methods previously listed, investigators performed a systematic review of journal databases.

They analyzed data gathered from RCTs published between January 1996 and September 2018.

In total, 20 trials comprising 4,570 patients were examined, with Kolluri et al extracting data pertaining to anatomic success, Venous Clinical Severity Score (VCSS), health-related quality of life (HRQoL), pain score and adverse events.

“A Bayesian fixed or random effects

MAY 2020

model was selected for analysis. Rank probability graphs were generated for various treatments and corresponding ranks obtained to estimate their probability of being best.

“Relative treatment effects were calculated in terms of log odds ratios for anatomic success and adverse events. Mean difference was calculated for VCSS, HRQoL and pain score,” the authors explain.

Regarding the primary outcome measure of anatomic success, it was found that VenaSeal had the highest probability of being ranked first (p=0.980), followed in order by RFA (p=0.365), EVLA (p=0.397), surgery (p=0.290), MOCA (p=0.695) and sclerotherapy (p=0.982).

“For secondary outcome measures,” Kolluri et al continue, “VenaSeal system ranked third for VCSS (p=0.332), fifth for EuroQol-5

RAGHU KOLLURI

times higher with surgery, and 1.1 times higher with RFA, as compared to the arm of patients treated with VenaSeal.

“Limitations of this analysis include restricted data availability in terms of time points and pooling of data. Thus, the analysis could be performed only at the available time points. Another limitation with this analysis is that it compared the methods for the first six months after treatment, which is a relatively short period,” acknowledged the authors.

“Results were reported in different manners in the included studies;

hence, fewer data points could not be pooled and used in this analysis.”

Concluding, Kolluri et al write that the findings suggest the VenaSeal system to be a promising therapeutic option in terms of superior outcomes as assessed by anatomic success, reduction of pain score and lesser chance of occurrence of adverse events in patients treated with CVI in contrast with other interventions.

“Previous studies have already reported that the use of CAE for CVI may reduce the time to return to work or normal activity, minimizing pain and improving the patient’s comfort,” they explain.

“In total, the current level of clinical data shows the unique benefits of this non-thermal, non-tumescent, nonsclerosant treatment in management of CVI. “The existing evidence is robust to demonstrate the safety and effectiveness of CAE in treating these patients; additional economic analysis including a cost-effectiveness analysis would provide interesting perspectives to the real-world insights to patients, payers, and providers.”

SOURCE: DOI.ORG/10.1016/J. JVSV.2019.12.061

“The existing evidence is robust to demonstrate the safety and effectiveness of CAE in treating these patients”— Raghu Kolluri et al Dimension (p=0.420), and third for Aberdeen Varicose Vein Questionnaire (p=0.300).”

Commenting on these results, the investigators note that while VenaSeal was slightly inferior to some interventions in terms of HRQoL, “the 95% credible interval of log odds ratio indicated insufficient evidence for any concrete conclusion to be drawn.”

Moreover, VenaSeal ranked first in reduction of postoperative pain score from baseline (p=0.690) and demonstrated the lowest occurrence of adverse events (p=0.650).

Odds of occurrence of adverse events—including wound and ground infection, pulmonary embolism and deep vein thrombosis—was 3.3 times higher in the sclerotherapy arm, 2.7 times higher in the EVLA arm, 1.6 VASCULARSPECIALISTONLINE.COM • 19