Vascular Specialist@VAM–Conference Edition 1

LY MER AS FOR NOWN K

In this issue: 4C rawford Forum Discussing ‘quality vascular care for all’

14 Trainees How start to a vascular training program

6C arotid surveillance CEA study prompts 17 VAM through protocol discussion the lens 8C OVID-19 and ALI A pictorial VESS Paper Session review of hears about new data the first day of from VASCC registry the conference

THURSDAY JUNE 16 2022 | CONFERENCE EDITION 1

THE OFFICIAL NEWSPAPER OF THE

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VON LIEBIG FORUM

RESEARCHERS REPORT HIGHER THREEYEAR AMPUTATION, REINTERVENTION RATES IN BLACK AND HISPANIC CLTI PATIENTS

75th VAM opens

From the first VAM that featured just eight papers, to VAM 2022 with many more times that many presentations, each annual meeting to today’s 75th edition, has featured research, friendships and the desire to improve patient care.

“If this is your first year attending VAM, we are so glad you are here,” said SVS President Ali AbuRahma, MD, at Wednesday morning’s Opening Ceremony. “You are in for a wonderful time, full of innovation, friendship, scholarship, and plenty of fun. Never before have we had a meeting with such a wide range of opportunities.”­—Beth Bales

Study probes VQI registry for open infrainguinal surgery patients, finding disparties are partly down to demographic differences, writes Jocelyn Hudson

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n a study of more than 7,000 chronic limb-threatening ischemia (CLTI) patients, researchers found that Black and Hispanic patients had higher three-year amputation and reintervention rates; survival, however, was higher among Black patients and similar between Hispanic and White patients. Aderike Anjorin, BA, from Duke University Medical Center, Durham, North Carolina, delivered these findings yesterday during the William J. von Liebig Forum.

Anjorin stated that Black and Hispanic patients have higher rates of CLTI and suffer worse outcomes after lower-extremity bypass compared with White patients. The underlying reasons for these disparities are unclear, she said, specifying that data on long-term outcomes are limited. In order to address this gap in the literature, Anjorin and colleagues examined differences in three-year outcomes after open infrainguinal revascularization for CLTI by race/ethnicity, and explored potential factors contributing to these differences.

The research team identified all CLTI patients undergoing primary open infrainguinal revascularization in the Vascular Quality Initiative (VQI) registry from 2003–2017, with linkage to Medicare through 2018 for long-term outcomes, the presenter detailed.

She communicated that primary outcomes were three-year amputation, reintervention, and survival, and that secondary outcomes were factors associated with disparate outcomes.

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SIX YEARS, MUCH GROWTH AND MULTIPLE CHANGES TO JOURNAL OF VASCULAR SURGERY PUBLICATIONS By Beth Bales Their terms about to end, Peter Gloviczki, MD, and Peter Lawrence, MD, editor-in-chief and senior editor, respectively, of the Journal of Vascular Surgery family of publications reflect on their time at the helm and the changes they’ve seen—and implemented—along the way.

JVS publications include the flagship journal, Journal of Vascular Surgery, in its 39th year of publication; Journal of Vascular Surgery: Vascular and Lymphatic Disorders (JVS-VL), now in its 10th year of publication; JVS-Cases, Innovations & Techniques (JVS-CIT) and the newest member of the family, focusing on basic and translational

science, JVS-Vascular Science (JVS-VS). The journals are sometimes known by their cover colors, a change instituted by Gloviczki and Lawrence, with red for JVS, blue for JVS-VL, gray for JVSCIT and green for JVS-VS. They have overseen a number of changes and accomplishments. “We have considerably transformed our editorial policies, increased the diversity of our editorial boards and included more than 25% more women and underrepresented minorities,” they said in a farewell message of sorts in the journals’ June issues that reflects upon their six years as editors. Their terms end

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Vascular Specialist | Thursday 16 June 2022

FROM THE COVER: RESEARCHERS REPORT HIGHER THREE-YEAR AMPUTATION, REINTERVENTION RATES IN BLACK AND HISPANIC CLTI PATIENTS continued from page 1 Anjorin informed the VAM audience that a total of 7,108 CLTI patients were included in the study. Of these patients, she specified, 5,599 (79%) were non-Hispanic White, 1,053 (15%) were Black, 48 (1%) were Asian, and 408 (6%) Hispanic.

Presenting the study findings, Anjorin reported that Black patients had higher rates of three-year amputation (32% vs. 19%; hazard ratio [HR]: 1.9 [95% confidence interval: 1.7–2.2]), reintervention (61% vs. 57%; HR: 1.2 [1.1–1.3]), and survival (62% vs. 58%; HR: 1.1 [1.01–1.2]) compared with White patients. Hispanic patients, the speaker added, experienced higher rates of amputation (27% vs. 19%; HR: 1.6 [1.3–2]) and reintervention (70% vs. 57%; HR 1.4 [1.2–1.6]) compared with White patients; however, survival was similar between the groups (62% vs. 58%; HR: 1.1 [0.98–1.3]).

In addition, Anjorin relayed that the low number of Asian patients prevented meaningful assessment of amputation (20% vs. 19%; HR: 0.9 [0.4–2]), reintervention (55% vs. 57%; HR: 0.8 [0.5–1.2]), or survival (64% vs. 58%; HR: 1.2 [0.8–1.9]) in this group.

In adjusted analyses, the speaker communicated, the association of Black and Hispanic race with amputation and reintervention was explained primarily by differences in demographic characteristics (age, sex) and baseline comorbidities (tobacco use, diabetes, renal disease).

Anjorin concluded that disparities in amputation and reintervention rates are partly attributable to demographic characteristics and the higher prevalence of comorbidities in Black and Hispanic patients with CLTI. “Interventions to improve early diagnosis, risk factor modification, and postoperative surveillance in these populations may confer longterm limb salvage benefits,” the speaker told VAM attendees.

“Is ethnicity simply a marker for socioeconomic status, and is that driving these outcomes?” was the first question in the discussion following Anjorin’s presentation. “It is very likely that socioeconomic status plays a role,” the speaker

responded. However, she stressed that the data used in the team’s study make it hard to establish exactly how big a role it plays, in part because all patients that have been included are insured, and therefore likely do not represent the entire CLTI population. Expanding on this point in response to another question, Anjorin remarked that there are other factors at play in the differing outcomes. She emphasised the importance of considering social determinants of health, such as health literacy and geographic location affecting access to centres for exercise therapy, for example. “Unfortunately, we do not have these variables in the current dataset,” she said.

SVS president and session moderator Ali AbuRahma, MD, West Virginia University, Charleston, West Virginia, was keen to get Adjorin’s take on whether CLTI patients were visiting a physician too late and therefore presenting with too advanced disease for treatment. The speaker replied: “We did look at urgency status, and in our adjusted analysis this did not really play a huge role for amputation or reintervention, so it really was the higher burden of comorbidities that drove these differences.”

In another question from the audience, a delegate asked whether the presenter could comment on racial disparities as they pertain to the decision to undergo primary amputation, i.e. those who have an upfront decision to undergo

“Interventions to improve early diagnosis, risk factor modification, and postoperative surveillance in these populations may confer long-term limb salvage benefits”

primary amputation as opposed to revascularization and then amputation. Given that the research team used VQI data, Anjorin responded that they do not have the information on individual patient decision-making.

Honing in on the specifics of the study, one delegate asked whether the study group looked at target artery for their analysis. The team looked at distal bypass, Anjorin communicated, noting that they focused on bypass into an infrapopliteal target specifically. “For Black patients, the association with amputation was slightly attenuated, I think by 0.1, and for Hispanic patients, when we looked at distal bypass reinterventions specifically, the association for Hispanic patients and reintervention was attenuated.”

Anjorin performed the analysis and delivered the presentation “Racial and ethnic disparities in long-term outcomes following open revascularization for chronic limb-threatening ischemia” under the guidance of senior author Marc L. Schermerhorn, chief of the Division of Vascular and Endovascular Surgery at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.

A number of the researchers involved in this study have authored other, published work on the topic of healthcare disparities in vascular disease management, including, most recently, a paper titled “Disparities in five-year outcomes and imaging surveillance following elective endovascular repair of abdominal aortic aneurysm by sex, race, and ethnicity”

by Marcaccio et al. This study was also led by Schermerhorn.

The research team behind this study report in the May 2022 edition of the Journal of Vascular Surgery (JVS) that Black females had higher five-year aneurysm rupture, reintervention, and mortality after elective endovascular aneurysm repair (EVAR) compared with White male patients, while White females had higher rupture, mortality, and loss-to-imaging follow-up. They relay that Asian females also had higher rupture, and Black males had higher reintervention and loss-to-imaging follow-up.

FROM THE COVER: SIX YEARS, MUCH GROWTH AND MULTIPLE CHANGES, TO JOURNAL OF VASCULAR SURGERY PUBLICATIONS continued from page 1 at the end of June. In addition, the journals now are part of a JVS portfolio that encompasses a wide range of communications vehicles, with the additions reflecting changing landscape media and information platforms. Among the portfolio are monthly “Editors’ Choice” videos, press releases, visual abstracts, the increasingly popular JVS Journal Clubs and the Audible Bleeding podcasts.

Today, JVS has an all-time high impact factor of 4.268, and the PlumX metrics, reflecting social media impact, has seen a major increase.

“I think we had a vision of what we wanted to achieve,” said Gloviczki. At the time, the two had known each other well for more than a decade, with a common history. Both had connections with Leslie and Susan Gonda, vascular benefactors who contributed generously to Mayo Clinic, institutional home of Gloviczki, as well as to the University of California Los Angeles, where Lawrence is director of the UCLA Gonda Vascular Surgery.

Said Lawrence of their time in leadership: “He was the driving force, but he and I walked together.”

Chief among their aims was to maintain the journals’ excellence, and also grow them and broaden their scope to cover additional key areas of vascular disease management. “We knew our specialty was (and is) becoming more diverse. More women are going into it, there is more ethnic, racial and cultural diversity,” said Lawrence.

“And we knew vascular surgeons were not all doing the same operations. To keep the involvement of members as the field changed, we needed to change as a journal. We needed to separate the types of papers being published.”

For example, increasingly more papers were being submitted to JVS that belonged, instead, to JVS-VL, published in collaboration with the American Venous Forum. The journal first known as “Case Reports” and then “Cases and Innovative Techniques” was renamed JVS: Cases, Innovations and Techniques.

This permitted expanding the range of papers. “We could take topics originally published in JVS that concentrated on innovations in practice management or education and put them in CIT,” said Lawrence.

Both also felt that there needed to be a

Peter Lawrence and Peter Gloviczki place in JVS and the SVS for papers concentrated on basic and translational research, not simply emphasizing clinical research.

“So we initiated JVS-Vascular Science— and got a renowned basic research scientist to be editor [Alan Dardik],” said Lawrence.

They also oversaw creation of four separate websites, for submission to each journal, plus separate editorial boards.

The two emphasized an international presence, attending meetings around the

world and spreading the word about the journals. They invited surgeons in other countries to be part of the editorial boards and sought international guidance on certain clinical practice guidelines. Today, more than 50% of submissions come from outside the United States, compared to approximately 10% earlier.

They added an internship program, to train young people how to become good reviewers while also emphasizing diversity, equity and inclusion issues. “We took the cream of the crop,” said Gloviczki.

Lawrence also takes pride in the publication’s online Journal Club, led by Paul DiMuzio, MD, and Misty Humphries, MD. The club educates vascular surgical trainees in interpreting whigh-level clinical and basic science articles and how to appropriately apply the information to clinical practice and future research.

Both men know they are leaving the “family” in good hands, particularly with the restructuring to add strength and guidance. “It’s a good idea to have someone at the top overseeing all four journals,” said Gloviczki. “They certainly have a very bright future.”

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Vascular Specialist | Thursday 16 June 2022

CRAWFORD FORUM

Trust, transportation, insurance hamper ‘quality vascular surgery care for all’ In a session focusing on disparities in care, an absence of patient trust in their doctors and hospital systems yesterday morning emerged as a key talking point amid a comprehensive deep dive into some of the problems vascular surgeons tackle in their efforts to broaden access to quality vascular care.

A PANEL OF EXPERTS ASSEMBLED BY SOCIETY FOR Vascular Surgery (SVS) President-elect Michael Dalsing, MD, for the E. Stanley Crawford Critical Issues Forum probed impediments to universal access across the U.S., covering workforce numbers and distribution, rural isolation, urban care deserts, access to insurance, and diversity and inclusion.

A question from the audience that came after the panel had each delivered a presentation on access hurdles—posed by Mahmoud B. Malas, MD, chief of vascular and endovascular surgery at the University of California Davis—raised the specter of the trust patients place in their providers based on care received in the past. Part of the problem is transportation, Malas said, but trust, he insisted, figures greatly in the conundrum. “When we were trying to understand why a majority of African Americans were getting PTFE grafts instead of vein, even though they have good veins, or that they were getting a catheter a lot more to start their dialysis than fistulas, we didn’t really understand what was going on until we started interviewing patients,” he said. He referred to a study of all U.S. dialysis patients that he was involved in while based at Johns Hopkins Hospital that looked at racial disparities. “Every single patient said I don’t trust Hopkins, doctors, or hospitals.

There is a lot of concern that they have no trust in us as doctors, hospitals and providers, because they had a historically bad outcome, and had no trust in the hospital system.”

Samantha Minc, MD, who delivered a talk looking at the issues surrounding access to care in rural America, said Malas’ example was “an exact reason why mixed methods research is going to be the way for us to understand these issues related to disparities.”

Community engagement and reversing lack of trust, said Andrew Gonzalez, MD, assistant professor of vascular surgery at Indiana University School of Medicine in Indianapolis, are dimensions that build through the development of long-term partnerships. He described how his mother, a pediatric hematology oncologist in the 1960s, would brave her urban setting to give out childhood vaccinations. That was realistic then as it was a practice incentivized by the county hospital. “But I think

Panelists at the Crawford Forum

most of us, if we announced to our division chief, that we had a plan to get the doppler and roll through the ’hood checking ABIs [ankle-brachial indices], we would probably be laughed out of the room.”

Gonzalez, who in his talk laid out the access problem in “urban vascular care deserts,” emphasized “the need to think of multilevel, multilateral interventions—and we probably need to do this by partnering.” One of the ways in which this can be achieved, he said, is through financial incentives being aligned for both hospitals and government entities. “It is also important we have a role in being seen in the community,” he said.

Minc, meanwhile, suggested that should a way be found to make transportation grant feasible “a lot of communities are going to benefit.”

Her work right now, said said the assistant professor of vascular surgery at West Virginia University in Morgantown, West Virginia, is focused on community engagement. “As vascular surgeons, what a community is to us may differ a little bit.” Primary care providers (PCPs), Minc pointed out, represent a community with which to partner. “In rural areas, especially where we are, very isolated areas, these PCPs do everything. They are very independent. They multitask. They come to me and say, ‘Just show us how to do the wound care and we’ll do it.’”

SPOTLIGHT ON THURSDAY@VAM OPENING DAY IS IN THE REAR-VIEW MIRROR, with attendees enjoying a wide range of presentations. What’s on tap for Thursday? A plethora of education, exhibits and, of course, the chance for participants to get together with friends and colleagues.

The day starts, for the convenience of international registrants livestreaming VAM 2022, with the International Chapter Forum, from 6:30 to 8 a.m. at the Hynes Convention Center, Room 210.

Speakers will discuss a wide range of topics, including attracting medical students to the specialty, digital strategies to update vascular surgeons in Mexico, research presentations, and the Medical University of Warsaw’s report on complex endovascular treatment of 840 patients with aortic diseases.

Jan S. Brunkwall, MD, PhD, vascular surgeon at the University of Cologne in Germany will present the Roy Greenberg Distinguished Lecture, “More is Less and Less is More!” from 9:30 to 10 a.m. at HCC, Ballroom A/B. An important VAM moment occurs at 10 a.m. with the opening of the VAM Exhibit Hall, at HCC, Hall C/D. Be sure to save time to stop by exhibitors’ booths, enjoy Vascular Live presentations during coffee breaks and lunch, and stop by the SVS Booth (No. 607) to update information, get answers to questions and, from 10 a.m. to 2 p.m., have professional headshots taken at no charge.

Who will take home the prize? This year’s recipient of the prestigious SVS Lifetime Achievement Award will be announced at the Awards Ceremony, 10:30 to 10:45 a.m., HCC, Ballroom A/B. Learn how others tackle procedures and treatments in the always popular “How I Do It” session of video abstracts, from 1:30 to 2:30 p.m. HCC, Room 312. Six presentations are scheduled.

Membership section sessions have been added to this year’s VAM. Women will meet from 1:30 to 3 p.m. and young surgeons from 3:30 to 5 p.m. for educational sessions specifically targeted to their needs, both in HCC, 210. Get tickets at registration.

What’s VAM without fun? There’s plenty of the schedule for Thursday, from the Opening Reception from 5 to 6:30 p.m. in the Exhibit Hall, along with the Interactive Poster Session and the International Poster Competition PLUS a raffle; to targeted receptions for training programs and other groups.—Beth Bales

ADVOCACY SESSION MEDICARE CUTS: ‘IT IS CRUCIALLY IMPORTANT WE STAY ENGAGED IN THE PROCESS’ SOCIETY FOR VASCULAR SURGERY (SVS) members deemed payment and reimbursement among the top advocacy priorities for 2022.

A session Wednesday at VAM informed attendees about Medicare payment issues and relayed information on the past, what’s going on in the present and how members can impact the future.

Matthew Sideman, MD, chair of the SVS Advocacy Council, kicked off the session, hosted by the Government Relations Committee, by briefly reviewing the process of the legislative and regulatory processes.

While laws are in discussion, vascular surgeons have many chances to impact what those laws look like. “It’s crucially important we stay engaged in the process.”

Surgeons fought the Medicare Sustain-

able Growth Rate (SGR) for 15 years. Its replacement, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, hasn’t provided its planned financial stability. “Many in Washington, D.C. view it as a failed policy” Current advocacy efforts are focused not only on replacing MACRA but also on shorter-term issues on important legislation, including prior authorization.

Megan Tracci, MD, Advocacy Council vice chair, explained why Medicare payments are still going down.

Seventeen SGR patches over 12 years cost more than $169 billion, to no good effect.

SGR was then replaced by MACRA; results have been mixed and MACRA has meant vascular surgeons losing ground in every single year” since its passage.

“Our conversion factor is essentially the same as it was in 1998,” said Tracci. “Physicians have “been tightening our belt for 25 years and aren’t really the problem, she said.

Medicare spending has continued to grow, but its distributions have shifted. “It’s now $787 billion, and we’re down to 9 % of that.

We’re not going to save our way out of the U.S. government on healthcare.”

With the funding trend unsustainable, she said, “We need to drive change.” Fixing the payment model and fixing funding must go hand-in-hand, she said. “Advocacy must be data-driven, and we have to bring our data to the table.”

“We are one vascular surgery team,” emphasized Sean Lyden, MD, committee chair, who discussed recent committee efforts to impact change. “We represent all portions

of vascular surgery (in all settings) and represent everybody equally.”

He stressed the necessity to donate to the SVS Political Action Committee, which currently receives donations from only 7% of SVS members. “If government doesn’t feel like we’re a big voice, they don’t care,” he said.

“Government relations is about building relationships and getting in front of lawmakers. This requires money, he said. It also means continued reaching out to lawmakers and vital grassroots advocacy.

Despite some legislative success, such as mitigating proposed payment cuts, battles remain on the horizon, said Lyden. These include the 2023 Medicare Physician Fee Schedule proposed rule and identifying system payment reform options.—Beth Bales

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Vascular Specialist | Thursday 16 June 2022

CAROTID SURVEILLANCE Study of post-CEA surveillance prompts protocol discussion THE RESULTS OF AN ANALYSIS OF NEARLY 2,000 carotid endarterectomies (CEAs) “challenge the notion” that patients benefit significantly from the current postoperative surveillance guidelines, and suggest that these may be contributing to “oversurveillance”—an issue that should be addressed in future protocols for patient management post-CEA. These were among the talking points to emerge from a presentation delivered by Colleen P. Flanagan, MD, an integrated vascular surgery resident from the University of California San Francisco, who presented the results of a retrospective study looking at the long-term results of post-CEA surveillance within an integrated regional healthcare system, delivered during Plenary Session 2 Wednesday morning.

Flanagan and colleagues, along with senior author Robert Chang, MD, assistant chair of vascular surgery at San Francisco’s Kaiser Permanente Foundation Hospital, the healthcare system in question—sought to evaluate the long-term utility of surveillance after CEA in preventing stroke and identifying restenosis.

Current Society for Vascular Surgery (SVS) guidelines recommend a surveillance regimen consisting of up to five duplex ultrasound assessments in the first two years after a CEA, with annual scans thereafter, Flanagan noted in her presentation. Conversely, current recommendations from the European Society for Vascular Surgery (ESVS) favour a less rigorous approach, advocating carotid artery surveillance if there are signs of cerebral malperfusion during carotid clamping.

The study included patients who underwent CEA for severe (70–99%) carotid artery stenosis between 2008 and 2012, who were then followed up until 2019. Flanagan

described Kaiser Permanente as a “large, integrated regional healthcare system”, and detailed that patients who had undergone ipsilateral intervention previously, or who died within 30 days of their operation were excluded.

The primary outcomes, Flanagan told delegates, were ipsilateral severe restenosis or ocColleen p clusion, and ipsilateral stroke. She Flanagan also noted that a competing risks analysis was used to quantify freedom from the primary outcomes.

In terms of results, 1,923 carotid arteries in 1,816 patients were treated with CEA during the study period, Flanagan noted, of which 831 (43.2%) were for symptomatic indication. Mean follow-up time was 6.6 years (SD=3.3 years). A median of three surveillance studies were completed across the patient population during the study period, lower than the five recommended under current SVS protocols, and 13.5% of patients received no postoperative surveillance at all, Flanagan reported.

The presenter noted that 1.4% of arteries underwent reintervention during the study period, and of the 71 ipsilateral postoperative strokes that occurred, only three occurred in the setting of a known severe restenosis. The five-year risk of severe restenosis, occlusion and ipsilateral stroke seen in the study were 6%, 9.9% and 2.7% respectively, Flanagan noted.

“The risk of severe restenosis and occlusion were especially low, if [a] patient’s first postoperative imaging study was normal, whereas ipsilateral stroke decreased only slightly,” she stated.

“Despite less frequent surveillance compared to SVS guidelines, our observed ipsilateral stroke rate was actually lower than those previously reported in clinical trials,” Flanagan went on to remark. “Risk of restenosis was also particularly low, especially if the patients received a normal postoperative imaging study.

“Our data suggest a reconsideration of carotid surveil-

lance protocols are warranted after CEA. Following a normal first postoperative imaging study, additional scans are likely not necessary.”

The study team is conducting further analysis in order to identify any sub-populations that may require more frequent surveillance and attempting to understand the concurrent contralateral disease rate within this population, the presenter reported.

The study’s findings elicited a strong response from Ali AbuRahma, MD, speaking from the floor, who commented that he has been “preaching on the same issue” for over a decade.

AbuRahma said that he had been involved in collecting randomised trial data over 10 years ago which he said suggest that: “If you do surgery right from the first time… the value of having postoperative ultrasound frequently, to me, was absolutely unacceptable.”

A need for additional and unnecessary surveillance may place an increased financial burden on overstretched healthcare systems, he said. “I am trying to keep that in mind when we put the guidelines together this time for carotid management,” AbuRahma commented further. “I want the audience to be careful and perhaps we need to revisit the same issue.”

Expanding, Flanagan told Vascular Specialist@VAM that “oversurveillance is a problem primarily because it constrains important resources that other patients need.” The day-to-day implications of this overuse of finite hospital resources can be delays in access imaging, which many patients require as part of screening, surveillance or diagnosis of their conditions, the research team elaborated.

“Oversurveillance is a problem primarily because it constrains important resources that other patients need” COLLEEN P. FLANAGAN

CAROTID REVASCULARIZATION

LOW RATE OF NEW WHITE LESIONS DETECTED AFTER TCAR USING DIFFUSION-WEIGHTED MRI

By Will Date NEW WHITE LESIONS ARE NOT A common occurrence in patients who have undergone transcarotid artery revascularization (TCAR), a study in which patients were assessed post-procedurally using diffusion-weighted magnetic resonance imaging (DW-MRI), has found.

This was the finding delivered by Raghu Motaganahalli, MD, who presented data from a multicenter, single-arm, open-label study evaluating the incidence and volume of new white lesions occurring within 30 days after TCAR. Motaganahalli told attendees of Plenary 2, Wednesday morning, that the outcomes of the analysis should serve as the benchmark for future compar-

isons evaluating carotid revascularization strategies on cerebral new white lesions.

Diffusion-weighted imaging has high sensitivity and specificity for the early detection of ischemic lesions, Motaganahalli detailed in his presentation, noting that on DW-MRI, early ischemic lesions appear as new white lesions. Data from previous studies suggest that there is around a 17% chance of patients developing new white lesions following a TCAR procedure, Motaganahalli said, adding that the study presented at VAM 22 is the first in the U.S. to evaluate

the occurrence of new white lesions using DW-MRI. Fifty five patients were enrolled across five centers from the U.S., as well as centers in Madrid, Spain, and Munich, Germany. Each patient underwent three MRI scans, one within the 72 hours preceding the TCAR procedure, another before their discharge from hospital, and a third at 30day follow-up.

Relating to the study’s primary endpoint, detection of new white lesions from the DW-MRI scan, Motaganahalli communicated that new white lesions were seen in 14.5% of patients prior to the TCAR procedure, with a mean volume of 0.11cc. New white lesions were then seen in 21.8% of the study population in scans taking place between 12–60 hours post-procedure, with a mean volume of 0.03cc. Predominantly these were distributed in the territory of the middle cerebral artery, Motaganahalli said.

“When you

look at the 30-day follow-up, the majority of these lesions disappear,” Motaganahalli then detailed, adding that lesions persisted in only 5.8% of the patients assessed at this timepoint. The mean volume of the lesions at this point was 0.21cc, which were again predominantly located in the territory of the middle cerebral artery. No incidences of stroke or neurological death, the study’s secondary endpoints, were observed.

“Patients who underwent TCAR and DW-MRI post-procedurally had a low incidence of new white lesions,” the presenter told attendees of the Plenary 2 session.

Of these, he added, the majority were in the ipsilateral hemisphere, and located in the middle cerebral artery territory and distribution.

“These lesions are very small, and those procedures [when] followed-up the majority of them are resolved,” Motaganahalli added. The results of the study should serve as a benchmark, and point to the detection of new white lesions as a surrogate marker for future carotid revascularization clinical trials, he concluded.

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FAST TALK: TAAA

OFF-THE-SHELF BRANCHED ENDOGRAFT FOR TAAAS DEMONSTRATES SAFETY AND EFFECTIVENESS THROUGH TWO YEARS IN BOTH STABLE, SYMPTOMATIC PATIENTS TWO-YEAR TARGET VESSELrelated freedom from all-cause and aneurysm-related mortality for an off-the-shelf multibranched endovascular device for the treatment of thoracoabdominal aortic aneurysms (TAAAs) came in at 78.5% and 98.6%, VAM attendees heard.

The data relate to clinical outcomes and target vessel patency in patients who underwent endovascular TAAA repair with the Zenith t-Branch in the first company-initiated, real-life registry of a patient pool covering elective, symptomatic and ruptured TAAAs. Nikolaos Tsilimparis, MD, from Ludwig Maximilian University in Munich, Germany, reported the results yesterday morning during the International Fast Talk session.

The analysis was carried out at three Eu-

The SVS would like to thank the following companies for their support in the SVS Industry Partnership Program.

ropean sites between 2012–2020 on repairs in patients receiving t-Branch and bridging stents for the celiac (CA), superior mesenteric (SMA), left renal (LRA), and/or right renal arteries (RRA).

Eighty patients (mean age 71.0) were enrolled—six patients had symptomatic TAAAs, with 15 patients having contained ruptures. Technical success was achieved in 98.75% of patients. Median follow-up was 22.2 months. Beyond 12 months, 38 adverse events occurred in 20 patients, including two aortic ruptures (one study aneurysm and one non-study aneurysm) and six deaths (none aneurysm-related), Tsilimparis told VAM. Tsilimparis said the research team went through each target vessel in order to determine how each of them performed.

L to r: Manuel Garcia-Toca, Fedor Lurie, Ahmed AbouZamam, Jr., Palma Shaw, and Nikolaos Tsilimparis

Throughout the study duration, two patients had bridging stent compression, including covered and uncovered CA stents in one patient, and a covered LRA stent in the other, he revealed. Freedom from secondary intervention was 76.3% at 24 months.

Seven patients had nine endoleaks (seven Type III and two Type Ic) involving bridging stents. Fourteen target vessel-related secondary interventions were performed, primarily consisting of stent placement for endoleak, stenosis, or occlusion. One reintervention involved bridging stent placement as part of a staged procedure. Freedom from loss of primary patency were 94.8%, 100%, 91.3%, and 89.3% for the CA, SMA, LRA, and RRA, respectively, at 24 months. Freedom from loss of secondary patency in the CA, SMA,

LRA, and RRA were 96.3%, 100%, 98.2%, and 98.3% “The celiac artery with the bridging stents seemed to do very well: the first year there were only a few occlusions, and primary and secondary patency were high. The two-year results were pretty similar to one year,” Tsilimparis explained. “After the few occlusions, there was a stable finding. The superior mesenteric artery was the vessel that performed the best and had the least concerns, with 100% patency at two years.

More challenging were the renal arteries.”

He concluded, “At two years, specifically looking at target vessels, the results are supportive of the safety and effectiveness of the device and the technique and, of course, we need long-term data.”

Y K O N U! A H Gold T Platinum Boston Scientific Gore & Associates

Abbott Medtronic

Silver BD

Bronze 3M Cook Medical Philips Janssen Pharmaceuticals

8

Vascular Specialist | Thursday 16 June 2022

PANDEMIC PROGNOSIS

ALI CAN OCCUR WITH OR WITHOUT ATHEROSCLEROTIC DISEASE AND PORTENDS WORSE PROGNOSIS IN COVID-19 PATIENTS

By Jocelyn Hudson ACUTE LIMB ISCHEMIA (ALI) CAN OCCUR WITH or without atherosclerotic disease and portends a worse prognosis in patients with COVID-19. This risk persists after COVID-19 infection due to a lingering co-inflammatory state, and D-dimer may be a useful screening test in at-risk patients. This is according to Max V. Wohlauer, MD, assistant professor of surgery at the University of Colorado Denver in Aurora, Colorado, who yesterday outlined a study assessing revascularization outcomes of ALI in COVID-19 patients.

Wohlauer delivered the presentation during a Vascular and Endovascular Society (VESS) paper session on behalf of first author Mahmood Kabeil, MD, senior author Robert F. Cuff, MD, assistant professor at Spectrum Health in Grand Rapids, Michigan, and on behalf of the Vascular Surgery COVID-19 Collaborative (VASCC).

“Coagulation and inflammation are linked, and a coagulopathy has been described with SARS and other respiratory viruses,” said Wohlauer, noting an increased D-dimer and

other coagulation derangements in patients with COVID-19 infection. Giving additional context to his talk, the presenter noted that ALI is a risk factor for amputation and mortality in patients with COVID-19 infection, and that high D-dimer levels are associated with an increased risk of thrombosis in COVID-19 patients.

Outlining their methods for the study in an abstract, the researchers note that VASCC formed the basis of their analysis.

A registry was developed in March 2020, they write, in order to assess the impact of COVID-19 infection on vascular surgery patients and practices. At VAM, Wohlauer reported an interim data analysis of 94 patients from 18 sites across five countries with the aim of providing an insight into revascularization strategies and outcomes for COVID-19-associated ALI. The speaker noted that the 94 patients included in the interim analysis had a mean age of 64 years and that 37% were female. In this cohort, only 15% had a history of peripheral arterial disease (PAD), he added, and none had a prior hypercoagulable state. Only 2% had active cancer, and the rate of tobacco use was 21%.

Wohlauer was keen to emphasize the fact that 90% of the patients in the cohort had no prior history of vascular intervention. In addition, he detailed that ALI was the initial COVID-19 presentation in 21% of the cases, with the remaining 79% experiencing ALI a median of eight days after a positive COVID-19 test.

Giving further details on the patient cohort, the presenter noted that 53% were categorized as Rutherford 2b. He added that 89% of the thrombus was located in the lower extremity, 8% in the upper extremity, and 3% in the infrarenal aorta. Of the patients with lower extremity thrombus, he detailed that the majority was in the femoropopliteal region.

Reporting revascularization strategies in this cohort, Wohlauer detailed that 63% of patients underwent open revascularization, 16% endovascular, and 22% had no revascu-

larization. In the patients who had no revascularization, he specified that 52% of the time it was because the limb was not salvageable. For others, it was related to the severity of COVID-19 pneumonia.

In terms of other outcomes, the presenter revealed that the mean hospital stay was 14.7 days, and mean intensive care unit (ICU) stay was 5.6 days. Thirteen percent required an amputation, 5.2% had a pulmonary embolism, 5.2% had a stroke, and 6.2% had sepsis. There was a 15.5% major adverse limb event rate in this cohort.

One of the key findings Wohlauer highlighted was a 31% in-hospital mortality rate. He also reported that, on the other end of the scale, 40% of patients had no major complications in hospital. Age was an independent risk factor for in-hospital mortality, he said, but was not a risk factor for major adverse limb events.

Wohlauer summarized that ALI is the initial COVID-19 symptom in up to one-third of patients, and that the overwhelming majority of patients with COVID-19 ALI have no prior vascular history, and that age is an independent risk factor for mortality, but not a risk factor for major adverse limb events. D-dimer, he informed the audience, may be a useful screening test in patients at risk for COVID-19-associated ALI. He thanked all of the VASCC members who contributed data to this project, and acknowledged the VASCC Project 2 ALI Working Group. He mentioned that the study is actively recruiting patients and that the organization welcomes contributions.

“The overwhelming majority of patients with COVID-19 ALI have no prior vascular history”

INTERVIEW Vascular Surgery Interest Groups propel students’ awareness and engagement in the specialty Analysis out of Illinois records increase in vascular surgery elective choices after start of VSIG events A STUDY OF THE IMPACT OF Vascular Surgery Interest Groups (VSIGs) can have on piquing awareness and engagement of medical students in the specialty found a spike among first years taking electives in vascular surgery after a series of interest group meetings were initiated.

The finding was delivered under the title “Gaining access: Events with the greatest impact on student interest in vascular surgery” during yesterday’s International Fast Talk session.

Presenting author Richard Li, BS, a thirdyear medical student at Carle Illinois College of Medicine in Urbana, Illinois, and colleagues investigated the relationship between the type of event staged and the impact it had on retaining event attendees, increasing interest in vascular surgery, and enhancing knowledge and awareness of the field.

Li pointed out an important backdrop to the research: These days, more than 70% of matched medical students in surgical specialties identified surgery as their top choice by the second year of medical school, he said.

The Carle VSIG held four interest group

meetings throughout the school’s fall semester—one each with the group’s physician mentor, a vascular surgery resident, the program director of the Carle vascular surgery residency program, and demo deployments from industry representatives.

“Before each event, students were asked to fill out a form inquiring about their interest and knowledge of the field of vascular surgery on a scale of 1–10, with 1 being the lowest interest and knowledge,” Li detailed. “After each event, students were again asked to fill out a form which included the same questions regarding their interest and knowledge of the vascular surgery field.”

Li said the research team found that postevent surveys showed students as having a high interest in vascular surgery: “The average level of interest stayed consistent with minor fluctuations before and after the events. Of note, the event with the program director had the largest increase, from 5.91 to 7.53. Regarding interest in vascular surgery, each event had a high standard deviation.

This could be due to students who are both changing their opinions and solidifying their thoughts about vascular surgery as a career

choice.”

The students who attend the VSIG’s events tend to have an interest in vascular surgery, Li added, “and we do find that a large standard deviation for change of interest is a desirable outcome—having a student go from a two to an eight is just as important as an eight to a two.”

Attendance was “very high,” he said, averaging between 20–30 students from an average class size of 50.

“Why does this matter?” he pondered.

Just 13% of students were interested in vascular surgery when they arrived.

“Since we’ve started, over seven students have elected to do electives in vascular surgery, with five of them starting their first year of medical school—up from zero.”

VSIGs “def initely” have an impact, Li said, “and I highly recommend for this to be a call to action to reach out to your VSIGs.” Li and colleagues plan to put the data

from the study to use in order to develop a series of events with “maximum impact” for increasing exposure and awareness of vascular surgery.

“Event responses demonstrate that VSIGs are critical to educating medical students about vascular surgery and promoting interest in the field.”

Moderator Ahmed M. Abou-Zamzam, MD, noted an element of surprise at the statistic showing they had established 13% interest in vascular surgery from “the get-go.” He further asked whether the research group had tracked elements such as food offerings. “Two of the events, we actually had no food,” Li said in response. “We still managed to get high representation.”

Richard Li

9

www.vascularspecialistonline.com

SET Study demonstrates feasibility, effectiveness of at-home exercise therapy plus cognitive behavior therapy for IC A mobile phone-administered, home-based exercise therapy program for patients with intermittent claudication (IC) incorporating cognitive behavior therapy (CBT) was feasible, with 78% of participants completing the whole course, VAM heard yesterday morning.

THE FINDINGS WERE PART OF A study delivered by Oliver Aalami, MD, from the Stanford University School of Medicine, Stanford, during the William J. von Liebig Forum (Ballroom A/B).

Previous studies have shown “a trend towards improved outcomes with greater patient engagement and higher intensity and duration walking session recommendations,” Aalami explained.

Aalami reported having chosen patients whose PAD had been confirmed by abnormal ankle-brachial or toe-brachial index, or who had IC. The program they participated in was 12 weeks of homebased, mobile phone-delivered, exercise therapy, Aalami elaborated. Participants were tasked with performing phone-based, six-minute walk tests and completing mini-WIQ QOL [Walking Impairment Questionnaire and Quality of Life] surveys.

They were also asked to complete three

health education courses (What is peripheral arterial disease?; Exercise; and Nutrition) and were asked to record at least three 30-minute exercise therapy walks a week using their personal mobile phones.

Participants also received daily ‘doses’ of health education via text message.

Alongside this, participants had regular weekly check-ins with health coaches trained in CBT techniques such as motivational interviewing. They also spoke with a health coach at the beginning, middle and end of the program to discuss their progress. Aalami stated that his reasoning for wanting to include CBT techniques in the program was that it is linked to immediate and lasting behavior change.

Of the 145 patients (40% women; mean age=65) onboarded across 18 institutions (of which 44% did not offer in-person exercise therapy), 78% of patients completed the program, Aalami told VAM delegates.

SAVE THE DATE!

June 14-17, 2023 | National Harbor, MD

In total, patients recorded having spent 149,135 minutes walking 5,205,943 steps as part of the exercise therapy program.

Aalami added that 19 of those initially enrolled paused, withdrew or were non-responsive due to medical issues, technical difficulties or privacy concerns.

Ninety-two percent of patients achieved the CBT S.M.A.R.T goals (specific; measurable; achievable; realistic; timely) they had set prior to beginning the program, Aalami then acknowledged.

Regarding freedom from intervention, at six months, the figure was 92%, and at 12 months, 69%. This, Aalami told Vascular Specialist@VAM, is promising, as it goes some way to mirroring the five-year results observed in an in-person supervised exercise therapy study in the Netherlands.

He also spoke to the challenges of implementing exercise therapy for IC and

PAD patients in the U.S. Among the obstacles, he cited poor program availability, the requirement for patients to travel to a facility for in-person therapy, and the low rate of reimbursement. While the Centers for Medicare and Medicaid Services granted National Coverage Determination for Medicare beneficiaries with IC in 2017, the reimbursement only includes facility costs, leaving physician fees uncovered. Aalami asserted that “the biggest challenge is not the tech or the patients or the providers, it is reimbursement.”

Aalami underscored to the VAM audience that he and his team found a mobile phone-administered, home-based exercise therapy program incorporating CBT to be feasible, adding how it could be deemed effective since 92% of patients achieved their CBT S.M.A.R.T goals. He explained that engagement rose as a result of the home-based exercise therapy being offered where it had not been previously in the traditional format.

Aalami concluded that “accessible and lower-cost digital health approaches to exercise therapy for patients with PAD and intermittent claudication could play a role in addressing the wide supervised exercise therapy utilization gap faced today.”

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Vascular Specialist | Thursday 16 June 2022

FLOORPLAN MAP HYNES CONVENTION CENTER 900 Boylston Street, Boston, Massachuestts 02115 t: 877-393-3393 f: 617-954-3326 w: signatureboston.com

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Emergency Exit

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(4,000 Person Seating Capacity)

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Veterans Memorial Auditorium (25,760 sq ft)

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Elevator

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Lobby & Pre-function

Restrooms

Public Use

Permanent Concessions

Ring Road

Charging Stations

Non-Public Access

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Executive Boardroom 300

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www.vascularspecialistonline.com

THURSDAY SCHEDULE AT-A-GLANCE Thursday, June 16, 2022

Sheraton Boston Hotel Connection

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Registration

Outside Hall C

6:45 to 8 a.m.

International Chapter Forum

210

6:45 to 8 a.m.

Industry Breakfast Symposia (not eligible for CME credit) B1: What You See is Not What You Get: A Case-based Discussion on the Role of IVUS in Peripheral Interventions, Sponsored by Boston Scientific and Philips

HCC, 312

B2: Clinical Insights in PAD: Reducing the Risk of Major Thrombotic Vascular Events, Sponsored by Janssen Pharmaceuticals

306

B3: Redefining Thrombectomy with Hydrodynamic Maceration and Powerful Aspiration, Sponsored

by Abbott

304

Medical Student Program: Introduction to Vascular Surgery

311

Medical Student Program: How to Succeed as a Vascular Surgery Residency Applicant

200

General Surgery Resident Program: How to Succeed as a Vascular Surgery Fellowship Applicant

206

8 a.m. to 9:30 a.m.

S3: Plenary Session 3

Ballroom A/B

8 a.m. to 5 p.m.

SVN Annual Meeting

HCC, 302

9:30 to 10 a.m.

E1: Roy Greenberg Distinguished Lecture

Ballroom A/B

10 to 10:30 a.m.

Coffee Break

Exhibit Hall C/D

10 a.m. to 6:30 p.m.

Exhibits

Exhibit Hall C/D

10:30 to 10:45 a.m.

Awards Ceremony

Ballroom A/B

10:45 a.m. to 12 p.m.

S4: Plenary Session 4

Ballroom A/B

11:30 a.m. to 1 p.m.

Physician Assistant Section Luncheon

304/306

12 to 1 p.m.

Meet the Leaders Luncheon & Leadership Development Program Graduation

Ballroom C

12 to 1:30 p.m.

Box Lunch in Exhibit Hall

Exhibit Hall C/D

1 to 5 p.m.

Physician Assistant Section

304/306

1:30 to 2:30 p.m.

Journal of Vascular Surgery Special Session

200

1:30 to 2:30 p.m.

VH: “How I Do It” Video Session

312

1:30 to 3 p.m.

C3: Thoracic Outlet Syndrome

Ballroom A/B

1:30 to 3 p.m.

Women’s Section: Supporting Women Vascular Surgeons – From Recruitment Through Senior Leadership

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1:30 to 4:30 p.m.

P1: Updated Guidelines and Unresolved Controversies in Carotid Disease

309

2 to 3 p.m.

How to Start a Vascular Training Program

310

2:30 to 3 p.m.

Policy/Advocacy Session 2

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3 to 3:30 p.m.

Coffee Break

Exhibit Hall C/D

3:30 to 5 p.m.

C4: There’s a Zebra in the Room: Aberrant Vascular Pathologies and Current Management Strategies

Ballroom A/B

3:30 to 5 p.m.

Young Surgeons Section

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Opening Reception

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Women, Leadership, Diversity and Young Surgeons Reception

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7:45 to 9:30 p.m.

Women's Leadership Dinner

Sheraton, Independence West

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Vascular Specialist | Thursday 16 June 2022

YOUR SVS Special sessions geared to those in community practice, OBL settings TWO SPECIAL VAM MEETING sessions on Friday will focus on the specific needs of surgeons in the community practice and outpatient-based settings.

Immediately adjacent to each will be town halls, to allow section members to ask questions about the section’s direction and offer information on programs they would like to see in the future.

SVS has five special membership sessions.

This year, for the first time, VAM offered special education presentations geared specifically to the members in those sections.

Friday’s sessions will explore two facets of being in independent, community practice: starting and maintaining a practice and the elements involved in providing outpatient care in an office-based lab (OBL).

“Leaders of these sections are presenting topics they feel are the most pressing to their members,” said William Robinson III, MD, chair of the SVS Postgraduate Education Committee. The PGEC oversees this and a host of other educational programming.

“What pertains to an academic member

is not likely relevant to those running a business. These members need information on the nuts and bolts of managing a practice, how to hire, billing and coding, that kind of thing. And the needs of those in an outpatient-based setting are even more specific.

“We’re pleased to be able to offer sessions so tailored to our members’ requirements.”

The SVS Community Practice Section (SVSCPS) takes place in HCC, Room 210.

From 1–1:30 p.m. the section is hosting a Town Hall; from 1:30–2:45 p.m., the main educational session takes place; and at 2:45 p.m., the Excellence in Community Practice Award will be presented.

Moderators Daniel McDevitt (chair of the section Steering Committee) and Sean Lyden will moderate the educational session, entitled “Starting Your Own Independent Practice—What you Need to Know.”

“Part of our thinking is that we want to encourage surgeons to go into private practice,” said McDevitt, adding that 70% of vascular surgeons go into an employed situation. ‘It’s very likely people finishing training today are going into employment. We want to give people the tools to start the journey.”

The selected topics serve as a “primer for all the different aspects of running a successful practice,” he said. They include: ● “Why open an independent practice,” Benjamin J. Herdrich, MD ● “Basic business planning,” Joseph Hart, MD ● “Space: lease, purchase, design, location,” Daniel McDevitt, MD

PEER REVIEW JVS ANSWERS QUESTIONS FROM ITS READERS THE VASCULAR ANNUAL MEETING is going out on the airwaves.

At least one session is, at any rate: a special concurrent session Thursday afternoon presented by the Journal of Vascular Surgery family, the official publications for the Society for Vascular Surgery.

The entire session—with panelists informally gathered on a couch as opposed sitting at a dais—will be turned into a podcast to be aired by Audible Bleeding, the popular SVS vascular surgery broadcast.

The format will be rapid-fire question-and-answer discussion, in the spirit of the ESPN sports network show “Pardon the Interruption,” said Gale Tang, MD, co-moderator with Imani McElroy, MD. “The idea behind this JVS interactive session involves the opportunity for the audience to pose any question they wish to those involved with the Journals of Vascular Surgery, at all levels of involvement in the publication process,” said Paul DiMuzio, MD, an assistant editor of JVS publications. “Think of it as how

people discuss a topic around a work water cooler.”

Panelists are JVS Senior Editor Dr. Peter Lawrence, plus Laura Drudi, MD, Christopher Audu, MD, Ulka Sachdev-Ost, MD, and Alan Dardik, MD, all of whom are also involved with the publications. Audu and Drudi are part of the first group of JVS interns; Sachdev-Ost is an associate editor, the first to focus on diversity, equity and inclusion issues; and Dardik is the first editor for the newest publication in the family, JVS: Vascular Science.

The podcast will include discussion by the moderators and panelists of questions submitted ahead of time by members and others interested in the journals, plus Twitter polls on various aspects of the publication process. These include ideas on how to strengthen manuscripts, dealing with rejection, continuing interest in DEI issues at the publications and whether published papers are even relevant in an era of social media, YouTube videos and sound bites.

The JVS Special Session takes place 1:30– 2:30 p.m. Thursday in HCC Room 200.

● “Personnel: Administrative, clinical, partners, advanced practice,” Clifford Sales, MD, MBA ● “Billing and coding,” Geetha Jeyabalan, MD ● “Marketing,” Gregory Clabeaux, DO ● “OBL consideration,”.

Robert G. Molnar, MD, MS ● “Tips, tricks, and pitfalls,” Daniel McDevitt There also will be time for discussion as well as a summary. In addition, at 2:45 p.m., the section will announce and honor the recipients of this year’s SVS Excellence in Community Practice Awards.

Meanwhile, the SVSCPS activities will be followed by the Sub-Section on Outpatient & Office Vascular Care (SOOVC), which will host a Town Hall from 3–3:30 p.m. and an educational session from 3:30–5 p.m., also in HCC, Room 210.

Robert Molnar, MD, and Jayer Chung, MD, will moderate the session, called “Providing Outpatient Vascular Care in the Office-based Lab (OBL)—Evaluating Trends, Quality and Value-based Care.”

Molnar chairs the section’s Executive Committee. “We selected six talks to highlight how to provide outpatient vascular care in this setting,” said Molnar.

“The presenters all have experience in the OBL arena and the presentations were chosen to address current trends, quality and the value-based care that is provided in the OBL setting.” Patient satisfaction, quality outcomes,

finances and reimbursement are all on the agenda, and the session also will present an update on the SVS/American College of Surgery’s Vascular Center Verification and Quality Improvement Program (VCV&QIP).

“We believe those in attendance will receive a well-rounded overview of the OBL space and will also answer many questions our members and surgeons might have,” Molnar said. Topics include: ● “The OBL: A venue that provides value, quality and needed outpatient vascular care,” Anil Hingorani, MD ● “ The ESRD (end-stage renal disease) Lifeline: How OBLs provide timely and cost-effective ESRD access care,” Franklin S. Yau, MD ● “ The value of patient satisfaction: Quality outcomes in the OBL with a patientcentered focus,” Alison J. Kinning, MD ● “ How the OBL provides value to the community and its hospital systems,” Jacqueline Majors, MD ● “ OBL financial stability: Protecting reimbursement and cutting costs,” Bob Tahara, MD ● “ Update on the SVS/ACS Verification Program and its potential in support of SOOVC goals,” Michael C. Dalsing, MD, MBA ● Panel discussion ● Summary Thursday’s special presentations focused on the sections for physician assistants in the vascular setting, women and young surgeons.

GREENBERG LECTURE

Greenberg Lecture raises prospect that “less is more and more is less” with aortic disease treatment JAN S. BRUNKWALL, UNIVERSITY OF Cologne in Cologne, Germany, will present the Roy Greenberg Distinguished Lecture, titled “More is Less, and Less is More!, from 9:30 to 10 a.m. Thursday, in Ballroom A/B of the Hynes Convention Center.

The late Roy Greenberg, of the Cleveland Clinic, died in December 2013 at the age of just 49, of cancer. He was known for his innovations and research, particularly in complex aortic disease, and for embracing endovascular surgery. He also was known worldwide as a teacher, mentor and researcher. According to published reports, he was issued nearly 100 patents on endovascular therapy on the basis of his research.

Brunkwall told Vascular Specialist@VAM: “My presentation will highlight that endovascular treatment is less invasive than open surgery, and therefore the preferred option for many patients. However, a key factor is the impact of case volume load; high volume centers are associated with results whereas less experience tracks to more com-

plications and more deaths. Another important consideration that is quite obvious but not adhered to by everybody is that strict compliance with instructions for use (IFU) yields better results, and I will illustrate this using examples.”

Further, open surgery will also be forefronted as a very durable option and good solution for juxtarenal and abdominal aortic aneurysms, which will avoid more extensive endovascular procedures.

Brunkwall will also touch on acute aortic dissection treatment, maintaining that endovascular treatment is less invasive and has better results with respect to mortality and devastating complications, such as paraplegia, than open surgery.

Again, sticking within the IFU will deliver long lasting results, he says, pointedly noting that he will also show some examples of endovascular treatments that should never have been on the market. “Less humble means more trouble,” he says, referencing these.

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Vascular Specialist | Thursday 16 June 2022

TRAINING

Bolstering the vascular workforce: Session details how to start a training program

The workforce shortage issues set to plague vascular surgery over the next few decades, alongside an aging population and increase in vascular disease, forms the backdrop to a Thursday afternoon session designed to help surgeons navigate the tricky waters of starting a vascular training program, writes Bryan Kay.

M

alachi Sheahan III, MD and Jeffrey Jim, MD, who together chaired the new program development section of the SVS Future of Vascular Surgery Task Force, will moderate and attempt to answer two top-line questions for those mulling over the possibility: “Do you have the resources? And where can you find help?”

The session will help usher attendees through the process of establishing programs, including leadership and faculty requirements, the constitution of curricula, and other needs like a vascular lab.

Sheahan will introduce a guidebook, entitled How to Develop A Vascular Surgery Training Program, a collaborative work from the Association of Program Directors in Vascular Surgery (APDVS) and the Society for Vascular Surgery (SVS).

“The U.S. population is increasing and aging,” he will tell those looking to help plug the workforce shortages expected to ensue through 2050. With cardiovascular disease continuing to be the country’s leading cause of death and morbidity, and the prevalence increasing 1–2% annually, the burden will remain, he will outline. The workforce phenomenon is international, Sheahan will add, sharing statistics laying out the scale of shortages in the United Kingdom, France

and Canada. The session will look to explore the concept of increasing the supply of vascular surgeons, meaning more trainees, and explore the question of “can we preserve vascular surgery?—which comes amid a burgeoning field of “vascular specialists” who are not vascular surgeons, Sheahan tells Vascular Specialist@VAM. Through the APDVS-SVS guidebook, a session aid, attendees will learn about the complexities and intricacies of both the five-year integrated vascular residency and the vascular fellowship.

Earlier this year, Sheahan and Jim outlined the scale of the task at hand in a presentation at the

“With a bit of a push, there are a lot of people out there who want to train vascular surgeons” MALACHI SHEAHAN III

EXAM PREPARATION REVIEW BOOK SEEKS TO PLUG HOLE IN VSITE PREPARATION PROCESS WHEN UNIVERSITY OF Massachusetts Medical School integrated vascular surgery resident Thomas Creeden, DO, was preparing for his first Vascular Surgery In-Training Exam (VSITE), it struck him there was a gap in the market.

While those training in most other surgical specialties had access to a high-yield textbook with which to prepare for exams, boards and even rotations, he mused, vascular surgery did not. “The modern-day textbook is something like 4,000-pages long, and seems kind of daunting,” Creeden tells Vascular Specailist@VAM. So he decided to do something about the anomaly: After some encouragement from mentors, he went ahead and produced one himself. The result is The Vascular Surgery Review Book.

What started out as a culling-together of his notes in intern year morphed into a more organized undertaking during the second and third. Eventually, he got serious with the encouragement of UMass vascular chief Andres Schanzer, MD, and program director Jessica Simons, MD. The driving force was to create a reference text that would be fundamentally easier and quicker to work through.

The book was published in the middle of June, and is avail-

able both in print and as a Kindle edition.

It was also be available at the University of Massachusetts table at the General Surgery Resident/Medical Student Program: Residency Fair on Friday (5–6:30 p.m., Hall A).

Creeden, who will be in attendance at the table, was himself drawn to vascular surgery after a process of elimination, realizing he enjoyed the blend of minimally invasive procedures, open surgery, medicine and critical care.

“Once I spent a month on it, I wanted to spend another month on it, and then another month, and it just started snowballing for me,” he says.

The book publishing process ramped things up a notch. Creeden spent much of his spare time putting the title together, but then realized over the last three or four months the easy part was writing it.

Once he had navigated potential copyright pitfalls, he hired professional help to complete the publishing process, including a medical illustrator and a cover designer. “I’ve been very encouraged hearing other vascular surgery training programs are already utilizing the book and providing copies for their residents,” The he adds.— new title Bryan Kay

annual meeting of the Society for Clinical Vascular Surgery (SCVS) annual meeting in Las Vegas. Helped by the task force’s efforts, Sheahan explained, 28 new vascular training programs had been established nationwide.

The collaboration formed between the SVS and APDVS helped clear up the prerequisites of the Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) for the faculty and program director requirements needed to start both an integrated program and a fellowship.

The APDVS also provided stewardship to help guide those getting started through an often “byzantine and confusing” process, Sheahan said. They also increased outreach efforts through such mediums as the VAM 2022 session in question, which is currently a recurring feature on the VAM schedule.

“With a bit of a push, there are a lot of people out there who want to train vascular surgeons,” Sheahan said.

Malachi Sheahan III

The session takes place in Hynes Convention Center Room 310 from 2–3 p.m.

TRAINEES EXPLORING ALTERNATIVE TRAINING PATHWAYS TO BOLSTER VASCULAR SURGEON-FORCE THE ROLE OF ALTERNATIVE AND collaborative training pathways in concert with the integrated vascular surgery residency (0+5) and the vascular fellowship (5+2) will play an important role as the specialty tackles the expected shortfalls in workforce numbers over the next 30 years.

That was the main thrust of the message put forward by Jeffrey Jim, MD, chair of vascular and endovascular surgery at the Minneapolis Heart Institute-Abbott Northwestern Hospital in Minneapolis, yesterday afternoon during a VAM 2022 Concurrent Session entitled, “Progressing and Sustaining our Vascular Surgery Workforce into the Future through Innovation in Surgical Education.”

Jim spoke on the rise of the 0+5, the fate of the 5+2 and how innovation might help drive the specialty forward as vascular surgery confronts the highest projected growth in demand for its services as the population continues to increase.

The introduction of the integrated pathway in 2006 was popular with academic institutions, attracted “top” candidates from medical school and allows control of the entirety of a future vascular surgeon’s training.

However, the financial cost is significant and can be labor intensive, Jim pointed out.

The 5+2 fellowship, was the standard in training for decades. In 2018, a change in requirements allows “community practice” based fellowships, which eliminated the need

for an affiliated medical school or surgery residency and is associated with lower cost.

This has allowed an increased growth in programs in the past couple of years, Jim continued.

Ultimately, Jim said that starting new fellowship programs “may be the most efficient way to increase the number of trainees.”

Alternative pathways are myriad and present a mixture of opportunities and challenges, he noted. They include postgraduate mentoring that encourages trainees into smaller communities; “+3” vascular training among trainees who have already competed two years of core training; community training programs that offer a year of vascular training to general surgery graduates committed to community practice. Jim also noted opportunities to partner with community hospitals to develop rotations to increase trainee clinical experience. This in particular may help boost trainee involvement in open aortic procedures amid the declining number of such cases to which graduates are exposed. This type of collaboration will also allow programs to increase the number of trainee positions.

There will be a shortage of available vascular surgeons in the U.S., Jim told attendees.

But despite the successes in increasing the number of graduates in the last decade, he added, “we need to be flexible and innovative” to ensure future success.—Bryan Kay

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THROUGH THE LENS »

VAM opening day was abuzz with activity across the host venue. Between the Opening Ceremony, the SVN 40th annual conference, Crawford Forum and opening plenaries, the program offered a full range of educational and networking opportunities.

Education and celebration took center stage at the Hynes Convention Center at Opening Day of the 2022 Vascular Annual Meeting and the Society for Vascular Nursing 40th Annual Conference (top photos). The day featured a wide range of education, including the latest in research at the plenary sessions, and a number of other educational sessions, including SVS Foundation Resident Research Award recipient Christopher Audu, MD (right)

“This is the premiere vascular meeting for the presentation of new research” ANDRES SCHANZER

18

Medical Editor Malachi Sheahan III, MD Associate Medical Editors Bernadette Aulivola, MD | O. William Brown, MD | Elliot L. Chaikof, MD, PhD | Carlo Dall’Olmo, MD | Alan M. Dietzek MD, RPVI, FACS | Professor HansHenning Eckstein, MD | John F. Eidt, MD | Robert Fitridge, MD | Dennis R. Gable, MD | Linda Harris, MD | Krishna Jain, MD | Larry Kraiss, MD | Joann Lohr, MD | James McKinsey, MD | Joseph Mills, MD | Erica L. Mitchell, MD, MEd, FACS | Leila Mureebe, MD | Frank Pomposelli, MD | David Rigberg, MD | Clifford Sales, MD | Bhagwan Satiani, MD | Larry Scher, MD | Marc Schermerhorn, MD | Murray L. Shames, MD | Niten Singh, MD | Frank J. Veith, MD | Robert Eugene Zierler, MD Resident/Fellow Editor Laura Marie Drudi, MD Executive Director SVS Kenneth M. Slaw, PhD Director of Membership Marketing and Communications Tara J. Spiess, CAE Managing Editor SVS Beth Bales Marketing & Membership Specialist Amber Dunlop Assistant Marketing & Social Media Manager Kristin Crowe

Published by BIBA Publishing, which is a subsidiary of BIBA Medical Ltd. Publisher Roger Greenhalgh Content Director Urmila Kerslake Managing Editor Bryan Kay bryan@bibamedical.com Editorial contribution Jocelyn Hudson, Will Date, Clare Tierney and Anthony Strzalek Design Terry Hawes Advertising Nicole Schmitz nicole@bibamedical.com Letters to the editor vascularspecialist@vascularsociety.org BIBA Medical, Europe 526 Fulham Road, London SW6 5NR, United Kingdom BIBA Medical, North America 155 North Wacker Drive – Suite 4250, Chicago, IL 60606, USA

Vascular Specialist is the official newspaper of the Society for Vascular Surgery and provides the vascular specialist with timely and relevant news and commentary about clinical developments and about the impact of healthcare policy. Content for Vascular Specialist is provided by BIBA Publishing.

Content for the News From SVS is provided by the Society for Vascular Surgery. | The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher. The Society for Vascular Surgery and BIBA Publishing will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services, or the quality or endorsement of advertised products or services, mentioned herein. | The Society for Vascular Surgery headquarters is located at 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018. | POSTMASTER: Send changes of address (with old mailing label) to Vascular Specialist, Subscription Services, 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018. | RECIPIENT: To change your address, e-mail subscriptions@bibamedical.com | For missing issue claims, e-mail subscriptions@bibamedical. com. | Vascular Specialist (ISSN 1558-0148) is published monthly for the Society for Vascular Surgery by BIBA Publishing. | Printed by Vomela Commercial Group | ©Copyright 2022 by the Society for Vascular Surgery

VS@VAM BRIEFS VASCULAR LIVE

Be sure to save time in the schedule for Vascular Live theater-in-the-round presentations in Exhibit Hall C. These sessions, on a variety of topics of importance to vascular surgeons, typically play to big crowds.

All Vascular Live events will take place at the Vascular Live stage, at the back of Aisle 700 in Hall C, on Level 2 of the Hynes Convention Center.

Thursday, June 16 10 to 10:25 a.m.

Tips and Tricks for Suture-Mediated Closure and Repair for Arterial Access Sites Sponsored by Abbott Speaker: Elena Rinehardt, MD 12:15 pm to 12:40 p.m.

Real-World Clinical Strategies with the Venovo™ Venous Stent System Sponsored by BD Speaker: Patrick Muck, MD, FACS 1 to 1:25 p.m.

Overcoming Challenges in TEVAR, Today and Tomorrow Sponsored by Gore & Associates Speaker: Ali Azizzadeh, MD 3 to 3:25 p.m.

Reimagine Aspiration with Hydrodynamic Thrombectomy Systems Sponsored by Abbott Speaker: Loay Kabbani, MD, MHSA, FACS 5:15 to 5:40 pm Treating Complex VTE in My Practice Sponsored by Penumbra Speaker: Carlos Bechara, MD Overview: This presentation will focus on the use of Lightning™ 7 Intelligent Aspiration in cases and to assist in treating complex VTE cases.

Friday, June 17 9:30 to 9:55 a.m.

Advancing Health Equity by Addressing Disparities with TWO2 Homecare Therapy Sponsored by Advanced Oxygen Therapy Speakers: Mike Griffiths, MD, and Anil Hingorani, MD 12:15 to 12:40 p.m.

Remove with Rotarex Sponsored by BD Speakers: Drs. Frank Arko and Bryan Fisher 1 to 1:25 p.m.

Data-driven decision-making: Clinical considerations in SFA occlusive disease treatment Sponsored by Gore & Associates Speaker: Caitlin Hicks, MD 3 to 3:25 p.m.

TCAR: The Road to Standard of Care Sponsored by Silk Road Medical Speakers: Drs. Marc Schermerhorn, Megan Dermody and Jeffrey Jim Presentations: • TCAR in 2022 and Beyond: The Current and Future State of TCAR • How Can TCAR Improve Efficiencies Within Your Practice • TCAR: Perspectives From a Practicing Physician: How TCAR Can Benefit Patients (Vascular Live presentations are not eligible for CME credit. Listing is as of June 3, 2022.)

Vascular Specialist | Thursday 16 June 2022

Compiled by Beth Bales

BID ON SILENT AUCTION ITEMS UNTIL FRIDAY EVENING’S GALA While hundreds of people will be dressed up and having a ball at the SVS “Cheers to 75 Years” Gala Friday evening, they’re not the only ones who can participate.

As long as they have internet access, all those with other plans for the evening can still bid (and raise bids!) on the 70-plus items offered in the Silent Auction. (The Live Auction is, naturally, restricted to those in attendance. The Gala itself is sold out.)

A wide range of prizes are available, from pet and family portraits, to artwork, gift cards and vacations, including: • A weekend kayaking expedition on West Galveston Bay, in Texas (including all-you-can-eat-and-drink shrimp and beer!) guided by two eminent vascular surgeons, John Eidt, MD, and Alan Lumsden, MD • Golf at a number of courses, including Stanford University Golf Course with Ron Dalman, MD • A fishing trip weekend in Horseshoe Beach, Fla. • A “tiny home” getaway cabin rental at one of 20 Getaway Outposts across the country • A five-night stay in Disney Springs, Florida • A fly-fishing trip to Maine • Multiple vineyard visits • A week in Breckenridge, Colo., or Hermosa Beach, Florida • A stay at the storied Greenbrier Bidding will close at 8:15 p.m. (Eastern Time) Friday, June 17.

Peruse the offerings at vascular.org/Gala22Tickets. All bidding hopefuls must register before participating.

LIFETIME ACHIEVEMENT AWARD-WINNER TO BE ANNOUNCED

Always a closely guarded secret, the 2022 recipient of the Society for Vascular Surgery’s Lifetime Achievement Award will be unveiled during the 2022 Awards Ceremony.

The ceremony is set for 10:30 to 10:45 a.m. Thursday in Ballroom A/B of the Hynes Convention Center.

The award is one of the highest honors the SVS bestows on a member. It recognizes the member’s outstanding and sustained contributions both t the profession and to SVS, as well as exemplary professional practice and leadership. Peter Gloviczki, MD, and Peter Lawrence, MD, editor-in-chief and senior editor, respectively, of the Journal of Vascular Surgery publications, also will be honored during the Awards Ceremony.

A special thank you to

Our VAM VAM 2022 2022 Supporters!

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Surmodics

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www.vascularspecialistonline.com

COMMENT&ANALYSIS CORNER STITCH

MENTORSHIP: WHY MORE VASCULAR SURGEONS SHOULD CONSIDER MENTORING YOUNG MINDS

By Sheng Dong, MPH ADDRESSING CHALLENGES OF diversity and inclusion within medical schools and the larger physician workforce should begin with a conversation about the intrinsic barriers to higher education.

In an economic analysis report of medical school matriculants published by the AAMC, it was found that nearly 75% of each medical school class from 2007-2018 came from the top two quintiles of family income (Youngclaus & Roskovensky, 2018).

In fact, only 5% of students in medical school come from the lowest quintile of familial income. Had someone told me that I only had a 5% chance of getting into medical school, I may have chosen a different career path. Getting a four-year undergraduate degree, study materials for the MCAT, applying to dozens of schools, and possible gap years to strengthen your application only to tackle four more years of tuition is a colossal commitment to make—exponentially more-so for children of lower working-class families. In addition, students from lower SES families may also struggle to adapt to the steep learning curve of the hidden curriculum, which requires one to understand the social norms and practices associated with becoming a more competitive applicant (Giroux & Penna, 1979). What these students are looking for is not a golden ticket that grants free admission into medical school—what they are really searching for is guidance on how to navigate the systems necessary to succeed.

Growing up, my mother always told me to get a proper education so that I would never be forced to work as gruelingly as she does.

Guidance was hard to come by when your parents don’t know the language, culture, or systems of the country you live in. Back in 2013 as a junior in high school, my life was forever changed when I attended a 10-week medicine immersion program for under-represented and disadvantaged youths at Mount Sinai Icahn School of Medicine. It was this experience that connected me with my mentor, Dr. Vicki Teodorescu (AKA Dr. Teo),

who inspired me to embrace the challenge of becoming the first in my family to attend college.

IT’S NEVER TOO EARLY OR TOO LATE TO BECOME A MENTOR

Never underestimate the impact you can have on a potential mentee. From a fresh intern to someone bordering on retirement, there is knowledge to be imparted that can enrich a student’s personal and academic journey. Throughout my time shadowing Dr. Teo, I learned about the importance of developing meaningful relationships with people to achieve a common goal, the impact of fluid teamwork in overcoming challenging tasks and the value of being inquisitive. Mentorship is more than just helping improve clinical decision-making or operative skillset, it can help mentees develop self-efficacy towards achieving their goals. Even simple gestures like giving positive affirmation and motivation can be significant to mentees.

We should view mentorship as an investment in the life of another. Finding meaningful extracurricular activities to strengthen college applications can be a struggle for many students from working-class families.

Experiences with a physician mentor can act as a stepping-stone for many students of disadvantaged backgrounds to be considered for other competitive programs, which may help spark a passion for a field of medicine they never considered before.

It was during the clinic visits with Dr. Teo that I first learned about the concept of social determinants to health. Although I did not understand the concept at the time, I began noticing certain trends and patterns in the patients that we saw, and I could not help but ask questions. Why there were so many patients who were homeless requiring dialysis access? Why were visits with non-native English speakers longer than usual?

Why did patients on Medicaid seem to have longer patient charts than patients with private insurance? This curiosity in the social determinants behind vascular surgery then led to my decision to major in the Sheng Dong

social sciences in college, conduct research on the interaction of education and health, become an AmeriCorps English teacher, and pursue a graduate degree in public health, and become a medical student. Mentorship helped expose me to a world that I had never known about before, which planted the seed for my educational journey.

MENTEES MUST BE PROACTIVE: IT’S A TWO-WAY STREET

There are several qualities that make a great mentee. Becoming one requires a dedication to learning and an unrelenting desire for continuous self-improvement. It is not enough for mentors to provide the opportunity - mentees must also be proactive.

However, tackling new challenges can often be intimidating, since there is a risk of failure. Failure can become crippling to new learners but mentees that clearly communicate their needs and demonstrate a commitment to problem-solving, soon learn to embrace their failures and learn from them.

In fact, failure is often a necessary ingredient in the recipe for success in any venture.

MAXIMIZING THE IMPACT OF MENTORSHIP

There are several different styles of mentorship. Mentorship can be an evolving process, one that requires trying different approaches and seeing what works and

what doesn’t. Systems of constructive feedback are crucial.

Mentorship is such a valuable tool at the disposal of physicians. It has the capacity to not only change the lives of students, but to shape what the future of medicine can look like. As I reflect on the impact of mentors in my life, I’m inspired to want to become a future mentor myself—particularly to students who come from lower working-class families that face challenges of social inequity and barriers of access to higher education. Dr. Teo’s mentorship catalyzed my academic journey into medicine. For most of my upbringing the idea of college felt unobtainable and unaffordable to an inner-city public-school kid like myself. Had it not been for this experience, I would not be here today—just like Dr. Teo. It is my hope that more vascular surgeons consider the possibility of mentoring students of working-class backgrounds as they can bring such unique diversity in life experience to the profession of medicine. Tackling the challenge of representation is an extraordinary task but creating more opportunities for mentorship can be the first step in investing towards the future of vascular surgery.

SHENG DONG is a medical student at George Washington University School of Medicine and Health Sciences in Washington, D.C.

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INDICATIONS FOR USE IN THE U.S.: The GORE® TAG® Conformable Thoracic Stent Graft is intended for endovascular repair of all lesions of the descending thoracic aorta, including: Isolated lesions in patients who have appropriate anatomy, including: Adequate iliac / femoral access; Aortic inner diameter in the range of 16-42 mm; ≥ 20 mm non-aneurysmal aorta proximal and distal to the lesion. Type B dissections in patients who have appropriate anatomy, including: Adequate iliac / femoral access; ≥ 20 mm landing zone proximal to the primary entry tear; proximal extent of the landing zone must not be dissected; Diameter at proximal extent of proximal landing zone in the range of 16-42 mm. CONTRAINDICATIONS: The GORE® TAG® Conformable Thoracic Stent Graft is contraindicated in: Patients with known sensitivities or allergies to the device materials (Table 1); Patients who have a condition that threatens to infect the graft.

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INDICATIONS FOR USE UNDER CE MARK: The GORE® TAG® Conformable Thoracic Stent Graft is indicated for endovascular repair of the descending thoracic aorta. CONTRAINDICATIONS: Patients with known sensitivities or allergies to the device materials; patients with a systemic infection who may be at increased risk of endovascular graft infection. Refer to Instructions for Use at eifu.goremedical.com for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available.

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Products listed may not be available in all markets.

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