21 minute read
COVID-19 and ALI
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 revascularization. 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 acknolwedged the VASCC Project 2 ALI Working Group. He mentioed that the study is actively recruiting patients and that the organization welcomes contributions.
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 “definitely” 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
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. 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.”
SAVESAVE THETHE DATE!DATE!
JuneJune 14-17,14-17, 20232023 || NationalNational Harbor,Harbor, MDMD
FLOORPLANMAP
HYNES CONVENTION CENTER 900 Boylston Street, Boston, Massachuestts 02115 t: 877-393-3393 f: 617-954-3326 w: signatureboston.com
Second Level
900 Boylston Street | Boston, Massachusetts 02115 t877.393.3393 | f 617.954.3326 | SignatureBoston.com
Entrance to Prudential Center
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Business Center
PLAZA LEVEL
Café
(Flexible Meeting Space)
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Rochambeau
Show O ce Exhibit Hall A
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Boylston Street Entrance
KEY:
Exhibit Space
Meeting Rooms
Ballroom
Lobby & Pre-function
Public Use
Ring Road
Non-Public Access
Loading Dock Pre-Feb Area & Loading Dock Covered Truck Access Food Services
Emergency Exit
Exhibit Hall A
(38,770 sq )
Sheraton Boston Hotel
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Show O ce Exhibit Hall B
Exhibit Hall B
(36,900 sq )
SECOND LEVEL
Hilton Boston Back Bay
Dalton Street
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Veterans Memorial Auditorium (25,760 sq )
(4,000 Person Seating Capacity)
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Permanent Concessions
Charging Stations
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Exhibit Hall C
(37,750 sq )
Sheraton Boston Hotel Connection
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THURSDAY SCHEDULE AT-A-GLANCE
Thursday, June 16, 2022
6 a.m. to 6 p.m. Registration 6:45 to 8 a.m. International Chapter Forum 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 B2: Clinical Insights in PAD: Reducing the Risk of Major Thrombotic Vascular Events, Sponsored by Janssen Pharmaceuticals
Outside Hall C 210
HCC, 312
306
B3: Redefining Thrombectomy with Hydrodynamic Maceration and Powerful Aspiration, Sponsored by Abbott
304
6:45 to 8 a.m. Medical Student Program: Introduction to Vascular Surgery Medical Student Program: How to Succeed as a Vascular Surgery Residency Applicant General Surgery Resident Program: How to Succeed as a Vascular Surgery Fellowship Applicant 8 a.m. to 9:30 a.m. S3: Plenary Session 3
311
200
206
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
210
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 2 206 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 3:30 to 5 p.m. Young Surgeons Section 5 to 6:30 p.m. Opening Reception IP: Interactive Poster Session
Ballroom A/B
210 Exhibit Hall C/D Hall D
IPC: International Poster Competition 6:30 to 7:30 p.m. Women, Leadership, Diversity and Young Surgeons Reception 7:45 to 9:30 p.m. Women's Leadership Dinner
Hall D Sheraton, Constitution A Sheraton, Independence West
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 ● “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.
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.
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 complications 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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