Vascular Connections, August 2020—Review Edition by BIBA Publishing

Vascular Connections The Official Newspaper of the Vascular Annual Meeting

REVIEW EDITION

SOCIETY FOR VASCULAR SURGERY • AUGUST 2020 • SVS ONLINE

Unveiling an AI-driven risk stratification tool to attain better stroke prediction By Bryan Kay It’s one of the most intractable areas of focus in all of vascular disease, and the source of—inarguably, Brajesh K. Lal, MD, emphasizes—the most intensely studied vascular surgical procedure anywhere in the sphere of the specialty. And for some years, Lal has had the development of a more accurate method of risk assessment for this perennial vascular problem fixed firmly in his sights: carotid disease.

ow, the Baltimore-based director of the University of Maryland’s Center for Vascular Diagnostics and the National Institutes of Health Vascular Imaging Core Facility may be a little closer to his target. Lal is speaking to Vascular Connections shortly after he delivered the interim findings of the CRISP (Carotid risk prediction consortium) trial during Scientific Session 9 at SVS ONLINE on July 2. Lal and colleagues had unveiled data on the novel application of artificial intelligence (AI) algorithms to more successfully risk stratify those with carotid atherosclerosis. They demonstrated, he told the digital conference, that a composite of carotid plaque geometry and tissue composition, patient demographics, and clinical information “has a better predictive performance for major adverse neurological events [like stroke] than the traditionally utilized degree of stenosis alone.” The company behind the AI, Bostonbased Elucid Bio, proudly announced ahead of Lal’s SVS ONLINE presentation that the technology in question, called vascuCAP, had shown a more than 70%

The CRISP trial: Novel AI tech and carotid stenosis risk The interim results of the study could be a step toward revolutionizing stroke risk assessment

Brajesh K. Lal

“We all as clinicians know we have to move beyond percent stenosis. It’s not effective, it’s not sensitive and it’s not specific” BRAJESH K. LAL

n C arotid stenosis is one of the most intensely studied vascular disease entities. n C urrent stroke risk assessment for patients with carotid atherosclerosis relies primarily on assessing the degree of stenosis. n A composite, including elements like carotid plaque geometry and clinical information, has better predictive performance than degree of stenosis alone. n Using the vascuCap-powered predictive model on asymptomatic patients could help identify those at a high risk for future major adverse neurological events.

improvement in accuracy of stroke prediction as compared to stenosis-based guidelines over a six-year time period. But in order to get to the heart of Lal’s current risk prediction quest, he first takes Vascular Connections on a little history tour of carotid disease. Those studies to which he draws reference—beginning in the 1970s and continuing unabated through today— were united in their search for the best treatment for asymptomatic carotid stenosis patients. And all of them indicate that “if you take 100 people with asymptomatic carotid stenosis and perform carotid endarterectomy [CEA], and randomize 100 people with asymptomatic carotid disease and give them the best available medical therapy,” the patients who received a CEA did a little better, Lal says. Yet, the challenge remains that, even among those who did not undergo surgery, stroke rates were “not tremendously high.” If those 100 patients are followed, about two per year suffer a stroke. “What the clinical standard of care is—that if you select patients based on the degree of stenosis—and the only clinical risk stratification tool across the world is percentage stenosis, selecting patients based on this only lets you identify a subgroup of patients where 2% of them are going to develop a stroke. When you think about it, it’s not a very sensitive or specific risk stratification tool. It’s the best we have.” The bottom line: Percentage stenosis is not the ideal way to risk stratify patients in order to identify those who will have a stroke. The research group worked across four centers, and recently added a fifth. “We were able to collect a reasonably large cohort of patients,” Lal says. “It’s a very unique cohort—asymptomatic carotid stenosis at baseline—and at least

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SVS ONLINE closing act: The coming changes set to shape vascular surgery future By Beth Bales What lies in store for vascular surgery as the specialty peers down the road into its future? Many changes—both possible and confirmed—according to leading specialists who took part in the final SVS ONLINE session, “Assuring quality in vascular surgical care: The future of center, program and surgeon accreditation,” held July 2. SOCIETY FOR VASCULAR SURGERY (SVS) president Ronald L. Dalman, MD, and program chair Matthew Eagleton, MD, moderated the multi-part session, which looked into the future of vascular surgery, not with a crystal ball, but with data, trends and developments in the works. Here are some of the issues explored. First up: setting the standard for quality and appropriateness, verification and quality improvement. Immediate past president Kim Hodgson, MD, kicked off the session discussing the vital importance for vascular surgery to model the way in delivering quality, appropriate care. Hodgson presented data demonstrating practitioners across specialties are performing certain vascular procedures at levels far outside the norm as established by practice guidelines and Vascular Quality Initiative (VQI) data. He noted that among specialties, vascular surgeons make up the smallest percentage of this cohort, but as long as vascular surgeons are represented, the specialty must recognize it has a problem.

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Unveiling an AI-driven risk stratification tool to attain better stroke prediction Continued from page 1

two CAT scans performed at least two months apart. So we could also study how the plaque was changing over time.” Armed with all of the demographic and clinical features of the cohort, as well as the geometric features of the plaque, including percentage stenosis, Lal and colleagues got to work on neuro-network analysis—where the vascuCAP AI component steps into the fray. “We essentially poured all of thjs data into a series of multiple progression models, neuro-network models, all sorts of multivariable, analytic models, and all sorts of combinations,” he says. “The algorithm then selects out the one that provides the best model, so there’s a very objective way in which the neuro-network does this. And the best model has the best combination of sensitivity and specificity using the best combination of features.” What this amounted to, Lal goes on, was new ground being broken: “For the first time, we were able to quantify what the sensitivity and specificity of the percent stenosis predicting a stroke is.” In short, he says, this “utilizes morphologic characteristics of the plaque. When you do that, you get a fairly good sensitivity and specificity in terms of predicting a risk for stroke.”

SVS ONLINE closing act: The coming changes set to shape vascular surgery future Continued from page 1

Hodgson postulated that the current reimbursement system, while created with positive intent, is widely viewed to be misaligned and may be incentivizing inappropriate, rather than appropriate, care. Still, every physician should be keeping an eye on his or her own data relative to their colleagues as well as local and national benchmark trends. This is the basis of applying quality improvement principles in practice. QUALITY IMPROVEMENT

SVS leaders have spent the past 18 months developing the Vascular Verification and Quality Improvement Program in partnership with the American College of Surgeons. This program establishes a set of quality standards for the functioning of a “vascular center of excellence” and seeks to help all practices raise the standard of quality. R. Clement Darling III, MD, in Albany, New York, and Michel S. Makaroun, MD, of the University of Pittsburgh Medical Center, will facilitate the first pilot testing of the standards and the program for inpatient and outpatient care. IDENTITY AND STRENGTH

Alan Dietzek, MD, of Danbury Hospital in Connecticut, emphasized the continuing need for vascular surgery to have a strong, recognized identity as a small specialty swimming amongst giants such as general

That’s where the research program stands at this point: modality identified, confirmation it can be performed in a standardized vascuCAP fashion, identification of left carotid 3D means of image analysis, visualization correlating this with histology, and, finally, finding software to accelerate postprocessing. In terms of the final piece in this timeline, muses Lal, that means bringing processing down “from three hours to about 15 minutes.” So where do the researchers go from here? “The next step is to use a retrospective dataset to demonstrate proof of concept,” Lal says. “And the final step is going to be to identify a prospective group of patients who are followed longitudinally. I’m talking to a bunch of people to put that together. My anticipation is—looking at these numbers—we’re going to need about a 600-patient study. This has already become a 200-person study in its retrospective analysis, and I don’t think it will be a problem identifying 600 people.” Lal is loath to describe these developments as a disruptive innovation. But he believes that if the current trajectory of his team’s research is maintained, this could be a game

changer in asymptomatic carotid disease risk stratification. “I look at it this way,” he says: “The European Society for Vascular Surgery guidelines have very emphatically introduced the concept that we have to move beyond degree of stenosis. Everybody has intuitively known that, but for the first time we are beginning to talk about it in our guidelines. The Society for Vascular Surgery guidelines, which are in the making as we speak, are most likely going to be incorporating statements regarding that, too. We all as clinicians know we have to move beyond percent stenosis. It’s not effective, it’s not sensitive and it’s not specific. So what I can say, without using any adjective, is that if this story continues the way it is—and I have no reason to believe that it won’t because we’ve been very rigorous in how we’ve analyzed our data—I think this has the potential to the change way we risk stratify patients, and select patients for interventions in those who have asymptomatic carotid disease. It’s a very exciting and very interesting development.” In a nutshell, results so far have assured Lal of something important: “For the first time, plaque assessments have become reliable with a reachable technology. They were always reliable if you were willing to spend $2,500 per scan, another three hours of post-processing time, which is also money, and surface coil, which is $30–40,000 on top of a million-dollar MR machine. Before you know it, you’ve essentially priced yourself out of a clinically applicable tool. Now plaque imaging is coming within clinical reach. I truly believe it’s just a matter of time.”

surgery and cardiology. He noted it is essential for its survival to stand on its own and separate from the American Board of Surgery (ABS) so as to stand on equal ground with the ABS and Internal Medicine Board at the American Board of Medical Specialties. Dietzek acknowledged that a new ABVS cannot likely improve upon the outstanding job and support provided at the American Board of Surgery through the Vascular Surgery Board (VSB), but “ABVS is more than accreditation”; it is about visibility, strength and independence of our specialty, which is vulnerable under the current conditions.”

BOARD CERTIFICATION

SEAT AT THE TABLE

“Only we have the power to change ourselves; we can’t grow if we don’t change”—

Currently, vascular surgery “has no seat at the ABMS (American Board of Medical Specialists) table,” recognized by the medical community and public as the No. 1 body for certification of medical specialists, he said. Dietzek queried as to why the U.S. News & World Report publication fails to recognize vascular surgery in its own report citing abdominal aortic aneurysm (AAA) metrics when vascular surgery performs the vast majority of these procedures but includes cardiology and thoracic surgery in that title. Dietzek respectfully requested the publication to make this simple change. Such a move would be a “giant leap forward for the education of patients,” he said. “We need to take our heads out of the sand,” said Dietzek. “Without an independent (review committee for vascular surgery) we will become relatively irrelevant in the vascular disease domain.” Moreover, such a committee will provide innovation and help “achieve the visibility and recognition we deserve.” In closing, Dietzek added that vascular surgeons will remain the “firepersons” of the operating room. “Now,” he said, “we need a firehouse.”

“Certification of vascular surgery trainees is changing like never before,” with the introduction of Entrustable Professional Activities (EPAs), inclusion of simulationbased learning and testing, and continuous certification, said Gilbert R. Upchurch Jr., MD, chair of the Vascular Surgery Board. The traditional training approach is time-based, geared to the same experiences for all and can result in a variable product reflecting different rates of learning. Competency-based education is more focused on achieving competence for all. Canada is moving toward EPAs, said

AMY REED

Upchurch. Benefits include less variability in training, minimums for all trainees, aligning assessment with society needs and possible credentialing in residency to allow graduated independent practice and in transition to practice based on demonstrated competence. Upchurch also discussed surgery recertification, including the new “continuous certification.” Results from a 2017 survey, which showed 58% prefer more frequent, open-book, lower-stakes assessments to the 10-year model while 67% prefer assessment to be every two years or more. TRAINING THE NEXT GENERATION

Speaking from the perspective of program directors, Association of Program Directors

in Vascular Surgery (APDVS) past president Amy Reed, MD, maintained that “integrated training is here to stay. It’s not an experiment and it’s not second-tier.” Integrated pathways have resulted in more vascular surgeons in the workforce than before. However, the specialty needs to sustain interest among and recruit Generation Z, and also increase diversity, she said. “This issue is not going to go away without each one of you doing your part, reaching out and overcoming our stereotypes of gender and skin color.” She suggested the future holds a move to EPAs and reviving the “3+3” program (three years of general and three years of vascular surgery training) currently not in use. That pathway would save fellows time and money and increase the number of surgeons in the workforce, she said. And case minimums, she predicted, will be greatly reduced or eliminated in favor of quality outcomes and experience. “Only we have the power to change ourselves; we can’t grow if we don’t change,” she said. Most speakers, in fact, stressed the move to quality outcomes. “Outcome measures are coming, whether we like or not,” said Dalman. Ben Harder of U.S. News & World Report, in speaking of its physician rankings, said: “outcomes is our focus going forward. It’s part of the evolution of our public reporting program.” Dalman also noted the SVS’ upcoming branding campaign will help differentiate vascular surgeons from other specialists working in the same space. “We set the standards,” he said. Referring to the SVS ONLINE program, he said, “Everything we’ve talked about in the past two weeks focuses on improved care. The underlying theme is improving patient care,” adding: “The best way to promote ourselves is to back it up with what we deliver.”

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Patients with large AAAs see higher five-year mortality with EVAR compared to open repair By Bryan Kay Large abdominal aortic aneurysm (AAA) repair is associated with higher adjusted five-year mortality, reintervention and rupture rates after endovascular aneurysm repair (EVAR)—but not after open repair, a prize-winning paper at the SVS ONLINE digital conference concluded.

evertheless, an increasing majority of patients with a large AAA undergo EVAR, the researchers behind the findings revealed during late-breaking Scientific Session 9 on July 2. The study, presented by Livia de Guerre, MD, a research fellow at the department of vascular and endovascular surgery at Beth Israel Deaconess Medical Center, Harvard Medical School, in Boston, was the winning entry in the SVS ONLINE e-Poster Competition: “EVAR for large abdominal aortic aneurysms is associated with higher late reinterventions, ruptures and mortality.” In introducing the subject matter, de Guerre drew attention to previous research that shows a large variation in repair diameter. And a large proportion of patients who undergo surgery are above the Society for Vascular Surgery (SVS) thresholds of 5.5cm in men and 5cm in women, according to de Guerre et al. “However, the risk of AAA rupture strongly increases with increasing aneurysm diameter,” she told attendees. “Also, comparison of predictive preoperative risk of operative mortality stratified by AAA diameter category shows increasing mortality risk in larger aneurysms: 20.8% of the large AAAs are of medium mortality

risk compared to 3.5% in the medium-sized AAAs, and 1.3% in small AAAs. However, the effect of the large preoperative aneurysm diameter on long-term outcomes is unknown.” So de Guerre et al set out to investigate the association of large AAA diameter with late outcomes, and compare EVAR and open repair in patients with large AAAs. They deployed the Vascular Quality Initiative (VQI) registry linked with Medicare claims for long-term outcomes. The investigators included all patients who underwent elective open or endovascular infrarenal aneurysm repair between 2003 and 2016, with a large AAA diameter defined as above 65mm. Primary outcomes were five-year reintervention, rupture and mortality rates. The study population consisted of 21,749 patients, of which 19,527 underwent EVAR while 2,222 received open repair. Of the EVAR patients, 14.6% had a large AAA; meanwhile, 24.4% of the latter contingent bore an AAA classified as large. “Concerning baseline characteristics, the large AAA cohort was older, more commonly male, and more likely to have renal disease and congestive heart failure compared with patients with smaller

A meeting of firsts By Beth Bales The Society for Vascular Surgery (SVS) notched plenty of firsts this year with its virtual meeting, SVS ONLINE: “New Advances and Discoveries in Vascular Surgery.” THESE INCLUDE THE MERE PRESENTATION of the first virtual meeting, of course, said Matthew Eagleton, MD, SVS Program Committee Chair. The committee plans the educational programming for the Vascular Annual Meeting, canceled in the wake of the COVID-19 pandemic. Others included the first virtual SVS Business Meeting and online election of officers, he said, in presenting a wrap-up July 2 of the two weeks of educational, scientific Matthew Eagleton

aneurysms,” de Guerre said. With the use of EVAR for large AAAs increasing over time, she pointed to a statistic for endovascular repair of these aneurysms Livia de Guerre from 2016: Some 88% were carried out by way of the minimally invasive method. That compares to 36% in 2003, de Guerre added. “Five-year freedom from reintervention after EVAR was lower for large AAAs at 75%, compared to 84% for smaller AAAs” she explained. “However, after open repair, reintervention rates were similar between larger and smaller aneurysms. Adjusted five-year freedom from late rupture after EVAR was also lower for large AAA repairs, with 91% vs. 95% for smaller AAA repairs. However, after open repair these rates were smaller and similar between aneurysm sizes. Also, adjusted five-year survival after EVAR was lower in large AAA compared to smaller AAA, with 58% vs. 66%.” Looking only at patients with large AAAs, and comparing EVAR and open repair, de

large AAA diameter compared to smaller aneurysms undergoing EVAR had higher mortality, reinterventions and rupture rates, “while after open repair these outcomes were similar.” Furthermore, de Guerre went on, “EVAR for large AAA is associated with worse adjusted five-year survival compared to open repair, which is not seen in patients with smaller aneurysms.” The researchers used the VQI risk score to calculate predicted open repair mortality for large AAA patients who are currently selected for EVAR. Some 73% had a predicted open repair mortality below 5%. “As the SVS suggested elective open repair for AAA be performed at centers with a documented perioperative mortality of 5% or less, our application of this predictive model shows that the majority of patients currently undergoing large AAA EVAR have an acceptable open repair operative risk,” de Guerre added. The research team concluded: “Large AAA diameter was associated with higher five-year mortality after AAA repair, regardless of repair type. After EVAR for large AAA, there was a higher likelihood of five-year mortality, reinterventions, and ruptures compared to open repair for large AAAs and compared to EVAR for

“After EVAR for large AAA, there was a higher likelihood of five-year mortality, reinterventions, and ruptures compared to open repair for large AAAs and compared to EVAR for smaller aneurysms”— LIVIA DE GUERRE ET AL Guerre continued, adjusted survival at five years was lower after EVAR: 55% vs. 63%. Yet, when comparing EVAR and open repair survival after smaller aneurysm repair, the survival benefit lasted longer, she said. In short, she remarked, patients with

and industry programming. Eagleton noted the tremendous faculty support for the entire program, with 240 faculty members and moderators for scientific sessions, invited sessions, Vascular and Endovascular Surgery Society (VESS) presentations, the e-Poster Competition and the OnDemand presentations; the 840 registrants for SVS ONLINE; and the Resident, Student Outreach Committee programming, which drew more than 300 attendees to four virtual sessions. This programming is now available at vsweb.org/ Planner2020, at the “general Residents/Students” tab. Eagleton further detailed the continued collaboration with other societies, including the American Venous Forum, VESS, the Society for Vascular Nursing (SVN) and the Vascular Quality Initiative (VQI), as well as continuing programming for SVN and the VQI. Meanwhile, the e-Poster Competition drew thousands of views, Eagleton added. Eagleton thanked the SVS staff for its work in revising the programming, promoting it and presenting it in just 80 days. “I hope the audience didn’t recognize anything going on behind the scenes,” he joked. “And I hope we get to meet in San Diego in 2021,” the site for next year’s meeting on June 2 to 5, 2021. SVS President Ronald L. Dalman, MD, acknowledged Eagleton “for his leadership of the past three years” as chair, calling the job “one of the most important jobs at the

smaller aneurysms. Therefore, in patients with large AAAs who are medically fit, open repair should be strongly considered. Furthermore, these findings highlight the necessity for rigorous long-term follow-up after EVAR.”

Society for Vascular Surgery.” Dalman also noted the pandemic’s “unprecedented challenges” not only on the meeting itself but also the Society as a whole and thanked immediate past president Kim Hodgson, MD, for his “leadership under really trying circumstances. “He had other ideas for his presidency but given the challenges of the moment he more than rose to the occasion,” said Dalman. The weekly town halls Hodgson created on many important topics directly addressed membership COVID-19-related concerns and were “exactly what we needed in the moment.” Dalman also thanked SVS executive director Kenneth M. Slaw, PhD, who changed course in the middle of the year and led the staff in meeting the challenge of repackaging hundreds of abstracts and other programming for the virtual meeting. “It’s been a great experience, but I hope we don’t end up doing that again. No offense, Matt,” he said to Eagleton,” but I prefer the in-person meeting.” Eagleton heartily agreed with the sentiment. “On behalf of the Executive Board, the Program Committee, hundreds of participants, committee and council members, and all of our members, I thank everyone for their support of SVS and SVS programming as we move on into the unknown,” said Dalman.

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COVID-19 survey: Support of hospitals and societies ‘paramount’ to promoting well-being of vascular surgeons By Jocelyn Hudson and Bryan Kay Responses to the COVID-19 pandemic practice, anxiety, coping and support survey for vascular surgeons, recently presented in a Special Scientific Session on COVID-19 during SVS ONLINE on June 27, reveal higher anxiety and stress levels in vascular surgeons worried about the negative consequences of care delays to their patients, worries about family, friends, and colleagues being infected with COVID-19, adequacy of personal protective equipment (PPE), changes in home routine, and financial concerns. THE SURVEY, SPONSORED BY THE Society for Vascular Surgery (SVS) Wellness Task Force, “identified several areas where vascular surgeons can be supported at

AUGUST 2020 | REVIEW EDITION

institutional, regional, and national societal The 28-item Brief Coping Orientation levels,” remark the authors, Sherene to Problems Experienced (Brief-COPE) Shalhub, MD, associate professor of surgery inventory was used to assess the active and in the division of vascular surgery, the avoidant coping strategies, and additional department of surgery, at the University of qualitative data were collected using openWashington School of Medicine, Seattle, ended questions. Nicolas Mouawad, MD, chief of vascular Shalhub et al note that the COVID-19 and endovascular surgery in the McLaren pandemic has led to “unprecedented Health System-Bay Region challenges for healthcare in Bay City, Michigan, and systems globally,” which led colleagues. the investigators to design and They conclude: “Vascular administer a global survey surgeons globally are to examine the impact of experiencing multiple COVIDCOVID-19 on vascular surgeons 19-related stressors during this and explore the COVID-19devastating crisis. These findings related stressors faced, coping highlight the continued need strategies employed, and for hospital systems to support support structures available. their vascular surgeons and the Nicolas Mouawad The investigators report that importance of national societies a total of 1,609 survey responses to continue to invest in peer support (70.5% male, 82.5% vascular surgeons in programs as paramount to promoting the practice) from 58 countries (43.4% USA, well-being of vascular surgeons during and 43.4% Brazil) were eligible for analysis. after the COVID-19 pandemic.” Some degree of anxiety was reported by Shalhub and Mouawad describe the 54.5% of the respondents. Most respondents survey as an “anonymous cross-sectional (around 60%) used active coping strategies global survey.” Data were collected 14–24 and the avoidant coping strategy “selfApril 2020 using REDCap. Survey results distraction” and 20% used other avoidant were then analyzed to evaluate the impact coping strategies. of COVID-19-related stressors on vascular Multivariable analysis identified the surgeons as measured by the Generalized following factors as significantly associated Anxiety Disorder 7-item (GAD-7) scale. with increased self-reported anxiety levels:

Avoiding burnout and achieving wellness By Beth Bales Coaching, institutional and cultural changes, advocacy, identifying issues, and banding together all can play a part in vascular surgeons’ avoiding burnout and achieving wellness.

session during SVS ONLINE: “New Advances and Discoveries in Vascular Surgery” examined wellness and chaos, covering various facets of the problem and possible solutions. Dawn M. Coleman, MD, chair of the Society for Vascular Surgery (SVS) Wellness Task Force, moderated the session. “Many of the most talented and passionate are at the highest risk of burnout,” said Jeffrey Smith, MD, a former surgeon and now a Certified Professional Coach. He formed SurgeonMasters, which assists the Task Force with wellness issues. Back and neck issues and growing cynicism prompted him to drop surgery, a profession he had loved, and become a surgical coach instead. Coaching, he said, addresses the “physical, mental and emotional toll of being a surgeon. … It can turn anxiety into a healthy anxiety,” he said. “We need to practice healthier coping strategies, have peer support, maintain connections and get coaching.” Lack of personal time plus overall work demands and stress are the top reasons why 26% of respondents to a national surgical workforce survey would consider leaving their practices within two years. The figure excluded those who would simply retire. At the same time, 80% would choose surgery again, said Julie Freischlag, MD, CEO and dean at Wake Forest Medicine and Wake Forest Baptist Health in North Carolina.

She suggested several leader-led initiatives. Initiate parental leave, create lactation rooms and faculty lounges, permit working from home—“COVID has taught us it does work,” she said—create year-long on-call schedules and expect staff to take vacations. Create pleasant traditions such as parties, book clubs, awards and family picnics. “Highlight the next layer of people in your institution by allowing them to run service lines and ORs [operating rooms]. They’ll feel valued.” She repeated the adage, “you must be the change you want to see in the world.” She urged: “Do that with actions. Be that change.” The government, said Margaret Tracci, MD, of the University of Virginia and chair of the SVS Government Relations

“Many of the most talented and passionate are at the highest risk of burnout”— JEFFREY SMITH Committee, creates many of the practice burdens that contribute to burnout. They include “electronic health records, prior authorization and E&M (evaluation and management) documentation, barriers to telemedicine … the cumulative burden of administrative chores,” she said. “There’s unity in the House of Medicine” that something has to give. And more stressors loom, including workforce shortages, an aging population and medical school debt. Coronavirus has exacerbated financial concerns, already

26%

of respondents to a national surgical workforce survey would consider leaving their practices within two years. But:

80% would choose surgery again

staying in a separate room at home or staying at the hospital/hotel after work (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.08–1.79), donning/doffing PPE (OR 1.81, 95% CI 1.41–2.33), worry about potential adverse patient outcomes due to care delay (OR 1.47, 95% CI 1.16– 1.87), and financial concerns (OR 1.90, 95% CI 1.49–2.42). Finally, they state that hospital support (OR 0.83, 95% CI 0.76–0.91) and use of positive reframing as an active coping strategy (OR 0.88, 95% CI 0.81–0.95) were noted as factors significantly associated with decreased self-reported anxiety levels. “This survey it is a first step in understanding the psychological impact of COVID-19 on vascular surgeons,” Mouawad told Vascular Specialist. “The findings of this survey identify multiple stressors experienced by vascular surgeons globally during this devastating crisis and highlight the continued need for hospital systems and national societies to invest in and promote the well-being of vascular surgeons through peer support programs during the COVID-19 pandemic. Further analysis is focused on the specific effects of this pandemic on vascular trainees around the world, on our largest international cohort in Brazil, and the impact on vascular surgery practice in the U.S.” building over the past two to three decades, she added. “Vascular surgeons are intensely concerned about the financial impact on families, staff and the community.” In addition, Medicare reimbursement cuts of an estimated 7–8% scheduled to take effect Jan. 1, 2021, are coming at the worst possible time, she said. SVS’ policy and advocacy groups are pushing back, said Tracci, with efforts that include personal protective equipment supplies, records reform, trainee debt relief, legislative fixes to regulatory burdens and more. SVS has joined a Surgical Care Coalition with other surgical groups to fight the upcoming Medicare cuts. Contributions to the SVS Political Action Committee have “never been more important,” said Tracci. Panelists offered some suggestions. Task Force co-chair Malachi Sheahan III, MD, acknowledged “endlessly juggling” and, like many of his colleagues, worrying about meeting both personal and professional priorities. In the end, he said, a person’s most important choices are “your spouse and your job—your partners, he said. “If you trust your partners, you won’t be worried about the details and you’ll have a better life.” Smith advocated getting others involved. “You need more than one voice” to make an impact. Several urged participating in advocacy efforts. “There’s not a better time for surgeons to get involved, to run your hospital, run your clinic,” said Freischlag. “Blame it on the virus, and change it.” Registered SVS ONLINE participants can view the session recording. Visit vsweb. org/Planner2020.

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Women are at a higher risk of iliac vein stent failure, VESS session hears By Jocelyn Hudson A recent study on iliac vein stenting showed lower longterm patency rates for women when compared to their male counterparts. The data were presented on June 24 at SVS ONLINE during the Vascular and Endovascular Surgical Society (VESS) session. LEAD INVESTIGATOR EFTHYMIOS AVGERINOS, MD, associate professor of surgery at the University of Pittsburgh Medical Center, Pittsburgh, expressed his hope that the results will be confirmed by others and eventually lead towards more aggressive anticoagulation and follow-up protocols. Stenting of iliac venous outflow is becoming increasingly popular as a minimally invasive treatment that has proven effective and safe in the management of thrombotic and non-thrombotic peripheral venous disease in appropriately selected patients. While experience and literature are expanding, the gender effect in outcomes of venous stenting is unknown.

SVS Foundation chair ruminates on historic second term By Beth Bales Emphasizing prospective trials, increased financial support, and promoting research and research awards are just a few of the tasks on the to-do list of Peter Lawrence, MD, as he begins a second turn as chair of the Society for Vascular Surgery (SVS) Foundation.

he Foundation Board this year eliminated the automatic move of the immediate past president into the chair position, extended the term to three years instead of the traditional one and increased the size of the Foundation Board of Directors to also include more non-physician members. The changes were announced during the first SVS Annual Business Meeting on June 15 in the run up to SVS ONLINE. Lawrence chaired the Foundation several years ago, following his year as SVS president. Pointing out it is difficult to initiate and complete major projects in just one year, Lawrence said he is excited to have a second opportunity, with research, how research is funded, and results all part of his major focus. The SVS Foundation funds a number of research grants annually, to influence and

The Pittsburgh group performed a retrospective study (2007–2019) on 200 patients (231 limbs) who underwent iliac vein stenting for thrombotic or nonthrombotic indications. Patients were divided into two groups based on their gender. Avgerinos emphasized the baseline similarities of Efthymios Avgerinos the populations compared. There was no difference in type of venous disease between males (85% thrombotic, 15% non-thrombotic) and females (84% thrombotic, 16% non-thrombotic). The male cohort had a higher rate of infrainguinal stent extension (11% vs 6.9%, p=0.02). Females had a higher rate of left-sided stenting (80.9% vs. 66%, p=0.01). There was no difference in the median stent diameter used between the cohorts. The vast majority of stents were Wallstents (Boston Scientific). Primary patency at five years was significantly higher for the male cohort (94.1% vs. 74.4%, p=0.01). The association remained similar when dividing per indication, “thrombotic” or “non-thrombotic.” On adjusted cox regression female gender was a predictor of loss of primary patency within five years (hazard ratio, 4.04; p=0.007). A similar association was also confirmed with infrainguinal stenting. “Men and women differ considerably at biological and hormonal levels and these differences translate to a variable platelet and coagulation factor function. Considering the high incidence of venous thromboembolism (VTE), understanding the influence of gender is critically needed.

improve future patient care. A top priority is examining all current grants and funding priorities “in terms of how they contribute to vascular research and whether the grants are providing the information that will help in the management of patients,” he said. That job will take more than one year and was an impetus in extending the chair term. Research figures prominently in both his career and in his role as senior editor of Journal of Vascular Surgery publications. “I believe vascular surgeons and the field of vascular disease management need more and better research,” Lawrence said. To that end, he also wants to increase the Foundation’s endowment fund to permit support of more research. A major priority is to try to increase the support for physicians or projects that deal with prospective randomized data, which leads to top-level 1A care management and would add support for decisions from the Medicare Payment Advisory Commission (MedPAC). Lawrence added that SVS members’ research typically is showcased in the journal publications, “which need the

Sex-specific factors appear to affect not only the individual risk for VTE, but also have an influence on clinical presentation, and outcomes,” explained Avgerinos. Avgerinos further discussed the lack of consensus and existing variability on anticoagulation protocols following iliac vein stenting: “Our current protocol includes an antiplatelet plus low molecular weight heparin for 2–4 weeks, then a direct oral anticoagulant or coumadin for 3–6 months depending on the underlying risk factors (female gender being one of them). For thrombotic cases and complex reconstructions, lifelong anticoagulation is preferred. We still have a lot to learn.”

Primary patency at five years was significantly higher for the male cohort

94.1%

Peter Lawrence

decisions determining reimbursement sometimes were made from extensive literature review, but with few prospective trials, which “limited what Medicare was willing to reimburse.” This lack can also limit best treatments

“We need to include patients and donors who are not surgeons but have significant interest and passion in vascular disease”— PETER LAWRENCE highest-quality research.” Additional prospective research, including on devices and comparing treatment to no treatment, as opposed to retrospective trials, is critical, he said. When serving on MedPAC, he said, he realized that some

for patients, he said. For example, no Level 1A evidence exists that concludes an ultrasound yields better information than a simple physical exam. “But we know it and we use imaging every day.” Research in vascular disease, particularly

74.4%

on treatments, is difficult to conduct prospectively, he said. And research on devices often is not funded by the National institutes of Health, the Department of Veteran Affairs or the Department of Defense. “But we need to do more prospective research,” he emphasized. Of course, these imperatives require funding, and Lawrence will emphasize fundraising. “In non-profits, the phrase is ‘No money, no mission.’ If the mission is to improve research in vascular disease, we need to raise significant funds for our foundation.” He praised the idea to diversify the board and increase the number of non-SVS member participants, which will go some way toward broadening the Foundation Board’s diversity and outlook. “We need to include patients and donors who are not surgeons but have significant interest and passion in vascular disease,” he said. Such participants sometimes have the vision and can raise the resources in order to create and build programs and centers, he said. He also heaped praise on immediate past president and president, Kim Hodgson, MD, and Ronald L. Dalman, MD, respectively, who under the old order would have chaired the Foundation during what is now Lawrence’s second time in the position. To the credit of both leaders, he said, “they had the foresight to realize one-year terms don’t get your foundation where it needs to go.” To learn more about the SVS Foundation and to donate, visit vsweb.org/SVSFoundation.

AUGUST 2020 | vascularspecialistonline.com

Vascular Connections | 7

International Lecture: Argentine endovascular colossus discusses new PAD therapy By Beth Bales and Bryan Kay A new therapy of hydration and oncotic pressure of plasma helped 100% of certain elderly peripheral arterial disease (PAD) patients in terms of pain, ankle-brachial index (ABI) and walking time, endovascular pioneer Juan C. Parodi, MD, said on Tuesday, June 30. MOREOVER, SIX MONTHS LATER, of discontinuing diuretics and Cilostazol. patients continued to improve significantly. Patients were administered 2.5 liters of fluid Parodi, who was delivering this year’s and 0.6 grams of albumin (egg white and International Lecture as part of SVS albumin powder) every 24 hours. ONLINE, is the 2020 recipient of the The 131 patients who complied with the Society for Vascular Surgery (SVS) therapy realized “significant” improvements, International Lifetime Achievement Award. including increases in skin temperature He was introduced by Enrico Ascher, in the feet, walking time and distance to MD, chair of the International claudication and in ABI, as Relations Committee. After well as a decrease in pain, said receiving a pile of nominations Parodi. Subsequently, increasing from vascular societies dotted all the albumin concentration to across the world, “one surgeon 4 grams prompted a secondary surpassed all expectations,” positive change. explained Ascher. In addition to other positive “He is a prolific surgeonresults, said Parodi, “in the scientist, a successful inventor, last 12 months, our cases of a superb technical surgeon, a angioplasty and/or stenting man who fought for the poor Juan C. Parodi dropped dramatically,” by almost and for equal education for all,” 90%. continued Ascher of Parodi. And in 2006, He called the therapy perhaps the “most said Ascher, he was honored to present to important to the whole conservative Parodi the very first Medal for Innovation in approach to treatment” and suggested Vascular Surgery. vascular surgeons try it before more Parodi and colleagues were inspired to invasive treatments. “We never expected to devise a prospective trial after considering have this kind of response,” he told panel two PAD patients, for whom the common moderators. “Sometimes this looks like a factor was dehydration; both experienced “a miracle.” significant improvement of symptoms after Provider or family involvement to assure proper hydration in less than 48 hours.” compliance is crucial, he added. He and fellow researchers assembled Parodi said one of his original patients, a trial group of 132 adult patients with aged 74, who had had several surgical and disabling claudication or rest pain who endovascular attempts to treat a severe failed to improve after five months ischemia of the left lower extremity, of complete medical treatment. The completed the therapy. The patient later treatment continued, with the exception sent Parodi a picture of himself on top of

Congratulations, 2020 Distinguished Fellows and community practitioners By Beth Bales The Society for Vascular Surgery congratulates its 2020 Distinguished Fellows and recipients of the Excellence in Community Service Award.

a mountain, water bottle in hand. He had walked “4 kilometers without pain,” and was taking no medication but still following the protocol. “We never imagined this,” Parodi said. Another patient who had had invasive treatment on one leg successfully completed the protocol and did not require invasive treatments on the other leg. “We’re saving suffering for the patient. We’re saving money,” said Parodi. “Probably we were doing too many (treatments) and too much.” Panelists called the therapy “significant” and “important.” Parodi pointed out trial limitations in the patient numbers, the fact there was no control group and the short follow-up period. Parodi is known for conceiving the concept of endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). In 1990, he received a call from the then president of Argentina, Carlos Menem, regarding the leader’s cousin, who was deemed too sick for open repair. Parodi performed the treatment (he had never done so on a human) and “it turned out to be a resounding success,” said Ascher. The American College of Surgeons said “Parodi’s success with EVAR literally changed vascular surgery.” Frank Veith, MD, invited Parodi to New York to operate there, which “sparked the endovascular revolution and significantly extended the reach of our specialty,” said Ascher. In 1993, President Menem suffered his own health issues, a potentially fatal blood clot. Parodi operated to clear the right

“[Juan C. Parodi] is a prolific surgeonscientist, a successful inventor, a superb technical surgeon, a man who fought for the poor and for equal education for all”— ENRICO ASCHER

he Distinguished Fellow designation is bestowed upon Active, International or Senior vascular surgeon members who have distinguished themselves in a sustained manner by making substantial contributions in two of the award categories of research, service and education. This year’s designees are: Hernan Bazan, MD, Carlos Bechara, MD, Dawn M. Coleman, MD, Javairiah Fatima, MD, Melissa Kirkwood, MD, Paul Kreienberg, MD, Raghu Motaganahalli, MD, Graham Roche-Nagel, MD, Charles Ross, MD, Palma Shaw, MD, William Shutze, MD, Matthew Sideman, MD, Matthew Smeds, MD, and Wei Zhou, MD. The SVS Excellence in Community Service Award, meanwhile, is an honor bestowed on a member who has exhibited outstanding leadership

carotid artery successfully and without complications. And years earlier, in 1980, Parodi removed a gangrenous gall bladder from a poor priest, refusing payment. Thirty-four years later, Parodi received an invitation to visit the Vatican to see that priest, now Pope Francis, and be thanked. Parodi also invented other procedures, devices and treatments. “He saved a sitting president, he saved a (future) pope,” Ascher said of Parodi. “He has saved hundreds of thousands of lives with his innovative approaches and, ladies and gentlemen, he saved our specialty.” Parodi, an honorary SVS member, is chief of vascular surgery at Trinidad Hospital in Buenos Aires, honorary professor of

131 patients with disabling claudication who complied with 2.5 liters of fluid and 0.6 grams of albumin (egg white and albumin powder) every 24 hours realized “significant” improvements, including increases in skin temperature in the feet, walking time and distance to claudication and in ABI, as well as a decrease in pain surgery at Universidad de Buenos Aires and professor of research at the University of Michigan. Following the presentation, panelist Matthew Eagleton, MD, jokingly asked Parodi if he garnered “special influence” with his patients because he had treated the Pope. “He prays for me every day,” Parodi responded, adding, “and I need it because I am a sinner.”

within his or her community as a practicing vascular surgeon. This is only the second year that this award has been in existence. It acknowledges an individual’s sustained contributions to patients and the wider community in which recipients operate, such as partnerships or collaboration with organizations in the community or implementing innovations to advance community health, plus exemplary professional practice and leadership. Additionally, the award only goes to a surgeon who has been practicing for at least 20 years. This year the recipients are: Krishna Jain, MD, Russell Samson, MD, and William Shutze, MD. Both honors typically are announced during the Vascular Annual Meeting (VAM). This year’s awardees will now be recognized at the 2021 meeting in San Diego, California.

| Vascular Connections

AUGUST 2020 | REVIEW EDITION

CEA provides inhibitive effect on stroke prevention for eight years over no surgical intervention By Bryan Kay Carotid endarterectomy (CEA) has a small but significant effect on stroke prevention through eight years compared with no surgery, investigators who carried out a cohort analysis in a large integrated health system found. A RESEARCH TEAM LED BY ROBERT CHANG, MD, assistant chair of vascular surgery at Kaiser Permanente Foundation Hospital in San Francisco, made the discovery following a retrospective study that sought to emulate a randomized trial using observational data. The findings were delivered during SVS ONLINE Scientific Session 7 on July 1. “Since the publication of the ACAS (Asymptomatic Carotid Atherosclerosis Study) trial in 1995, the evolution of medical management and the optimal role of carotid endarterectomy in stroke prevention has been an area of intense debate and study,” explained Chang. “According to data from ACAS, ACST (Asymptomatic Carotid Surgery Trial) and the 10-year ACST report, the number needed to treat in order to prevent one stroke was 17, 19 and 22, respectively. Similarly, performing 100 CEAs compared with medical management alone would prevent

5.9, 5.3 and 4.6 strokes, respectively.” Short of the results of studies like CREST 2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial), further populationbased research is needed to assess the contemporary benefit of CEA, he argued. The purpose of the study by Chang et al was to examine the effectiveness of CEA with standard medical management compared with standard medical management alone for the prevention of stroke in asymptomatic patients. Robert Chang The investigators identified all patients with 70-99% asymptomatic carotid stenosis with no prior intervention within the previous six months. Some 3,824 eligible patients met eligibility criteria. Participants were followed from their first imaging study between 2008 and 2012 through the earliest of: ipsilateral ischemic stroke (the primary outcome), death, health plan disenrollment, or December 2017, the researchers noted. Event-free survival was followed over eight years between two treatment strategies: intervention within 12 months from cohort entry versus no intervention during the entire follow-up. The mean age of the cohort was 74, 58% of whom were

“As surgeons, we appear to do a good job of selecting patients for surgery, perhaps in a way that escapes capture in an electronic system”— ROBERT CHANG

Cannabis use disorder linked to greater odds of perioperative MI in vascular surgery patients By Bryan Kay

male, while 73% were white, 12.3% were active smokers and 21.7% were diabetic. A total of 1,467 underwent CEA, with 2,357 not doing so. During the study, 38% completed follow-up without an outcome, 46% died, 12% lost membership, and 158 patients, or 4.1%, experienced the primary outcome. “When we look at the risk difference calculated as a percentage, we show a statistically significant advantage with surgery starting in year two, with a relatively small absolute effect,” Change told attendees. “Starting in year three, the risk difference favoring surgery is between 2 and 3% out to eight years.” The findings show that for every 100 patients, three strokes could be prevented if these 100 patients underwent surgery compared to if they did not out to eight years, he continued. “As surgeons, we appear to do a good job of selecting patients for surgery, perhaps in a way that escapes capture in an electronic system.” The adjusted hazard ratio (0.81, 95% CI, 0.68–0.93) and cumulative risk differences for each year of follow-up demonstrated the protective effect of intervention starting in year two through year eight compared with patients not receiving either intervention. Summing up, Chang added: “Further study is required to identify unmeasured confounders and the relationship with mortality in this high-risk population. The small absolute effect and the resource utilization needed to bring about such an effect requires further research into appropriate patient selection. “As we await the results of ongoing randomized trials, population-based research can inform this challenging problem in vascular surgery.”

510,007

Active cannabis use disorder was associated with significantly higher odds of perioperative myocardial infarction in vascular surgery patients, researchers reveal.

urthermore, people with the disorder were far likelier to have an acute perioperative stroke diagnosis when undergoing carotid endarterectomy, according to Brandon McGuinness, MD, a resident at McMaster University in Hamilton, Canada, who presented the findings during Scientific Session 2 of SVS ONLINE on June 23. “Due to limitations in administrative data, it is unclear if this represents a true effect or selection bias,” he said. “These findings warrant further investigation in a prospective cohort.” The rationale of McGuinness et al was built around heavy cannabis use’s known adverse impact on cardiovascular and cerebrovascular outcomes—this being the case both in the general population and in patients presenting for surgery, they said. “However, there have been no previous studies that have focused on patients undergoing vascular surgical procedures. The objective of this study was to determine the perioperative risk of cannabis use disorder, primarily cardiovascular risk, in perioperative vascular surgery patients.”

A cohort of more than half a million was derived from the National Inpatient Sample (2006–2015). A retrospective study was devised involving people undergoing one of six elective and emergent vascular surgical procedures: carotid endarterectomy, infrainguinal bypasses, open abdominal aortic aneurysm (AAA) repair, aortobifemoral bypass, endovascular aortic aneurysm repair, or peripheral arterial endovascular procedures. Patients with active cannabis use disorder, as identified by the International Classification of Diseases, 9th edition, were matched in a 1:1 fashion using propensity scores. The primary outcome was perioperative myocardial infarction (MI). Secondary outcomes included cerebrovascular accident, sepsis, deep vein thrombosis, pulmonary embolism, acute kidney injury requiring dialysis, respiratory failure, in-hospital mortality, total cost and length of stay. Among the 510,007 patients identified, rates of the disorder in the cohort increased from 1.3 to 10.3 per 1,000 admissions

Among 510,007 patients identified, rates of cannabis use disorder increased from 1.3 to 10.3 per 1,000 admissions over the 10-year period (2006–2015) (p<0.001) over the 10-year period. After propensity score matching, the cohort consisted of 4,684 patients. “Those with the disorder demonstrated a statistically significant higher rate of perioperative MI (3.3% vs. 2.1%; odds ratio [OR]: 1.56; 95% confidence interval [CI], 1.09–2.24; p=0.0159),” McGuinness told viewers. “We also measured a statistically significant higher rate of perioperative

stroke in those with cannabis use disorder (5.5% vs. 3.5% OR: 1.59; 95% CI, 1.20–2.12; p=0.0013).” Additionally, in a sensitivity analysis— where the risk was evaluated within each type of procedure—this increased risk of perioperative cerebrovascular accident was primarily seen in patients undergoing carotid endarterectomy, he said. Those with the disorder demonstrated lower rates of sepsis (3.3% vs. 5.1%; OR: 0.64; 95% CI, 0.47-0.85; p=0.0024). “In a separate sensitivity analysis, using survey specific logistic regression procedures in the entire unmatched cohort, we obtained similar results, though the findings for sepsis and cerebrovascular accident failed to reach statistical significance when correcting for multiple testing (myocardial infarction: p=0.0011; cerebrovascular accident: p=0.0306; sepsis: p=0.0087),” McGuinness explained. Other secondary outcomes, including cost and length of stay, did not reach the level of statistical significance. “As can be seen, the increased odds of stroke in those with cannabis use order are mainly incurred in those undergoing carotid endarterectomy,” McGuinness noted. “The increased rate of myocardial infarction in those with cannabis use disorder is consistent with prior studies both in elective surgical patients and the general population.” Further studies are warranted to evaluate the management of cannabinoids among heavy users in the perioperative setting, he said.

| Vascular Connections

AUGUST 2020 | REVIEW EDITION

SVS pilots SET app for peripheral arterial disease patients By Beth Bales Doctor-prescribed and -supervised exercise therapy is going digital. The Society for Vascular Surgery (SVS) will begin piloting a ground-breaking app for Supervised Exercise Therapy (SET), for at-home use by patients with peripheral arterial disease (PAD). THE SET APP WAS INTRODUCED THURSDAY, JUNE 25, during the Society’s virtual meeting, SVS ONLINE: “New Advances and Discoveries in Vascular Surgery” as part of a session on “Digital Health Advancements in Vascular Surgery.” SVS member Oliver Aalami, MD, of Stanford University and a member of the SVS Health Information Technology Task Force, is developing the app, powered by Cell-Ed, a remote learning and telehealth company. Physicians and healthcare providers must prescribe the app, which will include health education, exercise assessment and goal-setting, and coaching. The app will help schedule exercise, monitor compliance and report feedback for later follow-up. Weekly interactions with a live coach will help guide the patient, he said. The app works on any mobile device. SET is a first-line therapy for PAD patients, carried out in

hospitals and clinics with physicians “immediately available,” said Aalami. Therapy generally includes three sessions a week over 12 weeks, with walking alternating with resting periods, for 30 to 60 minutes. The therapy has been shown to lower the need for intervention. However, despite its success, only 50% of providers in a 2019 survey reported referring patients to a SET program, though more than 95% would have liked to; transportation is one issue. SVS is launching the app with 50 patients from across the United States. A national launch is planned for the final quarter of 2020. In addition, the Vascular Quality Initiative (VQI) is exploring integration for patient-recorded

outcomes reporting, an exciting development, said Aalami. Reimbursement from private and federal insurers is being evaluated. “We look forward to the participation of all SVS members […] to the benefit of all patients with PAD,” he said. The SET program includes a baseline assessment, daily walks five days a week, with podcast content and nudges, benchmark assessment at the half-way point, end-ofprogram assessment, health coaching throughout, and optional education units and surveys Aalami is a clinical associate professor of surgery and director of biodesign for digital health for vascular and endovascular surgery at Stanford, in Palo Alto, California.

AUGUST 2020 | vascularspecialistonline.com

What’s up with industry By Beth Bales Webinars and other programming sponsored by vascular surgery industry partners during SVS ONLINE remain available for registrants to view. Visit vsweb.org/Planner2020. Industry-sponsored webinars and OnDemand sessions are not eligible for CME credit. They include: 3M + KCI: “Decreasing risks of surgical site infections in vascular surgery to optimize surgical outcome” Speaker (Industry): Ellen D. Dillavou, MD, Duke University Avenu Medical, Inc.: “Ellipsys for EndoAVF: Creation to cannulation” Speaker (Industry): Alexandros Mallios, MD, Institut Mutualiste Montsouris BD/Bard: “Experience with WavelinQ™ EndoAVF system” Speaker (Industry): Todd L. Berland, MD, New York University Langone Medical Center

Vascular Connections | 19

Speaker (Industry): George Mueller, MD Inari Medical: "Inari, defender of the forsaken” Speaker (Industry): Thomas Tu, MD, Inari chief medical officer Speaker (Industry): Steven Abramowitz, MD, MedStar Washington Hospital Center Speaker (Industry): David J. Dexter, MD, Eastern Virginia Medical School Terumo Aortic: "TREO endograft and aortic sac shrinkage" Speaker (Industry): Michael C. Stoner, MD, University of Rochester

Use of covered balloon expandable stents for treatment of complex AIOD: New 3-year data and insights from the Gore VBX Flex clinical study Sponsored by Gore Moderator: Benjamin Pearce, MD, University of Alabama at Birmingham

Thompson Surgical Instruments, Inc.: “What’s the BIG deal about minimally invasive anterior spine exposure?” Speaker (Industry): Jonathan Schoeff, MD

Expert insights for REVAR success during challenging times Sponsored by Medtronic Moderator: Jean Starr, MD, Ohio State University

By Beth Bales Submissions to the Journal of Vascular Surgery (JVS) publications have skyrocketed over the course of 2020, increasing 78% thus far this year. Part of the increase is due to a surge in COVID-19 manuscripts, which accounted for 12% of the submissions, editor-in-chief Peter Gloviczki, MD, said during the report on the publications during the second SVS Annual Business Meeting on June 20.

Speaker (Industry): Jean M. Panneton, MD, Eastern Virginia Medical School Clinical insights in chronic CAD/ PAD: Reducing the risk of major cardiovascular events Sponsored by Janssen Pharmaceuticals, Inc. Speaker (Industry): Sonya Noor, MD, Buffalo Endovascular and Vascular Surgical Associates Treatment consideration of EVAR & TEVAR (arterial embolization) Sponsored by Abbott Speaker (Industry) Samuel Steerman, MD, RPVI; Eastern Virginia Medical School assistant professor of surgery, Sentara Vascular Specialists TCAR: Protection from stroke and so much more Sponsored by Silk Road Medical Speakers (Industry): Jeffrey Jim, MD, Minneapolis Heart Institute at Abbott Northwestern Hospital; Angela A. Kokkosis, MD, Stony Brook Medicine; Peter Schneider, MD, University of California San Francisco

Webinars, first presented live, are:

Recap of JVS journals at Annual Business Meeting

The SVS line up of peerreviewed journals

Speakers (Industry): Frank R. Arko III, MD, Sanger Health and Vascular Institute Jean M. Panneton, MD, Eastern Virginia Medical School

A slide detailing surgical site infections from Ellen D. Dillavou’s presentation

JVS FAST-TRACKED THE ACCEPTED COVID-19 manuscripts (54% have been accepted) and made them freely available online. During the past year, JVS also created separate websites for each journal, to streamline the submission process and allow authors to submit directly to their publication of choice. The other peer-reviewed publications in the SVS family are JVS: Venous and Lymphatic Disorders (JVS-VL), JVS Surgery Cases and Innovative Techniques (CIT) and JVS Vascular Science (online only). Gloviczki said JVS has become much more selective, accepting only 28% of abstracts, a major drop from the 48% rate for last year. Submissions are also increasing to JVS-VL, reflected in the 40% acceptance rate, down from 53%. In addition, JVS Vascular Science launched in 2020 and is, Gloviczki said, “off to a really great start.” New programs also have been added, he said, including the popular Audible Bleeding podcast, which boasts an average of 1,000 listeners. Senior editor Peter Lawrence, MD, presented several awards for outstanding achievement. Among the accolades were awards for best reviewers, best new reviewers, and most cited papers across both JVS and JVS-VL. Thomas Forbes, MD, professor and chair in the division of vascular surgery at the University of Toronto in Ontario, was recognized as Editor of the Year. The Journals’ freely available collection of COVID-19 submissions now includes more than 100 letters and full-length articles. Visit vsweb.org/ JVSCOVIDColletion.

“The SVS launched JVS Vascular Science in 2020 and the publication is off to a really great start”— PETER GLOVICZKI

For more information, email SVSonline@ vascularsociety.org.

View SVS ONLINE sessions, claim credits through October By Beth Bales Scientific sessions, educational presentations, forums and industry webinars from the Society for Vascular Surgery’s virtual meeting are now available as OnDemand recordings for viewing and for claiming educational credits*. REGISTRATION IS required to view the recordings from SVS ONLINE: New Advances and Discoveries in Vascular Surgery. Attendees who previously purchased and attended the “live” program can access the recordings as part of their registration fee. Fees range from $0 to $75 for SVS members and are $200 for non-members. To register, visit vsweb.org/ RegisterOnline. Recordings of the “live” sessions are now available. To view them, registered participants need to start at the 2020 ONLINE planner, at vsweb. org/Planner2020. Log in with SVS credentials; presentations will be available by clicking on the red “Recorded SVS ONLINE Live Webinars” tile at the top

of the page. Industry webinars that were presented live will be available via the “Recorded Live Industry Webinars” tile alongside the left navigation panel. Many recorded educational and special sessions carry Continuing Medical Education and/or Maintenance of Certification (CME/MOC) credits. After viewing a session or sessions, participants may simply click on the CME/ MOC information menu link, also in the left navigation panel in the Planner and follow the instructions there. A participant who received credit for a session while ONLINE was in progress cannot receive credit for the same, recorded session. Materials that were part of the OnDemand portion of the meeting remain available. For more information email education@vascularsociety.org. *Industry-sponsored presentations and selected OnDemand programming are not eligible for CME credits.