Vascular Specialist–April 2022

22–23 YOUR SVS Looking ahead SVS sets sights on FY2023 and long-range future, including Medicare cuts

Vol.18 No.04 April 2022 Official Publication

Featured in this issue:

TRAINING & EDUCATION

www.vascularspecialistonline.com

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OUR PAST IS PROLOGUE The losing battle to train more Black doctors

VAM NEWS Latest program and Gala developments

CASE SERIES A rare insight into pediatric bone tumor resections

Supply & demand:

[Private]practice matters Vascular surgeons in private practice could play a crucial role in alleviating one of the existential problems currently vexing the specialty: The training of future generations of specialists and its intersection with declining numbers of open abdominal aortic aneurysm (AAA) repairs.

BY BRYAN KAY

BY BRYAN KAY

THE ABILITY OF THOSE IN PRIVATE PRACTICE TO contribute to the total number of training positions available across the United States, as well as to broaden the church of open aortic cases available for trainee involvement amid the fall in AAA repairs performed surgically, was brought into sharp focus during a training and education scientific session held during the 2022 Annual Symposium of the Society for Clinical Vascular Surgery (SCVS) in Las Vegas See page 10–11

ADVOCACY

SVS says AMA membership helps safeguard vascular surgery’s future

BY BETH BALES The Society for Vascular Surgery (SVS) is urging members to join the American Medical Association (AMA) in a bid to maintain a critical voice in the decision-making process for the specialty.

The reason is simple: Unless the percentage of dual members increases, the Society is in danger of losing its place at the table when crucial decisions are made regarding coding for vascular procedures and the Relative Value Scale (RVS) Update Committee (RUC), which advises Medicare on how to value a physician’s work, says SVS Policy and Advocacy Council chair Matthew Sideman, MD. The RUC is a multispecialty committee dedicated to describing the resources required to provide physician services which the Centers for Medicare & Medicaid Services See page 11

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FROM THE EDITOR

Our past is prologue: We are losing the battle to train more Black doctors

BY MALACHI SHEAHAN III

My mother was a child of the 1960s. Despite not having a college degree, she was determined to teach my sister and I that women could do anything. I guess my sister was really the intended target, but I was certainly along for the ride. Every doctor she ever took us to was a woman—to the point where I didn’t even realize men could be doctors.

It was never a conscious thought, just an ingrained assumption that all doctors were women. My realization to the contrary came embarrassingly late.

MY FAMILY SPENT A GOOD PART OF MY EARLY life living in a remote part of New York, near Montreal.

We were culturally isolated. The TV shows were in French, so I could barely figure out what the Flintstones were up to, never mind the guys living in green tents on M*A*S*H. Somewhere near my 11th birthday, I decided it was time to announce my career choice. “I’m going to be a paleontologist,” I confidently declared. Without looking up from her newspaper, my mother shut it down quickly and viciously. “You’re never going to meet a wife digging around in the desert. You should be a doctor.” Slightly stunned by my mother’s uncharacteristically sexist take, I retorted, “I’m not even looking for girls, I’m looking for DINOSAU… Wait, I can be a doctor?”

It is easy to overlook or minimize the importance of representation. Until you experience a lack of it. As we have seen with the increasing numbers of women in our specialty, representation truly matters. We know that enrolling more Black students in medical school will help recruitment for decades to come. The barriers, though, to increasing the number of Black doctors in the U.S. are deep-rooted.

In the early 1900s, the Carnegie Foundation commissioned Abraham Flexner to evaluate the state of medical education in North America. Flexner

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

4 | Vascular Specialist

visited all 155 medical schools in Canada and the U.S., issuing a detailed report of his findings in 1910. Flexner concluded that the rise of for-profit schools resulted in an overproduction of poorly trained physicians. The ensuing Flexner Report led to radical changes in medical education and became the basis for our now antiquated model, which includes two years of basic science. Critics pointed out that Flexner had received no medical instruction and valued science over clinical training. Pioneering physician William Osler worried that this emphasis on basic science would produce a generation of “clinical prigs.”

While I am unsure of the precise definition of “prig,” I do enthusiastically add my support to Osler’s concerns regarding medical curricula. However, more germane to this discussion is that within 15 years of the Flexner Report, more than half of all U.S. schools had closed.

The seven existing Black medical schools, with fewer resources, were disproportionately affected. By 1920, only two, Meharry Medical College and Howard University, remained. These closures had an enduring and tragic effect on our ability to produce Black doctors. By 2018, Black and African American individuals represented 13.4% of the U.S. population but only 5% of physicians. A 2020 JAMA study estimated that if all seven Black medical schools had remained open, an additional 35,315 Black

physicians would have entered the workforce. Flexner’s recommendations that led to the demise of these five medical schools do not appear to be based on any deepfelt bigotry. There is ample evidence that Flexner argued fervently for the survival of Meharry and Howard.

Still, he is quoted stating that Black students should be trained as “sanitarians,” and in that role would also be protecting white people from disease. Flexner, though, knew Howard and Meharry could not survive without significant financial endowments from white people, so some have painted these statements as an appeal to these potential donors.

At best, Flexner was an ignorant idealist, too rigid in his beliefs to appreciate that the need to continue educating Black doctors should supersede his desire to impose daunting standards on the schools willing to train them.

AMA requirements Flexner was not solely responsible for the onerous requirements placed on Black medical schools. In 1906, the American Medical Association (AMA) Council on Medical Education sent a letter to every medical school urging them to require at least a year of college science classes continued on page 6

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

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April 2022

COMING UP IN THE NEXT ISSUE! Vascular Specialist

is relaunching with a brand new look Your monthly SVS newspaper is also set to become the official daily newspaper at VAM, replacing Vascular Connections

Look out for Vascular Specialist@VAM at the meeting in Boston, June 15-18

FROM THE EDITOR

Our past is prologue: We are losing the battle to train more Black doctors continued from page 4

prior to admission. This prerequisite would immediately and dramatically reduce the number of qualified Black applicants since few Black colleges offered these courses, and even fewer white colleges would admit them. Another AMA requirement banned classes after 4 p.m., which disproportionately affected Black students who had to work to pay tuition. Under these new restrictions, three Black medical schools closed before Flexner began his tour.

After the Flexner Report, the surviving two Black medical schools were caught in a tug of war. On one side, Flexner stated the AMA’s regulations were “choking” the few remaining Black schools, particularly Meharry. The AMA countered that Flexner and the Carnegie Institute should help secure large financial endowments for the schools to help them meet the requirements.

The AMA’s suppression of Black doctors began in the 1800s. Six of the first 13 AMA presidents resided in active slaveholding and trading states. The AMA claimed not to discriminate based on race, leaving admission decisions to its local chapters. Black doctors, however, found few chapters that would accept them, particularly in the South.

AMA membership was critical for a physician and often tied to licensure and hospital admitting privileges.

In 1869, the AMA chapter in the District of Columbia refused admission to three qualified Black doctors. A subsequent U.S. Senate investigation found the group guilty of excluding doctors “solely on account of color.”

A bill to repeal their charter was presented to Congress but never passed. In 1870, the three excluded doctors joined other D.C. physicians to form the racially integrated National Medical Society (NMS).

When the NMS attempted to be recognized by the AMA the following year, they were accused of admitting irregulars, specifically those who had not received a formal medical license or education. This was an extremely unfair hurdle because their licenses would have been issued by the D.C. chapter that had already excluded them. That year, the AMA Committee on Ethics reviewed charges against three groups accused of admitting irregulars. The accusations against the two all-white delegations were tabled, and these groups were recognized. The racially integrated NMS was denied entry by a 114-82 vote, in which 36 members of the D.C. chapter were allowed to participate. At the same convention, the AMA voted to issue the statement, “That inasmuch as it has been distinctly stated and proved that the consideration of race and color has had nothing whatsoever to do with the decision of the reception of the (NMS) delegates.” In other words, they voted to declare themselves not racist.

Great Society By 1950, Meharry and Howard combined to produce about 100 Black doctors annually, while the remaining white schools added only 10 to 20 more. President Lyndon Johnson began the Great Society programs in the 1960s with the lofty goals of ending poverty and injustice.

Johnson believed that education would be the great equalizer. His projects, combined with the advances of the Civil Rights era, led to minority enrollment in U.S. medical schools climbing from 2% to nearly 9%. Unfortunately, this progress then stagnated for 20 years.

In 1991, Robert Petersdorf, president of the Association of American Medical Colleges (AAMC), announced a plan to enroll 3,000 Black and Hispanic medical students annually. He spoke to the 124 U.S. medical school deans, who met him with some skepticism. They did not even 6 | Vascular Specialist

receive 3,000 minority applications a year. How were they supposed to double enrollment? Undaunted, Petersdorf launched Project 3000 by 2000.

Under Petersdorf, the AAMC began new efforts at nearly every level of the education system. Pipelines programs were built, and articulation agreements were formed in which medical schools automatically admitted students meeting set academic goals. Race and ethnicity were factored into admission decisions, and for the first time in decades, progress was achieved. Black and Hispanic enrollment in U.S. medical schools increased from 1,500 in 1990 to more than 2,000 in 1995. But then, a seemingly unrelated legal ruling in Louisiana threatened everything.

Project 3000 by 2000 employed a method commonly referred to as affirmative action. Even though affirmative action is the only technique that has ever proven successful in increasing minority enrollment in higher education, it has a long and tangled legal history in the U.S. The first mention of affirmative action came on May 6, 1961, in Executive Order 10925. President John F. Kennedy called on government contractors to “...take affirmative action to ensure that applicants are employed and that employees are treated during employment without regard to their race, creed, color, or national origin.” In 1966, President Johnson established the Office of Federal Contract Compliance Programs in the U.S. Department of Labor to enforce these requirements. Subsequently, President Richard Nixon issued Executive Order 11478, which called for unilateral affirmative action in all government employment.

In 1978, affirmative action faced its first major legal challenge. Allan Bakke, a white male who had been denied admission to the University of California Davis School of Medicine two times, filed a lawsuit against the university. The medical school reserved 16 out of 100 spots for minorities at that time. The case found its way

“This fall, the use of race as a consideration in admissions may face its death in the Supreme Court.

Edward Blum, an anti-affirmative action crusader, has filed separate lawsuits against Harvard and the University of North Carolina” to the Supreme Court, where Bakke won and was granted admittance to the school. The court, however, did rule that race could be used as a factor in admissions, but quotas violated the 14th Amendment’s Equal Protection Clause.

In 1992, Cheryl Hopwood and three other white applicants to the University of Texas Law School filed suit alleging that the school discriminated against them by using an affirmative action admissions process that placed Black and Mexican American applicants in a separate admissions pool and consequently accepted members of those groups over non-minority students who had comparable grades and test scores. The U.S. District Court for the Western District of Texas found in favor of the university. U.S. District Judge Sam Sparks stated in the decision, “until society sufficiently overcomes the effects of its lengthy history of pervasive racism, affirmative action is a necessity.” The case was then brought to the U.S. Court of Appeals for the Fifth Circuit. Here Hopwood v.

Texas was overturned, and affirmative action rejected. The ruling read, “the University of Texas School of Law may not use race as a factor in deciding which applicants to admit in order to achieve a diverse student body, to combat the perceived effects of a hostile environment at the law school, to alleviate the law school’s poor reputation in the minority community, or to eliminate any present effects of past discrimination by actors other than the law school.”

The Supreme Court declined to review Hopwood v. Texas. Therefore the ruling became law in Texas, Mississippi and Louisiana. Even though the decision only applied to three states, the precedent was far-reaching.

Schools across the U.S. adjusted their admissions policies, fearful of lawsuits. A 2003 Supreme Court decision in Grutter v. Bollinger later invalidated Hopwood v. Texas.

Here, the court held that the Equal Protection Clause of the 14th Amendment does not prohibit the narrowly tailored use of race in university admission plans as part of a compelling interest in promoting student diversity.

Still, the reversal came too late. Project 3000 by 2000, which had made the first progress in minority medical school enrollment in over 20 years, was abandoned.

AMA apology In 2008, the AMA issued an apology for its “past history of racial inequality toward African American physicians.” In 2020, the AAMC removed Abraham Flexner’s name from its award for distinguished service to medical education.

Today, though, more than atonement is needed.

Every year, 21,000 students are admitted into the 154 U.S. medical schools. Black men often make up less than 500 of them. The AAMC reports that essentially every minority group saw an increase in medical school enrollment between 1978 and 2014, except for Black men.

Black males face specific challenges: a higher likelihood of attending underfunded high schools and a lower chance of participation in AP courses, gifted programs and STEM classes. A 2021 UCLA study published in the Journal of General Internal Medicine found that the percentage of doctors who are Black males has remained unchanged since 1940.

Financial considerations are also important. More than 70% of medical students come from homes with an average income of over $74,000 (2016 terms).

Underrepresented minorities disproportionately come from lower socioeconomic backgrounds. As such, they carry an average debt of over $200,000 upon graduating from medical school. The Brookings Institute found that the net worth of the average Black family is about 10% of the average white family.

The Medical College Admission Test (MCAT) poses another potential fiscal barrier. The registration is $320, but more affluent applicants can afford to spend thousands on tutoring, creating another disparity. The AAMC walks a tightrope in defense of the role of the MCAT in the admissions process. They have asked medical schools to de-emphasize the scores, but the AAMC also administers the exam.

This fall, the use of race as a consideration in admissions may face its death in the Supreme Court. Edward Blum, an anti-affirmative action crusader, has filed separate lawsuits against Harvard and the University of North Carolina. Both cases were unsuccessful in federal district court, and the litigation against Harvard failed in the First Circuit Court of Appeals. The Supreme Court has paired the lawsuits and is bringing them to Washington to hear.

Previous Supreme Court rulings allowing affirmative action have been close decisions, usually with a moderate conservative justice holding the swing vote. No moderate conservatives remain on the court. Many legal experts anticipate a 6–3 decision mandating complete “color blindness” in the admissions process. Based on Blum’s own documents, he expects that if his petition is successful, and affirmative action declared illegal, the share of Harvard students who are Black would fall from approximately 14% to about 3%. While its legal basis hangs in peril, we should consider the ethical implications. To dispute the validity of affirmative action as a tool in higher education admissions, one must successfully defend one of two positions. Either diversity does not matter, or a means other than affirmative action can achieve it. Neither position, however, is scientifically viable. At a certain point, ignorance becomes a choice.

April 2022

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VAM NEWS

How abstracts are selected The abstracts presented at the Society for Vascular Surgery (SVS) Vascular Annual Meeting (VAM) are the result not just of thorough research, but also a meticulous—and blind—selection process.

THE PROCEDURE STARTS months ahead of the yearly annual meeting, with the posting of guidelines and policies just prior to abstract submissions opening in mid-November.

The submission period runs for eight weeks. The 25-member SVS Program Committee reviews all abstracts. Each member first expresses preferences for three of the 13 or so abstract topic categories and the chair, currently Andres Schanzer, MD, assigns four to five people to one of five groups. One of the five reviews all submissions in the “aortic” category, which is typically the largest. The other four groups tackle several categories—such as vascular medicine, trauma or carotid—each.

Each group also includes one to two members each from the Vascular and Endovascular Surgical Society (VESS), the SVS’ longtime VAM collaborator.

VESS holds its spring meeting in conjunction with VAM and sponsors several hours of abstract presentations on the Wednesday of the meeting.

Members of these small groups perform blinded reviews, assigning each

abstract a score from 1–5. The final score report for all abstracts includes the average score, standard deviation, any conflicts of interest and comments.

“It is an important—even vital—part of the selection process that reviewers don’t have any idea who is part of the research team,” said Schanzer. “We select abstracts based on the science presented, not the researchers’ names.”

On separate conference calls, each group uses the score report and notes to select the top 10 to 15 abstracts from each category to put forward for the VAM program. After the small groups make their selection, volunteers search on PubMed and other search engines to determine if the work has been published or presented before, which is against the clearly stated policies.

Finally, all abstracts are presented to the entire Program Committee for selection for VAM presentation.

At the selection meeting, members involved with a paper as an author, or even part of the institution where the researchers are affiliated, leave the room, explained Schanzer.

Submitting authors may choose which sessions where they do, or do not, want their work presented.

Selecting to speak only at a plenary session is perhaps the biggest obstacle to an author’s chances of making the program, he added.

“It behooves an author to select all categories.”— Andres Beth Bales Schanzer

Help tell the SVS story through images THANKS TO SMARTPHONES, ALMOST everyone usually has a good camera at hand and thousands of digital photos in storage.

So get that phone charged and be ready to click the button and capture your lives and specialty, from photos of your practice and your travels, to vascular training and vascular surgery’s history. You could win recognition along the way.

In celebration of its 75th anniversary, the SVS is hosting a photo contest highlighting the past, present and future of vascular surgery. By sharing photos of life as a vascular surgeon, trainee, student, nurse or other vascular professional, members will help tell the Society’s collective story.

The nine-week contest began in March and will end on May 25, with a new photo category—and honorees—each week. One winner and three runners-up will be selected in each category. All 36 winners will be recognized on the SVS website and during VAM.—Beth Bales For information on consent forms and to submit photos, visit vascular.org/2022PhotoContest.

8 | Vascular Specialist

Gala auctions taking shape IT’S SPRING NOW, BUT THOSE WHOSE WINTERS seem never-ending might consider bidding on a week-long stay in Florida for next winter. Cold and snow are much more bearable when a week of sun and sand beckons part-way through.

Access to a three-bedroom condominium in Ormond Beach, Florida, is just one of the attractions being offered via the live and silent auctions, part of the SVS “Cheers to 75 Years” Gala to benefit the SVS Foundation. The event will be held the evening of Friday, June 17, during the 2022 Vascular Annual Meeting (VAM) in Boston.

Also available is a custom loupes box hand-crafted of imported exotic wood, complete with an inscription of the high bidder’s choice.

A long weekend in the Hamptons in New York—that string of seaside communities on Long Island immortalized in books and movies—will be on the auction block, as will a fishing weekend for two in Florida and a weeklong stay in Hermosa Beach, California.

Though the Gala’s live auction will be available only to Gala ticket-holders, anyone, anywhere, can bid on the silent auction prizes, via computer. Those items will be available in early June, ahead of the Gala itself.

Organizers still seek additional items for the two auctions. Of particular interest are sporting events, especially in upgraded seating such as skyboxes; experiences such as a weekend fly-fishing; or, as at the 2019 Gala, climbing Mount Rainier in Washington state; and artwork, fine liquors and wine.

A dwindling number of tickets remain available for the Gala, which will feature a reception, plated dinner, entertainment and dancing—plus the live auction—at the Sheraton Boston Hotel, the VAM “Headquarters” hotel.

Tickets are $500 each, or $5,000 a table. As of late March, two Platinum and one Gold Premium tables ($20,000 and $10,000 each, respectively) remained available. Learn more at vascular.org/Gala22Tickets.

Meanwhile, elsewhere at VAM, while the vast majority of programming is included in the registration fee, some courses and events require a ticket— even if there is no fee associated with it. Be sure to include ticketed sessions in your registration, or return to registration to add them. Visit vascular. org/VAM-2022/registration.—Beth Bales

VAM packed from beginning to end

BY BETH BALES

FROM THE OPENING CEREMONY ON THE Wednesday morning of VAM, to announcing the winners of the Poster Competition Championship Round on Saturday afternoon, attendees at the 2022 meeting will find plenty to keep them interested.

That’s by design, said Andres Schanzer, MD, chair of the SVS Program Committee, which oversees the VAM schedule. He added attendees should be sure to keep that in mind when making travel arrangements.

“We’ve been adjusting the schedule, starting last year, to make sure the plenary sessions are free from competing sessions. Then, working with the Postgraduate Education Committee [PGEC], which oversees more than 25 other educational sessions, we crafted a schedule with as few overlapping topics as possible.”

On Wednesday morning, for example, attendees can move from the abstracts at the International Fast Talk session, to the Opening Ceremony, to the William J. von Liebig Forum (the first plenary session), to the second plenary session, and then to the E. Stanley Crawford Critical Issues Forum, without missing any other sessions.

In the afternoon, attendees can choose the Vascular and Endovascular Surgical Society (VESS) abstract presentations from 12:45 to 6 p.m. or two “Ask the Expert” sessions, a special session on policy and advocacy, as well as the International Poster Competition and a welcome reception for the World Federation of Vascular Societies (WFVS).

Similar choices are in store Thursday through Saturday between postgraduate courses and other educational sessions. “All in all, we’ve reduced overlap as much as possible,” said William P. Robinson, MD, PGEC chair. The readjustments allow attendees to maximize their experience, taking in sessions on a wide variety of topics. And beyond the educational offerings, there continue to be several special events as well, among them: ● The Roy Greenberg Lecture, 9:30 to 10 a.m.

Thursday, presented by Jan Brunkwall, MD, of the University of Cologne, Germany ● The Awards Ceremony, presenting the recipient of the SVS Lifetime Achievement Award and/or of the SVS Medal for Innovation

“All in all, we’ve reduced overlap as much as possible” William P. Robinson

April 2022

THIS ADVERTORIAL IS SPONSORED BY ACHL

CLTI, VTE and post-thrombotic syndrome: Leading experts discuss crucial decision-making in interventional approaches For Anahita Dua, MBChB, the stark realities and complexities of peripheral arterial disease (PAD) patients undergoing endovascular treatment for chronic limb-threatening ischemia (CLTI) coalesce into one important truth: the necessity of entering the operating room armed with “a plan A, a plan B and a plan C.” READINESS IS KEY, ACCORDING TO THE assistant professor of surgery at Massachusetts General Hospital and Harvard Medical School in Boston, if the ultimate goal of restoring appropriate flow to the foot is going to be obtained.

Dua was speaking as part of an expert group of faculty drawn from across vascular surgery, interventional cardiology and interventional radiology to discuss the latest advances and key decision-making strategies used when considering intervention for four key vascular conditions: CLTI, venous thromboembolism (VTE) encompassing acute iliofemoral deep vein thrombosis (DVT) and acute pulmonary embolism (PE), and postthrombotic syndrome (PTS). In a series of Interactive CME Touchpoints, Dua and other leading expert clinicians cover the identification of candidates for interventional procedures, the latest clinical trial data on available and emerging devices, as well as case-based applications for practice, for each disease process.

When it comes to CLTI, she is clear on what constitutes the key to interventional success: “Procedural planning is probably the most important thing when you’re approaching a patient from an endovascular standpoint,” Dua tells viewers of the 45-minute activity during which she and Mitchell Weinberg, MD, chair of the Department of Cardiology at Staten Island University Hospital in New York, discuss the latest updates in approaches to interventions for CLTI. “You can only know your enemy if you’ve looked at the procedural planning prior, and you know what you have available to you on the shelf in order to approach these patients. Obviously in the case of endovascular treatment, no matter how good you may be, if you don’t have the tools that you need, and you don’t have them readily available for you, [then] you can’t achieve the goals that you want. So, in procedural planning the key is two-step: One, you need to look at the previous imaging of the patient, and two, look at the most recent imaging, and compare it to the previous imaging to determine where exactly your target is and how you intend to get there.”

Alternative plans gather importance given interventionists can confront numerous challenging scenarios, Dua adds. That might be failure to navigate a lesion, or achieving breakthrough, but the balloon won’t track. Over the course of the CLTI Touchpoint activity, Dua and Weinberg cover risk assessment of CLTI, examples of above-the-knee interventions, the challenges faced when treating PAD below-the-knee, along with the latest clinical trial and safety data, and case-based applications for practice.

Management of acute iliofemoral DVT Kush Desai, MD, associate professor of radiology, surgery and medicine at Northwestern University Feinberg School of Medicine in Chicago, notes the fertile grounds

April 2022

applications for practice. “The incidence of DVT in the U.S. is about 1 million cases per year, or just under,” Murphy points out, “so the occurrence of PTS is also correspondingly high. Further, the prevalence is very high because often the patients are not treated. They are managed with compression, so there’s more and more patients over time that have this [condition].

Unfortunately for them, quality of life mirrors that for other severe, underlying medical conditions, including COPD [chronic obstructive pulmonary disease], heart failure, diabetes with complications, and these are often younger patients in those groups.”

Addressing a question from Desai on whether she saw any gaps in the treatment of PTS, viewers hear from Murphy on knowledge deficits she sees among many physicians who encounter these patients—and the patients themselves. “There is a gap in education for referring providers,” she explains. “I think we’ve seen a greater increase in referring in the past five years or so, but I think a lot of physicians still don’t know that we can treat these patients.”

A lot of technical training needs to be done, she tells Desai. “I think we both still treat a lot of stent complications as more providers start doing these procedures without formal education, so I think there’s a need for training. From a technical standpoint, I think we still need treatment options for the inflow. Some patients are not candidates for stenting because of poor inflow or have stent failures because of poor inflow, and we don’t really have good options once these stents occlude, which is why it’s important to treat them correctly and to select patients correctly.”

interventionists currently occupy in the treatment of DVT. In the acute iliofemoral DVT activity in the Touchpoint series, he outlines how despite advancements in the medical treatment of DVT, nearly half of all patients go on to develop post-thrombotic syndrome (PTS). Endovascular interventions have shown promise, Desai tells viewers. “This is a really exciting time in DVT management and DVT intervention because we now have prospective, high-quality evidence that is giving us a clearer idea of when we should intervene on patients,” he says. “DVT is a really common problem, and there are patients that have more severe forms of DVT—those that expand up into the iliac vein. In those patients, we have the possibility through endovascular interventional methods of actually improving their quality of life, in the short-term improving some discomfort, and, most importantly, reducing the severity of post-thrombotic syndrome that can result if they were treated with just Crucial decision-making in acute PE anticoagulation alone.”

In addition, Adrian Messerli, MD, an interventional The 30-minute Touchpoint includes video cardiologist and a professor of medicine at the University commentary on key clinical trial data and patient of Kentucky in Lexington, navigates viewers through selection for endovascular updates on guidelines and trials interventions to reduce the risk dotting the current interventional of PTS. Meanwhile, Desai also therapeutic PE landscape. In addresses the impact and severity of this Touchpoint, Messerli draws PTS, and the role of interventions particular attention to “the in improving patient quality of underuse” of catheter-directed life. He covers topics such as the thrombolysis. “A common question PTS burden, specific clinical trials is whether or not catheter-directed that examine the use of cathetertherapies are underused for directed interventional methods for treatment in acute PE,” he explains.

“Some patients are not improving outcomes after DVT, and “I think level-1 evidence is still candidates for stenting lacking, so this is a somewhat a “How I Do It” case. because of poor inflow contentious question. However, Closing in on PTS when you look at surrogate or have stent failures Meanwhile, Desai introduces endpoints, namely right ventricle because of poor inflow, to left ventricle ratio reduction, and Erin Murphy, MD, director of the Venous and Lymphatic Institute at and we don’t really have recognizing the benefits for patients Sanger Heart and Vascular, part of terms of in-hospital mortality and good options once these in Atrium Health, in Charlotte, North recurrent PE, I think there’s a strong stents occlude, which Carolina, at the juncture of PTS. argument that these therapies While discussing the latest is why it’s important to should be used more liberally. updates in the condition, the expert “In addition, for those who have treat them correctly pair in venous disease review the been using these therapies for a newer dedicated venous stents now while, anecdotally these patients and to select available, as well as limitations with typically feel better quicker, and patients correctly” conservative therapies in another I think that’s an important issue Erin Murphy, MD 30-minute Touchpoint activity. as well.”

Making use of images, charts and graphs, Desai and Murphy Ensure you are prepared to optimally offer their expert perspectives on the treatment of PTS, manage your patients with CLTI, VTE, or post-thrombotic the benefits of venous stenting, and the best follow-up syndrome by accessing these engaging CME activities today. approach in patients post-stenting. They delve into risk Visit www.achlcme.org/interventional-approachesassessment of PTS, non-procedural versus procedural svs and learn about tackling complications from this group care, the latest clinical trial data on the four dedicated of expert faculty. Supported by an educational grant from venous stents that have been developed, and case-based Boston Scientific Corporation.

vascularspecialistonline.com | 9

COVER STORY

TRAINING & EDUCATION

Supply & demand:

[Private] practice matters continued from page 1

home for continuing efforts, and one-on-one mentorship for new program leaders. Ultimately, the initiative worked, said Sheahan. Stressing more work remained to be done on the matter, “with a bit of a push, there are a lot of people out there who want to train vascular surgeons,” he added.

Private practice interest Meanwhile, Sheahan’s data also showed that just two of the 12 private practices identified and contacted as

Malachi Sheahan III et al looked into data on the progress being made to increase the number of vascular training programs in the U.S.

(March 19–23). Discussion was stirred by data delivered

by Malachi Sheahan III, MD, on the success of a national initiative carried out to explore how to overcome barriers and better help those interested in starting new vascular training programs, as well as new statistics presented by Thomas F. X. O’Donnell, MD, that showed the “significant proportion” of open AAAs completed without any trainee participation.

Sheahan, chief of vascular surgery at Louisiana State University (LSU) in New Orleans, told SCVS attendees how since he was charged with helping spark an increase in vascular training programs in 2019, his research had demonstrated a sharp increase to 28 new programs in the last three years—compared to just seven in the three years prior.

Working under the auspices of the Society for Vascular Surgery (SVS) and the Association of Program Directors in Vascular Surgery (APDVS), he and colleagues on a taskforce formed for the initiative reached out to 172 general surgery programs then without an associated vascular surgery program, and 12 large private practice groups thought large enough to support a fellowship.

They tackled the issue at a critical juncture: since the inception of the integrated vascular surgery residency training paradigm in 2007 through 2015, the sum of new programs increased every year, Sheahan pointed out. Then the level essentially flat-lined for four years. “You can see that the number of new training programs stagnated around 0–2 a year. Since the initiative was started, we have 28 new programs. In the three years before the taskforce, we had seven programs total approved, then in the three years after we have 28 new programs,” he said.

Four key planks of the initiative aided the taskforce efforts, Sheahan explained. First, they sought—and gained—clarification from the Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) over faculty and program director requirements needed to start both an integrated program and a fellowship. They then set about providing stewardship to help guide those getting started through an often “byzantine and confusing” process, Sheahan said. They also increased outreach efforts through such mediums as a recurring Vascular Annual Meeting (VAM) session on how to start a vascular training program, the creation of an ad hoc APDVS committee to act as a 10 | Vascular Specialist

“You can see that the number of new training programs stagnated around 0–2 a year. Since the initiative was started, we have 28 new programs” Malachi Sheahan III potential sites for vascular fellowships expressed an interest in starting a program within the following three years, with the most common barriers cited being financial (50%), administrative (42%), and lack of interest (42%).

During post-presentation questions, this detail prompted Brigitte Smith, MD, program director of the vascular surgery fellowship at the University of Utah in Salt Lake City, to ponder whether private practices could partner with programs such as her own to increase opportunities.

“I have one spot a year for fellowship; could I offer two spots a year if I partnered with these private groups?” she asked “They don’t need to start their own program necessarily, but would they be willing to take trainees?

That seems like a way to increase spots, if not programs.”

Sheahan explained that the absence of any kind of fellowship in the hospitals where the private practice surgeons operated appeared to be the main hold-up, alongside a gap in knowledge. “Part of it is still the RRC’s fault, in that how big some of these requirements are. So them clarifying in the last couple of years allowed a bloom in programs,” he said.

Responding to acknowledgment from the floor over recently successful Match seasons, Sheahan noted that the first two virtually administered interview processes during the pandemic for both integrated and fellowship programs saw 100% of positions filled—essentially a first.

Earlier, Sheahan had conceded how when the question of vascular surgery training programs was looked at through the prism of “supply and demand,” he belonged to the demand side of the equation, arguing for a need to increase the number of students and residents in order to generate more programs. “We built all these programs but it seems like we are increasing demand as well,” he added during the question period.

Those operating outside of traditional training

institutions potentially making a contribution to raising the level of trainee involvement in open aortic cases was the backdrop to O’Donnell’s data, which was garnered from the National Inpatient Sample between 2004–2015.

By looking at 140,000-plus cases, O’Donnell and colleagues at Beth Israel Deaconess Medical Center in Boston showed that some 38% of open AAA cases were performed at institutions classed as urban non-teaching hospitals, with 58% carried out in urban teaching locations and 4% at rural hospitals.

“Over time, open AAA volume in rural hospitals fell 89%, urban non-teaching volume dropped 87%, and urban teaching hospitals fell 58%,” he said. “At the end of the study period, rural hospitals accounted for 2.9% of open AAA volume, urban teaching centers 78%, and urban nonteaching hospitals 19%. However, in the last two years of our sample, non-teaching hospitals still accounted for almost 1,400 open repairs on average annually.”

O’Donnell continued: “Overall, mortality was 5%.

There was no difference between teaching status in either group or in adjusted analyses. Despite concerning training experience with open AAA repair in recent years, a significant proportion of the open AAA repairs in the United States occur without any training participation.

These data suggest that partnerships between vascular training programs and unaffiliated hospitals offer one potential solution to current deficiencies in open aortic training.”

Yet, bringing private practice vascular surgeons into the fold is not without challenges, members of the audience observed. Most of those practicing in non-teaching hospitals do so because they don’t want to perform cases with residents and fellows, said Linda Harris, MD, program director of the vascular fellowship and vascular residency programs at the University at Buffalo in Buffalo, New York.

She also queried O’Donnell over how many open cases were realistically available at the 92 hospitals highlighted in the study, with the post-2015 period showing a sharp decline according to his research. “Based on the way of the trend, it’s probably about a thousand per year or so, maybe a little less than that,” O’Donnell said. “It’s a large opportunity; it’s certainly not every private hospital that will want to have residents come or fellows come. But any improvement is good, so we’ll take what we can get.”

In his capacity as an audience member, Sheahan chimed in to point out that aortobifemoral bypass surgery should be part of conversations about trainee involvement in open aortic surgery. “We have to get away from reporting open AAA as open aortic numbers, because they are not synonymous,” he said. “If you combine aortobifemoral and AAA, it’s not as dire as it looks. Yeah, open AAAs are going away, but we’re still doing a fair number of aortobifemorals, so consider that, too, when you publish.”

Robert Hacker, MD, a vascular surgeon at SSM Health in St. Louis, remarked that he would gladly cooperate with the teaching hospitals in the area to boost trainee exposure to open aortic surgery at his non-teaching urban medical center. “I’m really concerned that the people going to take care of me and you guys are not going to have the experience to do open,” he said. “Because as these aneurysms with endografts start failing, there’s no more metal to put in, and they’re going to have to be done open.

I think you’re going to see a big mortality jump in a few years,” as surgeons at institutions like the Mayo Clinic start to retire, Hacker added. “I would strongly encourage the academic centers to reach out to the private and academic people like myself and develop relationships, because there’s a lot to be learned and lot of people who can teach.” Gilbert R. Upchurch Jr., MD, a session moderator, brought the conversation to a close with a note on inroads being made. “We need to partner with people in practice.

We’re doing that at the University of Florida,” he said.

“We have a third fellow who’s going to be going down to work in Daytona. I know they’re doing this at SIU with conversations I had today. There is hope.”

April 2022

Interview: SCVS leaders discuss training challenges, position of private practice, diversifying generation of surgeons

The training and education session had touched on such topics as the Vascular Surgery Board (VSB) Certifying Examination and the virtual interviews that have been the new reality for both program directors and vascular surgery trainees over the last couple of years. And while the session delved into the number of open aortic procedures taking place in different types of vascular practices, and touched on the prospect of increased private practice involvement in training future vascular surgeons, it also heard about sobering data laying out programmatic engagement with DEI in U.S. training programs, as well as the obstetric experience of trainees.

This coalesced with some of the personal experiences laid out in the later DEI focus session. The visceral nature of some of the perspectives offered were not lost on incoming SCVS President-elect M. Ashraf Mansour, MD, professor Barriers thrown up between the worlds of and chair of the department of surgery at Michigan State University in Grand Rapids, who moderated the focus private or community vascular surgery and academic practice need to be dismantled for session, and new Vice President Jean Bismuth, MD, a vascular surgeon at the Katy Heart & Vascular Institute, in Houston, the betterment of the specialty at large. At Texas, and associate professor of surgery at Louisiana State stake are some of the very fundamentals of University. “My bias is that vascular surgeons are educated what makes vascular surgeons unique among people,” Mansour told Vascular Specialist in a joint interview with Bismuth. “But, obviously, being educated and being specialists who tackle disease of sensitive are two different things. Certainly, there the vasculature. are some people out there who are in powerful THOSE WERE SOME OF THE THEMES positions who are completely insensitive and emerging out of reflections on a robust pair completely ignorant of the issues, and of the of sessions at the recent Society for Clinical impact of their behavior on their trainees or Vascular Surgery (SCVS) Annual Symposium their colleagues. that focused on key questions of the future “When Jean and I were training, the Caron direction and demographics of the specialty. understanding was you were going to come Rockman The generational changes taking place to work, you were going to work hard and across society at large, and in medicine and you were not going to complain. There was no vascular surgery, found purchase in a scientific 80-hour week; if you were tired, it didn’t mean you session on training and education issues such could go home. I remember many times being as the state of open aortic repair, but also, tired at work and having to do more work, crucially, on matters related to diversity, and falling asleep on my way home driving. I equity and inclusion (DEI), and how these think that stuff doesn’t happen as much these impact the specialty’s body politic. Outgoing days, because we have rules in place, and SCVS President Caron Rockman, MD, people are more sensitive to all of M. Ashraf director of NYU Langone’s vascular surgery these things.”

Mansour residency and fellowship programs in New The generational divide some of these York, captured parallels running through some issues exposes highlights a need for greater of the key existential changes taking place that the understanding and interaction among those of an SCVS sessions brought into focus—suggesting older vintage in what is “a much more sensible how breaking down barriers might further the and sensitive space,” continued Bismuth. vascular surgical cause.

The DEI focus session heard from “In our field, as in almost all fields these University of Southern California chief of days, there’s talk about increasing diversity of vascular surgery Vincent Rowe, MD, an our workforce, and trying to recruit diverse African American, “who bared his soul,” said Jean individuals,” Rockman told Vascular Specialist.

Mansour, and Erica Leith Mitchell, MD, the Bismuth “Women in particular in the past have been vascular chief at the University of Tennessee traditionally, perhaps, discouraged from entering Health Science Center in Memphis, over her very specialized surgical fields, and this certainly has struggles in academic medicine. Bismuth recalled the changed very significantly over the past couple of years, but I experience of a colleague, who, after speaking at a regional think we still have more work to do. society meeting a few years ago about some of the struggles “The issue of the training itself, and the decrease in open he was facing in his personal life, attracted some negative aortic surgery, is a real challenging one. I don’t think it’s post-address commentary from attendees. The recent SCVS going to get better, because as our endovascular, or less perspectives “are in direct contrast to that,” he said. “We are invasive interventions, get better and better and better, actually saying that we would like to hear these things. These there is going to be, by nature, a decrease in open aortic are the human aspects of what we do every day. We share surgery, and the nature of that surgery is going to be more more today, and there should be a common understanding.” complicated.

Then there are those more acute training issues, such as “I thought the idea of talking about ‘private practice’ adequate numbers of procedures in certain types of cases, surgeons, or community surgeons, to aid in this is a particularly aortic. “The whole notion of recruiting the wonderful resource. I also think that for those people who community surgeons to have trainees rotate through their are doing a lot of open aortic surgery by the nature of their cases is brilliant,” Bismuth reflected. Even if only 30–40% of patient population, it would be nice if they could be assisted those in private practice were keen on the idea, that would to start formal training programs. The lines between the represent big progress, he added. “And it brings the private ‘academic surgeon’ and the pure private practice surgeon in practice guys into the circle in a very meaningful way. We our field—the walls need to come down in some way. I think keep on talking about how to involve the private practice it’s an artificial distinction that is not necessarily helping us.” guys more­—I can't think of a better way.”—Bryan Kay

April 2022

SVS says AMA membership helps safeguard vascular surgery’s future continued from page 1

(CMS) considers in developing relative value units (RVUs). Ultimately, these recommendations are critical to physician reimbursement.

To participate in the AMA’s RUC meetings, a specialty must have a seat in the AMA House of Delegates. To have that important seat—which provides that specialty with a voice in decisionmaking—the organization must hold a certain percentage of members who also are AMA members, said Sideman.

Sideman acknowledged that some SVS members hold ill will against the AMA because of the payment cuts that went through at the beginning of the year. “Some of our members see the AMA as part of the problem, and not the solution,” he explained. However, Sideman urged all members, despite that sentiment, to join the AMA. “Whether you agree with the AMA, or if you don’t feel like they speak for you, they are the way to be heard in the current system,” said Sideman. “The AMA is how we have a voice. If we lose our spot there, we lose our voice.”

The AMA wields great power through its role in sending recommendations for reimbursement to CMS. Should SVS lose its all-important spot in

“Whether you agree with the AMA, or if you don’t feel like they speak for you, they are the way to be heard in the current system” Matthew Sideman the House of Delegates, the SVS will no longer be able to influence coding and RVU decisions.

Members stand to lose far more than the $420 membership dues, he said—albeit, costs are lower for those in their first four early years of practice and military physicians, at $280.

Although the RUC provides recommendations, CMS makes all final decisions about what Medicare payments will be. Many physicians believe, erroneously, that the RUC determines payment, Sideman pointed out. Instead, the group provides comments to the government about policy, he said. The committee summarizes all the deliberations and forwards them to CMS, with CMS then determining RVUs and values.

Congress then sets the conversion factor for the Medicare Physician Fee Schedule, which subsequently determines reimbursement.

Sideman said if SVS loses its representation, SVS could submit its own comments on codes relevant to vascular procedures. “But those recommendations would be seen as biased and self-serving, whereas those from the RUC process are deliberated by multiple specialties; they have the ‘stamp of approval’ of an independent multispecialty body.” vascularspecialistonline.com | 11

DEVICE NEWS

F/BEVAR review reveals less than 20% of patients suffered intraoperative adverse event

BY JOCELYN HUDSON

A retrospective evaluation of 600 fenestrated or branched endovascular aneurysm repairs (F/BEVARs) for the treatment of complex aneurysms revealed that fewer than one in five patients experienced an intraoperative adverse event, according to a press release announcing study results published in the March 2022 edition of the Journal of Vascular Surgery (JVS).

THORACOABDOMINAL AORTIC ANEURYSM (TAAA) repair is among the most complex and serious

operations in the realm of surgery, the press release notes. Endovascular repair of these aneurysms is now established as a viable alternative to open surgical repair, and, according to the principal author, Gustavo Oderich, MD, of the University of Texas Health Science Center in Houston, “studies have demonstrated superior results to open repair.”

However, he continued, “despite many technical improvements in complex endovascular repairs, the procedure remains technically demanding with significant risks. Technical failures indeed may result in disastrous complications, such as loss of a kidney, bowel or spinal ischemia.”

As reported in the March edition of the JVS, the aim of this study was to review the incidence of intraoperative adverse events and the impact on outcomes of F/BEVAR for the treatment of complex aortic aneurysms.

The authors reported on 600 consecutive repairs performed at the Mayo Clinic between 2007 and 2019. The overall 30day mortality was 2% and there were 122 intraoperative adverse events, defined as any intraoperative complication or technical problem requiring an additional or unplanned procedure among 105 patients (18%). The most frequent events included 55 target arteries, 46 access, and seven graft

Cook Medical receives FDA Breakthrough Device designation for Zenith Thoraco+ endovascular system COOK MEDICAL’S ZENITH Thoraco+ endovascular system (Thoraco+) has received Breakthrough Device designation from the Food and Drug Administration (FDA), according to a company press release.

The company pointed out that while the product is not yet commercially available, the benefits of the designation include priority review, and interactive and timely communication with the FDA during the clinical trial and pre-market phases of review, in order to help get potentially lifesaving devices to patients more quickly.

The Thoraco+ is the second product from Cook Medical to receive a Breakthrough Device designation in 2022.

Cook communicated that the device is built on the strength of the Zenith platform and represents a

12 | Vascular Specialist

next-generation endovascular graft for the treatment of thoracoabdominal aortic aneurysms (TAAAs). The system is indicated for the endovascular treatment of patients with Crawford classification I–IV TAAAs. The Thoraco+ is an off-the-shelf device incorporating four side branches for the celiac, superior mesenteric, left renal and right renal arteries.

Cook advised that in order to Zenith accommodate Thoraco+ varied patient endovascular anatomy, the system Thoraco+ would be available in a range of diameters and lengths.

In January, Cook announced having received Breakthrough Device designation from the FDA for a new drug-eluting stent (DES) designed for below-theknee (BTK) interventions.

The new stent is designed to treat patients suffering from chronic limbthreatening ischemia (CLTI).—Bryan Kay

600 repairs

30-day morality was:

2% Additional or unplanned procedure in

105

patients, or:

18% Data published in JVS on intraoperative adverses events occurring during F/BEVAR

complications. Although intraoperative adverse events did not affect patient survival (odds ratio [OR]: 1), suggesting the intraoperative rescue maneuvers were successful, there were more major adverse events in the intraoperative adverse event group, mostly due to acute kidney injury (27% vs. 11%, p<0.001). Risk factors for the intraoperative adverse events included female sex (OR: 2.5), presence of target artery stenosis (OR: 2), and Crawford extent II aneurysm (OR: 1.9).

“Data on the incidence of intraoperative adverse events during F/BEVAR and the clinical sequelae have not been previously described in detail,” said Oderich.

“This large single-center study showed that intraoperative adverse events were present in 18% of patients who underwent this procedure, two-thirds of which required additional procedures to treat the complications.

“Endovascular technology continues to evolve. Novel devices have added preloaded systems, lower profile fabric, and steerable catheters and sheaths to minimize procedural difficulty.”

The study also underscores the need for not only careful treatment planning, but also for operators to have an armamentarium of skillsets and devices to address intraoperative adverse events, it was further noted.

Medtronic issues voluntary recall for subset of IN.PACT Admiral and IN. PACT AV DCBs MEDTRONIC RECENTLY TOOK THE decision to recall a subset of its IN.PACT Admiral and IN.PACT AV paclitaxel-coated percutaneous transluminal angioplasty (PTA) balloon catheters due to the potential for pouch damage resulting in a loss of sterility. This is according to a news alert from the company dated March 31.

Medtronic communicated that approximately 6,000 IN.PACT Admiral catheters and three IN.PACT AV catheters distributed to customers globally are impacted by this recall. “Medtronic is communicating to customers with affected product on hand to immediately quarantine and return the product to Medtronic, as well as send back a signed confirmation form,” the company detailed.

The news alert continued: “The pouch damage was discovered during a routine inspection. Upon investigation, a change implemented to one manufacturing line was determined to be the cause. All batches manufactured on this line after that change are being retrieved. The problem on that line was fixed. Additionally, to ensure no further issues, production on all lines was paused until a follow-up packaging inspection was completed.

No further errors were discovered.”

IN.PACT Admiral balloon

According to Medtronic, the company had received no complaints involving this issue. In addition, they reported that there have been zero reports of injury or death related to this issue.

“There are no actions required for patients where the affected IN.PACT Admiral and IN.PACT AV catheters were used during a procedure. Patients should continue to be monitored in accordance with the medical facility’s standard care protocols,” the release detailed.

The company stressed that, for most regions, there is little or no impact for customers to order replacement product.

It advised that customers may reach out to Medtronic customer service (800-5515544, selection option “Vascular”) for any questions regarding their return or ordering replacement product.

The company further noted no other Medtronic products are affected by this issue, and that all appropriate regulatory bodies have been notified.—Jocelyn Hudson

“The pouch damage was discovered during a routine inspection” April 2022

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INDICATIONS FOR USE The AURYON Atherectomy System is indicated for use in the treatment, including atherectomy, of infrainguinal stenoses and occlusions, including in-stent restenosis (ISR).

References: 1. Rundback J, Chandra P, Brodmann M, et al. Novel laser-based catheter for peripheral atherectomy: 6-month results from the Eximo Medical B-LaserTM IDE study.

Catheter Cardiovasc Interv. 2019;94(7):1010-1017. 2. Shammas NW, Chandra P, Brodmann M, et al. Acute and 30-day safety and effectiveness evaluation of Eximo Medical’s B-LaserTM , a novel atherectomy device, in subjects affected with infrainguinal peripheral arterial disease: results of the EX-PAD-03 trial. Cardiovas Revasc Med. 2020;21(1):86-92.

3. Auryon. Instructions for use. AngioDynamics; 2020.

AngioDynamics, the AngioDynamics logo, Auryon, and the Auryon logo are trademarks and/or registered trademarks of AngioDynamics, Inc., an affiliate or a subsidiary. © 2020 AngioDynamics, Inc. US/PA/AD/405 Rev 01 9/2020

PEER REVIEW

JVS group enters new era with brand chief and teambased approach

BY BETH BALES

WITH CHANGES OCCURRING regularly in the publication business of scientific journals, the Society for Vascular Surgery (SVS) is planning changes with its own Journal of Vascular Surgery (JVS) publications. Effective July 1, Immediate Past President Ronald Dalman, MD, will be executive editor of JVS, and will oversee its three sibling journals, JVSVenous and Lymphatic Disease, JVS-Cases, Innovations and Techniques and JVS-Vascular Science. “He’s chief of the overall JVS ‘brand,’” said Peter Henke, MD, chair of the SVS Publications Committee.

Thomas Forbes, MD, will take over as editor-in-chief of JVS, while Matthew Smeds, MD, Ruth Bush, MD, and Alan Dardik, MD, become editors-in-chief of JVS-VL, JVS-CIT and JVS-VS, respectively.

Each editor will recruit and form his or her own teams of associate and assistant

editors to carry the journals forward, said Henke. “It’s a team, not just one editor-inchief,” he said. “This will be the editorial team discussing and coming to consensus on policies and direction.”

With the second of three-year-long terms for the existing editors—Peter Gloviczki, MD, and Peter Lawrence, MD—ending this summer, plus the need for a new publishing contract, the SVS Executive Board thought this the perfect time to investigate possible changes overall, added Henke.

The SVS hired a publishing consulting firm to review the entire editorial structure, comparing it to that of other similar publications. This led to SVS leadership’s decision “to make a fairly significant change,” Henke said.

Currently, Gloviczki and Lawrence oversee all four journals. “It’s become a full-time job, and they already have careers,” said Henke. He noted that it became clear the workload needed to be spread across more people.

The team approach also helps the Society fulfill its commitments to diversity, equity and inclusion (DEI) promises to engage younger and more diverse members of SVS as reviewers and editors. With each editor developing his

or her own team, many more early-career efficiency of the review process and vascular surgeons will have the chance institute other changes to ensure all the to get involved and become engaged JVS journals “remain the optimal choice as reviewers, and move up over time to for authors and high-impact manuscripts.” become editors, he said.

Dalman added: “We want to explore The changeover officially begins July more synergies between the journals 1, but the new team is already part of the and other media portals of the JVS. existing one, attending editor calls and Despite its limitations in defining quality learning the ropes. and influence in our specialty, we will “We’ll take the next three-to-four continue to make structural changes months to get everyone up to speed and to drive the impact factor to reflect the ensure a smooth transition,” Henke said. true value of the journals and their Dalman and Forbes are intellectual content. And, working on their own vision we will continue to explore of the future, and they count new publishing structures, themselves fortunate and including further open access grateful for the “robust team ventures, to maximize the in place with outstanding impact of our journals’ leadership from the current content.” editorial team,” said Dalman.

Forbes called this an “We're honored to be exciting time for academic handed the reigns of the JVS Peter Henke publishing, “with new journals and to build on the opportunities to meet the legacy of Drs. Gloviczki and Lawrence, needs of our audience and our authors and their predecessors,” agreed Forbes. and to continue to be the premier Dalman said both are looking ahead vascular surgery journal and platform,” he to workflows and other structures to said. “Just as vascular surgeons are known ensure everyone remains “aligned and ‘on for their innovations, we will develop brand’ for the high editorial standards of innovative delivery models for new the JVS.” knowledge to the benefit of all vascular He and Forbes want to boost the surgeons and their patients.”

Select gene single nucleotide polymorphisms found to be associated with venous ulcer formation and persistence

BY SARAH CROFT

Looking to the future, genetic testing may play a role in guiding the intensity of therapeutic interventions and preventive strategies in patients with venous disease. This finding comes from a case-control study on the clinical implications of genetic variation of venous stasis ulceration, presented by lead researcher Rabih Chaer, MD, during the 2022 annual meeting of the American Venous Forum (AVF) held Feb. 23–26 in Orlando, Florida.

VENOUS STASIS ULCERS ARE THE MOST COMMON cause of non-healing lower-extremity wounds and can persist despite adequate pressure and ablation therapy, Chaer, chief of vascular surgery at UPMC Presbyterian in Pittsburgh, explained. “Although great progress has been made in wound care and treatment regimes, the response remains variable, and, regardless of the clinical strategy used, it is evident that there is a lot of variability in the outcomes of patients who present with similar disease patterns.”

Few institutional theories have examined the role of single gene polymorphism independent genesis of venous stasis alteration, he said, and the most recently published series have typically focused on a few target genes and were limited by small sample size. Chaer’s case-control study, funded by a AVF-JOBST Clinical Research Grant, held the hypothesis that genetic profiling of venous stasis ulcers can potentially stratify patients according to their potential for disease progression, healing, and also guide them through preventive strategies and levels of therapeutic intervention. Chaer relayed that the study’s 14 | Vascular Specialist

purpose was to determine whether single nucleotide polymorphisms (SNPs) in select genes can affect ulcer formation or healing. He noted that genotyping was carried out for 19 targeted SNPs associated with wound healing or thrombophilia, using Taqman SNP genotyping technology. Of those, five of the markers were validated using real-time polymerase chain reaction (PCR) to ensure genotype clustering. Repeat samples were performed at the initial run and multiple replications were performed to ensure genotype accuracy. Data related to the patients’ venous disease were prospectively collected for two years and included demographics, ulcer information and clinical management. Additionally, logistic regression models were

“Genetic testing may play a role in guiding the intensity of therapeutic interventions and preventive strategies” Rabih Chaer

used to identify factors associated with ulcer formation and healing using a cut-off p-value of 0.2 to capture trends.

Chaer explained that the primary endpoints were ulcer healing or ulcer recurrence, and the secondary endpoints included the genetic association with ulcer healing, and time for healing and recurrence. The researchers also looked at genotype and phenotype correlation for the variables, and analyzed clinical variables.

Chaer said that MMP12 was found to be significant in the study as associated with inflammation. Another was associated with fibroblast activity, such as GP6. F13A1 (factor 13A1) was associated with thrombophilia. The study enrolled a total of 377 patients: 23% (n=85) with CEAP (Clinical, Etiology, Anatomic, Pathophysiology) classification 5, 33% (n=126) CEAP 6, and 44% (n=166) controls (aged 50 years or older). All patients underwent a systematic evaluation of their superficial venous system.

The average patient age was 63±12 years, 13.3% (n=50) were African Americans, and 56% (n=211) were females.

The average follow-up time for CEAP 5/6 patients was 19±10 months (range: 0–50 months; median: 23 months).

CEAP 5/6 patients had a lower incidence of the GP6 SNP (rs1654416).

Recalling the results, Chaer said that in the CEAP 5 group, 17.1% (19/111) of limbs had ulcer recurrence (average time period to ulcer recurrence was 13.62 months). In the CEAP 6 group, 46.9% of limbs (n=67/143) healed, 32.2% (n=46) improved, and 21% (n=30) worsened (mean time to ulcer healing was 7.38 months).

On multivariate logistic regression, GP6 and MMP12 (rs651159) SNPs were protective against ulcer formation, whereas F13A1 (rs5985), SLC40A1 (rs11568351), and HFE (rs1800730) were associated with ulcer persistence. GP6 was the only gene that was found to be significantly less expressed across the cases.

“Select gene SNPs seem associated with venous ulcer formation or persistence, and genetic testing may play a role in guiding the intensity of therapeutic interventions and preventive strategies, as well as patient and provider expectations,” Chaer concluded.

April 2022

VASCULAR ASSIST

Rare case series shows 100% limb salvage in pediatric bone tumor resections with vascular involvement

BY BRYAN KAY

A retrospective review of a rare set of pediatric bone tumor resection cases with significant blood vessel involvement has demonstrated 100% limb salvage and 0% local recurrence.

THE 14-YEAR EXPERIENCE INVOLVED 117 CASES treated at Louisiana State University (LSU) and Tulane University in New Orleans by a vascular and pediatric orthopedic surgical team. First-named researcher Malachi Sheahan III, MD, chief of vascular surgery at LSU, said the series likely represents the largest known set of its kind in the literature, demonstrating how a multidisciplinary team can tackle pediatric bone tumors “with minimal blood loss, excellent limb salvage and low rates of local recurrence.”

Data on the findings were revealed during the 2022

annual meeting of the Southern Association for Vascular Sheahan said his team's approach involves securing Surgery (SAVS) in Manalapan, Florida ( Jan. 19–22). the neurovascular bundle as a unit to then achieve Sheahan and colleagues started to take part in exposure to the bone. The technique used when dealing pediatric bone tumor cases—comprising osteosarcomas, with osteochondromas is similar to that used with osteochondromas and aneurysmal bone cysts—in 2006, osteosarcomas, he added. “With aneurysmal bone cysts, in later discovering no apparent reports of the value provided the literature these have a very high rate of recurrence,” by vascular surgery in their execution.

Sheahan continued. “They’re not malignant but they Sheahan told SAVS attendees how the are very, very vascular and devastating to the series counted 57 osteosarcomas, bone involved. You can’t resect the entire 51 osteochondromas and nine bone, so either you do curettage or aneurysmal bone tumors embolization. Our technique is to through 2019, and provided do both. The literature reports an insight on the techniques a 30% recurrence rate, and I’m utilized in order to arrive going to report a 0% recurrence at the outcomes he rate with this technique.” reported from the podium.

Speaking from the conference The average age of the floor, Martyn Knowles, MD, population of patients in a vascular surgeon at UNC the study was 11.6, with Health Care in Raleigh, North 56% of them being female.

Carolina, the designated The patients were derived discussant for the paper, from across the U.S., with queried Sheahan on how the their varied chemotherapy patient population was followed and radiation therapy and how decisions were made treatment regimens accounting over when and when not to resect. for a central weakness of the dataset, “We follow them for life—we don’t he pointed out. have literature on kids and reconstructions When dealing with osteosarcomes, Sheahan to let us know when it’s OK to let them go, ” explained, “it’s our job to find out what’s tumor Sheahan said.

Osteosarcoma and what’s inflammation. With every single “The technique is as much art as science. At the of the proximal one of these, it looked like the blood vessels start of this approach, we started sending a lot of humerus were involved based on the preoperative MR frozen sections of tissue off to see if there was [magnetic resonance], but in most cases you can develop tumor present. That led me to be more aggressive with a plane between the tumor and the vessels. If you can’t, the vessel salvage and identifying what’s inflammation then you ligate the vessels and reconstruct. It’s cancer, so and what’s tumor. That’s easier to do in situ than you don’t leave anything behind.” radiographically, I think,” he added.

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April 2022

vascularspecialistonline.com | 15

VASCULAR SCIENCE

At VRIC, Clowes lecturer to walk in research footsteps of field progenitor

BY BETH BALES

WHEN KATHLEEN MARTIN, PHD, GIVES THE Alexander W. Clowes Distinguished Lecture at the Vascular Research Initiatives Conference (VRIC) in May, she’ll be discussing research that the late Clowes himself studied.

“He’s really the father of this field,” she said. “I’m pleased to be able to build on what he founded. My research is very much in the same field that he started.”

Martin said Clowes, a renowned surgeon-scientist who contributed greatly to VRIC, established the first models of vascular injury after surgical interventions. He died in 2015 and the VRIC lecture named for him was created a few years later.

This year’s conference theme is “Translational Immunology and Cardiovascular Disease.” Martin will discuss the plasticity of smooth muscle cells (SMC), which are “incredibly versatile and almost stem celllike in nature” in that they can change their phenotype dramatically and are highly proliferative, forming new lesions after vascular injury. “Dr. Clowes outlined how this happens,” said Martin.

Her research lab at Yale University in New Haven, Connecticut, wants to define the cellular signaling and epigenetic mechanisms that regulate vascular SMC function in intimal hyperplasia, atherosclerosis and transplant vasculopathy. Understanding how these cells dramatically alter their phenotype may provide new

insights for treatment and prevention of vascular disease.

SMCs make up the muscular layer of blood vessels, allowing them to contract and relax, and help control blood pressure, vascular tone and blood supply. Her lab’s major focus is studying how SMCs can so dramatically change their state, from a healthy contractional phenotype to cells that lose their ability to contract and can potentially become fibrotic. Her lab has identified novel master regulators of SMC phenotypic switching.

This smooth muscle plasticity impacts many vascular diseases, she said, including atherosclerosis—“the reason we need so many vascular interventions.” Other diseases include aneurysms, intimal hyperplasia, transplant vasculopathy, vascular calcification and more. It also affects the interventions—stenting, ballooning, bypass procedures, grafts and others—performed to treat vascular diseases.

“This smooth muscle plasticity is relevant to a wide range of cardiovascular diseases, as well as transplant pathology,” said Martin. Science has come a long way toward eliminating outright organ rejection, but chronic

“Most cells don’t have this ability to completely change their fate” Kathleen Martin

transplant rejection is a major concern and cause of death with limited treatment options, she said. Her recent work has suggested new possibilities. “If we can contribute something that could help transplant patients […] we’d be thrilled,” Martin added.

Martin, who trained as a cell biologist, got her first research position in vascular surgery at Dartmouth Medical School in Hanover, New Hampshire, where she learned of the challenges vascular surgeons face in treating vascular disease. In fact, there, she and SVS members Richard Powell, MD, and Eva Rzucidlo, MD, worked together on stent therapeutic drugs in SMC. “It really opened up this new research direction to me,” she said.

“Most cells don’t have this ability to completely change their fate. I found it fascinating.”

She misses that day-to-day contact with vascular surgeons, though she still collaborates with SVS member Alan Dardik, MD, and many other physician-scientists.

“I’m excited to get feedback from the SVS community at VRIC, and eager to hear their suggestions,” she said.

VRIC takes place Wednesday, May 11, at the Sheraton Grand Seattle Hotel, Seattle—the day before and in the same venue as the American Heart Association’s Vascular Discovery Conference.

To learn more and to register, visit vascular.org/ VRIC22.

Kathleen Martin

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16 | Vascular Specialist

April 2022

VETERANS AFFAIRS

Community care at the VA

BY MICHAEL COSTANZA, MD, AND VIVIENNE HALPERN, MD

Concerns about veterans getting access to quality healthcare in a timely fashion led to the Veterans Choice Act in 2014 followed by the VA MISSION Act in 2019.

These programs provide veterans with the opportunity to receive healthcare in the community that is paid for by the Veterans Health Administration (VHA).

THE INITIAL VETERANS CHOICE ACT WAS available to veterans if they lived more than 40 miles from a VA facility or could not be scheduled for an appointment within the VHA wait time goals (usually less than 30 days). The MISSION Act expanded eligibility criteria to include: Service not available at a VA, or veteran lives in a state without a full-service VA Drive time: >30 minutes for primary care; >60 minutes for specialty care; >40 miles to a VA providing specified care Appointment wait time: >20 days for primary care; >28 days for specialty care Community care in the veteran’s best medical interest as determined by patient and clinician Quality of care provided by the VA for the veteran’s specific condition fails to meet its own quality standards Even before the expansion of services triggered by the MISSION Act, the VA provided non-VA, community-based healthcare for more than 25% of veterans. The 2022 VHA budget requested $23 billion in discretionary funding for community care that represents an increase of 26.5% from the 2021 budget and makes up nearly one-fourth of the total medical care appropriations. In 2021, the more than 4.75 million veterans received community care referrals, of which approximately 34,000 (less than 1%) were referred for vascular surgery care. The most common reason for vascular surgery referrals was distance (50%) followed by unavailable service (33%).

The MISSION Act aims to provide veterans with timely access to high-quality healthcare that is geographically accessible. However, meeting these ambitious goals may require a more nuanced solution than simply increasing referrals to community care providers. Challenges include how to evaluate the outcomes of community services, helping veterans make informed decisions about community care, maintaining open communication between the community and the VA, evaluating the cost effectiveness of community services, and determining

Rockman: A family story of self-identity

BY BRYAN KAY

OUTGOING SOCIETY FOR CLINICAL Vascular Surgery (SCVS) President Caron Rockman, MD, delved into her family history from late-19th century and early20th century Russia to deliver a poignant message to Annual Symposium attendees during the 2022 SCVS Presidential Address: “the importance of embracing April 2022

when geographic proximity increases quality. Recognizing telehealth could help decrease the number of community and addressing each of these areas will be important in the care referrals placed for “distance.” An expanded role future success of VA-sponsored community care. for telehealth will also bring new challenges unique For many veterans, travel to a large VA medical center to a technology-reliant healthcare system. Rural areas represents a hardship, and the MISSION Act attempts often lack broadband availability to support telehealth to address this by allowing for community care that encounters. Ensuring that veterans have access and is geographically closer. However, community care, technologic support will play a role in determining regardless of its convenience, does not always translate how much telehealth can provide for more timely and into faster or better-quality service. Remote areas rarely convenient care. offer surgical specialty care, and veterans requiring these Non-VA providers play an extremely important but services may be best served by staying within the VA. potentially overlooked role in the VA’s community care Quality studies comparing the VA and community program. The rapid increase in community care requests services have shown that the VA has the same or lower triggered by the MISSION Act has undoubtedly taxed the rates of surgical morbidity and mortality compared to the entire referral system. Non-VA providers who have the general community. Wait times for specialty care also may expertise and capacity to care for referred veterans often not be uniformly shorter in the community compared to experience difficulty in gathering information from the VA the VA. Ensuring that veterans benefit from the MISSION and in getting authorizations for follow-up visits.

Act will require close evaluation and monitoring of the Bureaucratic inefficiencies and delays in receiving availability and timeliness of community services. compensation can discourage non-VA providers from To achieve the goals set by the MISSION Act, veterans accepting future referrals. Long-term success for the and their VA caregivers will have to make informed MISSION Act hinges on the VA’s effort to engage nondecisions regarding community care. Ideally, quality VA providers. Creating a user-friendly referral system metrics from the community and the VA will be available that maintains continuity of care and provides prompt for comparison so the veteran can make an informed and appropriate compensation for non-VA providers choice. The access and sharing of these quality measures will help foster a network of high-quality care. The VA requires active participation by the VA. Raising awareness stands alone as an effective and committed provider for of the VA’s quality measures and performance among the nation’s largest integrated healthcare system. With veterans and VA providers represents half of this equation. the MISSION Act, the VA steps into a more prominent The other half should focus on setting up role as a healthcare payor. Ensuring that incentives for community health systems veterans continue to receive timely and to track and share quality measures high-quality care will require sustained with VA providers and patients. cooperation and coordination between The VA’s healthcare system the VA and community providers. centralizes patient data and facilitates Efforts that promote sharing and communication between VA providers. comparing quality measures, open This system promotes quality care and communication, cost containment, Michael Vivienne reduces cost by decreasing the risk of and the innovative use of telehealth, Costanza Halpern duplicated therapy and coordinating will be be central to ensuring that care programs for veterans with “Long-term success for community care plays a vital role medical and mental health concerns. the MISSION Act hinges on within the VA health system.

As community care expands, the the VA’s effort to engage References VA will need to develop an effective 1. Kullgren JT, Fagerlin A, Kerr EA. communication system in order to non-VA providers” Completing the MISSION: A promote sharing information between blueprint for helping veterans make the VA, community providers, and the most of new choices. J Gen veterans. Opening and maintaining these communication Intern Med 2019;35:1567-70. channels will foster efficient care, and possibly lead to a 2. Massarweh NN, Itani KM, Morris MS. The VA comparative evaluation of community and VA outcomes MISSION Act and the future of veterans’ access and patient experience. to quality healthcare. JAMA 2020;324:343-4.

Telehealth may allow the VA to provide more timely 3. Schlosser J, Kollisch D, Johnson D, Perkins T, Olson and efficient care by meeting veterans where they are. In A. VA-Community dual care: Veteran and clinician perspectives. J Community Health 2020;45:795-802. addition to routine follow-up appointments, which can 4. Stroupe KT, Martinez R, Hogan TP, Gordon EJ, Gonzalez occur in the veterans’ home, telehealth can also support B, Kale I, Osteen C, Tarlov E, Weaver FM, Hynes, DM, more detailed, specialty-specific evaluations. Telehealth Smith BM. Experiences with the Veterans’ Choice visits conducted in community-based outpatient centers Program. J Gen Intern Med 2019;34:2141-9.

(CBOCs), or local wound clinics, can employ licensed nursing staff to perform a basic vascular exam. These telehealth encounters shorten wait times and eliminate MICHAEL COSTANZA AND VIVIENNE HALPERN the barrier of long travel distances. Maximizing the use of are members of the SVS VA Vascular Surgeons Committee.

all aspects of our self identity,” she said— as individuals, as people and as vascular surgeons. “Mirror, mirror, on the wall...” told the story of Rockman’s maternal great grandfather and his youthful dream of becoming a pharmacist, a feat ultimately achieved by his daughter, Rockman’s grandmother. Her grandmother briefly became a female pharmacist in the U.S. of the 1930s, an unusual role among her peers for the time, before becoming a housewife and mother. Rockman told SCVS delegates gathered in Las Vegas (March 19–23) she knew none of this story while her

grandmother was alive. She also in the mirror,” she had told later discovered among her her SCVS audience. “Did she late grandmother's effects see herself as a housewife, that, although she had not mother and homemaker worked as a pharmacist typical of her generation? for more than 60 years, she Or did she see, instead, an had paid to have her license educated professional woman maintained well into the later unusual among her peers. My years of her life. All of this sense is that she was trying to Caron Rockman with factored into the thinking see both sides of herself.” behind the address, Rockman incoming President Sean That resonated, Rockman Roddy at SCVS 2022 informed Vascular Specialist told VS, because she too had in an interview. “I often wondered over the faced that dilemma—and many of her own years about what she saw when she looked peers may perhaps face such conflicts. vascularspecialistonline.com | 17

COMMENTARY

Corner Stitch From proposal to podium: Tips for getting your abstract accepted at academic conferences

BY CHARLES DECARLO, MD

STRIVING FOR EXCELLENCE in research is one of the defining characteristics of an academic surgeon.

But simply doing great research is not enough. The dissemination of that research through academic forums, presentations and publications is just as critical because others need to share in that research, peer-review it, and, ultimately, implement your findings for the world to become a better place.

On the personal front, presenting your research at meetings is an excellent way to maximize the exposure of your research, while simultaneously providing a platform for career advancement, networking and collaboration. After a great research project is conceived and completed, the next step is to get your work to an academic conference. But this can be a daunting and confusing task. I am excited to share my tips for success with you for every step in the process.

Choose a project that is both relevant and feasible

Making your project stand out and be worthwhile starts at the design phase. Your research question should aim to fill a gap in knowledge and not reproduce something that has already been done. However, strictly filling a gap in knowledge may not be enough to earn a plenary presentation. An attractive abstract addresses current events/developments in the field, studies rare disease processes, or introduces or expands on new techniques or methods.

Producing a methodologically-sound abstract that addresses one of the aforementioned is the best way to secure the podium.

Before embarking on a project, familiarize yourself with the literature in the field and ascertain exactly where your project fits in. It does not have to 18 | Vascular Specialist

be something earth-shattering; simply detailing how new guidelines on a topic impact your local hospitals practices may be enough as long as someone, somewhere will be able to use your research to take better care of patients.

To that end, make sure that your project is feasible—it should be something you can complete in the time, and with the money, or resources, allotted to you.

Writing and submitting your abstract

The title, the background/introduction, and conclusion of your abstract are key

to piquing interest in your work, while summarizing your key findings and conveying the overarching message. Each of these sections should be concise yet emphasize the significance of your work.

While we all strive to have robust and valid methods, the gritty details of your statistical methods do not need to be included in your abstract.

Conferences want their program to include content on a broad array of vascular disease. Try to ensure your research is categorized appropriately, but recognize some categories are harder to be selected for than others simply because the space does not exist on the program. To that end, familiarize yourself with all the conferences in your specialty so you can ensure the maximal chance of acceptance, ideally for a podium presentation.

Prepping for your talk

Congratulations on getting accepted!

People have different processes for preparing, so this might not work for everyone. Personally, I write down everything that I am going to say and memorize it rather than relying on presenter mode or written notes. I find that this helps my confidence, improves the flow of the presentation, and allows for better eye contact with the crowd. For your slides: keep it simple. Figures and pictures are good; copious text is not.

Your big moment

It is hard not be nervous when presenting, especially if it is your first time; however, there are a few things in your favor. First, you know your project and data better than anyone in the crowd. Second, most

Partnering with industry: ‘We should not allow our relationships to influence how we choose to treat patients’ Industry players and device-makers have helped spark new science and innovation in vascular surgery amid flatlining National Institutes of Health (NIH) funding, but physicians must pay heed to the conflicting agendas in the partnerships formed with these companies, a focus session on ethical issues in practice at the 2022 Annual Symposium of the Society for Clinical Vascular Surgery (SCVS) in Las Vegas (March 19–23) heard.

“INDUSTRY SPONSORS A HUGE AMOUNT OF SIGNIFICANT research and NIH funding has been stable for a long time,” Alik Farber, MD, chief of vascular and endovascular surgery at Boston Medical Center, Boston, told the SCVS 2022 gathering.

“Given NIH funding that is limited, and given the pay lines that

people who stand up to ask questions have found your project interesting— people very rarely will stand up to attack you.

Writing the manuscript before your presentation (or at least doing the literature review), and anticipating questions with the help of your mentors, are the best ways to be prepared for discussion of your presentation at the podium. While this is certainly a step outside most people’s comfort zone, it gets easier the more you do it.

The rest of the meeting

Networking is a great way to create new professional relationships, and advance your exposure and career. While there are sometimes organized events to promote, this such as job fairs, most networking opportunities occur outside of the meeting sessions. Welcome receptions, dinners and breaks between sessions are great opportunities to meet people.

Conferences should also be an enjoyable experience, so don’t hesitate to set aside time to check out the host cities, meet up with friends, etc. Attendings want to talk and hear from you.

As a final word, rejection of your abstract from a meeting is not an indication of a poor abstract. Many great abstracts do not make the cut, and everyone has had an abstract rejected that they thought was great. Do not let rejection deter your efforts. Find another meeting and resubmit.

CHARLES DECARLO is a PGY6 integrated vascular surgery resident in the division of vascular and endovascular surgery at Massachusetts General Hospital in Boston.

have been decreased recently, industry-sponsored research adds new science and innovation. I’m sure industry leadership, when they plan their trials, try to do everything they can to make useful clinical trials to try to help physicians and patients.

But [industry’s] clear primary fiduciary duty is to get their devices through the regulatory process to market, sell them and optimize profits.”

It is therefore incumbent upon surgeons participating in industry-sponsored trials and partnerships to “understand the conflicting agendas” and be transparent about them, he said. The comments came as Farber delivered a presentation entitled, “Are we too cozy with industry?”

To balance these relationships and ensure they are lawful, “we should accept the fact we have our own agendas” he added. “We should not allow our relationships to influence how we choose to treat patients. I could repeat that 10 times.

This is critical.” To the question at hand, Farber answered, “I think as a specialty we’re not, but I think individually we need to look at ourselves in the mirror and figure it out.”—Bryan Kay

“Given NIH funding that is limited, and given the pay lines that have been decreased recently, industrysponsored research adds new science and innovation”Alik Farber

April 2022

CLTI

WIfI score does not predict successful healing after transmetatarsal amputation, study finds

BY BRYAN KAY

A higher initial Wound, ischemia, and foot infection (WIfI) classification score at initial presentation in chronic limb-threatening ischemia (CLTI) patients who underwent a transmetatarsal amputation (TMA) was not associated with a major amputation down the road, according to a retrospective review of 55 TMAs performed by a multidisciplinary limb preservation team at the University of Washington (UW) in Seattle.

RESEARCHERS AT THE INSTITUTION SOUGHT to establish whether the Society for Vascular Surgery

April 2022

(SVS) lower-extremity threatened limb risk stratification system could predict successful healing following TMAs, ultimately determining it does not—with the data showing this included both the wound and ischemia score on presentation, as well as after revascularization.

The study findings were revealed during the 2022 Society for Clinical Vascular Surgery (SCVS) Annual Symposium held in Las Vegas (March 19–23).

Despite the core conclusion, presenting author Jake Hemingway, MD, a vascular surgery resident at UW, told delegates: “We found that excellent wound healing can still be achieved despite very advanced CLTI and, thus, we shouldn’t use the WIfI stage alone to try and preclude patients from attempts at limb salvage.

“There still is a need for further investigation into how we can monitor our patients after undergoing a TMA to know when further work needs to be done to maintain that wound.”

The 51 patients included in the study combined for a 12-month major amputation rate of 33%—12 carried out below the knee, and six above.

Hemingway said the study data demonstrated that an unsuccessful TMA was down to primary failure in 10 patients, “in which they simply never were able to heal their wound, as opposed to secondary failure, which was

“There still is a need for further investigation into how we can monitor our patients after undergoing a TMA to know when further work needs to be done” Jake Hemingway

wound breakdown remote from their initial TMA.” Four patients experienced TMA failure due to infection, developing either necrotizing infection or wet gangrene during their initial healing process, Hemingway added.

“When we looked at the factors that were actually associated with major amputation, we found that none of the following were: Either a higher initial WIfI stage wound or ischemia score at the initial presentation; or whether patients had improvement following revascularization—this was also not associated; neither was the ischemia score post-revascularization,” he explained.

Hemingway told SCVS attendees that the UW research team is now set to turn its attention to a new phase of the study to look at other non-invasive, nonpressure-based measures, such as pedal acceleration times, in order to establish the most predictive system for successful healing after a TMA.

Jake Hemingway

vascularspecialistonline.com | 19

NEWS BRIEFS

SVS members receive deep discount on key textbooks Society for Vascular Surgery (SVS) members receive many important discounts as a privilege of belonging. These perks include discounts to important references in diagnosing and treating vascular injury, including Rich’s Vascular Trauma and Rutherford’s Vascular Surgery and Endovascular Therapy.

BOTH WORKS ARE PUBLISHED IN ASSOCIATION with the Society. Members receive 30% off when using the SVS discount code, SVS30. The fourth edition of Rich’s Vascular Trauma was released in November 2021. The fully updated edition reflects recent changes in vascular injury patterns, wounds and trauma care. It draws from current research and a wide variety of peer-reviewed publications to keep surgeons up to date with the latest evidence-based management strategies and techniques, according to publisher Elsevier.

It was written and edited by vascular surgeons who are also trauma specialists with proficiency in both opensurgical and endovascular techniques. Editors are Todd E. Rasmussen, MD, and Nigel R. M. Tai, MS FRCS. With the SVS discount, the cost of Rich’s is $160.99.

Visit vascular.org/Rich’s for information and to buy the book.

Pre-orders are being accepted now for the 10th edition of Rutherford’s Vascular Surgery and Endovascular Therapy, to be released in November. Multidisciplinary and international authors contributed to the two-volume set, which is considered an “outstanding reference for vascular surgeons, vascular medicine specialists, interventional radiologists and cardiologists, and their trainees who depend upon Rutherford’s in their practice,” said Elsevier.

Former SVS Presidents Anton Sidawy, MD, and Bruce Perler, MD, are again the editors.

See vascular.org/RutherfordQandA for a question-andanswer session with Perler on the new edition. With the SVS code, the price of Rutherford’s drops to $297.49. Visit vascular.org/Rutherford10 to purchase the set and get more information.—Beth Bales

SVS Foundation announces VRIC trainee award-winners The SVS Foundation has selected four trainees to present their high-scoring research at the 2022 Vascular Research Initiatives Conference (VRIC) in Seattle, on May 11 (writes Beth Bales).

VRIC IS DEDICATED TO STIMULATING and encouraging interest in research among trainees who are aspiring academic vascular surgeons, according to the Foundation. “The meeting's exclusive and intimate atmosphere allows for the free exchange of ideas and development of collaborative projects equally among senior and junior investigators.”

Recipients are: Mario Figueroa, MD; general surgery resident at Rutgers-UMDNJ; postdoctoral research fellow at Medical University of South Carolina Abstract title: “Vascular smooth muscle cell mechanotransduction through serum and glucocorticoid inducible kinase-1 promotes interleukin-6 production and macrophage accumulation in murine hypertension” Mentor: Jean Marie Ruddy, MD Carson Hoffmann, MD; research fellow, Emory University Abstract title: “Modifiable mesenchymal stem cell defects in veterans with diabetes mellitus” Mentor: Luke Brewster, MD Kevin Mangum, MD, PhD; vascular resident, University of Michigan Abstract title: “MOF expression regulates interferon ß in diabetic wound macrophages and impairs tissue repair” Mentor: Katherine Gallagher, MD Molly Schieber, MS; MD-PhD student, G3, University of Nebraska Medical Center Abstract title: “Microvessel oxidative stress predicts changes in leg function of patients with peripheral arterial disease after supervised exercise therapy” Mentor: Iraklis Pipinos, MD

Book your VAM hotel rooms today

Roddy assumes SCVS reins The Society for Clinical Vascular Surgery (SCVS) 2022 Annual Symposium in Las Vegas (March 19–23) saw Sean Roddy, MD, officially take over as president from Caron Rockman, MD. He will serve a one-year term.

M. Ashraf Mansour, MD, becomes president-elect, with Jean Bismuth, MD, taking over as vice-president and Alik Farber, MD, as secretary.—Bryan Kay

20 | Vascular Specialist

The Society for Vascular Surgery (SVS) has room blocks available at five Boston hotels near the Hynes Convention Center, home for the 2022 Vascular Annual Meeting (VAM).

This year’s “Headquarters Hotel” is the Sheraton Boston Hotel, at 39 Dalton St., Boston, directly connected to the Prudential Center and the Hynes Convention Center.

It is 0.3 miles, indoors, to the convention center. The other hotels are: Boston Marriott Copley Place, 0.4 miles to Hynes; Boston Park Plaza, 0.9 miles; Hampton Inn and Suites Boston Crosstown Center, 1.4 miles; and Hilton Boston Back Bay, 0.2 miles.—Beth Bales

Foundation seeks applicants for VISTA projects

BY BETH BALES

The SVS Foundation will seek proposals in mid-April for pilot outreach projects to help identify needed vascular services in underserved portions of the U.S. The projects will be part of the Foundation’s VISTA (Vascular Volunteers In Service To All) program. The initial focus is expected to be on defining barriers to care and on the education of both local community healthcare providers and their patients.

“We want our surgeons to survey the medical landscape around them, asking themselves, ‘What is the need here and how can I help?’“ said Foundation Chair Peter Lawrence, MD. “It could be basic information about vascular disease, the importance of knowing risk factors, public education on when to seek care. A person with diabetes might not have the specific knowledge needed to know when to see a physician about foot ulcers that could lead to the need for amputation.”

Projects should help identify improved pathways to treatment, optimizing or expanding use of existing local providers. The Foundation wants proposals that emphasize providing evidence-based management of vascular disease, not the promotion of specific products, devices or medications. The expected timeline would be two to three years. Ideal proposals would include: • A concise impact statement delineating a realistic potential benefit to the target community • Metrics for success and specific deliverables • Plans for ongoing communication and either virtual or physical support for the target community • Follow-up plans and information on potential scalability of the project consistent with planned future phases of the VISTA Program

Learn more about VISTA at vascular.org/VISTA.

Vascular Surgery Board seeks director nominees The Vascular Surgery Board (VSB) of the American Board of Surgery (ABS) is seeking director nominees to serve a six-year term beginning July 1. Nominations are being accepted through April 15. The VSB is comprised of approximately 12 members from across the spectrum of vascular surgery with responsibility for initial and continued certification.—Malachi Sheahan III

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Hotels nearby VAM

IN MEMORIAM Honorary member Jorg D. Gruss, MD, a Distinguished Fellow of the Society for Vascular Surgery (DFSVS), from Germany, passed away in July 2021.

Coleman becomes APDVS president-elect The Association of Program Directors in Vascular Surgery (APDVS) announced new appointments to key leadership positions during the 2022 APDVS annual meeting held in Rosemont, Illinois (April 1–2).

Jason Lee, MD, who recently completed his year as president of the Vascular and Endovascular Surgery Society (VESS), took over from Murray Shames, MD, as APDVS president.

His term will run until 2024. Meanwhile, Dawn Coleman, MD, became presidentelect, and Benjamin Pearce, MD, took over as one of the organization's councilorsat-large.­­—Bryan Kay

April 2022

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YOUR SVS

SVS turns its sights to FY2023, long-range future

BY THE SVS STAFF

In January, the Society for Vascular Surgery (SVS) Strategic Board met and forged its objectives for the coming fiscal year.

TWO MONTHS LATER THE COURSE IS BEING set for action as goals translate into objectives, and objectives transform into programs embedded in the budget for the 2023 financial year, or FY2023. Here are a few highlights of the year to come.

Advocacy It is going to be another year of intense battle over Medicare payment cuts as the enormous efforts to delay the full impact of 2022 cuts hit their deadlines and the full brunt are back on the table for potential implementation. The SVS Policy and Advocacy Council, led by Matthew Sideman, MD, and Megan Tracci, MD, and the PAC Steering Committee, led by Mark Mattos,

SVS future initiatives going into FY2023

Education The Education Council under the leadership of Linda Harris, MD, will introduce and implement a new threeyear education strategic plan for the SVS, built upon results from the comprehensive Needs Assessment completed in 2021.

The future portends a holistic, integrated approach for the entire organization, with the goals of expanding SVS education offerings to meet the needs of a rapidly diversifying membership. To be relevant and competitive, the SVS will embrace an education strategy that allows for a centralized content planning and a decentralized implementation process.

Additional programs, new formats, personalized programs for different audiences and demographics, and more opportunities for vascular surgeons to earn continuing medical education (CME) credit, are around the corner.

And then there is the Vascular Annual Meeting (VAM) in Boston in June. VAM 2022 will continue the celebration of the 75th Anniversary of the SVS, which kicked off the festivities as an organization at VAM 2021 in San Diego, and will mark the 75th VAM in the Cradle of Liberty. The VAM Program Committee, led by Andres Schanzer, MD, and the Postgraduate Education Committee (PGEC), headed up by William P. Robinson, EDUCATION Diversity also reaches into VAM, with sessions planned for new SVS sections

back up in May 2022 proximal to the American Heart Association’s Vascular Discovery Conference.

As a champion for research, the Research Council also has completed an extensive evaluation of key SVS and SVS Foundation research awards and found every dollar invested in early-career researchers leads to an almost 10-fold return in future research grant funding. SVS and Foundation programs are major career and discovery accelerators.

Clinical practice William Shutze, MD, chairs the Clinical Practice Council, which has launched some of the most important and innovative new efforts overseen by the SVS in the past several years. It has supported the initiation and growth of the Wellness Task Force, led by Dawn Coleman, MD, and Malachi Sheahan III, MD, into a full SVS standing committee, and is poised to implement an array of innovative programs and approaches to meet a growing need within the SVS membership.

This council also championed the workforce initiative to develop an economic valuation study of vascular surgery, published in 2021, which is driving the launch of a first-of-its-kind healthcare consulting initiative within SVS, partnering with SG2, to deliver solutions to systems seeking to optimize vascular care.

The council also supported and facilitated the evolution of the SVS Community Practice Committee, which under the leadership of Daniel McDevitt, MD, CLINICAL PRACTICE The Clinical Practice Council has been at the helm of important new efforts, including on surgeon wellness

RESEARCH The future of vascular research was recently laid out by the SVS Research Council

ADVOCACY The SVS is braced for the continuing battle over Medicare payment cuts

MD, and Peter Connolly, MD, are standing firm to meet these challenges. But they need help… your help.

They need your engagement, your voice, your letters to Congress and your PAC donations, which open doors to discussion and action.

But the first subtle winds of change are blowing as members of Congress and various Congressional staff tire of the seemingly endless annual battle, and begin to question whether there is a more permanent solution to current challenges with the Medicare Physician Fee Schedule. To accelerate these winds of change, the SVS Medicare Payment Reform Task Force is convening in a “Payment Reform” Summit in June to begin sculpting and shaping alternative solutions for Medicare payment.

To shape and strengthen the advocacy leaders of the future, the council is also implementing its first Advocacy Leadership Program Cohort, seeking 10–12 SVS members with a passion for public policy and advocacy to get into the pipeline for future SVS advocacy leadership. The Coding Committee is following a similar track in seeking interns and early-career vascular surgeons with a passion for coding policy to begin training as the next members who oversee work values and codes.

The Government Relations Committee, chaired by Sean Lyden, MD, will be pressing hard on payment, but also accelerating efforts to advance legislation to ease 22 | Vascular Specialist

burdens on prior authorization and augment solutions for ever-growing workforce shortages and challenges.

MD, have worked overtime to continue making improvements and enhancements to heighten the value and increase the reach of the meeting experience for SVS members and guests.

These improvements include expanding the number of streaming sessions, implementing several new innovative PGEC sessions, and adding sessions on policy and advocacy and our new Women’s and Young Surgeons Sections. In addition, we will be providing all available OnDemand content from the meeting within the week following the meeting. We will also create a plan to engage younger surgeons both in the development of content and accessing content through visual abstracts.

Research The Research Council, led by Raul Guzman, MD, is literally sculpting the future of vascular research. The council recently hammered out its top 10 research priorities for the decade to come, soon to be published in the Journal of Vascular Surgery (JVS). The top 10 will be leveraged to help shape focus and funding for vascular surgery research. The priorities tell a story about how the specialty and the SVS are evolving, with the introduction of vascular population health and vascular health disparities to the list.

The Vascular Research Initiatives Conference (VRIC), popular with the vascular research community, will link

The first subtle winds of change are blowing as members of Congress and various Congressional staff tire of the seemingly endless annual battle and begin to question whether there is a more permanent solution to current challenges transitioned to the Community Practice Section, giving hundreds of SVS members the opportunity to engage more deeply with colleagues who share a common interest in community practice. The interest, investment in, and support of community and office-based programs will be enormous in the coming years—including establishment of new research networks, educational programs and representation within SVS. The Clinical Practice Council and Quality Council are working together to develop an educational series of webinars to facilitate learning and transfer of knowledge to assist in translating clinical practice guidelines into vascular surgery practice.

The long-range future of the Clinical Practice Council has also started to come into focus with initiatives to explore the potential of regional emergency vascular care April 2022

networks, and the potential development of a vascular emergency care course, working closely with the SVS Physician Assistant Section and the Society for Vascular Nursing (SVN).

New future initiatives under exploration also include development of a third-party peer-review program for smaller community and outpatient practices that have sporadic access to feedback, and the development of an expert witness program.

The interest, investment in, and support of community and officebased programs will be enormous in the coming years, including establishment of new research networks, educational programs and representation within SVS

Quality The SVS Quality Council was established four years ago and is currently led by Thomas Forbes, MD. It is focused on advancing and optimizing the SVS as the go-to center delivering guidance and education derived from evidence-based models of quality and appropriateness in vascular care. Many of the council’s initiatives that began with its inception are nearing launch-ready in the coming year.

The SVS has been working with the American College of Surgeons (ACS) for the past two years on the design, testing and launch of a national verification program for vascular centers of excellence that will add vascular to the portfolio of such programs within the ACS. Eights pilot sites—four in-patient and four office-based center—have helped shape and refine the program standards and process in 2021 and the Vascular Center Verification and Quality Improvement (VCVQI) program appears ready for launch by midSVS VITALITY A number of recent SVS presidents have embraced change and innovation

QUALITY Next up on the SVS appropriate use criteria slate: carotid treatments

2022. This effort began within the SVS under the leadership of Kim Hodgson, MD, and Tony Sidawy, MD, and is now led by R. Clement Darling III, MD, and William Shutze, with continued support and engagement of Sidawy who is the chair of the Board of Regents of the ACS. No topic has sparked more interest and discussion this past year than appropriateness of care, and the role and responsibility of the SVS as a society to provide clinical guidance. This is especially challenging in areas of practice where strong evidence is sparse.

Establishing appropriate use criteria (AUC) is the mechanism, process and tool utilized by medical societies to provide some guidance.

The SVS Appropriateness Committee, led by Jeffrey Siracuse, MD, has been working on producing its first AUC on intermittent claudication, with the AUC process led and expertly facilitated by Karen Woo, MD. The first SVS AUC is expected to be approved and published soon. Next up for an AUC? Carotid disease treatments.

Another major challenge has been to advance quality improvement initiatives throughout the SVS and its membership. To that end, the Quality Council helped establish a new Quality Improvement Committee, led by Jessica Simons, MD, to develop and deliver education and initiatives. Work has begun to compile April 2022

survey and needs assessment data from SVS members about their approaches to quality improvement in practice, and a compendium of articles forming a primer is under development for publication in JVS. The centerpiece, or core, of SVS quality initiatives is our registry, the Vascular Quality Intiative (VQI).

Under the leadership of Fred Weaver, MD, and Jens Eldrup-Jorgensen, MD, the VQI continues to set the bar, not only for quality in registry data integrity, structure and process, but also in leveraging the power of real-world evidence to advance quality and safety in vascular care. In the year ahead, the VQI will continue to drive quality initiatives in its regional network, foster and expand original real-world evidence research, and continue discussions regarding optimal position and utilization of the VQI to advance and accelerate national and international quality initiatives.

SVS vitality With regard to the health and vitality of the SVS as a medical society, there is virtually no aspect of the SVS that has not been explored for potential change and innovation the past several years. The willingness to do this by past SVS Presidents Ronald Fairman, MD, R. Clement Darling , Michel Makaroun, MD, Kim Hodgson, and Ronald L. Dalman, MD, as well as current President Ali AbuRahma, MD, and Presidentelect Michael Dalsing, MD, has literally reshaped the SVS and positioned it well for whatever the future brings.

Over the past six years, the SVS has restructured its governance with a new Executive and Strategic Board model; moved to an internet election for open officer positions, providing a choice of two candidates for each vacancy; established new governance-level Diversity, Equity and Inclusion (DEI) and Communications committees to organize and advance SVS in such areas as its branding campaign and toolkit; and established four new pilot member sections for Community Practice, Young Surgeons, Women and Physician Assistants to drive and enhance member value.

The SVS appointments process has been overhauled to maximize the number of members who can engage and serve on SVS committees, with an eye toward early-career and DEI representation. The SVS also developed a management relationship with the SVN in alignment with the goal of supporting the “vascular team.”

On the horizon for the SVS is exploration of ways to further enhance communications and value for members through a potential SVS Enterprise App; continued investment in furthering and integrating DEI principles across SVS activities and initiatives, including a planned multi-vascular society DEI Summit; a substantial increase in focus, investment, and engagement of early-career members; and further focus on dialogue and collaboration with vascular societies to strengthen unity across the specialty and diminish divisions.

The FY2023 budget, approved March 29, and effective April 1–March 31, 2023, is embedded with the resources and support to move all of these key initiatives forward.

In Washington, dollars drive access

BY JANICE MESSIER, MD It is well documented that cohesive medical teams deliver higher quality care more consistently. The SVS Presidential Address by R. Clement Darling III, MD, in 2018—“Looking forward through the past: Changing me to we in the evolution of team-based vascular care”—is a good reference point underscoring why.

This is the way it should work. But for decades, the promising “vision” of team-integrated care has been at complete odds with the “implementation strategies,” most notably the payment system. Work Together!? How can we when the payment system pits specialty against specialty, physician against physician, and physician against nurse, like some sick reality TV show? And who is enjoying this show? Not patients and their families, not physicians and their teams.

What we need to be talking about is fortifying an understanding that, to one extent or another, every cognizant vascular surgeon must share. In the modern era, compensation for the vascular care we provide is inextricably tied to the federal government, whether through Medicare and Medicaid reimbursement policies, or federal agency influence on our negotiations with private payors. Without a strong unified voice, we are doomed to struggle to subsist, challenged by litigiousness on one side, and ever-reduced resources on the other, as powerless puppets to those in charge of our income stream. Get it straight!

You may have gathered that I harbor no delusions concerning these pressures being motivated by fair pay, equity of healthcare access and delivery, or any other lofty proselytizing parroted in the media. However, recall that politicians, particularly those seeking re-election, respond to their constituencies. The problem is that we—the vascular surgery community—while having made some headway in communicating to Congress, are still far from an effective constituency.

In advocacy, funding drives access and influence,

and it is fair to say that the vascular surgery community has not consistently funded the delivery of a unified message. We have not made it clear that we and the patients we represent should be the special interest group they care about.

A PAC—Political Action Committee—is the only legal and fully transparent way for our members to financially support the representation of our views on Capitol Hill.

Our SVS PAC is fueled by funds from Society members who understand what we do and choose to participate by contributing into the SVS PAC account. We use this money to support candidates for elected office.

The allocation of donated funds is nonpartisan and determined by members’ committee assignments and their alignment with—and support for—our collective values and needs.

But we have only a small trickle of fuel when we need a gusher. Some 80% of all vascular surgeons in the U.S. are SVS members. Of that number, only 7% of Active members donate.

Despite this very small participation level, our 2021 legislative strategy succeeded in alleviating or delaying some of the major cuts proposed for 2022. However, we know this success was temporary and that we, as a specialty, need to prepare to launch a broader effort aimed at ensuring a rational, sustainable reimbursement going forward—one that doesn’t leave us staring over a cliff at the end of every year. In the 2020 election cycle, 112 health professional PACs contributed a combined $21 million to political candidates. For perspective, I am personally acquainted with a junior U.S. senator from a large Southern state who spent a total of $10 million to get elected last year! It is additionally sobering to find our Society ranked 55th in political donations—a total of $82,000—to Congress.

While we outspent the American College of NurseMidwives, our anesthesiology colleagues/competitors donated a whopping $1.6 million. Other voices are getting louder. Ours need to do the same. Donate to our PAC at vascular.org/PAC. Janice Messier is on the SVS PAC Steering Committee.

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