Vascular Specialist–December 2021

27 VAM 2022 Boston calling Planning continues apace for the next Vascular Annual Meeting in Boston

Vol.17 No.12 DECEMBER 2021 Official Publication

Featured in this issue:

www.vascularspecialistonline.com

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15

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COVID-19 One simple trick to tone abs and identify fake news

INTERVIEW Wei Zhou on diversity and change at WVS

CORNER STITCH Why young surgeons can thrive in VESS

CMS

COUNTDOWN TO THE CUTS

The SVS issues a call to action on pending Medicare cuts as time runs out for Congress to act on potentially devastating cuts to vascular surgery

BY BETH BALES

SPREAD THE WORD AND KEEP informed. Contact Congress. Donate to the Society for Vascular Surgery (SVS) Political Action Committee (PAC).

These are the recommendations of SVS members well-versed in advocacy in advance of pending devastating cuts from the Centers for Medicare and Medicaid Services (CMS).

Vascular surgeons face several cuts via several different sources which, taken together, can mean reimbursement losses of 9–20%, depending on the procedure and site of service. “This will affect not only the bottom line but also patient care,” said Matthew Sideman, MD, chair of the SVS Policy and Advocacy Council, during an SVS Town Hall on Nov. 10 that delved into consequences of the impending cuts.

Sideman and other members of the SVS Medicare Cuts Task Force presented information on the history of declining reimbursement, outlined the source of these current cuts and talked about efforts to reduce them, including what’s been done and what can still be done. But they were clear: It’s going to be a tough fight— and some of the cuts are final.

Sideman outlined the five different reimbursement cuts: the final-year implementation of updated supplies and equipment pricing of 4% and an update to clinical labor staff payment rates—1% this year and 4% over four years. However, said Sideman, “If you own your own office and purchase your own supplies, this will have a much higher impact than 1%.”

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FROM THE EDITOR

One simple trick can tone your abs and identify fake news!

BY MALACHI SHEAHAN III, MD

This is part two of an editorial examining the role of fake news and science denial in the COVID-19 pandemic. More people in the U.S. died of COVID-19 in the year after the vaccine was approved than in the year before. As of Nov. 30, 2021, 59% of Americans are fully vaccinated.

We are 60th in the world. It is a public health catastrophe that was almost entirely preventable. Too often, science and medicine have become matters of opinion, of personal belief. There are solutions to this infodemic, but not all are intuitive.

CLEAR COMMUNICATION AND INSTRUCTIONS are a cornerstone of public health, but as the battle over the pandemic became political, the waters were muddied.

One official who kept a sound, consistent message was Jennifer Avegno, MD, director of the New Orleans Health Department. Folksy at times, “Wash your hands like you just ate crawfish and you need to take your contacts out,” but never failing to keep a coherent dialog. “People who continue to refuse to take the lifesaving COVID vaccine are now also putting the entire community in jeopardy.”

Avegno’s efforts led to a higher than the national average vaccination rate in New Orleans. We also became the

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

2 | Vascular Specialist

first city in the U.S. with a proof-ofvaccination or negative COVID-19 test requirement for indoor bars and restaurants. When I asked Avegno about techniques for reaching the vaccinehesitant, she told me, “It really depends on why they’re hesitant. Some people just want to talk to a trusted medical professional who will answer their concerns calmly and without judgment.

Others need myths they’ve read on the internet debunked, though that’s really hard to do. I think the majority of people who are left unvaccinated now are afraid but don’t even know why, or are so far down a political rabbit hole that there’s little you can say to change their minds.”

In its quixotic quest for objectivity, the mainstream media often confuses the public with “both sides” reporting. So while 97% of climate scientists believe in anthropogenic climate change, only 55% of the U.S. adult population are aware that consensus has been achieved. It is common practice for the media to deliver the opinions of dissenting scientists and physicians as if they were experts, even if their expertise is in another field. Mark McDonald, MD, a consultant to Florida Gov. Ron DeSantis, was quoted as saying ivermectin was an “effective, safe, inexpensive treatment” for COVID-19. McDonald is a child psychiatrist. Scott Atlas, MD, was an advisor to the president of the United States, faculty at Stanford, and a fellow at the Hoover Institution. In April 2020, Atlas said: “We can allow a lot of people to get infected. Those who are not at risk to die or have a serious hospital-requiring illness, we should be fine with letting them get infected,

In its quixotic quest for objectivity, the mainstream media often confuses the public with “both sides” reporting. So while 97% of climate scientists believe in anthropogenic climate change, only 55% of the U.S. adult population are aware that consensus has been achieved

generating immunity on their own, and the more immunity in the community, the better we can eradicate the threat of the virus.” Atlas has no training in infectious disease; his expertise is in magnetic resonance imaging. In fact, his lack of relevant knowledge and experience was so egregious, it was called out by dozens of his former Stanford colleagues as well as Richard Baron, MD, the president and CEO of the American Board of Internal Medicine.

In searching for dissenting opinions, the media often amplifies the voices of the uniformed. Some call it the death of expertise. Much like the one-out-of-five dentists who does not recommend sugarless gum for their patients who chew gum, contrarians can always be found. In my own household, there is an extremely vocal faction that believes Squid Game is appropriate viewing for 12- and 9-year-olds. Fortunately, since this faction is comprised solely of 12- and 9-year-olds, they receive very little publicity.

Too often, the media portray science in absolutes, as offering proof. But math is based on proof; scientists continually collect evidence and refine hypotheses. As time goes on, science improves. While we initially hypothesized that the airborne transmission of COVID-19 was unlikely, subsequent evidence contradicted this belief. Therefore the Centers for Disease Control and Prevention (CDC) issued new guidance, and our knowledge evolved. As reported in the media, however, this seemed scattershot and led to an eroding of confidence in science.

Fake news sources have flourished as traditional vehicles fail. Recognizing misleading or false stories is a skill that can be learned, but the tell-tale signs may be more subtle than a generous offer from a foreign monarch.

Clickbait often proposes “One simple trick” or something “You won’t believe.” Here’s some fun, generate your own clickbait. Start with some digits, add a gerund (a continuous form of a verb), and then some superlative adjectives like cutest, best, and most unbelievable. Here’s one: 23 reasons why joining the SVS will give you the hottest body! continued on page 4

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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December 2021

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FROM THE EDITOR

One simple trick can tone your abs and identify fake news!

trips, and days they get to leave school early. Suddenly Luke looked up and said, “Wait a minute, why is DADDY driving us to the doctor?” Dread swept through the festive atmosphere of the back seat of my car. Someone, or (oh God), someones were getting the jab. Think about how a pediatrician’s office conducts this process. The doctor doesn’t say, “It looks like Luke has some vaccine hesitancy.

Perhaps he would like to hear me debunk Andrew Wakefield’s 1998 Lancet article, which falsely linked the MMR vaccine to autism?” Instead, vaccinations are treated as the social norm. Presumptive language is employed, “Today, Luke is getting his polio and varicella vaccines.”

As physicians, we can help our vaccine-hesitant patients, friends, and family members, but, too often, we use the wrong technique. Doctors frequently engage in a method of debate called topic rebuttal. We do this at scientific meetings when discussing papers with our peers. Topic rebuttal is conducted through fact-

continued from page 2

OK, your mileage may vary, but by learning how to create fake news, you also learn to recognize it. False stories arise too quickly and spread too far to debunk in real-time. So psychologists at the University of Cambridge came up with a way to prebunk them. They developed an online game called Bad News. In it, the user creates a fake news site and learns the six different techniques commonly employed: impersonation, emotional exploitation, polarization, conspiracy, discredit, and trolling. In a controlled trial, the researchers found that individuals who played the game demonstrated a significant increase in their ability to detect fake news items.

Since over 40% of U.S. adults report getting their news from Facebook, instilling emotional intelligence in our population is imperative to mitigate the fallacies of fake news.

One such program, already in schools, is called Social-emotional learning (SEL).

SEL curricula emphasize critical thinking, emotion management, conflict resolution, decision-making, and teamwork. A 2011 metaanalysis of 213 SEL programs comprising Americans over 270,000 students demonstrated an were fully increase in academic performance and a decrease in adverse neurologic symptoms vaccinated as such as anxiety and depression. The concept of Nov. 30 of SEL is not new. Benjamin Franklin created the first system in the 1700s. For decades, these Most science deniers don't programs have existed in all 50 states with widespread necessarily lack information, but bipartisan support. Recently, however, organizations they almost always lack trust. such as Parents Defending Education have tried to turn them into political footballs. Taking issue with standards To override their emotional such as “I can make ethical decisions about when and connection to their beliefs, we must how to take a stand against bias and injustice in my everyday life or community,” the group has accused SEL employ patience and empathy programs of being vehicles for social justice activism. By politicizing SEL programs, these advocacy groups threaten our best defense against the rising wave of anti-science based counterarguments. This technique, though, is only disinformation campaigns. effective in good faith arguments where both sides are Psychologists have demonstrated that the actions of elite open to learning. Lecturing, shaming and ostracizing are cues and advocacy groups affect the gap between scientific also wildly ineffective at changing firmly held opinions, and public consensus on many issues. In 1956, Elvis Presley usually serving to entrench the person further. The fake was publicly inoculated with Salk’s polio vaccine on the set news complex is well developed and (ironically) very of the Ed Sullivan Show. At that time, the vaccination rate scientific in its methods. Most physicians have not learned among American teens was 0.6%. In the next six months, useful modes of persuasion. Our approaches are often 80% of the teens would follow his elite cue and join Elvis detrimental. among the vaccinated. Today, perhaps no one has the In 350 B.C., Aristotle described the three rhetorical cultural reach of Elvis, but we need to find influencers appeals, Logos (logic), Ethos (credibility), and Pathos who can push public health measures and create safe (emotion). Aristotle described Pathos as almost a cheat social norms in this pandemic. This is why it was a big code, effective at overriding reason and logic. Most science deal for Louisiana Republican Rep. Steve Scalise to endorse deniers don’t necessarily lack information, but they almost the vaccine publicly; he serves as an elite cue to many always lack trust. To override their emotional connection conservatives. If nothing else, we need to counter the to their beliefs, we must employ patience and empathy. overhyped media coverage of vaccine skepticism among Motivational interviewing is a collaborative, goalcertain NFL players, and past and present celebrities (say it oriented style of communication that has even shown ain’t so Busta Rhymes!). efficacy in one of the most challenging clinical scenarios— When contemplating how to approach my vaccinephysical addiction. When using the technique with the hesitant patients, I considered the almost automatic vaccine hesitant, it is essential not to ask why they don’t process in which they are delivered in our pediatrician’s want the vaccine. That only reinforces their negative office. Truth be told, I used to think my kids got vaccines feelings. A better question to start with is, “On a scale of essentially every visit. The reality was my wife maintained one to 10, how motivated are you to vaccinate?” If they the vaccination schedules imprinted on her memory answer anything other than one, focus the discussion on with Terminator-like accuracy. When the visit calls for why they didn’t pick a lower number. This highlights their a shot, she becomes “busy,” and I step in. This statistical positive feelings towards the vaccine. The conversation can improbability occurred suddenly to my youngest on a then be guided by technique rebuttal in which you discuss drive to the doctor’s office one afternoon. The kids were the standard methods science deniers use to mislead. in the joyous merriment reserved for Christmas, Disney These commonly include cherry-picking evidence, creating

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59%

4 | Vascular Specialist

impossible expectations, conspiracy theories, false logic, and fake experts. Reviewing these practices also serves to indoctrinate against further susceptibility to bogus claims. Another key component of technique rebuttal is non-judgmental empathetic listening. The goal is to find your subject’s reasons for hesitancy and bounce them out of a rationalization loop. People who answer one on the motivation scale are in a precontemplation state.

Thankfully, this is relatively rare. In studies of parents who oppose childhood immunizations, only 3% were in a precontemplation state.

There are many reasons why someone might not be open to persuasion. Feeling threatened or hopeless are the most common. An interesting example of a method for communicating with people in a precontemplation state is Street Epistemology. The goal of this process is not to change the other person’s mind entirely but to shift their confidence in their belief. Here is a simplified version of the method: 1. Build rapport (Ethos) 2. Identify the claim the Ranking us person is making 3. Confirm to the other person you understand 4. Clarify the terms the other person is using (e.g., mind control, politics, microchip) in the world 5. Identify their confidence level in their claim 6. Identify their methods for arriving at their confidence level 7. Ask questions to determine if these are sound Whatever technique you employ, the goal is to open the person to an ambivalent position—one where a good faith discussion can be had. Remember, people in certain groups not only don’t care about your approval, they actively don’t want it. This is why it is easier to convince some individuals to get the vaccine than wear a mask. A vaccine can be obtained in secret, without fear of ostracization.

Consider your faith in the vaccines. Is it based on reading every page of the Food and Drug Administration (FDA) reports? More likely, you believe because the people you have confidence in—people like you—believe. It is improbable you can convince the vaccine hesitant to trust these same people. But with effort and the proper approach, you might be able to get them to trust you.

=

60th

References 1. P reston S, Anderson A, Robertson DJ, Shephard MP, Huhe N (2021) Detecting fake news on Facebook: The role of emotional intelligence. PLoS ONE 16(3): e0246757. https://doi.org/10.1371/journal.pone.0246757 2. Lewandowsky S, Pilditch TD, Madsen JK, Oreskes N, Risbey JS. Influence and seepage: An evidence-resistant minority can affect public opinion and scientific belief formation. Cognition, Volume 188, 2019, Pages 124–139, 3. https://popular.info/p/the-new-bugaboo 4. https://www.scientificamerican.com/article/how-elvisgot-americans-to-accept-the-polio-vaccine/ 5. Fackler A. When science denial meets epistemic understanding. Sci & Educ 30, 445–461 (2021).

6. https://www.nature.com/articles/d41586-021-02152-y 7. https://www.niemanlab.org/2019/06/yes-itsworth-arguing-with-science-deniers-and-hereare-some-techniques-you-can-use/ 8. https://www.scientificamerican.com/article/to-understandhow-science-denial-works-look-to-history/ 9. https://www.nytimes.com/interactive/2021/05/20/ opinion/covid-19-vaccine-chatbot.html

MALACHI SHEAHAN III is the Claude C. Craighead Jr. professor and chair in the division of vascular and endovascular surgery at Louisiana State University Health Sciences Center in New Orleans.

December 2021

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180

COMMENTARY

Beyond the bed pan: A nurse’s journal in the COVID-19 pandemic

BY TIAN QIU, RN

The past two years felt like a blur. Where do I even start? It was January 2020; I was doing my nurse practitioner clinical rotation with a family doctor in Toronto. We saw the news of a mysterious virus ravaging the city of Wuhan, China, and we both knew this was not just some ordinary flu. This was serious. We started ordering personal protective equipment (PPE) online, screening patients, and wearing masks. That was all before the government knew that COVID-19 had already arrived in Canada.

ONCE I RETURNED TO MY hometown of Montreal, Quebec, I went back to work on my vascular surgery unit.

The unit was busy as usual; people were going about their own business. I was the only one wearing a mask on the unit, and I was even told by multiple people I should not be wearing them because I was creating unnecessary fear. Two days later, we were told that all the part-time nurses had to be distributed to other units because there was a significant spike in COVID cases in the hospital and a shortage of nurses. That was the moment that the harsh reality finally sunk in. The pandemic had arrived.

I was sent to the cardiac care unit (CCU) at the Montreal General Hospital (MGH) during the first wave. Fortunately, we

6 | Vascular Specialist

did not have any COVID patients, even though all our rooms were prepared for them. Because we were the CCU team, we were responsible for any codes in the hospital, including COVID patients. I had seen first-hand how the virus devastated other floors, especially the internal medicine ward. Everyone was exhausted after a code because of the extra PPE and N95s we had to wear. Due to a lack of PPE, we were asked to re-use our N95s for an entire week before discarding them. Sometimes a code can last well over an hour, and there were more than 10 people crammed in a small cubicle of space. I could see how the pandemic had affected people physically and mentally.

People began to experience

burnout at work; the numbers of sick calls skyrocketed; and there were not enough nurses to cover the sick calls. A CCU nurse’s maximum patient number is two, but I had up to three patients as a nurse with limited CCU background. I was juggling between school and work, and I could feel I was struggling. Finally, the excess amount of stress tipped the scale. I became severely ill.

I had subacute thyroiditis and was almost admitted to the hospital due to thyrotoxicosis. I lost 20 pounds in three weeks, and I could barely get out of bed. I was walking with a walker because my leg muscles were so atrophied. I lost most of my thyroid function, and my heart, liver, and kidneys were damaged during the thyrotoxicosis.

After almost five months of recovery, I finally returned to my beloved vascular surgery unit, my second home. I honestly think we have the best unit culture in the hospital because we work as a team.

Everyone has each other’s backs.

Although we were short-staffed just like every other unit, the spirit remained high.

For me, the main issue that the pandemic exposed was the severity of the nursing shortage. Nurses had been crying out over poor working conditions for years before Tian Qiu the pandemic,

but the government did nothing and the budget cuts kept coming. The key remains to improve the working conditions of nurses to prevent them from leaving for the private sector.

Lastly, the COVID vaccine should be the thing that brings us back to normal— uniting us all, not dividing us. Politicians use it as part of their campaign agendas.

In western culture, people tend to put themselves before the good of society and others. In East Asian culture, the good of society is above all individual needs. That is why there are more anti-vaccine protests in western countries than in Asian countries.

I firmly believe in people’s right to choose. However, if you are a healthcare worker, especially a nurse or doctor, then it is your duty/oath to cause no harm to your patients. One way to do that during a pandemic is to get vaccinated. One reason behind people’s hesitancy on this vaccine is the spread of misinformation/ disinformation on social media. People do not realize that those who spread false information have other political agendas.

The only way to fight misinformation is by educating people.

Knowledge is power.

TIAN QIU has been a vascular nurse since 2012, and a cardiology nurse since 2015. He is currently training to be a nurse practitioner and is based at Royal Victoria Hospital at the McGill University Health Centre (MUHC) in Montreal.

December 2021

CMS

COVER STORY

Countdown to the cuts continued from page 1

Also coming are expiration of conversion factor relief (3.75%) and the end of a moratorium on sequestration (2%)—unless Congress acts, the sequestration will resume on Jan. 1, 2022.

Meanwhile, a 4% PAYGO cut was triggered by passages of the American Rescue Plan in the spring. PAYGO is a budget rule (“Pay as you Go”) requiring that tax cuts and mandatory spending increases be offset. “Between sequestration and PAYGO, we’re starting off 2022 at 6% down, without the other cuts,” said Sideman. “We feel Congress needs to waive PAYGO cuts before the end of the year.”

He said CMS has projected an overall impact of just 5% for vascular surgery; the SVS projects 12.75%. But the impact depends on practice setting and service mix.

Members running office-based labs (OBLs) could see reductions of up to 22% for some codes.

also met with CMS, hosted meetings with the Domestic Policy Council (DPC) in the White House as well as with the Office of Management and Budget regarding the proposed Medicare Physician Fee Schedule and the clinical labor proposal.

Congressional education comprised a second phase of the SVS campaign. The Society held Congressional fly-in events, with members talking with lawmakers about the cuts, and contacting lawmaker staffs later to encourage outreach to CMS to delay and mitigate the clinical labor cuts.

“We are now in phase three,” said Sideman, outlining steps to take: Spreading the word through member education, “so you all know what’s facing us and what can be done,” he explained.

Donate to the PAC and attend SVS PAC-hosted events with members of Congress, Sideman continued.

“It’s crucial to getting a seat at the table. Last year, we successfully blocked 7% cuts for 2021, and this year’s challenge is even bigger. Support us in educating legislators and seeking long-term solutions.”

Megan Tracci, MD, vice chair of the SVS Advocacy

Dialysis access

Vascular lab

(CPT CODE 36902)

(CPT CODE 93880)

will get more than one “ask,” she said. “Each ask is going to probably be a separate part of this fix. Do we anticipate we’ll win all of them? No; it will probably be a mixed bag.” She added, “SVS and its membership have done unprecedented work. We’ve been pushing hard and effectively on these issues.”

The Society has posted on its website a link to a spreadsheet detailing the impact on vascular codes of the final proposed Physician Fee Schedule for 2022. This supplies necessary information for members’ letters to Congress on the effect of the schedule, panelists said.

(Visit vascular.org/MedicareTaskForce to download the spreadsheet.)

Meanwhile, Sideman outlined their projections on some of the final outcomes.

On the conversion factor, he stated: “I think we can get motion on that. I think there’s a good chance to get extension of relief on at least some part of the 3.75%.

If we continue to work hard on our grassroots work with Congress and get co-sponsors on House Resolution 6020, from Reps. Ami Bera and Larry Bucshon to extend certain increases in payments for physicians’ services

Lower-extremity endovascular

Vein clinics (CPT CODE 36475)

(CPT CODE 37225)

Facility setting (increase):

OBL (estimated):

Facility setting of the surgeon’s professional fee:

9%

14%

8%

Office setting (anticipated cut to the global fee):

Facility setting (hospital outpatient) of professional fee:

11%

9% SNAPSHOT OF THE CUTS

Snowball effect Mark Mattos, MD, co-chair of the SVS Political Action Committee (PAC) Steering Committee, said the driving force behind the 3.75% conversion factor cut is that it was only addressed by Congress for one year, when there were changes in payments for office visits for 2021, versus adding money to the fee schedule on a permanent basis.

He added that reimbursements for vascular surgeons have declined nearly 20% since 2001. “We have to go through Congress to effect change,” he said. “No one should devalue what we do.”

The cuts will trigger a snowball effect, starting with the payment reductions, progressing to the loss of surgical staff and reduction of patient volume; delayed patient care and the shift of Medicare patients to tertiary centers; adverse effects on teaching, training and research; and, finally, to increased burnout, practice loss and early retirement.

“Last year we were worried about 9% cuts,” said Sideman. “This year, it’s potentially a 20% pay cut for OBLs that only do certain types of services. They’re going to be shutting their doors.”

When CMS issued its proposed Physician Fee Schedule rule in July, SVS responded immediately, forming the SVS Medicare Cuts Task Force and collaborating with those facing similar cuts as part of the Clinical Care and Surgical Care coalitions. Members analyzed the impact, studied the negative drivers and specific technical problems that were part of the rule leading to the cuts, and then wrote highly detailed letters on the analysis to CMS, outlining the cuts’ impact on patient care.

More than 180 SVS members answered the call for member engagement, writing personal letters to CMS. SVS December 2021

OBL (anticipated cut to the global fee):

18%

Facility setting (hospital outpatient) of professional fee:

10%

OBL (anticipated cut to the global fee):

11%

*as of Dec. 6, 2021

Council, added: “The easiest way to support us is to support the PAC. That gets our leaders into the room to advocate for our issues.”

Lobbying Congress SVS members, in fact, held a number of virtual meetings with lawmakers in November to inform them of the cuts’ effects and to seek help. Additional meetings were scheduled for December as Vascular Specialist was going to press.

“Tell your lawmakers what we’re facing in the cuts and to act now. We’re making it very easy for you on our Voter Voice page (vascular.org/VoterVoice), which tells you how to reach out to leaders,” said Sideman.

Sean Lyden, MD, chair of the SVS Government Relations Committee, urged members to ask their families and friends to contact lawmakers. “Anyone can go on there and find out who their reps are,” he said. “We have to tell Congress immediately. If they don’t hear from enough of us, they won’t care. We’re just going to get crushed. It’s happened before at the bottom of the ninth, but if we don’t get people excited now…”

Sideman said SVS has notched some wins during this process to mitigate the cuts from CMS’ clinical labor proposal, including a rate increase for angio techs, CMS agreeing to use median—not mean—salary data from the Bureau of Labor Statistics, as well as a different fringe benefits multiplier. In addition, CMS also agreed to a fouryear phase-in for the clinical labor staff payment rates.

And, most importantly, he said, “there’s still time to impact cuts. But we have to work hard.”

Each piece of the “fix” is essentially a separate legislative fix and a separate coalition,” said Tracci. Thus, members

under the Medicare program through 2022, we have some possibilities here.”

On a supplies and equipment re-pricing cut: “That is already a done deal. That is not going to go away,” he said.

“I don’t want people to think it will. But it’s the final year for that transition.” On sequestration: “It is going to be very challenging to get the moratorium extended. But, with winter coming and COVID cases going up, there is a chance.”

Congress is sympathetic on clinical labor cuts, and there is now legislation from Reps. Bobby L. Rush and Gus Bilirakis to delay, said Sideman. “However, we need to continue to press hard and continue to work on additional options for mitigation for Congressional consideration.”

As for PAYGO, he added, “that’s tricky. It has to do with overall Congressional spending and a little less to do with us.”

‘A lot can still be done’ “We’ve found and reached out and collaborated with other specialties that are going to be similarly affected by these cuts,” said Sideman. “We’ve talked to anyone and everyone who will listen to us: CMS, Congress, other offices in the Biden-Harris Administration. We’ve been very active in this and fighting hard for our members.”

Panelists reiterated the importance of donating to the PAC. McDevitt told the audience to multiply 20% of their income by 20 years. “Give a fraction of that to mitigate the cuts,” he said. “That’s a pretty good return on investment to me.” Tracci added that a PAC donation is an “investment in the future of our Society.” “Even though what we’re facing looks daunting, we’re still optimistic,” said Sideman. “There’s a lot that can still be done.” vascularspecialistonline.com | 7

AAA

Two-year follow-up data from EVAS2 IDE study delivered

BY BRYAN KAY

The confirmatory EVAS2 clinical study to evaluate the safety and effectiveness of Endologix’s Nellix endovascular aneurysm sealing system (EVAS) for the treatment of infrarenal abdominal aortic aneurysms (AAAs) contains positive two-year follow-up data, the leading investigator has revealed.

A FIRST STUDY UPDATE WAS presented by principal investigator Jeffrey Carpenter, MD, chairman and chief of the department of surgery at Cooper University Health Care in Camden, New Jersey, at the 2021 VEITHsymposium (Nov. 16–20) in Orlando, Florida. Carpenter told delegates data from two years of follow-up of patients treated with the EVAS device demonstrate 92% freedom from all-cause mortality, 100% freedom from migration, 100% freedom from saccular enlargement, 98% freedom from type Ia endoleaks, and 98% freedom from type II endoleaks.

“We’re only at two years of good followup,” Carpenter said, explaining that this

was the point at which “the signal of problems” emerged in EVAS1. However, he said the study investigators were hopeful of success in the current study as they continue to follow study participants, with data “holding up.”

Carpenter explained that at two years of follow-up in the device’s pivotal investigational device exemption (IDE) trial, “there was a signal of migration and a signal of aneurysm enlargement development.” A root-cause analysis found that thrombus “was playing a big role” in the case of migration, he told VEITH 2021 attendees. Regarding aneurysm enlargement, Carpenter continued, “we

Researchers present ex vivo demonstration of fluoroscopy-free complex AAA stent placement

BY BRYAN KAY

“I think this represents the beginning of the end of an era where we have to use lead to perform these procedures.” Those were the words delivered by Gustavo Oderich, MD, professor and chief of vascular and endovascular surgery at UTHealth’s McGovern Medical School in Houston, as he demonstrated the results of an ex vivo experiment in which the emerging Intra-Operative Positioning System (IOPS) imaging technology was used “totally radiation-free.”

O

derich was speaking during the 2021 VEITHsymposium (Nov. 16–20) in Orlando, Florida. He was displaying for the audience how he and colleagues used a 3D-printed aortic model, and performed a complex endovascular aneurysm repair (EVAR) on an abdominal aortic aneurysm (AAA) using the 3D, GPS-like surgical navigation tool, or electromagnetic image guidance.

“We’re all aware of the deleterious effects of ionizing radiation, particularly for complex endovascular 8 | Vascular Specialist

were originally employing what turns out to be a plug,” under an understanding that they only needed to fill the aneurysmal portion of the aorta with polymer—but not the seal zones, or “firewalls.”

Adjustments were made, resulting in “a revision of the instructions for use (IFU) to make sure that there was able to be sufficient polymer placed into the aneurysm sac to stabilize the stents and that we had good seal zones proximally and distally,” he said.

In 2019, Endologix issued a voluntary recall for the EVAS system in order to ensure optimal patient outcomes through the most appropriate use of the device, with the company noting that it had determined off-label use was occurring at “an unacceptable level, with the consequence of suboptimal results.” The 333 patients in EVAS1 retrospectively yielded the device IFU, Carpenter explained. Those in this group treated on-label experienced 97% freedom from migration, he added. EVAS2 consists of 92 patients and is an IDE prospective, multicenter, single-arm study with consecutive, eligible subject enrollment at

procedures,” Oderich—a member of the scientific advisory board of Centerline Biomedical, the company behind IOPS— told VEITH 2021 delegates, while pointing to data suggesting that exposure to radiation is 3-to-15 times greater during fenestrated-EVAR as during a standard EVAR procedure.

Oderich detailed how he and colleagues deployed IOPS during the experiment, hooking up a tracking system to the operating table alongside wires and catheters integrated with sensors—with capabilities not only to show the vascular anatomy but also multiple devices, explained Oderich.

The research team printed the anatomy of an aortic aneurysm and obtained computed tomography (CT) angiography of the model in order to create a map for the use of IOPS. The team proceeded to a hybrid operating room, performed an EVAR on the 3D model—connected to a fluid pump—and deployed a sensorized bifurcated stent graft. The major caveat being, explained Oderich, “we did not use fluoroscopy but IOPS.” Displaying outtakes from the procedure, Oderich pointed out the positioning of sensors on the bifurcated device, with positions at the top and also in the contralateral gate and the ipsilateral limb.

Oderich went on to outline catheterization of the lowest renal artery and advancement of the device.

“You can see one of the potential benefits of this imaging is how it allows you to see multiple dimensions—including

each site. Participants are being followed out to five years.

Summarizing the EVAS2 data delivered at VEITH 2021, Carpenter concluded: “Active sac management of EVAS has shown good freedom from type II endoleak and freedom from all-cause and cardiovascular mortality in all quartiles.

Clearly, a second-generation Nellix device is necessary if this is going to be an everyday infrarenal aneurysm repair device.”

“Clearly, a secondgeneration Nellix device is necessary if this is going to be an everyday infrarenal aneurysm repair device” Jeffrey Carpenter

X-ray fluoroscopy contrasted with the interactive navigation and real-time positioning of IOPS

“This procedure allowed us to do precise dilatation not using any lead, no fluoroscopy” Gustavo Oderich

from the bottom, which is the ideal view for us to cannulate a gate,” he said.

Intravascular ultrasound (IVUS) was also deployed in order to demonstrate “that the wire was indeed in the central lumen portion of the stent graft.”

After the procedure, a contrast CT was carried out in order to demonstrate proof of concept. “I want you to see how close we were from the target, which was the left, lowest renal artery, which was approximately a millimeter or two,” Oderich added. “This procedure allowed us to do precise dilatation not using any lead, no fluoroscopy.”

December 2021

PEOPLE

Wei Zhou: Prepared for change—and a more diverse, vocal generation of surgeons

BY BRYAN KAY

There was something of a different pulse to some of the matters around this year’s Western Vascular Society (WVS) annual meeting, recalls Wei Zhou, MD, a regular attendee over the last decade— particularly during a session dedicated to issues related to diversity, equity and inclusion (DEI).

THAT MIGHT’VE HAD SOMETHING to do with the presence of a contingent of voluble, young faculty. Crucially, this emerging generation is one that contains more women, greater diversity and a louder voice, Zhou muses. It is a new tenor that excites her—for the future it might portend, for the trails it might set for others. “I think the society wants to make a change,” says Zhou. “It’s time to be inclusive, it’s time to embrace new ideas.”

Zhou, an immigrant to the United States after high school, knows what extra obstacles can lie in the way of people with demographic characteristics such as hers. She knows what it has taken to reach her latest career milestone: During the recent WVS meeting in Jackson Hole, Wyoming, she was unveiled as the society’s presidentelect. As just the second woman to enter the presidential line, as well as the second Asian, she speaks of an element of surprise at the election, as much due to her relative youth as the ascension itself. “I’m still

trying to digest the news,” Zhou tells Vascular Specialist in an interview shortly before her first WVS Executive Council meeting. “But there are more early-career vascular surgeons who are women, who are diverse, and I have really embraced the change. As a society, we need to embrace change. I think, as a leader, you really need to embrace what’s going on with the pipeline.”

Zhou’s own career has followed a particular trajectory. Since vascular fellowship, she has remained Wei committed to academia, Zhou considering herself primarily a clinician-scientist.

“I enjoy the stimulating part of the science—though I’m a busy clinician I still enjoy the science part,” she says. “I have been lucky enough to have grant fundings from the VA [Veterans Affairs], NIH [National Institutes of Health] and the American Heart Association [AHA], from the American College of Surgeons [ACS] over the years.

I still have a research lab—stood-over-thebenchtop research.” Meanwhile, Zhou’s

clinical research interests have evolved.

While at Stanford, where she operated for 10 years, she had a particular interest in neurocognition, and how carotid disease and carotid intervention—particularly micro-embolization—affect cognitive function.

Now based in Arizona, where she serves as chief of the division of vascular and endovascular surgery at University of Arizona College of Medicine-Tucson, her role has altered. There, part of her attention has turned to bringing together vascular surgery and podiatry, focusing on limb salvage, which she says represents “a huge” part of her group’s practice.

“I embrace my podiatry colleagues and embrace the collaboration between podiatry and vascular,” Zhou explains.

“That has continued to develop the program, and I think that’s important because they’re both integral equally to our practice. Along with that, there’s lots of

“Not only do they recognize the need for change, but they definitely have a desire to make the change happen” Wei Zhou work, research and clinical questions that we can ask to improve our care for patients with diabetes and diabetic foot ulcers, and for limb salvage in the southwest.”

In that vein, different types of vascular practice also merit consideration in the crucible of diversity, Zhou continues.

“We’re not just an academic society; we’re a society that encompasses all types of vascular surgeons in the Western region.

People in private practice, people in large group practice, and academia. We also need to embrace our young early-career faculty and students who are lots more

In paying back, Joe Hart pays it forward

BY BETH BALES

For Joe Hart, MD, a larger donation to the Society for Vascular Surgery (SVS) Foundation this past year is helping him pay back several of his own scholarships and research opportunities from which he benefited.

“I

’m someone who’s been fortunate to get scholarships,” he said of his undergraduate and medical school years. “I’m from a big family—I needed the help! So I try to pay things back where I can. I’ve always been involved, but I was able to do something more substantial this year.”

During medical school at Northwestern, he received funding for a research opportunity he feels helped him get started in the right direction. After fellowship, he won an award through the Marco Polo Program to go to Europe for six months for training, research and project work. Now he tries to impact the future of vascular patient care by helping fund research that will affect that

December 2021

care. He calls himself a “hybrid,” working primarily in a clinical practice but also still trying to keep his hand in when it comes to research. He spent six years trying to make it his full-time pursuit.

But funding was an issue, as were the difficulties—as many researchers know—balancing research, clinical and patient needs.

Contributions to the SVS Foundation help researchers get that precious time they need to pursue projects

diverse. Outreach is definitely on my agenda.” That’s a vision she shares with current WVS President Vincent Rowe, MD, who took over from Michael Conte, MD, in Jackson Hole.

Zhou points to a survey conducted by the society’s new DEI committee. It showed that 30% of the membership who responded had plans to retire. “That raises a pipeline issue for our society,” she says.

The more vocal, up-and-coming generation were particularly impressive during a DEI committee breakout session at the meeting, Zhou points out. “I’m considered more of a mid-career senior faculty surgeon, so in my role I recognize the diversity, and I want to change but not only are [the younger faculty] diverse— their voices seem louder. Not only do they recognize the need for change, but they definitely have a desire to make the change happen.

“I was actually inspired by our earlycareer faculty members, especially women faculty and women members in our society. They’re extremely accomplished and very vocal. They inspire me to be more vocal regarding this aspect of our society.”

When serving on the WVS program committee, Zhou describes how the group would organize a diversity network session where such issues would be raised and discussed.

“That was it,” she recalls. There was industry interest and support, but the mode of the session was not as well received as that which emerged at the most recent meeting, Zhou adds.

“This year it was a different pulse,” Zhou explains. “The DEI committee was formed this year and the new young surgeon committee was formed this year, and lots of our young faculty members are women.

They are not just realizing the need for change, they demand change. Not only from the society but also from industry.”

to improve patient care, said Hart, currently an associate professor of surgery and radiology at the Medical College of Wisconsin in Milwaukee.

“I know it’s difficult to get funding, I know it’s important. Grants help our people get more funding to keep up their research, without clinical practice getting in the way.”

Hart also gives his time, serving on both the SVS Foundation Board of Directors and the VISTA—Vascular Volunteers In Service To All—Steering Committee.

And after spending more than five years in a relatively rural setting in northern Maine, he also understands and appreciates some of the Foundation’s newer initiatives like VISTA, which is aimed at providing access to vascular care to under-served populations.

He encourages everyone to participate in the Foundation’s work, echoing the sentiments of other Foundation committee members. “Even in my macand-cheese days I gave a little,” he said. “And I’m glad I’m in a place in my life where I can do more. It seems like the right thing to do.”

Joe Hart

The SVS Foundation has published its 2021 annual report. Read it at vascular.org/ FoundationAnnualReport21.

vascularspecialistonline.com | 15

VASCULAR SCIENCE

VRIC 2022 to be held May 11 in Seattle The Society for Vascular Surgery’s 2022 Vascular Research Initiatives Conference (VRIC) will return to its spring timeframe of the past several years.

ABSTRACT SUBMISSION FOR VRIC CLOSES AT 6 P.M. Central Time Tuesday, Jan. 11, 2022. Registration opens Feb. 10, 2022; look out for information on early-bird rates that will be available before then.

The conference will be held May 11, 2022, in Seattle, the day before—and in the same place—as the American Heart Association (AHA) “Vascular Discovery: From Genes to Medicine” Scientific Sessions from May 12–14, 2022.

The COVID-19 pandemic forced cancellation of the live VRIC in the spring of 2020, and a pivot to a virtual meeting that fall. In 2021, with the AHA not holding live sessions, VRIC joined the Vascular Annual Meeting (VAM) with a shortened program of four hours, over two days.

VRIC focuses broadly on emerging vascular science and translational research relevant to vascular patients.

Collaboration is key, with audience-presenter discussion that helps motivate participants to discover solutions to vascular disease issues.

The conference brings together vascular surgeons, vascular biologists, physicians with an interest in vascular

problems, vascular surgery trainees and research trainees focused on cardiovascular biology.

Highlights include the Alexander W. Clowes Distinguished Lecture, typically delivered by a noted scientist/researcher, and the always-popular translational panel and discussion. This year, the theme is “Translational Immunology and Cardiovascular Disease.” There will be four abstract sessions broadly focused on: ● Arterial remodeling and discovery science for venous disease ● Vascular regeneration, stem cells and wound healing ● Atherosclerosis and the role of the immune system ● Aortopathies and novel vascular devices

in vascular disease. The discussions surrounding the presentations often lead to collaborations and new directions for many in our vascular research community.”

VRIC presents some of the research at the ground-floor level in many ways, she said. This is research that “affects future treatment and management of vascular disease, and the care our members eventually will provide patients.”

For more information on VRIC—to be held at the Sheraton Grand Seattle Hotel—visit vascular.org/VRIC22.— Beth Bales

“VRIC allows us to identify important breakthroughs in understanding the mechanisms of vascular pathology that allow for development of therapies to prevent and treat common vascular diseases,” said Katherine Gallagher, MD. She chairs the SVS Basic and Translational Research Committee, which plans the conference; she herself is a longtime VRIC presenter and mentor to other presenters.

“This meeting is an excellent venue for research/ surgical trainees who focus on translational research

“VRIC allows us to identify important breakthroughs in understanding the mechanisms of vascular pathology that allow for development of therapies to prevent and treat common vascular diseases” Katherine Gallagher

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December 2021

VASCULAR CARE

Task Force to address question: How will we care for pediatric vascular patients?

BY BETH BALES

Along with the American Pediatric Surgical Association (APSA), the Society for Vascular Surgery (SVS) plans to minimize and close some very real gaps in vascular care—treating pediatric patients.

T

he two organizations have formed a joint task force on the issue to identify key areas of concentration for collaborative education, guideline development, and potentially training across the vascular and pediatric surgery fields. The end goal of the SVS/APSA Task Force on Pediatric Vascular Surgery Care is advancing the understanding and care of vascular disease among pediatric patients.

“Our residents spend no defined time across programs managing kids,” said Dawn Coleman, MD, task force lead.

“There are no training requirements to cover care of pediatric patients. So who will provide care, especially in acute emergencies?”

Coleman’s practice focuses in part on pediatric patients, and she covered the topic in a well-attended postgraduate course at the 2021 Vascular Annual Meeting (VAM). Resultant discussions, plus earlier conversations on the work of the SVS Population Health Task Force, “have identified a very clear gap in the care of children.” John White, MD, who is helping lead the task force effort, has long acknowledged this care gap and has sought to address it. The impetus: a young patient who could not receive the proper care in a major metropolitan area because he, the doctor, was out of town and no other vascular surgeon felt comfortable providing care to this 2-year-old.

Other cases also “really got me thinking” about the knowledge and care gaps, said White. “The fundamental issue is we don’t know how to optimize treatment for vascular problems in pediatric patients and on what basis.

Right now, we have more questions than answers.”

Surgeons treating adult patients need not concern themselves with neurological, bone or muscle development, for example, said White. In addition, general physicians are getting farther afield from physical exams, utilizing imaging studies heavily instead. And, distance-walking tests—a mainstay vascular exam for adult patients—don’t provide much information in children’s cases, he pointed out.

Many vascular surgeons acknowledge significant reticence about treating pediatric patients, primarily because of lack of training, particularly in open procedures, said Coleman.

However, in the cases of critical, timesensitive vascular emergencies, typically trauma cases, she said, “vascular surgeons may not find themselves with the precise team they’d like. This discomfort and lack of knowledge can impact the outcomes in a big way, including life or limb.”

The two doctors suggest the task force can collate clinical and practice resources for surgeons on the front lines presented with emergencies, plus working together through scientific studies to understand the natural history of the problem and care. “Ultimately, the goal from an educational perspective is to share broadly the expertise and resources of both groups,” said White, so that when faced with a pediatric vascular challenge, surgeons are empowered with appropriate resources to optimize care for these unique patients.

“We really need to work very hard and play catch-up ball, with better understanding of what children’s needs

From the SVS journals In the Journal of Vascular Surgery-Vascular Science (JVS-VS), Mohamed A. Zayed, MD, et al recently developed a novel arteriovenous graft platform for cell-replacement therapy (AVGRx). This platform could be “transformative for the long-term management of diabetes,” they wrote in JVS-VS. In the study they hypothesized that implantation of insulin-producing beta (ß) cells, or whole pancreatic islets, into the novel AVGRx platform can support cell viability and function in vitro and in vivo. “Future studies will help determine whether extended use of the AVGRx platform can be used for sustained euglycemia in patients with diabetes,” they concluded. Read more at vsweb.org/JVSVSGraftPlatform.

JVS-Cases, Innovations and Techniques (JVS-CIT) includes a grouping of four articles on unusual aneurysms, with “A rare case of left colic branch aneurysm presenting with rupture and intra-abdominal hemorrhage” and “Surgeon-modified fenestrated endovascular aortic repair for ruptured anastomotic aneurysm after open thoracoabdominal repair” among them. See the JVS-CIT September issue for all four articles. Access the publication at vsweb.org/JVSCIT.—Beth Bales

December 2021

are. We need to put together education models, we need to develop brand new areas of guidance and technology, such as for operating on a premature infant.”

Coleman emphasized the importance of leveraging multidisciplinary teams for these children, especially when specialty resources may be limited by hospital constraints.

In her own practice, she treats and operates on children with renovascular hypertension, a mainly developmental rare disease. “Our program rests on the expertise of the surgical team alongside pediatric nephrology, interventional radiology, cardiology, neurology, anesthesiology/ critical care and others,” she said.

White hopes the task force will go beyond putting together teams for emergencies. “Let’s get beyond that. Let’s discuss vascular care for kids overall.”

He cited care for young athletes and patient follow-up as two specific needs. “The high school athlete of today is a college athlete of 20 years ago,” he said. “The injuries we see— the vascular needs of these

patients—are different now. We have to catch up.”

He regards establishing follow-up with pediatricians and pediatric situations another important priority. Emergency room surgeons rarely do follow-up care, he said. “But in the cases of pediatric vascular emergencies, we want the surgeon to become part of that child’s healthcare team.”

He treats children with congenital vascular anomalies.

“Eventually that child will need to transition to both an adult primary care physician and a vascular surgeon who understand the impact of pediatric vascular issues on adult health.”

“We have the chance to do something incredible with this partnership,” said Coleman of the task force. “It will further our understanding of pediatric vascular diseases. Through data reconciliation, education and enhancing collaboration, this task force has the potential to have a powerful impact on not just rare, esoteric pediatric vascular disease, but common and time-sensitive pathology.”

The group will begin meeting in January 2022.

Call for Abstracts

Call for abstract and video submissions Nov. 17, 2021, to Jan. 12, 2022

Learn more: vascular.org/vam

vascularspecialistonline.com | 17

LEADERSHIP

‘Leveraging multiple teams and cardiovascular specialists’ This quarter’s Leadership Corner features Young Erben, MD, interviewing Charles B. Ross, MD, chief of vascular and endovascular services at Piedmont Heart Institute, Piedmont Hospital, Atlanta, since 2012.

I

am highlighting the innovative work of Dr. Ross, current medical leader of the Southeastern Vascular Study Group (SEVSG) and president of the Georgia Vascular Society. Dr. Ross is an advocate for vascular service providers and a well-respected vascular surgeon within his region. He understands the unique stresses placed on systems for vascular care and the providers and teams who must provide that care “in the trenches.”

Many of us are certainly reminded when we highlight Dr. Ross of the daily challenges we face while trying to juggle the needs of the patient, hospital system and of all providers involved within a hospital system.

Dr. Ross was recruited from the University of Louisville to the Piedmont Heart Institute, Piedmont Hospital, in 2012. The Institute was experiencing tremendous growth and development of all facets of its cardiovascular service line. Dr. Ross recognized the synergistic advantages of development of a system to care for all non-coronary vascular emergencies for the institute, the hospital and the healthcare system, and introduced the concept of a level one cardiovascular emergency program. Dr. Ross was teamed with Dr. William Morris Brown, Piedmont Heart Institute chief of cardiac surgery, to lead this effort. Dr. Ross gives credit to Drs. Michael Dalsing, Gary Lemmon, Arthur Coffey and the team at IU-Methodist in Indianapolis who mentored the Piedmont team. He said, “Basically, we adapted the groundbreaking IU-Methodist level one system to the needs of Piedmont and its metro Atlanta and north Georgia community—incorporating not just acute aortic syndromes, acute limb ischemia and ‘other’ vascular emergencies like acute mesenteric ischemia and venous catastrophes, but also acute pulmonary embolism response.” This required leveraging multiple teams and cardiovascular specialists as well as supporting consultants. The Piedmont Level I Cardiovascular Emergency Program went “live” on July 1, 2014, and has since served over 1,300 major emergencies.

Several questions come to mind when we encounter unique leaders like Dr. Ross.

What inspires you?

CR: Patients and teammates inspire me. The bravery of patients facing life- and limb-threatening situations is never lost on me. Daily inspiration may also come from a special nurse who provides critical and compassionate care, a perfusionist incredibly tired from overwork who works extra hours to support the ECMO program, or an advanced practice provider (APP) who spots an important piece of data that meaningfully changes a plan. Or watching my partners plan a complex aortic Charles B. Ross

18 | Vascular Specialist

endovascular reconstruction, or observing them develop a vascular service line at a satellite hospital—seeing progress in action. Everyone in the trenches being the best they can be—little things that sometimes no one else seems to see—inspire me.

What keeps you passionate about what you do?

CR: Vascular surgery as a specialty is the source of my passion. It is the history of vascular surgery, my everlasting appreciation of those who trained me, and my desire for the whole world to appreciate the miracles we produce, or contribute to, every single day. Turning passion to productive works, involvement with regional vascular societies, the PERT Consortium, and Society for Vascular Surgery (SVS) have been key for me. Failure pushes me forward as well. The present “fireman” struggle that all vascular leaders are facing has been particularly difficult for me. Piedmont is a large hospital with one of the highest acuity ratings of all “community hospitals” in this country. And, we have a large system of satellite hospitals unable to provide advanced vascular care much of the time. My partners and I live the role of “firemen of the hospital and system,” often multiple times daily. We do so in absence of resident and fellow support. Despite the attention offered by our SVS to this issue, I have been unable to achieve recognition and tangible support for my team for our contributions to the mission of the hospital and healthcare system as a whole.

I am continuing to work with our administrative team to quantify and gain credit for our efforts.

What about collaboration—you are known as someone who values multispecialty involvement. Can you elaborate?

CR: Collaboration works best when there is mutual respect, concern and empathy among team members. This was highlighted by Drs. Ali AbuRahma and Mark Bates in a special session at the Vascular Annual Meeting (VAM) this year. I felt as if my Piedmont colleague in interventional cardiology-vascular medicine, Dr. Andrew Klein, and I could have given the same talk with the same message. If an acute pulmonary embolism presents to me on call and I am in a case, it is seamless for me to call Drew and ask him to take it, and vice versa.

The taxonomy of our specialties does not matter.

The same is true for interventional management of acute limb ischemia.

Another major example of

Piedmont Heart and Vascular Institute collaborative effort is our cardiac and vascular surgery teamwork in offering comprehensive management of all acute aortic syndromes and complex aortic elective surgery.

Issues do arise that can be very destructive to collaboration, but they are imposed at higher levels than the trenches in which we provide patient care.

Differential payment based on specialty taxonomy for identical work is demoralizing. Marketing that favors one specialty above another and provides misleading messages that can change practice patterns is also troubling. These actions undermine collaboration.

Multispecialty collaboration in absence of incentives to support such activities creates winners and losers. For example, a hospital may wish for its vascular surgeons to support other services. But, if the hospital fails to recognize the opportunity lost by having a vascular surgeon on standby for six hours, without any billable service, what it is really asking is for vascular surgery to underwrite the other service. Of course, the vascular surgeon wants nothing but good care for patients, and vascular surgery wants to contribute to programs that are good for the hospital. But, in relative value unit (RVU)-driven compensation plans, or, worse still, private practice, vascular surgeons personally take a loss for participation. There are innumerable such examples, and we cannot be “shamed” into not speaking up. In my experience, for complex reasons, including historic undervaluation for vascular procedures as compared to others, vascular surgery ends up on the short end of the stick much of the time.

C C M M

What keeps you grounded?

CR: My colleagues and my family. I am so fortunate to have the most supportive and stable vascular partnership at Piedmont, and in the greater vascular surgical community in Georgia as a whole. Moreover, the national support I have felt has been so appreciated.

The ability to pick up the phone, and call mentors and colleagues for advice on administrative problems and manpower has been a great advantage. SVS membership has been foundational for me. More than anything, my participation in the SVS reminds me that I am not alone. Colleagues in the Young Erben participated in the PERT Consortium also represent 2020 Society for Vascular Surgery important sources of counsel (SVS) Leadership Development and gravitas for me. The PERT Program and is one of the community, both here in metro recipients of the 2021 Leadership Atlanta and nationally, basically Mastery Grant. She has been defines a multispecialty, multiable to use her skills learned institutional effort with a singular during the course to bring multimission—to reduce mortality and disciplinary teams together to morbidity of acute pulmonary address several vascular needs embolism. The chance to be part in her community. The Mastery of an effort to have a measurable, Grant permitted her to take positive impact on a frequently the Career Advancement and fatal disease process has been one Leadership Skills for Women of the most rewarding activities in Healthcare course offered in which I have ever engaged. But,

by Harvard Medical most importantly, it is my wife School and directed of 41 years, Kim, who tolerates

by Julie Silver, burdensome Epic activity, multiple MD, a renowned conference calls resulting in late innovator at dinners, and other academic and supporting nonclinical duties which tend to healthcare consume weekends. change and It is also our children, all working to hard workers and successful improve in their own early careers. disparities in Young Everything hinges on Kim the medical Erben and family. workforce.

Mastering leadership

December 2021

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SVS PAC

The time has come for everyone to walk the talk!

BY MARK SMITH, MD

The last time I looked, vascular surgeons were known for at least two qualities: being good problem-solvers and being realistic.

In everyday life, the vascular surgeon needs to solve a myriad of problems that present. Do the symptoms of this patient with blockage of femoral arteries need an intervention or continued conservative management? If intervention, what form does that take—percutaneous or open surgical? What is the best post-procedure medical anti-coagulation regimen for the patient with a recent stent placement and a history of duodenal ulcer?

FOR THE PAST YEAR, I HAVE HAD THE HONOR of serving on the Society for Vascular Surgery (SVS) Political Action Committee (PAC) Steering Committee.

During that time, I have achieved a greater understanding of the political issues that face vascular surgery and the future of the profession. Unfortunately, our ability to take care of our patients and direct compensation therein

are controlled by the actions of Congress. as a duty to our patients and ourselves. What Therefore, any influence we may want is sad is that fewer than 5% of the membership to have on these decisions, by definition, contributes to the PAC presently. A goal of requires interaction with those elected doubling that donor rate to 10% seems to be politicians in order to educate them and to a mighty undertaking. Yet, if we achieve this, persuade them to make better choices for our it means that one out of 10 members would patients and ourselves. This is the job of the be supporting the PAC activity for nine others SVS PAC in a nutshell. who are not. I hear lots of members talk the Mark With the Centers for Medicare and talk about how we need to make Congress Smith Medicaid Services (CMS) cuts on the horizon, see the light and increase the support for the SVS recently conducted a Town Hall to vascular surgeons so our patients can receive Unfortunately, improved treatments and get better outcomes. further explain the potential outcomes of the proposed cuts (see this month’s cover story). our ability to Everyone, and I mean every member of the In all, these proposed federal cuts would SVS, should feel it incumbent upon themselves take care of to contribute to the PAC for the common good impact vascular surgery by more than 11%, which is unsustainable for many vascular our patients of the Society and our field of medical care. I practices and our patients. hope that you agree with this stance. and direct Our most effective tool in terms of The 5% figure should really reflect those compensation members who have not contributed yet to communicating the devastation of these cuts to members of Congress has been through therein are the PAC, not the other way around as it exists PAC activity. This highlights the immediate Any amount will do. We are now in the controlled by today. necessity for this activity to continue and holiday season, during which giving thanks the actions and exchanging gifts is the mode of the day. I expand in order to influence the action.

Getting back to realism and problem of Congress hope that every member of the SVS will take solving: The problem to solve is how to some time to contemplate the existential crisis best establish relationships with our elected facing medical care today and the need to get officials so that the SVS may track the timing of their Congress pointed in the right direction. I believe it should decisions, try to educate them about the real facts on the then be an easy decision to contribute to the PAC. In ground in terms of patient care, and to—hopefully—sway addition, after you make the donation, I hope that you will them to take positions that will reflect the best decisions talk with every other vascular surgeon member you know for our patients and our practice of vascular surgery. to urge them to do the same.

This is exactly what the PAC does for you. Your PAC Please walk the talk. Wishing all of you and your contributions go to further the voice of the SVS and families a happy and safe holidays. vascular surgeons in Congress. This responsibility should be a communal one. That is, the need to contribute money MARK SMITH is a member of the SVS PAC for PAC activities falls on every member of the SVS equally Steering Committee.

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December 2021

CODING

Explaining the No Surprises Act

BY FRANCESCO AIELLO, MD, AND ANGELA L. CONFOEY, MHA

The vast scope of the No Surprises Act—legislation signed into law late last year—may mean some Society for Vascular Surgery (SVS) members are not aware of its provisions.

T

he No Surprises Act is part of the Consolidation Appropriateness Act of 2021 to address surprise medical billing at the federal level. This year, the Department of Health and Human Services (HHS) published interim final rules, “Requirements related to Surprise Billing” parts I and II. The underlying premise is to protect patients from surprise bills for emergency services and certain scheduled services provided by out-of-network clinicians at innetwork facilities while providing greater transparency for healthcare costs. The act outlines professional reimbursements for out-of-network services and establishes an independent dispute resolution process to help facilitate provider reimbursement from health plans.

What’s in the act? Let’s start with emergency services. Under this new legislation, patients will not be subject to bills by out-of-network providers at innetwork facilities beyond those expected if the care had been completely in-network.

The health plan must reimburse the provider directly rather than bill through the patient. The patient’s share, often the “surprise bill,” will be based on a costsharing obligation (co-pay/deductible for emergency services) at his or her existing in-network rate. But what is the actual out-of-network rate? The new rate for professional reimbursement will be based on the “recognized amount” and “qualifying amount.” Under these concepts, the reimbursement is determined

by specified state law or All Payer Model agreement, if applicable. If neither apply, as in most cases, then the out-of-network rate is determined by an agreement between the provider and the payer but will most likely default to the qualifying payment amount (QPA). The QPA will be based on the health plan’s median in-network rate for the same or similar services.

Therefore, the provider will receive an “out-of-network” reimbursement based on any state laws (i.e., all-payer rate-setting model), a rate agreed upon by the payer and provider, or the QPA. What about non-emergency services performed by out-of-network providers at in-network facilities (i.e. the provider sees a hospital consult but is out-of-network while the hospital is in-network)? The patient will pay the same as expected had the provider been in-network. The provider will be reimbursed based on the QPA and may not balance-bill (charge patients the difference) for certain services unless they meet the notice and consent for out-of-network services guidelines.

However, certain provisions can affect reimbursement for our services. What happens if there is a dispute between the health plan and the provider?

The No Surprise

Nominate ‘giver, doer’ for Excellence in Community Service Award The Society for Vascular Surgery (SVS) is asking members to consider who among the many excellent vascular surgeons they may know in community practice might be worthy of nomination for the 2022 SVS Excellence in Community Service Award.

APPLICATIONS FOR THE HONOR—OPEN ONLY to those who practice in the community setting—are due Feb. 1, 2022.

December 2021

Act provides legal recourse through arbitration. The independent dispute resolution (IDR) is a binding process to settle these differences and has been described as a “baseball style” arbitration where each party submits their case and expected payment. While the IDR can consider other factors such as level of training, patient acuity and teaching status, among others, they have been directed that the QPA is the most significant factor when deciding between offers.

This raises concerns as it deviates from the original guidelines for determining reimbursement. In particular, if a physician or group fails to agree on reimbursement rates and subsequently does not contract with the health plan, they are considered out-of-network—even if the facility is innetwork. According to the No Surprise Act, the health plan would reimburse these clinicians based on the QPA (the

The patient’s share, often the “surprise bill,” will be based on a cost-sharing obligation at his or her existing in-network rate plan’s median in-network rate), essentially bypassing any prior negotiations and potentially adversely affecting any other negotiations going forward.

Finally, for those uninsured/ self-pay patients, or those who pursue selfpayment if services are denied by their health plans, the “convening” provider (primary provider) will be required to provide a Good Faith Estimate for all scheduled services (>3

It may be hard for some to define the qualities that denote “excellence” among their community practitioner colleagues. To help get those thoughts going, here are some of the actions of past recipients, who give and do much: ■M entored students, from high school to medical school and beyond ■W ith partners, were early champions of “best practices” that included standardized group protocols and new technologies ■V olunteered on mission trips ■A ctive in SVS or local and state vascular surgery organizations ■H elped create a network of rural satellite clinics, plus a mobile vascular lab that took care to patients’ homes ■W ritten more than 100 peer-reviewed articles on improving ways to deliver patient care ■E levated the profile of vascular surgery with regular scientific presentations at state and local levels

days out), or upon request by the patient.

This estimate will provide expected charges for all services, both professional (including co-providers or any other clinician that will be providing billable services) and facilitybased. For a surgical procedure, these charges should include the surgery, any labs or tests, and anesthesia care. While the co-provider provision has been delayed until Jan. 1, 2023, all other services and their associated charges and discounts must be provided in an itemized fashion for the patient’s review prior to any intervention.

There are rigid timeline requirements and penalties, as well as recourse, if actual costs are higher than estimates (currently ≥$400 difference can trigger an appeal). This will require coordination between provider(s) and medical facilities to ensure appropriate estimates and subsequent reimbursement.

Lastly, this rule does not impact any bills generated when both the provider and facility are out-of-network.

This bill covers numerous other issues such as batch claims, audit processes, price comparison tools, continuity of care, etc., which are well beyond the scope of this article. We advise all providers to converse with their medical facility and/or group practice managers to help formulate a plan.

Clinicians should also utilize resources provided by national organizations such as the American Hospital Association (AHA) and American Medical Association (AMA) to ensure up-to-date information.

References: 1. h ttps://rules.house.gov/sites/ democrats.rules.house.gov/files/BILLS116HR133SA-RCP-116-68.pdf 2. https://www.cms.gov/newsroom/fact-sheets/ requirements-related-surprise-billing-partii-interim-final-rule-comment-period

FRANCESCO AIELLO is a member of the SVS Coding Committee, a professor of surgery at the University of Massachusetts Medical School, and chief medical officer of Revenue Management, UMass Memorial Health.

ANGELA L. CONFOEY is associate vice president in the Hospital Central Billing Office at UMass Memorial Health.

■ I n collaboration with a local community college,

assisted in developing one of the first accredited training programs for Registered Vascular Technologists in the country ■ I nstrumental in bringing modern vascular surgery to a rural community ■D eveloped practice guidelines for preventive screenings and follow-up of high-risk vascular patients, leading to tracking and outreach programs to improve the quality of the vascular care for patients proactively To be considered, applicants must be community practitioners and have been in practice as a vascular surgeon for at least 20 years. They also must have been an SVS member for at least five years, as well as demonstrate evidence of impact on vascular care or community health.—Beth Bales Learn more at vascular.org/CommunityServiceAward.

vascularspecialistonline.com | 21

COMMENTARY

Corner Stitch A society primed for young vascular surgeons, trainees and medical students

BY CHRISTOPHER AUDU, MD, AND LAURA MARIE DRUDI, MD

Welcome to December where the calendar is filled with abstract and registration deadlines to various meetings through the summer of 2022. In this month‘s column, we are highlighting the Vascular and Endovascular Surgery Society (VESS). Formerly known as the Peripheral Vascular Surgery Society (PVSS), VESS traditionally holds its winter annual meeting at a ski resort and is renowned for its casual attire dress code at its meetings. VESS is chic and boasts a loyal membership. But what is its secret sauce?

TO FIND OUT, WE’VE INVITED TWO YOUNG SURGEONS AND A PAST president to share their VESS origin stories and more. Matthew Smeds, MD, is the chief of vascular surgery at the St Louis University Hospital, St. Louis, and is involved with several VESS committees; Venita Chandra, MD, is the vascular surgery fellowship and residency program director at Stanford Health Care, Stanford, California, and co-chairs the resident education committee at VESS; and Matthew Corriere, MD, is a vascular surgeon at the University of Michigan, Ann Arbor, Michigan, and the immediate past president of VESS. Here’s what they had to say: MATTHEW SMEDS

On his VESS origin story: I was encouraged to attend the VESS (then the PVSS) winter meeting during my vascular surgery fellowship by Brian Peterson, a younger faculty member at my institution.

I presented a paper on the early use of the C3 excluder in high-risk aortic necks and was blown away by the camaraderie, openness to discussion, and support of trainees, medical students, and young faculty by the membership.

Another defining moment was the then VESS president (and one of my mentors from medical school) Karl Illig walking into the morning session where I was supposed to present. He was in his bathrobe and making an announcement that if we were wearing ties, we were doing it wrong (in response to which I slowly removed my tie!).

After becoming faculty, I began to regularly attend the winter meeting; I’ve been to all but one since graduation, and

22 | Vascular Specialist

an early mentor of mine, Peter Nelson, encouraged me to get involved with society committees. I became a member of the program committee for the spring meeting and have been involved in many other committees since then.

On VESS and developing a surgical career: VESS has been instrumental in my career development, as it’s given me the opportunity to have a voice in a national society both by my involvement with the societal committees, but also as a platform in which to present research and network with like-minded surgeons.

I have gone on to collaborate with many individuals who I’ve met at the meeting, or in committees, and developed good friendships with many. I think the best thing about VESS is the society’s openness to involving young vascular surgeons. It’s very easy to get involved and contribute.

You don’t have to be a “bigwig” or have gray hair. And, what’s more, I feel a lot

of things are actually accomplished by the various committees, as it’s a much easier society to navigate than some of the larger surgical societies. One example was an idea we had to create a virtual residency fair during the first year of COVID for medical students who were not able to travel to visit institutions. I proposed the idea in June, and the society made it happen by September with very little red tape.

What VESS has to offer young surgeons and trainees: VESS has many wonderful opportunities for medical students, trainees, and younger faculty. The medical student education program during the winter meeting is a great opportunity for students to learn about vascular surgery, experience a national vascular meeting, and meet surgeons, other students/trainees, program directors and leaders of institutions across the country in a very non-threatening and enjoyable atmosphere. VESS has sponsored virtual residency fairs yearly for the past two years that will likely continue, and this provides applicants the opportunities to meet with programs from across the country prior to the interview season.

Similar to the student program, the resident/fellow educational session is a great chance for trainees approaching

Twitter or Instagram and to check out the VESS YouTube channel that has prior meeting presentations, as well as surgical technique videos uploaded. VESS is truly the premier society for young vascular surgeons. Any medical student, vascular trainee, or young surgical faculty should try to get actively involved. You won’t regret it.

VENITA CHANDRA

On her VESS origin story: I first got involved in VESS as a vascular surgery fellow several years ago now. I found the programming for trainees at the time really helpful—targeted and thoughtful topics that were very relevant to me at that point. I also appreciated the opportunity to listen in on the conference. It was so refreshing to hear good science in a more casual environment. I was rubbing shoulders with people I looked up to, finding them all very approachable. Meeting people at this conference was a key part of my feeling like I “belonged” in the vascular surgery community.

VESS and developing a surgical career: As I mentioned above, the casual and more laid-back environment allows a chance to break the ice with many people you look up to from afar. This opened the doors for me to be involved in various

“Meeting people at this conference was a key part of my feeling like I ‘belonged’ in the vascular surgery community” Venita Chandra the end of their training to network and learn about the “real world” (and attend the VESS winter meeting if they haven’t already). During the spring meeting held at the Society for Vascular Surgery (SVS) Vascular Annual Meeting (VAM), the opportunity exists for young faculty to be “discussants” for abstracts being presented. This helps them get familiar with standing up in front of a crowd and discussing a paper/asking questions of presenters.

For young surgical faculty, opportunities such as the mentorship program, the travelling fellowship, and committee positions/involvement can help them get involved and active in the society.

For everyone, the opportunity to submit abstracts for presentations is great, and the society really embraces hearing new voices and topics during its meetings.

My rule is to always have something submitted to VESS, and you should too!

Finally, there are significant opportunities in social media to take part in societal happenings. I’d encourage everyone to follow the society (@VESurgery) on

collaborations, get invitations to various conferences, and, in general, have a wider audience of people I called friends and peers across the country.

On opportunities from VESS worth highlighting for younger surgeons and trainees: The trainee programs are really great. Great topics, good opportunities to get to know each other and start the process of getting to know a lot of the other members of this amazing society!

Honestly, it’s the relationships and friendships that come from this meeting that make VESS the amazing society that it is. As Dr. Smeds has outlined, we want you in VESS. MATTHEW CORRIERE

Reflections on VESS from a midcareer vascular surgeon: My first VESS meeting was in 2004, and I was a general surgery resident at the time.

Back then, the society was a bit smaller and called the PVSS. I had been to a few other academic conferences by then, but it was clear on the first morning

December 2021

that this one was different in several wonderful ways. The attire was informal, and the interaction was more personal and relaxed. I could see the presenters’ faces without the need for big-screen projection. The queue at the microphone seemed almost inviting—the people in the question line did more smiling than scowling, and some of them even had natural hair that was not yet gray. Faculty, trainees and families mingled between sessions, and the discussions seemed unexpectedly pleasant.

People were getting re-acquainted on more than just work. “What gives?” I thought. Some of these folks were the same successful vascular surgeons I had previously encountered elsewhere in more sterile meeting environments. They were up-and-comers in the field whose names could be found on prominent textbook chapters and journal articles.

At VESS, however, the vibe was different. With everyone sporting resort wear and surrounded by snow-covered peaks, there was a curious lack of politics, power lunches, or jockeying for position.

I wondered if it might be a group case of altitude sickness, but it turned out

SCVSS_2021_PrintAd_9.75x5.625.indd 1

December 2021

that people were just relaxed and having fun.

Attending VESS for the first time: Speaking of altitude, my first VESS meeting was also my first trip to Steamboat Springs, Colorado. My mentor and lab predecessors had alerted me to anticipate wonderful outdoor recreation opportunities. I had to borrow my gear from a fellow resident who did not need it that week (fortunately, he was

circumstances, one might take advantage of opportunities to laugh directly at attendings over circumstances that seldom arise at work, such as being out of shape, becoming a “yard-sale” (a term I learned after unknowingly demonstrating it to an esteemed New Englander colleague), or even publicly displaying hat-head hair chaos. As a young resident scraping by each month to put food on the table and pay the mortgage, I never would have made that first trip without the presentation opportunity. I left feeling energized and incredibly grateful.

“The networking, committee and leadership opportunities VESS creates are unparalleled, and seldom available elsewhere for earlycareer surgeons” Matthew Corriere pursuing another specialty that will go unnamed but frowns on informal dress and seldom appreciates the concept of fun outside the hospital).

As it turns out, both fun and laughter ensue when well-rested vascular surgeons convene in a beautiful place while separated from pagers, the emergency room (ER), vascular emergencies, and other interruptions. Under these

Great science coupled with great relaxation: Reflecting on my experiences with VESS over the past 17 years, I have acquired gray hair of my own. Other more pleasant epiphanies also come to mind. I have lost count of how often I have returned with my wife and kids (who are now adults), who caught on quickly and began reminding me on the trip home each year to earmark abstracts for next

time. The meeting is no longer a secret— VESS has outgrown some of the smaller venues and hotel demand consistently exceeds supply.

Correspondingly, the submissions are increasingly competitive, and it is never a given that a high-quality abstract will make the program (case in point: the Corriere lab got skunked this year, demonstrating absence of bias favoring the immediate past president).

Beyond the meeting, VESS has blossomed into a vibrant society working year-round on issues dear to young vascular surgeons like clinical practice, diversity, education and career development.

The networking, committee and leadership opportunities VESS creates are unparalleled, and seldom available elsewhere for early-career surgeons. I am also enjoying the swap from presenting at the podium myself to getting trainees and students up there for the first time. So, become a member; sign up here: www. vesurgery.org/my-vess.

CHRISTOPHER AUDU is a vascular surgery resident at the University of Michigan in Ann Arbor, Michigan. LAURA MARIE DRUDI is a vascular surgeon at Centre Hospitalier de L’Universite de Montréal.

11/11/21 3:48 PM

vascularspecialistonline.com | 23

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FALL ROUNDUP

New attending call model aimed at fatigue mitigation produces ‘stable’ workflow

Viz.ai reveals launch of new AI-powered modules for pulmonary embolism, aortic disease

A “paradigm shift” in attending call staffing with a focus on fatigue mitigation can be undertaken in a vascular surgery practice without disruption to clinical productivity, a study presented at the New England Society for Vascular Surgery (NESVS) annual meeting (Oct. 15–17) in Cape Neddick, Maine, demonstrated.

A research team implemented an attending call model similar to a resident “night float” in 2018 with the intention of limiting the number of continuous hours of coverage undertaken. “Attending wellness should be the aim of further interventions and study,” Elizabeth Blazick, MD, a vascular surgeon at Maine Medical Center in Portland, Maine, et al concluded. They had carried out a comparison of operative work relative value unit (wRVU) productivity before and after implementation of the weekly model.—Bryan Kay

Viz.ai—a company focused on artificial intelligence (AI)-driven intelligent care coordination—announced the U.S. commercial launch of its AI-powered modules for pulmonary embolism (PE) and aortic disease at the 2021 VEITHsymposium (Nov. 16–20) in Orlando, Florida.

The new modules allow for faster clinical decision-making and improved care coordination for patients suffering from these two life-threatening conditions, the company revealed.

Users can access all aortic and pulmonary imaging from the cloud, enabling care coordination regardless of geography, it added.

“This technology has changed the way we triage and treat stroke patients, dramatically improving their care,” said Richard Saxon, MD, of Tri-City and Palomar Health, San Marcos, California.—Bryan Kay

Smoking status ‘should not deter nor delay’ endovascular intervention in fempop vessels Smoking does not seem to affect reocclusion rates, interval to reintervention and the total number of interventions in peripheral arterial disease (PAD) patients with stents in the femoropopliteal segment, new research showed.

These were among the findings delivered by Sascha Wodoslawsky, BA, a medical student at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia during the Eastern Vascular Society (EVS) annual meeting (Sept. 23–26) in Charleston, South Carolina.

Wodoslawsky and colleagues set out to assess the relationship between smoking status and various different variables, probing three groups: current smokers, former smokers and never smokers.

They were operating against a backdrop of two decades’ worth of published studies showing “completely polarizing views,” she said—from those indicating that smoking 10 or more cigarettes was beneficial in reducing the rate of restenosis, to a more conventional view around smoking increasing the risk of graft failure or increased restenosis rates.

The 10-year retrospective chart review looked at the records of 287 patients, 36.6% of whom were current smokers, 48.8% former smokers and 14.5% never smokers.

The researchers found no significant difference in the likelihood of reintervention for in-stent restenosis, total number of reinterventions and interval to stent reocclusion between the three categories.—Bryan Kay December 2021

Amplifi vein dilation system demonstrates ‘encouraging’ clinical results in dialysis access Artio Medical announced that full results from its first-in-human clinical study of the Amplifi vein dilation system were presented at the 2021 VEITHSymposium (Nov. 16–20, Orlando) by Surendra Shenoy, MD, associate professor of surgery in the Washington University School of Medicine at Barnes-Jewish Hospital, St Louis.

“Data from the first five patients treated with the Amplifi system demonstrated more than a doubling of forearm and upper arm cephalic vein diameters following a mean treatment period of 8.6 days,” said Shenoy.

“We were able to successfully create an arteriovenous fistula (AVF) using treated veins in all patients and observed rapid and robust AVF maturation. These data are very encouraging, and I believe this technology has the potential to offer a much-needed solution for increasing AVF suitability and reducing maturation failure.”

The Amplifi vein dilation system is designed to stimulate arm vein enlargement prior to AVF creation to make more patients requiring vascular access for hemodialysis eligible for AVF surgery, reduce the time required for AVF maturation, and increase successful maturation rates.

“In this study, three of the five patients had pre-existing problems in the cephalic vein, which were made more apparent by Amplifi system treatment,” Shenoy added.

“In one patient, an AVF was made more proximally and, in another, angioplasty was performed, and both patients went on to have successful AVF maturation and use.”— Jamie Bell

Which direction now?

Vascular surgery once again finds itself at a crossroads, Michael Belkin, MD, chief of the division of vascular and endovascular surgery at Brigham and Women’s Hospital in Boston, told the Western Vascular Society (WVS) annual meeting (Oct. 16–19) in Jackson Hole, Wyoming, during a presidential guest lecture on the art and science of critical limb ischemia (CLI).

“Again, it’s an existential crossroads,” he told attendees. “We made the right decision last time, years ago, when we adopted interventional therapies as part of what we do as vascular surgeons, and I

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think, again, we now have to embrace all our tools.” Belkin was discussing bypass surgery and the question of whether it would be a lost art, and whether endovascular-first would become endovascular-only.

“The question is: Can we reproduce the results of PREVENT III? PREVENT III was done by a generation of surgeons who were bypassfirst,” Belkin said. Will those be reproduced by the current BASIL and BEST-CLI trials? He has his doubts: Michael “The art of bypass surgery, Belkin I think, is threatened.”

So, to the crossroads: “With endo, we have to

Peter Schneider

Surgeons must stay skilled in femorotibial/ pedal bypass surgery, PVI audience hears At Paris Vascular Insights (PVI) 2021 (21–23 October, Paris, France), Peter Schneider, MD, of the University of California San Francisco, San Francisco, emphasized the need for trainees to learn both open and endovascular techniques in a talk on how to remain skilled in femorotibial/pedal bypass.

Schneider recalled that an “extremely important question” when he was a trainee was ‘how will we learn endovascular?’ A couple of decades later, “the shoe is completely on the other foot,” he said, noting that the question now is ‘how will the trainees learn femorotibial bypass or pedal bypass and/ or how will we maintain those skills?’

“Bypass is not disappearing,” the presenter declared, referring to a graph showing a downward trend but then a stabilization, at least of cases in the U.S. Instead, bypass is evolving, Schneider stated. “We are going to more distal targets, we are going after endovascular failure, and we are treating patients with worse disease morphology, and worse tissue damage in the foot.”

In addition to this evolution, Schneider noted that “we know a few things about how to get good results from bypass,” giving the example of better wound healing when there is a bypass targeting a specific angiosome.

Turning to the key question of how to remain skilled in bypass surgery, Schneider believes that this should be addressed from a programmatic standpoint that “really depends on the size of your program and the number of bypasses being done.”—Jocelyn Hudson

leverage the technology and advanced technical skills we have to get the best results, but we have to use it in an evidencebased application,” he argued.

“And we have to maintain our open skills so that we can offer patients the best therapy for them.

“To those of us who are privileged to train the next generation of surgeons: it’s on us to make sure that our trainees are exposed to the technical aspects— judgmental aspects—of bypass surgery so that they can carry this on in the future.”—Bryan Kay vascularspecialistonline.com | 25

Subscribe today

October 2021 Issue 01 www.renalinterventions.net

In this issue:

Twelve-month Wrapsody results at CIRSE 2021 page 4

Alexandros Mallios page 12

Dialysis:

Latest debates in dialysis care page 17

Transplantation:

Healthcare disparities in the spotlight page 20

Renal community reckons with removal of race variable in kidney disease diagnosis

Bioartificial device receives KidneyX award after reaching preclinical testing AN IMPLANTABLE BIOARTIFICIAL kidney device (iBAK) has moved closer to becoming a reality after being awarded a US$650,000 prize from KidneyX. The device’s creator, the Kidney Project, received this award following the first ever demonstration of its functional prototype.

The Kidney Project is a US-wide collaboration led by Shuvo Roy (University of California San Francisco [UCSF], San Francisco, USA) and William Fissell (Vanderbilt University Medical Center, Nashville, USA).

In the past few years, it has successfully tested the two essential components that make up its artificial kidney technology—a haemofilter, which removes waste products and toxins from blood, and a bioreactor, which replic ates other kidney functions, like the balance of electrolytes in blood—in separate experiments.

To secure KidneyX’s Artificial Kidney Prize, the team married these two units in a scaled-down version of the artificial kidney that is roughly the size of a smartphone and evaluated its performance in a preclinical model following successful implantation. The units worked in tandem, powered by blood pressure alone, to provide continuous renal replacement therapy without the need for blood thinning or immunosuppressant drugs. This technology, which is intended to provide patients with improved mobility and physiological outcomes compared to dialysis, will now be upscaled for more rigorous preclinical testing and, eventually, clinical trials.

For the latest step forward in the development of this device, the Kidney Project team was awarded KidneyX’s Phase 1 Artificial Kidney Prize—becoming one of six winning teams selected from a field of innovators across Canada, Israel, Japan, The Netherlands, Portugal, Singapore, South Korea, the UK, and the USA. Other recipient technologies included a wearable, lightweight, dialysate-free artificial kidney (US Kidney Research Corporation) and genetically engineered pig kidneys designed to increase supplies of transplantable organs (Makana Therapeutics).

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iBAK device

(Credit: UCSF)

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The National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) have jointly released a report outlining a new race-free approach to diagnosing kidney disease. In its report, the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease recommends the adoption of the new estimated glomerular filtration rate (eGFR) 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation that estimates kidney function without a race variable.

and subsequent treatment of kidney diseases,” said ASN president Susan Quaggin. “By recommending the CKD-EPI creatinine equation refit without the race variable, the task force has taken action and demonstrated how nephrology continues to lead the way in promoting healthcare justice.

It is time for other medical specialties to follow our lead, and NKF and ASN stand ready to help however we can.”

In the USA, more than 37 million adults have kidney diseases and 90% are not aware they have diminished kidney function, the NKF-ASN statement adds, with a disproportionate number of these patients being Black or African American, Hispanic or Latino, American Indian or Alaska Native, Asian American, and Native Hawaiian or other Pacific Islander. These patient groups also face “unacceptable” health disparities and inequities in healthcare delivery.

he task force has also recommended the increased use of the protein cystatin C—a commonly used biomarker of kidney function—combined with serum (blood) creatinine as a confirmatory assessment of GFR or kidney function. The final report, which has been published online in the American Journal of Kidney Diseases (AJKD) and the Journal of the American Society of Nephrology (JASN), was drafted with “considerable input” from hundreds of patients and family members, medical students and other trainees, clinicians, scientists, healthcare professionals, and other stakeholders, to “achieve consensus for an unbiased and most reasonably accurate estimation of GFR”, according to a joint statement from the NKF and the ASN. “This recommendation by the NKF-ASN task force is an important step forward in assuring health and healthcare equity,” said NKF president Paul Palevsky. “We commend the task force for the time, thought, thoroughness and effort it took to explore this issue deeply, and recommend the best path forward for us all. The NKF and ASN urge all laboratories and healthcare systems nationwide to adopt this new approach as rapidly as possible so that we can move towards a consistent method of diagnosing kidney diseases that is independent of race. While the work of the task force is an important initial path forward, both of our organisations are committed to continuing to work to eliminate disparities in the diagnosis and treatment of kidney disease.”

“As the largest organisations representing kidney patients and health professionals, NKF and ASN are committed to eliminating health disparities that harm kidney patients, and ensuring that racial bias does not affect the diagnosis

Developing race-free recommendations Over a 10-month period, the NKF-ASN task force organised its work into three phases. The first involved clarifying the problem and evidence regarding eGFR equations in the USA; the second involved evaluating different approaches to address the use of race in GFR estimation; and the third involved providing recommendations based on this.

In April 2021, the task force published its interim report on reassessing the inclusion of race in diagnosing kidney diseases in AJKD and JASN, asserting that race modifiers should not be included in equations used to estimate kidney function, and that current, race-based equations should be replaced by a substitute that is “accurate, representative, unbiased and provides a standardised approach

T

“The NKF and ASN urge all laboratories and healthcare systems nationwide to adopt this new approach as rapidly as possible so that we can move towards a consistent method of diagnosing kidney diseases that is independent of race.”

Paul Palevsky Continued on page 2

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NEWS BRIEFS

Planning underway for next VAM One of the innovations—livestreaming— introduced at the 2021 Vascular Annual Meeting (VAM), is influencing the 2022 schedule.

“The streaming option, particularly for international members, was a big hit,” said Andres Schanzer, MD, chair of the Society for Vascular Surgery (SVS) Program Committee, which oversees VAM educational programming.

This year, SVS offered a livestreaming option for those who for whatever reason were not able to attend VAM in person. Seventeen sessions were livestreamed—including all plenary sessions, named lectures, a number of international sessions and the two presidential addresses,

by Kim Hodgson, MD, and Ronald L. Dalman, MD. Because of the popularity of the international sessions, as well as the time zone differences, for 2022, planners have moved the international sessions to early morning. “This lets our international attendees who are livestreaming to watch the sessions geared toward them during the day, and not late at night,” said Schanzer.

The move also allows the Postgraduate Education Committee to schedule additional educational content in the afternoons, in the form of concurrent sessions and those planned with particular audiences in mind.

Schanzer stressed the section sessions will be educational in nature, planned in close collaboration with the section leaders and the committee, and focus on cutting-edge topics relevant to each section. “Of course, we’re still in the planning stages for all sessions,” he said.

“But the Postgraduate Education Committee wants to offer content that is timely, relevant and specifically focused to the members of those particular sections.”

VAM will be held June 15 to 18, 2022, in Boston, with educational programming across all four days. Exhibits will be open June 16 to 17, and the SVS Foundation Gala will be the evening of Friday, June 17.

Learn more at vascular.org/VAM.—Beth Bales

PAD training alert!

Numbers limited to

75

Don’t miss out. Register now—and enjoy early-bird pricing—for the Society for Vascular Surgery (SVS) Peripheral Arterial Disease PARTICIPANTS Workshop coming up early in the new year.

The SVS has capped enrollment at just 75 participants to ensure each attendee receives plenty of individual attention. The course—with four hours of hands-on surgical skills training— will be Feb. 11 and 12, 2022, in Rosemont, Illinois, minutes from Chicago’s O’Hare International Airport.

Because of the hands-on training, organizers said they expect the course to fill up well before the beginning of February. Early-bird pricing discounts will end in early January. —Beth Bales

For more information visit vsweb.org/VESAP.

December 2021

Deadlines coming up for three Foundation awards Deadlines for the Society for Vascular Surgery (SVS) Foundation’s Resident Research Award, Vascular Research Initiatives Conference (VRIC) Trainee Award and the Student Research Fellowship Award are coming up.

■R esident Research Award, due Jan. 12, 2022: This prestigious award is intended to recognize trainees who are performing basic and translational research under the guidance of a vascular surgeon-scientist mentor. The trainee presents his or her research at the Vascular Annual Meeting (VAM).

■ VRIC Trainee Award, due Jan. 11, 2022: This award recognizes trainees in general surgery or vascular surgery who are pursuing basic and translational research projects and invites them to present their research at VRIC. ■ Student Research Fellowship, due Feb. 1, 2022: The award supports undergraduate college students and medical students at universities in the United States and Canada who are carrying out laboratory or clinical vascular research projects.—Beth Bales­­

Apply for VQI Fellowship in Training program Residents and fellows interested in vascular disease and quality improvement may apply now for the Vascular Quality Initiative (VQI) mentor-based program. A scholarship of up to $10,000 will be available for five participants. Applications close Jan. 1, 2022.

The Fellowship in Training (FIT) program is offered by the Society for Vascular Surgery Patient Safety Organization (SVS PSO). FIT provides a mentor-directed opportunity for residents and fellows to engage in quality improvement and metrics through VQI regional study group participation and grassroots quality assurance opportunities locally.

The 12- to 18-month program encourages FIT participants to develop quality charters and improvement projects—including research—using VQI data for presentation at national VQI@ VAM meetings. Five participants will be eligible for a scholarship award of up to $10,000, named in honor of Jack L. Cronenwett, MD, who is a co-founder of the VQI. See additional information regarding the FIT program as well as the Trainee application at vascular.org/ ApplyForFIT. Contact Betsy Wymer at bwymer@svspso.org or Gary Lemmon, MD, at GLemmon@svspso.org with questions.—Beth Bales

Dues are due With the curtain about to close on 2021, SVS members are reminded to pay their 2022 dues by Dec. 31.

Members thus will experience no lapse in the substantial benefits that accompany membership in the premier organization for vascular surgeons.

These perks include Journal of Vascular Surgery peer-reviewed publications, as well as clinical practice guidelines and reporting standards to facilitate exemplary patient care.

Pay dues at vascular.org/Invoices; email membership@ vascularsociety.org for a paper invoice.

Meanwhile, the SVS recently debuted online membership applications, with helpful tips built into the process. Also new is a rolling “anytime” membership application process, with applications considered monthly. To learn more about membership and its privileges, visit vascular.org/JoinSVS. Graduated Candidates in year four of their membership must transition to Active membership. Those who missed the Dec. 1 application deadline should apply quickly so any lapsed benefits may resume.­—Beth Bales

Spotlight Former SVS President Anton Sidawy, MD, has been elected chair of the American College of Surgeons’ Board of Regents.

He is professor and the Lewis B. Saltz Chair of the department of surgery at the George Washington University, Washington, D.C. Erica Leith Mitchell, MD, is interim chief of the division of vascular surgery, plus professor in the department of surgery, in the College of Medicine at the University of Tennessee Health Science Center in Memphis, Tennessee. She also is medical director for vascular and endovascular surgery at Regional One Health.

(Send “Spotlight” or “In Memoriam” information to communications@ vascularsociety. org.)

‘Meet the Experts’ webinars now available OnDemand Society for Vascular Surgery (SVS) members now have another chance to “Meet the Experts,” via computer screen and at no charge.

Three of the “Meet the Experts” webinars held in spring and summer are now available on SVS OnDemand, part of the Society’s online education platform. These one-hour recordings include hemodialysis access aneurysms, type II endoleak prevention and management, and advanced techniques for inferior vena cava (IVC) filter removal.

Members have free access to these videos, each carrying 1 AMA PRA Continuing Medical Education (CME) credit. Nonmembers pay $35. Visit SVSOnDemand. vascular.org.—Beth Bales

Add ‘Smile’ to holiday shopping list It is easy for SVS members to donate to the SVS Foundation, all while shopping online.

For those who purchase items online at Amazon, please remember to start your shopping at smile.amazon.com, with the SVS Foundation your designated charity.

The Foundation will receive 0.5% of the cost of eligible purchases.

If it’s your first visit, you will need to select the SVS Foundation as your charitable organization. The website will remember your selection and, if you start your shopping on the “smile” site, will result in the Foundation receiving donations from your holiday purchases.—Beth Bales

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