Vascular Specialist, October 2020

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SVS advocacy Comment letter due over proposed changes to QPP

Vol.16 No.10 OCTOBER 2020

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FROM THE EDITOR SCIENCE AT TWILIGHT AS ELECTION LOOMS

IN.PACT ADMIRAL DCB SHOWS ADVANTAGE

KING AIR NANCY 559 SURGICAL LESSONS FROM MIDAIR EMERGENCIES

INTERVIEW SPECIAL

HODGSON: BRINGING APPROPRIATENESS INTO SHARPER FOCUS

BY BRYAN KAY

IN 2019, KIM HODGSON, MD, KICKED off his presidential year by placing appropriateness and quality of care under the microscope. His turn organizing the E. Stanley Crawford Critical Issues Forum at the 2019 Vascular Annual Meeting (VAM) saw the then incoming Society for Vascular Surgery (SVS) president tell the story of a cardiology and cardiac surgery team that had carried out hundreds of unnecessary procedures nearly 20 years ago.

A year later, he would tell this summer’s digital replacement for VAM: “Many thought that while it made a good story, it could not happen today.” Yet just a day later, VAM 2019 heard from Caitlin W. Hicks, MD, assistant professor of surgery at John Hopkins Medicine in Baltimore, about how new

methodology had identified a significant number of physicians whose practice patterns might indicate failure to adhere to guidelines of care, Hodgson explained during the SVS ONLINE gathering for his State of the SVS address on June 20.

Further research from Hicks et al was to follow at SVS ONLINE on June 25, sharpening a core point of Hodgson’s address and appropriateness focus. They revealed a higher use of atherectomy during peripheral vascular interventions among non-vascular surgery specialists and physicians working primarily in outpatient settings.

Together, the two talks, a year apart, neatly bookended his presidency.

Hodgson did

continued on page 4

Kim Hodgson prioritized appropriateness while president.

SVS SET, shown left, is now a post-presidential focus

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FROM THE EDITOR

Science at twilight: Reasserting our democratic responsibility

BY MALACHI SHEAHAN III

THOMAS JEFFERSON sat alone in a Philadelphia boarding house. He was nervous; much was riding on the words he would now write. The sovereignty of a nation, the coming war, and, perhaps most important to Jefferson, his own life. Ostensibly, he was writing to King George III, but the fighting had already begun, and he knew that cretin was beyond reason. He was writing to inspire Americans to rise up as a nation, but he knew in his heart that would not be enough. The audience Jefferson needed to reach consisted of European leaders. France, Spain, the Netherlands, maybe even Russia. Without their support, the rebellion would be short-lived, and Jefferson would be executed as a traitor to the crown. He would center his appeal around a tenet: Wherever men can use reason and science to establish the truth of something, no monarch had any greater authority to rule.

Jefferson, after all, was a scientist. He referred to his appointment as president of the American Philosophical Society as “the most flattering incident of my life,” despite already serving as vice president of the United States.

Jefferson loved to observe nature in all forms; he even kept a detailed log of the weather. One day, he recorded the outside conditions at 6 a.m., 9 a.m., 1 p.m. and 9 p.m.

Maybe not so unusual, but that day was July 4, 1776.

Science became a core component in the framework of our government. In the very first State of the Union address, George Washington told Congress, “There is nothing which can better deserve your patronage, than the promotion of science and literature.”

As the election nears, most of you identify as Democrat or Republican. Without abandoning your core beliefs, I would ask you to consider another affiliation—that of a scientist. Scientists can be progressive or conservative.

Their one shared political principle is anti-authoritarianism.

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 Drudi, MD Executive Director SVS Kenneth M. Slaw, PhD Director of Membership, Marketing and Communications Angela Taylor Managing Editor SVS Beth Bales

2 • Vascular Specialist

Tyrants have taken many roles: dictator, pope and king.

Regardless of the form, eventually he (it is usually he) needs to tear down the truth. And it is science that stands in the way.

Heresy In 1591, Giordano Bruno moved to Padua, presumably to apply for the vacant chair of mathematics at the esteemed local university. Bruno was a scientist and philosopher who held many views that were incongruous with the tenets of the Catholic Church. Bruno lost the mathematics appointment to fellow scientist Galileo Galilei, so he returned to Venice to continue his research and teachings.

Bruno spoke freely about his theories. The world was changing. Venice was a liberal state, a Protestant sat on the French throne, and the extremist Pope Sixtus V had died the year before. The Roman Inquisition appeared to be ending. Nevertheless, Bruno’s confidence was ill-founded.

He was arrested and tried for heresy. Initially, Bruno’s trial in Venice seemed to be going well, but he was suddenly deported to Rome and imprisoned for seven years. The Church offered Bruno a chance to fully recant his theories, but he refused. Bruno stated that he didn’t even know what he was supposed to recant. Bruno was confident though, even as his death sentence was delivered. He told the court, “Perhaps your fear in passing judgment on me is greater than mine in receiving it.” Again though, he had misplaced his faith in the seeming enlightenment that was starting in Europe. Shortly after, he was taken to the Campo de’ Fiori and burned alive.

Thirty-three years later, Galileo, the winner of the mathematics chair Bruno coveted, was also arrested for heresy. The Catholic Church still maintained a geocentric model of the universe with a stationary Earth at the

center. Galileo recanted his heliocentric teachings, although he is said to have muttered, “and yet it moves,” immediately afterward. Despite his recant, Galileo spent the rest of his life in prison.

Galileo and Bruno are, of course, earlier examples of the clashes between authoritarians and scientists. More recently, Albert Einstein fled Hitler’s Germany, Enrico Fermi escaped Mussolini, and famed biologist Nikolai Vavilov was murdered by Stalin. Authoritarians require control over everything for success, even the truth.

Scientific vitality The framers of our constitution saw scientists as leaders, integral to democratic rule. Over the years, we have abdicated this responsibility. Our government representatives are now mainly lawyers, politicians and bureaucrats. Industry and religion have far more prominent voices in policy decisions.

Why did Jefferson and Washington consider science to be vital to our nation? It has to do with how we think and reason—the scientific method.

The scientific method involves observation, skepticism about these observations, formulating hypotheses, then testing and refining these hypotheses. In the absence of scientists, the majority of our government employs what can be called the judicial method. The judicial method works backward, starting with a thesis (e.g. my client is innocent). Then all data which support this thesis are presented, while those which dispute it are omitted. Of course, scientists have another name for this approach: confirmation bias. The goal of the scientific method is to find the truth. The purpose of the judicial method is often

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to create doubt. In pursuing the truth, scientists are loathe to claim certainty. In that gray area, the judicial method thrives.

You’ve often heard that not all scientists believe in anthropological climate change; therefore, the “jury is still out.” A 2015 study found that of 69,406 published climate scientists, only four did not believe that climate change was driven by man. Consensus has been achieved. It has been achieved for decades. In 1965, President Lyndon B. Johnson said, “This generation has altered the composition of the atmosphere on a global scale through a steady increase in carbon dioxide from the burning of fossil fuels.” Many groups fear scientific agreement because consensus endorses action. The playbook is to create doubt and confusion. There is no need to attack the evidence directly, just build uncertainty and prolong the argument. The oil and tobacco industries perfected this tactic decades ago.

As one cigarette executive said to author David Michaels, “Doubt is our product.”

Other factors also allow misinformation to spread in our country. Jefferson strongly believed that the freedom of the press was crucial to democracy. He wrote, “Wherever the people are well informed, they can be trusted with their own government.” However, journalists are now taught that impartiality in reporting is impossible. Lies are treated as opinions, as alternate facts. Statements from every side of an issue are often presented without judgment of their accuracy. To avoid more politics, I’ll use two examples from my household.

Scenario one: Luke (age 7): There is a monster under my bed.

Me: Go to bed. There is no such thing as monsters.

Luke: There is, too. His name is Jeebus.

Sheahan Family Gazette: “Differing opinions arise on the threat posed by Jeebus”

U.S. population to take the correct actions? There are two systems in the brain to assess outside stimuli. The experiential is the stronger motivator for action. This system relies on emotion, images and stories. It is a predominant driver of the survival instinct. Conversely, scientific information, charts, graphs, numbers and probabilities are processed by the analytic system. This is a poor driver for quick action. Most of the methods we use for public outreach are processed by the analytic system. This is a mistake. The gruesome pictures placed on cigarette cartons in Europe are an attempt to appeal to the experiential system.

Television producers are well aware of these processing systems. A news story that has accompanying video is much more likely to make the air. Why has the number of Americans who accept the science of climate change

You cannot teach a man anything; you can only help him find it within himself ‑ GALILEO ‑

Scenario two: Me: We just got a credit alert for a $7,000 charge.

Claudie (wife): I bought some shoes.

Me: We can’t afford that kind of cost.

Claudie: It’s not a cost, it’s an investment. Besides, I’m going to win Powerball this week.

Sheahan Family Gazette: “Pessimists clash with optimists over household economic future” Humans are also conditioned to infer causality. Event A happened, then event B; so A caused B. Rising lung cancer rates in the 1950s were attributed to the tar used on new road systems. The 1890 flu was blamed on new electric light technology. Rising diagnoses of autism must be related to vaccine use. This instinct may have helped ancient man survive and, therefore, may be a result of natural selection. A caveman might think, “Grog ate the orange berries and now he’s dead. Guess I’ll skip the orange berries.”

Societal outreach Public faith in science has eroded to dangerous levels.

While evolutionary natural selection and anthropological climate change have scientific consensus, they are denied by about 60% and 35%, respectively. Anti-science beliefs arise from most political spectrums. On the left, science denial takes the form of unsubstantiated fear in items like vaccines, nuclear power and GMOs. So while the right often opposes regulations for proven dangers, the left favors regulating things that are generally safe.

In times of dire need, how can we motivate the

OCTOBER 2020

risen dramatically in the past 24 months? Probably because we are watching images of the West Coast burn and new hurricanes slamming the Gulf every week.

Scientists used to be quite adept at society outreach.

In the past, the majority of research funding came from public benefactors. Scientists would make a great production of their accomplishments and their amazing work to come. Research was a form of public entertainment; often the best showman was funded. In 1959, the Soviet Union’s success with the Sputnik program caused a panic in the U.S. Government funding of research would increase more than 12 times over the next decade.

Scientists dropped public outreach for grant applications.

And the National Institutes of Health doesn’t look too favorably on “showmanship,” at least in my experience.

Those scientists who still attempted to reach the public— like Carl Sagan—were often vilified. Consider your feelings for Dr. Oz. Another hurdle to public understanding is that science is no longer a core component of many liberal arts or humanities curricula. Most Americans have no exposure to science past high school. While the nuances of carbonbonding patterns may not be relevant to most careers, familiarity with the scientific method would be beneficial.

In other fields, students learn that truth is relative and experiential, and rarely are they presented facts that have achieved consensus after scrupulous research. To these graduates, truth is never settled.

War on politics Still, there are examples of scientists enacting public change. In the early 2000s, several government agencies had their messaging changed, presumably for religious reasons. “Theory” was inserted before every mention of the Big Bang on the NASA website. False equivalencies between abortion and breast cancer were inserted into Centers for Disease Control and Prevention directives.

The Department of Health and Human Services removed online references to the efficacy of condoms in preventing AIDS. Stem cell research funding was halted. Scientists reported being pressured to alter or delete climate change reports. Inspired by these events, Shawn Otto, author of “The War on Science,” gathered a group to form Science Debate in 2007. Thousands of Nobel laureates, university presidents and other notable scientists joined on. Their mission was to compel presidential candidates to address current scientific issues such as climate change, genetic research and pandemics.

In the 2008 presidential campaign, Harold Varmis, a Nobel Prize-winning cancer researcher, chaired then-candidate Barak Obama’s science and technology committee.

Varmis supported the Science Debate movement and convinced Obama to participate. Obama, who did not seem to have a particularly strong interest in science previously, was inspired by this experience. After the election, he announced the President’s Council of Advisors on Science and Technology, including several members of Science Debate. Obama also appointed actual scientists to prominent positions in the government, including the secretary of energy, director of the National Oceanic and Atmospheric Administration and the head of the U.S. Geological Survey. Science Debate has continued, receiving full participation from every major presidential candidate in the 2012 and 2016 elections.

A government that relies on the judicial method of analysis will amplify confusion, uncertainty and fear.

Despite a technological revolution, scientific ignorance appears to be rising. Half of American adults don’t know it takes the Earth a year to revolve around the sun (apologies to Galileo and Bruno; give us another 400 years?). More than a third believe that astrology is based on science.

More than 2 million believe the Earth is flat.

The pandemic exposed these deficiencies. When we desperately needed the American public to believe in medical experts, Anthony Fauci stated that a “general antiscience, anti-authority, anti-vaccine feeling” hampered the COVID-19 response. Masks, social distancing and other precautions were utilized sporadically in the early phases, similar to having a No Peeing Zone in a pool.

The American experiment began with a plan rooted in science. Jefferson and Washington realized the threat posed to democracy by ignorance. Scientists can no longer avoid civics and public outreach. We need to be involved in our government and communities. A role for scientists was assumed by the Founding Fathers. The republic is not designed to survive without us.

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. He is the medical editor of Vascular Specialist.

vascularspecialistonline.com • 3

INTERVIEW SPECIAL

COVER STORY

Hodgson: Bringing appropriateness into sharper focus Continued from page 1

not mince his words then. Neither was he sparing outliers eschewing “proper, guideline-directed care” in a recent interview as he looked back on an unprecedented presidential year interrupted by COVID-19. At SVS ONLINE, he said, the appropriateness lens was cast on atherectomy because Hicks’ research, subsequently presented at SVS ONLINE, had come to the attention of the Wall Street Journal (WSJ), which had asked the SVS to comment on what was an appropriate rate of use of atherectomy.

“While unable to answer that question specifically, we could look to our Vascular Quality Initiative (VQI) for insight, and the findings, presented in my State of the SVS address, were concerning,” Hodgson tells Vascular Specialist. I don’t want people to think I’m just hammering atherectomy, but the tremendous variation in use of atherectomy across physicians and the undeniable effect of site of service on utilization rates certainly raises the specter of inappropriateness. Having advance knowledge of what was going to be presented at SVS ONLINE on atherectomy and having analyzed VQI atherectomy utilization rates for the WSJ, I think it’s pretty obvious that we have an appropriateness problem with regards to atherectomy, undoubtedly encouraged by ill-conceived reimbursement policies.”

Practice outliers In the recent research, outpatient settings like office-based laboratories

(OBLs) and ambulatory surgery centers have thrust to the fore as outliers. Yet, Hodgson is careful as he outlines realities on the ground. “I think we need to be clear that we are not critical of OBLs themselves—a lot of great work is done by our members in this venue and the movement towards this site of service continues,” he says. “But they’re also an environment that has very little oversight.

I think we just have to acknowledge that. This lack of oversight has allowed those from specialties less well-versed in vascular disease, and perhaps appropriate indications for treatment thereof, as well as those with misaligned incentives, to jeopardize both patients and the integrity of our specialty itself. I also don’t want to portray this as a problem only because of cardiology, or only because of radiology.

We have plenty of our own who are not following the guidelines. But clearly, the lack of oversight in the outpatient environment has enabled this.”

The ultimate goal is greater accountability, Hodgson goes on. “It’s not a perfect world. Even the verification program that we’re working on with the American College of Surgeons— which is an extension of our VQI—is a voluntary process at this point in time.

Only the well-behaved are going to apply in the first place. But you have to start somewhere, and the goal is that we can set the standards through the verification program. This is something that is helpful to focus on a little bit: The verification program is going to set the standards for what is done and where it’s done for the treatment of vascular disease. For right now, it’s voluntary. But in the big picture, we believe that governmental agencies are

AVF schedules education series for trainees, early-career practitioners

BY BRYAN KAY

The American Venous Forum (AVF) is to stage a four-part series of educational sessions running the gamut of venous disorders aimed at residents, fellows and early-career practitioners in vascular surgery, interventional radiology and a host of other specialties.

THE LIVE, VIRTUAL COURSE—TAKING PLACE at 8 p.m. on each of Tuesday, Oct. 13, Tuesday Oct. 27, Thursday, Nov. 12, and Tuesday, Dec. 1—is designed

4 • Vascular Specialist

SVS SET: How it works

looking for someone to do this for them.

This may become linked in the future to payment. And that would be our ultimate win.” The verification program forms one plank of Hodgson’s post-presidency focus.

SET app SVS ONLINE also saw the unveiling of the Society’s new Supervised Exercise Therapy (SVS SET) app, conceived and shepherded through development by Hodgson, with technological development by SVS member Oliver Aalami, MD, of Stanford University, California, and powered by telehealth company Cell-Ed. The technology allows for home-based, doctor-prescribed exercise, which has been heralded as an advance on in-person SET as a first-line therapy to prevent surgical interventions and delay the progression of peripheral arterial disease (PAD). Hodgson is taking on a leading role as the Society seeks to move the app toward an eventual widespread rollout. Right now, SVS SET is in clinical trials in order to determine its efficacy. In that vein, Hodgson revealed the SVS recently struck an agreement with health insurance giant Anthem to help fund the app’s clinical trial process.

“It’s not a perfect world”— Kim Hodgson

to provide a formal didactic curriculum covering the spectrum of venous disease.

Each of the four sessions is focused on a specific area, including venous thromboembolic disease, superficial venous disease, abdominal and pelvic venous disease as well as an installment on interesting and challenging venous disorders.

The course will be hosted and delivered by nationally and internationally recognized experts in venous disease, incorporating in-depth presentations as well as questionand-answer sessions.

The program is directed by Kellie Brown, MD, professor of surgery in the division of vascular and endovascular surgery at the Medical College of Wisconsin, Milwaukee. Other hosts include Ruth Bush, MD, associate dean of medical education and a professor of vascular surgery at the University of Houston College of Medicine; Ellen Dillavou, MD, associate professor of vascular surgery at Duke University School of Medicine in Durham, North Carolina; Mark Meissner, MD, a professor of vascular surgery at the University of Washington Medicine department of surgery; and Steve

“SET has gotten a tremendous amount of traction,” he explains. “We’ve signed a deal with Anthem to fund phase two and phase three of the app. And they’re very interested in seeing how our app can be incorporated into patient care in their healthcare system. That’s a pretty big deal.” Kenneth M. Slaw, PhD, SVS executive director, says the deal with Anthem led to tentative talks over a larger relationship involving potential collaboration on value-based care models.

A final note of pride for Hodgson is the passage of Society election bylaw changes, enfranchising, he says, “all SVS members to vote in our elections for the first time in the history of our Society,” which saw three-times more members vote in 2020 than in the Society’s highest previous year.

Meanwhile, as Hodgson considers the year as a whole, there isn’t a hint of wistfulness of what might have been.

“COVID changed the way we approached some things—it may have slowed a few things down—but frankly I’m quite proud, and I think the SVS is quite proud, that we continued to move forward with a number of initiatives,” he says. Rather, what will endure are his proudest achievements: the ongoing quality initiative, the SVS Diversity, Equity and Inclusion Task Force he oversaw, and the bylaw changes, which came just as he was about to pass on the baton to Ronald L. Dalman, MD.

Elias, MD, director of the Center for Vein Disease at Englewood Hospital and Medical Center in Englewood, New Jersey.

The two-hour-long sessions were born out of the traditional Trainee and Early Career Course ordinarily offered in-person. There is no charge to take the course for either vascular trainees or fellows. Fees for early-career AVF members and nonmembers is $125 and $250, respectively.

Registration is required. Visit www.veinforum.org.

Kellie Brown

OCTOBER 2020

PACLITAXEL

IN.PACT Admiral DCB shows ‘significant advantage’ over uncoated devices in fempop artery treatment analysis

BY BRYAN KAY

The IN.PACT Admiral drug-coated balloon (DCB) demonstrated a significant advantage in overall survival, amputation-free survival and target-lesion revascularization after femoropopliteal artery treatment through four-year follow-up when compared to uncoated balloons, a single-institution, retrospective review that tackled a head-to-head comparison between two discrete paclitaxel-coated devices found.

FURTHERMORE, THE LUTONIX DCB (BD Bard) showed a less clear advantage in major outcomes compared to uncoated balloons. Meanwhile, between paclitaxel balloons, the IN.PACT Admiral (Medtronic) was found to be advantageous over Lutonix only in the arena of amputation-free survival.

The findings were delivered Sept. 9 by Alexander H. King, MS, from the division of vascular surgery and endovascular

therapy, at University Hospitals Cleveland Medical Center during the Midwestern Vascular Surgical Society (MVSS) virtual annual meeting (Sept. 9–12).

With three paclitaxel-coated balloons currently approved for use by the Food and Drug Administration (FDA), King and colleagues set out to compare outcomes between the two, noting there has been no prior head-to-head comparisons between paclitaxel-coated devices.

‘No signal of increased risk of long-term mortality’ with paclitaxel-coated Luminor DCB, EffPac trial finds

BY SUZIE MARSHALL

AN AD HOC, TWO-YEAR ANALYSIS OF THE EffPac study found no signal of increased risk of longterm mortality, nor any adverse events, within two years of drug-coated balloon (DCB) angioplasty using a Luminor-35 device (iVascular). This was the conclusion presented by Ulf Teichgräber, MD, of University Hospital Jena, Germany, at the 2020 meeting of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) held virtually from Sept. 12–15.

Teichgräber is the principal investigator of the EffPac trial, a prospective, randomized controlled trial initiated by the federal authorities in Germany, and conducted at 11 study sites, that compares the paclitaxel-coated Luminor balloon with plain balloon angioplasty in the femoropopliteal artery segment of patients with peripheral arterial disease (PAD).

The primary efficacy endpoint of this study was late lumen loss at six months; secondary endpoints included primary patency, freedom from target lesion revascularization (TLR), Rutherford category, anklebrachial index, and quality of life score. All-cause mortality and target limb amputation were assessed as the primary safety endpoints.

Just published in Radiology, Teichgräber described to the CIRSE audience how he and his team conducted an ad hoc, two-year review of mortality and morbidity following OCTOBER 2020

Some 1,419 patients who had undergone were 93.2% for the IN.PACT Admiral, femoropopliteal artery percutaneous 88.9% for the Lutonix, and 85.8% for the revascularization from 2010–2019 were uncoated group. “Again, the IN.PACT analyzed to determine how use of the two Admiral showed superiority over a devices impacts on survival, amputation non-coated balloon but there was not a rates and need for reintervention. significant difference between the two The patients were placed DCBs,” noted King. in one of three groups: 41.6% “Amputation-free survival were treated with an uncoated showed differences across all balloon, with 58.4% receiving a balloon types,” he continued.

DCB. Of the latter, 60.6% were “IN.PACT showed rates of assigned the IN.PACT Admiral amputation-free survival of and 39.4% the Lutonix. Primary 64.3%, Lutonix 57.5%, and outcomes included all-cause non-coated 46.6%. All three mortality, freedom from major were significantly different from amputation, amputation-free each other on Kaplan Meier survival and freedom from Alexander H. King analysis.” target-lesion revascularization.

In terms of freedom from Further, adjunctive stenting was used target-lesion revascularization, IN.PACT in 26% of patients, atherectomy in 17%, was found to have an advantage over nonand a combination of both in 3.6%. In the coated balloons. However, no differences paclitaxel group, atherectomy was more between the two paclitaxel-coated balloons common, while among those who received were observed. Four-year survival rates an uncoated balloon, angioplasty as a were 75.4% for the IN.PACT Admiral, standalone procedure and bare-metal stent 72.3% for the Lutonix, and 71.5% for placement were more common. non-coated devices. King said the research The results showed a four-year survival team was able to conclude that individual rate of 64.1% among those given the DCBs may not yield equivalent outcomes, IN.PACT Admiral device, 60.6% in patients but that “through four-year follow-up, treated with the Lutonix DCB, and 51% the IN.PACT Admiral showed a clear in those who received an uncoated device. advantage over uncoated balloons, while Rates of freedom from major amputation Lutonix had a less clear advantage.”

DCB angioplasty in EffPac patients. The two-year followup of the EffPac trial was in fact completed in February 2019, but another study cast its shadow over the results.

Konstantinos Katsanos, MD, et al published a meta-analysis in the Journal of the American Heart Association (JAHA) in December 2018 that found an increased association between late mortality risk and paclitaxel use in the femoropopliteal arteries. “Numerous public debates about the safety of paclitaxel-coated balloons were triggered”, Teichgräber recalled.

This led the Federal Institute for Drug and Medical Devices in Germany to request a formal hearing on mortality of all ongoing studies concerning paclitaxel use in the peripheral arteries.

While the EffPac trial could not confirm a correlation between paclitaxel application and all-cause mortality— there was one death in the DCB arm, out of a total of 82 patients, and seven out of 85 in the plain angioplasty arm—a lot of patients were lost to follow-up.

In total, the EffPac trial randomized 171 patients into two arms: those treated with the Luminor DCB (85 patients), and those who received plain angioplasty (86 patients). At 24 months, 60 patients were left in the DCB group, and 56 in the plain angioplasty group, due to a lack of follow-up in nearly one third of patients. This represented a discontinuation of 25 patients in the DCB arm, and 30 patients in the plain angioplasty arm.

Under entreaty from the German institute, Teichgräber set out to find those EffPac participants lost to follow-up in order to gain further information on two-year mortality rates with paclitaxel devices.

“Paclitaxel showed a very low [mortality] risk ratio of only 0.15 compared to other trials, meaning there is no correlation of all-cause mortality associated with Luminor balloons,” Teichgräber inferred from their results. “Another interesting aspect [to look at] is cause of death,” he said.

“The only case of death in the DCB group was due to multiple comorbidities, which were hardly associated with the application of paclitaxel.” Patients in the plain balloon angioplasty cohort died of heart failure, sepsis, cholangiocarcinoma, respiratory failure and suicide. “A correlation between paclitaxel and cause of death is [therefore] quite unlikely,” he concluded. The total number of adverse events per patient was higher in the DCB group than in the plain balloon angioplasty group, though this difference was not statistically significant. The proportion of patients who experienced any adverse event was slightly higher in the plain angioplasty arm of the study, but again, this difference was not statistically significant. “So there is no real difference in adverse events between both groups,” Teichgräber summarized.

Summing up, Teichgräber said: “As we do not have a class effect between different DCB products, with our ad hoc analysis we can only give information on Luminor balloons, and their coating technology.

Therefore, it is important that other trials, with other DCB products, go the same way as we did with EffPac, and assess what happened to their lack-of-follow-up patients, and [see] if they could show equivalent results of all-cause mortality in their full cohort.”

“Paclitaxel showed a very low [mortality] risk ratio of only 0.15 compared to other trials, meaning there is no correlation of all-cause mortality associated with Luminor balloons”— Ulf Teichgräber

vascularspecialistonline.com • 5

TRAUMA

Paper claiming vascular surgeons ‘less well-prepared to rapidly achieve open exposure’ in trauma setting draws scorn

BY BRYAN KAY

A recent perspective published in the Annals of Surgery—which argued the shift toward endovascular care had led to a deficit in open surgical experience among the emerging cadres of trainees, impacting the treatment of vascular trauma injuries—has drawn broad censure from within the ranks of vascular surgery.

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ascular and general surgery graduates, as well as already practicing vascular surgeons, “are increasingly less well-prepared to rapidly achieve open exposure and control of injured vessels,” the paper claims. Meanwhile, trauma surgeons at major civilian trauma centers “also have increasingly limited experience with open vascular repair relative to even two decades ago, when trauma surgeons did most emergent vascular surgery.”

The arguments—contained in a piece entitled “Beyond the crossroads: Who will be the caretakers of vascular injury management?”—come from Joseph J. DuBose, MD, a clinical professor of surgery at the University of Maryland’s R. Adams Cowley Shock Trauma Center in Baltimore who is also affiliated with the Uniformed Services University of the Health Sciences in Washington, D.C, et al. The authorship also includes Todd E. Rasmussen, MD, attending vascular surgeon in the Military Health System and a professor of surgery at the Uniformed Services University.

As word of the publication spread, many vascular surgeons responded to the perspective’s core arguments in a robust discussion via social media.

“We need to dispel a myth,” wrote Joseph Mills, MD, professor and chief of vascular and endovascular surgery at Baylor College of Medicine in Houston, on Twitter. “Although our #VascularSurgery trainees get abundant endovascular experience, they still obtain substantial experience in open surgery.”

As they outlined their rationale, DuBose et al made the case that the “significant morbidity and mortality” of relatively uncommon vascular injuries require a level of open surgical skills and proficiency that are “increasingly difficult to acquire and maintain.”

The use of endovascular technologies for select trauma applications “show promise,” the authors write, “but the majority of contemporary vascular injuries continue to require open treatment.”

They argue: “There is a crossroads where we must choose to either abdicate all vascular trauma care to vascular surgeons or maintain vascular skills 6 • Vascular Specialist

within the group of surgeons called on to provide trauma care. One could argue each path has merits. We are now beyond

dreamers seem to be in short supply.

I’ve done hundreds of vascular trauma repairs—when we show up, the trauma team scrubs out. Which is fine—the 1970s aren’t coming back. But if the trauma community wants to try to build a cadre of co-trained surgeons, the military would seem to offer the best starting point.”

Ben Colvard, MD, a vascular surgeon in Cleveland, added: “Regardless of what a minority of vocal trauma surgeons say about managing vascular traumas on their own, when it comes down to brass tacks in the OR [operating room], the majority of trauma surgeons will #callvascular for a serious vascular injury at major trauma centers.”

Elsewhere in the perspective piece, DuBose and colleagues touched on how they see “this loss of skill in open vascular management” as potentially of most concern in rural and military environments “where endovascular options for trauma are not as readily available.”

“We need to dispel a myth. Although our #VascularSurgery trainees get abundant endovascular experience, they still obtain substantial experience in open surgery”—Joseph Mills that crossroads and have failed to design a system that meets the need.”

History Responses were brisk. Some members of the vascular surgery community sought to place into context their involvement in vascular trauma care.

Patrick Geraghty, MD, of Washington University School of Medicine in St. Louis, reasoned: “While I agree with the dream (fully vascular-capable trauma surgeons),

Tahlia Weis, MD, a vascular surgeon in Marshfield, Wisconsin, drew attention to the example of a rural level two trauma center in her state for which the nearest level one facility is at a distant remove.

“Most of our incoming traumas are coming from [greater than] 100 miles from us,” she tweeted. “Our trauma surgeons consult us for major vascular injuries. We acknowledge this is a standard of care.

This is what we teach our [general surgery] residents.”

Sherene Shalhub, MD, associate professor of surgery in the division of vascular surgery at the University of Washington in Seattle, commented: “Since ideal multidisciplinary care is available only in larger hospitals, a minimal set of competencies for those serving rural communities should be the focus during training.”

Sharmila Dissanaike, MD, chair of surgery at Texas Tech University in Lubbock, Texas, agreed that there was a need for minimal competency in vascular care for rural practice: “I see the consequences when this isn’t available in rural towns in my region. Not sure how best to do that though; exposure to vascular trauma and emergency revascularizarion would be key.”

Training Others indicated a problem with the paper’s starting point. “This whole argument exhausts me, the abdication of the majority of vascular injuries to [vascular surgery] already happened, years ago, at least at many places on the East Coast,” opined Reid Ravin, a vascular surgeon at Mount Sinai in New York, also via Twitter. “Training paradigms are only serving to reinforce the trend that stated decades ago.”

At the core of their perspective, DuBose and colleagues make a call for change within trauma training. “Limited course offerings for trauma/acute care surgeons must be followed by more substantial changes in both training and guidelines for referrals within trauma systems,” they write in the paper.

Meanwhile, in another Twitter response Guillermo Escobar, MD, program director for the Emory University vascular surgery fellowship and residency in Atlanta, stated: “The problem is that modern vascular management relies on access to endo [and] modern trauma relies on access to vascular.

Rural and military don’t have either.”

He added: “Do something proactive.

Make an ESP [early specialization program] like we have in vascular.”

Escobar went further. “Outcomes improve with subspecialists’ involvement, yet subspecialists are not always available [especially in rural areas and in the military],” he explained. Open surgery experience is lower for all, Escobar added, and some trauma surgeons want to be “surgeon totalis” after a one-year fellowship.

One passage from the perspective saw the authors write that vascular surgeons can develop a form of tunnel vision— “lesion vision”—amid what they term an increasing focus on endovascular modes of care. This drew particular ire. “It essentially accuses an entire specialty of performing inappropriate surgery,” noted Karen Woo, MD, associate professor of vascular surgery at University of California, Los Angeles (UCLA). “Fellow surgeons no less. This demands a response.”

SOURCE: DOI: 10.1097/ SLA.0000000000003912 OCTOBER 2020

WELLNESS

Study: Almost 40% of vascular surgeons report suffering chronic work-related pain

BY BRYAN KAY

majority said they were in a moderately strong amount of pain (mean score 3.9 ± 2.4). And 70% of the surgeons performing endovascular cases had a clinically relevant pain level (≥3), with 18% reporting very strong pain (7+).

“There is a high prevalence of clinically significant pain associated with the performance of open, endovascular and endovenous procedures,” the authors explain.

Surgeons performing endovenous procedures report the lowest pain scores (mean 2.0 ± 2.0). Pain following open surgery is highest in the neck, and after endovascular surgery pain is highest in the lower back, they find.

“Of note, 39.5% (291/736) of the entire cohort of vascular surgeons responding to the survey report they are currently suffering from chronic pain. Nearly onequarter (23.4%) sought medical care for chronic pain (172/736); 5.7% missed work (42/736); 9.9% had an ergonomic evaluation (73/736); 10% requiring surgery and other procedures, including traction (72/736); 2% (15/736) sought short-term disability; 1% (7/736) sought long-term disability due to physical issues; and 1.2% report they are leaving surgery due to work-related pain (9/736),” the investigators add.

Further results from the survey demonstrated that the pain surgeons suffered interferes with posture among 33% of respondents, sleep in 26%, reduces stamina in 20%, affects mobility in 18%, concentration in 13%, and interferes with relationships in 12%. In the operating room (OR), the pain affects teaching in 15% of those who returned a survey, slows down the speed of an operation in 13%; up to 10% alter their surgical approach because of pain; and 8.3% needed to take time away from the OR due to acute or chronic work-related pain or discomfort.

Among the 39 retirees, 26% ended their careers due to physical disabilities from work-related pain.

Meanwhile, high work-related physical discomfort was found to be significantly associated with burnout for open surgery as well as endovascular and endovenous procedures (burnout vs. no burnout, p<0.0001).

Risk factors

THE FINDINGS WERE DERIVED FROM A SURVEY of Society for Vascular Surgery (SVS) members carried out on behalf of SVS Wellness Task Force. It found that after a full day of open surgery, a majority of the respondents were in a moderately strong amount of pain.

Nearly 40% reported suffering from chronic pain.

Work-related pain has a tremendous economic and psychological impact on U.S. society, yet—despite the high mental workload, repetitive movements, and physical exertion to manipulate tissue and devices that comes with the performance of surgery—few surveys of surgical specialists have been reported, first-named author Max Wohlauer, MD, assistant professor of vascular surgery at the University of Colorado School of Medicine in Aurora, et al write. The researchers hypothesized vascular surgeons, who routinely carry out a combination of open and endovascular surgery, as well as endovenous interventions, would have “unique ergonomic challenges.”

The survey, mailed to 2,910 SVS members, was designed to identify the prevalence and severity of work-

8 • Vascular Specialist

related pain and disability among respondents. Questions related to surgeon wellness were also asked. % Pain was reported using the Borg sought medical care CR-10 scale: (0=no pain, 2=weak, for chronic pain 3=moderate, 4=moderately strong, 5=strong, and 10=extremely strong). Descriptive statistics and a univariate logistic regression model were developed to identify independent risk factors for work-related pain.

A total of 775 (26.6%) responded to the survey, with 39 retirees excluded. Those included had been in practice for 17.2 ± 11.6 years, with a mean age of 51.4 ±10.9 years, and 83.6% were male.

The researchers found that after a full day of open surgery, the average vascular surgeon is in a moderately strong amount of pain, with a mean pain score of 4.4 ± 2.3 on a 0-10 scale. Some 76% of the surgeons reported clinically relevant pain (≥3), and 22% noted very strong pain (7+). After a full day of endovascular surgery, a

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SOURCE: DOI.ORG/10.1016/J.JVS.2020.07.097

OCTOBER 2020

SENSORSPOT

A majority of vascular surgeons are in pain after a day of operating—with open and endovascular surgery identified as the type of intervention causing the greatest level of suffering, according to a study recently published in the Journal of Vascular Surgery.

Univariate analysis performed to identify risk factors for developing moderately strong pain or higher revealed that for endovascular surgery, obesity increased the risk of moderately strong pain by 60% (p=0.05). For every unit of body mass index increase above 30, performing endovascular surgery increased the risk by an additional 6% (p=0.01). Obesity was not an independent risk factor for developing pain performing open surgery or endovenous intervention, the researchers found. In terms of how workload constitution impacted pain, the authors found that surgeons who spend more than 50% of their case-mix performing open extremity surgery increased the risk of work-related pain threefold-plus (p=0.02).

“Performing surgery is a true privilege,” the authors write. “This unique, rewarding opportunity comes at a price, with nearly 70% % of vascular surgeons reporting took time away significant pain after a day of from the office operating. Forty percent have chronic pain. Altogether, more than 50% of the vascular surgeons answering the survey feel that physical discomfort will affect the longevity of their careers. This includes short-term and long-term disability due to physical issues, curtailing practice, or retiring early due to work-related pain. Work-related pain is shortening the careers of some vascular surgeons and reducing the productivity of others, which produces a negative impact on the surgical workforce.”

They cite a series of strategies that can be used to reduce pain induced by performing surgery, including exercise, posture awareness, yoga and micro-breaks.

MIDWESTERN VASCULAR

New data support televascular visits to help address rural vascular surgery shortage

BY BRYAN KAY

Researchers from the University of Minnesota unveiled new data supporting televascular consultations as a viable solution to the shortage of vascular surgeons in rural parts of the United States during the Midwestern Vascular Surgical Society (MVSS) annual meeting held virtually from Sept. 9–12.

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team led by Amy Reed, MD, professor and chief in the division of vascular surgery, department of surgery, at the institution, found the telemedicine platform makes vascular surgery consultation feasible and able to replace direct office visits for patients in locations from where they find it difficult to access vascular care.

The new study comes against the backdrop of heightened awareness of telemedicine amid the COVID-19 pandemic. The Minnesota research team highlighted a main draw of telemedicine in the current climate as the removal of the need for travel and exposure with conventional options for patient evaluation “too high risk from a public health standpoint,” presenter and research team member Jing Li, MD, told the Midwestern Vascular 2020 gathering on Sept. 12. “Clearly these visits provide greater access, decreased wait times, decreased travel, and decreased exposure for our patients.”

The investigation was a retrospective analysis of prepandemic telemedicine—or televascular—consultations conducted via live video over a five-year period ( January 2014–December 2019) at the Minneapolis Veterans Affairs (VA) Medical Center, backed up by electronic medical record (EMR) reviews. On the patient side, the televascular visits were conducted from local VA clinics, from where many of the participants also underwent any imaging studies.

The primary outcomes the researchers looked at were the location of patients, numbers of visits, types of visit, whether these were consultations or a follow-up, types of provider, as well as types of procedure patients went on to receive.

Study finds low mortality, high complications rates after aortic endograft explantation

BY BRYAN KAY

The explantation of aortic endografts—associated with high postoperative morbidity, particularly in patients with infected grafts—can be carried out with a low mortality rate, a new single-center study reveals.

10 • Vascular Specialist

They looked at a total of 708 telemedicine visits completed by 534 patients, of whom approximately 22.7% took part in multiple visits, explained Li. The majority had two visits, followed by those who took part in three.

Further, a handful had four or more.

Some 60.6% were new consultations, with the remainder representing follow-up evaluations either after an initial consultation, or post-surgically. Six providers were involved. Four were vascular surgeons, who performed 82.1% of evaluations. Two advanced practice providers (APPs) carried out the other consultations.

The patient cohort analyzed hailed from across five

“[Televascular consultation] is an effective option for providing surgical valuation.

That makes it a lot easier for both the patient and the surgeon. It’s adequate in helping us facilitate treatment of wide range of pathologies that we see from our experience”—Jing Li­

MOHAMMAD KHASAWNEH, MD, a vascular surgery fellow at the Mayo Clinic in Rochester, Minnesota, and the team behind the findings set out to assess outcomes in patients who underwent late open conversion of endografts after either an infection or an endoleak. The investigators undertook a retrospective review in a single tertiary center study of outcomes in patients who had undergone explantation of aortic endografts.

The results were delivered at the Midwestern Vascular Surgical Society (MVSS) annual meeting (Sept. 9–12).

Khasawneh observed a published late open conversion incidence rate of “anywhere between 1.9–4.5%.” The study drew data from across a 17-year period (2002–2019). A total of 108 patients who had an endograft explanted—66 with endoleaks, 42 with infections—were included.

states including and surrounding Minnesota— the others being Iowa, Wisconsin, North Dakota and South Dakota.

The average distance patients “ultimately did not travel,” observed Li, was 154 miles, (range: 20–601 miles).

The average amount of time saved from traveling was Jing Li 154 minutes (range: 27–532 minutes). Three locations— St. Cloud, Fargo and Sioux Falls—produced 79.2% of the visits studied, representing 79.8% of patients.

For these cities, the average traveling distance was 148 miles, with an average time saved of 150 minutes. Within this trio, the majority of patients were from St. Cloud, followed by Fargo, then Sioux Falls.

Furthermore, the researchers found that 36.3% (194) of the patients analyzed during the period went on to undergo 225 procedures. The majority received endovascular treatment (68.2%), a further 27.1% underwent open repair, while 4.3% had hybrid procedures.

The data also revealed that for 83% of patients, the initial encounter they had with the vascular surgery team came via a televascular consultation. “When we looked at all of the televascular consultations, 37.6% of them went on to have procedures, and 89.2% had one or more encounters with a vascular surgeon,” added Li. The research team believes the findings show that “televascular consultation is a feasible way to serve patients who are in a more remote area where it is difficult for them to obtain access without significant travel.”

Li concluded: “It’s an effective option for providing surgical evaluation. That makes it a lot easier for both the patient and the surgeon. It’s adequate in helping us facilitate treatment of a wide range of pathologies that we see from our experience.”

In a brief question-and-answer session following her presentation, Li was asked about any potential reimbursement or physician licensing issues since the study covers consultations conducted across state lines.

Li said she was unaware of any problems, explaining: “We should keep in mind this was all within the VA system, so all the patients seen were VA patients, and they were being seen by VA physicians. That makes it a little different than what we typically see outside the VA system.”

Over the study period, the authors found that the number of explantations increased. Between 2010 and 2014, 41 patients had explants, with another 50 undergoing an explantation from 2015 until the end of the study. This compared to 17 patients between 2002 and 2009.

The researchers found no difference between the two groups in terms of the type of endograft explanted, while endoleak type 1a was the most common at around 40%, with type 2 following at 22%, while 20% had a mixed endoleak presence. The endoleak patients had a higher rate of aneurysm sac size increase at 97%, compared to 31% in the infection group. The research team reported 10% in each grouping presented with a ruptured aneurysm. The extent of the aneurysms was significantly different between the two groups, Khasawneh told the MVSS audience. Those with an

infection were more likely to have an infrarenal aneurysm, he said. For those with endoleaks, a juxtarenal or pararenal aneurysm was more likely. Furthermore, four patients in the endoleak group had an extent IV thoracoabdominal aortic aneurysm (TAAA). Those with endoleaks were more likely to undergo a partial excision of the endograft compared to those with infections, which the research team found to be statistically significant.

In terms of outcomes, the 30-day mortality was significantly different between the two groups. Four patients from the endoleak group died but there were zero deaths among those with an infection. Meanwhile, those who had an infection were more likely to have a postoperative complication (71% vs 48%, p <0.01). There was no difference between the two groups in terms of major complications.

OCTOBER 2020

NEW ENGLAND SVS

Cigarette tax rises lead to drop in active smoking among claudication patients, study finds

BY BRYAN KAY

Increases in cigarette taxes appear to be an effective strategy to cut active smoking among patients who are undergoing interventions for intermittent claudication, the New England Society for Vascular Surgery (NESVS) virtual annual meeting (Sept. 11–12) heard.

THAT WAS THE CHIEF FINDING of an investigation into data derived from multiple medical centers across the United States entitled, “Patients undergoing interventions for intermittent claudication in states that increased cigarette tax are less likely to actively smoke.”

In addition, older patients and Medicare recipients are the groups most affected by the tax increases, the authors found.

The study data were presented

by Scott R. Levin, MD, a general surgery resident at Boston University School of Medicine, during a NESVS rapid-fire session on Sept. 12.

Levin et al set out against the backdrop of Society for Vascular Surgery (SVS) guidelines that state interventions for claudication should only be offered after patients

quit smoking. Yet, Levin told the NESVS audience, the prevalence of active smoking among claudication patients at the time of intervention remains high. In this vein, state cigarette taxes and smoke-free air laws such as workplace smoking bans have had promising impacts on smoking prevalence, he explained.

Levin and colleagues say population-level strategies on smoking prevalence among patients with claudication are lacking. In their study, they aimed to determine whether state cigarettes tax and smoke-free legislation have any impact on active smoking among patients receiving treatment for intermittent claudication.

The research team conducted a quasi-experimental study using Vascular Quality Initiative (VQI) data from 2011–2019. Tapping into

Open repair linked to higher long-term survival in patients deemed offlabel for EVAR

BY BRYAN KAY

Open repair of aortic aneurysms is associated with higher long-term survival in patients who fall outside the confines of endovascular aneurysm repair (EVAR) instructions for use (IFU), and should therefore be favored over EVAR among this cohort, the annual meeting of the New England Society for Vascular Surgery (NESVS) heard.

THE FINDING WAS PART OF A STUDY THAT showed treatment outside device-specific IFU—or offlabel use of EVAR devices—is associated with adverse long-term outcomes. “Patients with aortic neck anatomy that falls outside of graft instructions use, or IFU, pose unique challenges,” the NESVS meeting was told Sept. 12.

The research was conducted by a team of investigators at OCTOBER 2020

a well of 600 medical centers, they sourced roughly 60,000 patients in 25 states with at least three participating medical centers.

Zeroing in on state cigarette taxes and the implementation of smokefree workplace legislation, the investigators linked such tobaccocontrol policies with patients based on the state and month/year in which they underwent intervention.

They deployed a difference-indifferences statistical analysis—a causal inference technique—to estimate the impact of tobacco policies on active smoking.

Most patients in the sample were concentrated on the East Coast and in the Midwest of the country.

Across the study period, Levin said, active smoking decreased from 48–40%. The active smoking prevalence by state varied from 27% in California to 57% in West Virginia.

Eight states increased cigarette taxes by 73% on average (adjusted for inflation). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by the end of the study period.

The authors found that every $1 tax increase was associated with a roughly 6-percentage point decrease in active smoking, “representing a 12% relative reduction in the proportion of patients actively smoking [95% confidence interval (CI), -10 to -1 percentage points; p=0.02] compared to a 48% baseline prevalence,” Levin said.

Massachusetts General Hospital in Boston and delivered

by Thomas F.X. O’Donnell, MD. Their work sought to establish whether better options exist for patients outwith the EVAR IFU given “a lack of well-documented evidence,” comparing the modality with fenestrated EVAR (FEVAR) and open repair. They carried out a retrospective review of prospectively collected data from their parent institution between 2010 and 2019. This included all elective infrarenal and juxtarenal abdominal aortic aneurysm (AAA) repairs. The team studied three groups of patients: Those who underwent standard EVAR (474), FEVAR using the Cook Zenith device given it is the only commercially available fenestrated endograft (34), and open repair (143).

“First, we compared results in patients treated with EVAR based on adherence to the IFU,” O’Donnell said. “Next we studied the cohort of patients outside the IFU and compared results between treatment modalities. Not surprisingly, patients treated off-IFU were older, less often fit for open repair and had higher rates of co-morbidities. The most

The authors found that implementation of smoke-free workplace legislation was not associated with a change in active smoking. “After further adjustment for patient characteristics, we observed similar results,” he added.

Furthermore, patients between 60–79 years were the age group most affected by the tax increase. In terms of insurance type, those who receive Medicare were likewise the most impacted by tax rises.

“Patients undergoing interventions for claudication are less likely to actively smoke after states increase cigarette taxes,” Levin concluded. “Older patients and Medicare recipients were most price-sensitive, and smoke-free workplace legislation had no impact on active smoking.”

In answer to a question that queried what effects cannabis legalization might have on the trends revealed in the study, Levin added: “Typically, younger patients have been shown to switch to alternative products like e-cigarettes and marijuana, and that may be why we didn’t see as much of an impact of the tobacco laws on younger patients in our sample.

“They probably switched to alternative products and continued smoking.

“The older patients in our study were shown to have been most affected by the taxes, [and] might have been more impacted by the taxes by quitting as opposed to switching to other products.”

common IFU violation was inadequate neck length at 16%, followed by neck angle and width, each at 11%.”

Among EVAR patients, treatment outside the IFU was associated with almost six-fold higher adjusted rates for type 1a endoleaks (p=0.001) and more than two-fold higher long-term mortality (p=0.01). Among patients outside the IFU, treatment with FEVAR was associated with significantly higher rates of reinterventions, while EVAR and open repair were similar, O’Donnell said. Perioperative mortality was 0.46% overall, with no difference between repair types.”

Long-term adjusted mortality, meanwhile, was found to be significantly lower in patients treated with open repair compared to both EVAR and the Zenith FEVAR. Concluding, O’Donnell stated: “The three-vessel strategy of [FEVAR] does not appear to be the answer to difficult neck anatomy although more study is needed to determine whether this is true of all FEVAR or whether significantly longer seal zones of four-vessel devices provide better results.”

“Open repair appeared to be the most durable option for patients with anatomy outside the IFU”—Thomas F.X. O’Donnell

vascularspecialistonline.com • 11

COMMENTARY

BY ARTHUR E. PALAMARA, MD

This article has little, yet everything to with surgery. It is about decision-making under adverse circumstances. If you have not listened to the 43-minute YouTube video about King Air 559 Delta Whiskey, you should. It will inspire you. Then watch accident case study “Final Approach,” piloted by an orthopedic surgeon. These YouTube videos will force you to evaluate your decision-making under stress.

ON EASTER SUNDAY, 2009, DOUG White took off from Marco Island, Florida, with his wife and two teenage daughters in a high-performance, twin-engine King Air 200. They were returning to Louisiana from Doug’s younger brother’s funeral.

The weather was magnificent. The pilot was a graduate of the Air Force Academy who flew F-100s in the Korean War. Sitting in the co-pilot’s seat was Doug, who had flown smaller, less sophisticated aircraft but had not done so in years. He was totally unqualified to fly a complex aircraft. Several minutes after takeoff, the pilot slumped over and died after sustaining a fatal myocardial infarction. How Doug assumed the responsibility to fly the aircraft, as well as his interaction with air traffic control, is inspirational.

The severity of the crisis was made more intense because of the presence of his wife and daughters. But he never lost his cool. He picked up the radio and said: “This is Nancy 559 Delta Whiskey, and I am declaring an emergency.”

“What is your emergency?” came the response from Miami air traffic control (ATC).

“The pilot is unconscious, and I think he is dead. I need to talk to someone who is familiar with this aircraft and [can] help me land.”

“Do you have any flying experience?”

“Some, but in a much smaller airplane.”

“This is Miami, who is flying the airplane?”

“Me and the good Lord” “What do you want?”

“I want the longest and widest runway you have in Florida!”

“Hold on 559 Delta Whiskey, we’re finding help.”

ATC found Lisa, a pilot who gently guided him through the initial stages of flying the aircraft. The interchange between Doug and Lisa is almost comical.

Underlying the dialogue was her coolness and sense of reassurance. The listener can palpate the bond that was forming between them. She’s cool, calm and reassuring, while he remained controlled and firmly insistent on his and his family’s needs. The dire circumstance bound them together.

A decision was made to route Doug to Fort Myers. It is a large airport with less traffic. Other controllers were re-routing commercial aircraft to avoid collision since Miami was a far busier airport. Fort Myers 14 • Vascular Specialist

was not as crowded and had a 12,000 ft. runway. It was an ideal choice.

The time came to “hand” Doug off from Miami to Fort Myers ATC. He was instructed to change frequencies to contact Fort Myers.

“I don’t want to leave Lisa.” Doug’s voice clearly anticipates his sense of loss.

Lisa gently reassures him to “tune in the Fort Myers frequency on the second radio. If you don’t find them, push the first button, and I will be right there.” Her tone is almost motherly. “If you wander too far away from the nest, I’ll find you and help you,” she seemed to be saying.

It worked. Doug changed frequencies and connected with a male ATC who proved to be equally calm, reassuring and supportive. By sheer coincidence, the Fort Myers controller had a friend in Danbury, Connecticut, who was a check pilot for the King Air. He knew every nuance of the airplane. They connected via his cell phone. Every question that Doug posed, including flap settings, landing speed and trim control, were relayed to the friend in Connecticut, who responded with detailed instruction. Each recommendation was clear and simple to follow. The controller never overwhelmed the neophyte pilot with information, prodding more of a “do what I tell you step-by-step and you will be fine” message. Confidence grew on both sides. The experience became just a normal Sunday afternoon pleasure flight.

With no wind and conditions perfect, Doug landed the plane like a butterfly nestling on a flower. Doug asked where to turn off the runway. Audibly exhaling or perhaps stifling his emotions, the controller’s response was “anywhere you want.”

Doug made the turn onto the taxiway.

He knew how to retard the engines but not shut them off. As he approached the terminal, Doug remarked, “It would be a shame to come this far and then chop up people at the end of the runway!”

What we didn’t learn until the epilogue was that the Fort Myers controller’s cellphone connection with his friend in Danbury went dead, seconds after the plane touched down. As the saying goes, maybe there are no atheists in a fox hole. Or in airplanes or in an operating room.

The second emergency involves an orthopedic surgeon who took off from Sandersville, Georgia, on a beautiful

Sunday afternoon in a single-engine Piper Arrow. He was returning to the Baltimore area with surgery scheduled for the next morning. He listed his primary destination as Dover, Delaware. Baltimore was his alternate. Weather conditions in the area were less than ideal but expected to improve. With an extra hour of fuel on board, there should have been no problem.

The surgeon had all the “tickets,” meaning he had a decent amount of experience and was instrument rated—he should be able to land his aircraft in poor conditions.

As he was approaching, the conditions did not improve. The weather information he received from air traffic control was overly optimistic and his exchanges with the controllers were less than informative.

The controllers made suggestions offering two other alternative airports but both were socked in. He tried three airports and made two approaches, but backed off prematurely before reaching minimum altitudes. He circled around for an hour like a bee searching for its hive, looking for one clear strip after another. Each airport had a low ceiling, and each approach was aborted.

While he was certified to make an instrument approach and could have done that, he never tried. We will never know why.

Crash Unlike the controllers in the King Air emergency, the attitude of the air traffic controllers in this exchange was neither helpful nor reassuring. At one point, he asked about landing at a military field, Dover Air Force Base. The air traffic controller sternly told the surgeon that he could only land at a military base in an emergency. “Are you declaring an emergency?” she challenged. Possibly because of pride, over-confidence, failure to grasp the severity of his condition, or fatigue, he never used that option. Until the end.

He flew around for an hour searching for a safe landing spot, exhausting his fuel. With obvious pain in his voice, he announces: “I am almost empty.”

Finally, he says, “I am declaring an emergency,” and asked for vectors for Dover Air Force Base. The controller from Dover says encouragingly, “We are turning the runway lights on for you, sir.”

Finally, with a quivering voice, he says “I am out of gas, I’m not going to make it.”

The surgeon-pilot crashed and died 2 miles short of the runway.

The way these two emergencies were handled stand in stark contrast. Both the response of the pilots and ATC reaction to potential disaster are vastly different.

Doug had some flying experience but realized immediately that he was in over his head. He had the deliberate attitude of a person in a jam, and was not afraid to demand that the full resources of the federal government be used to save him and his family. All this with a dead guy sitting next to him and his family in the back. His forceful personality effectively created a team. Each conversation deepened the ATC commitment to save him and his family.

Everyone became an active participant in safely landing the airplane.

There is an epilogue to the King Air incident that deepens our faith in the brotherhood of mankind. All the air traffic controllers, the pilot from Danbury, Connecticut, and Doug received an Archie League Award for their efforts. But what really comes through is the lasting bonds that were formed between Doug and the controllers. Their action validated the best instincts of protecting human life.

The cockpit transmissions from the Piper disaster generate a sinister feeling of impending doom. The exchange is painful to listen to, but instructive. As surgeons, we can identify with the pilot’s thinking and sympathize with his mistakes. We have likewise experienced indifferent staff members who were supposed to assist us at critical moments but gave less than 100%.

Any of us who pick up a scalpel have, at one time or another, been “up to our ass in alligators.” (Lord, get me out of this and I’ll never do it again.) All of us have seen operating room personnel looking at a cellphone, or entering billing data into a computer when the operation was at the verge of falling apart, and some piece of vital equipment was lacking or blood was not arriving emergently. We have all looked around the room to see who was there to help us and found no one. It is a lonely feeling, much like the pilot, flying around alone on a dark, stormy night, attempting to find sanctuary.

This was likely the thinking of the surgeon-pilot who was trained to deal with unfavorable situations and not ask for help. Modern hospitals are terribly punitive, with surgeons expected to deal with adversity while relying on their own ability. Making demands or inferring unsatisfactory performance from ancillaries is sternly frowned upon and designates the surgeon as disruptive, kind of like being called a leper in the Middle Ages. His undemanding attitude made the controllers indifferent to his worsening condition, and the stark demand—“Are you declaring an emergency?”—backed him into a corner, challenging his ability. Of course, he should have declared an emergency and forced their total commitment to his problem. If he had, he would still be alive.

So how many times have we surgeons faced an emergency where we toughed it out and placed the life of the patient in jeopardy? Usually, we are successful but occasionally we are not. There are other surgeons and assets in the hospital who would have happily come to our aid. Like the King Air guy Doug, call for help early, and make a team out of your assistants.

Then everyone gets a trophy. I still wonder how the controllers involved in the Piper crash slept that night.

Arthur E. Palamara is a vascular surgeon in Hollywood, Florida, and is associated with Memorial Regional Hospital, part of Memorial Healthcare System in the same city.

OCTOBER 2020

MARTIN CHAVEZ

Flying lesson: King Air 559 Delta Whiskey

“This is Nancy 559 Delta Whiskey and I am declaring an emergency”— Doug White “What is your emergency?”— Miami air traffic control

“The pilot is unconscious, and I think he is dead.

I need to talk to someone who is familiar with this aircraft and help me land”

“Do you have any flying experience?”

“Some, but in a much smaller airplane”

“This is Miami, who is flying the airplane?”

“Me and the Good Lord”

“What do you want?”

“I want the longest and widest runway you have in Florida!”

OCTOBER 2020

“Hold on 559 Delta Whiskey, we’re finding help”

vascularspecialistonline.com • 15

EDUCATION

Coming up: VRIC and VAM 2021 submission portals set to open

BY BETH BALES

Abstracts for next year’s Vascular Research Initiatives Conference (VRIC) will be accepted beginning Nov. 3. VRIC 2021 is held the day before and in the same location as the American Heart Association’s “Vascular Discovery” scientific sessions. The meeting date and location will be announced soon.

Submissions will close in mid-January 2021. Learn more about VAM at vsweb. org/VAM21.

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bstracts for both VRIC and Vascular Discovery will be accepted through Jan. 19, 2021. Registration for the two meetings will open Jan. 6, 2021.

VRIC focuses on emerging vascular science and is considered the Society for Vascular Surgery’s annual meeting for basic and translational research. The conference includes abstract sessions, a translational panel, posters and the Alexander W. Clowes Distinguished Lecture. For more information, visit vsweb.org/VRIC20.

Meanwhile, VRIC 2020, canceled due to the COVID-19 pandemic, has been transformed into VRIC ONLINE, with planning still in progress for a virtual delivery on Nov. 5 and 12. It will feature the oral abstracts accepted for the VRIC 2020 program.

The submission site for VAM is to open in mid-November. Research to shed new light on diabetes, reinterventions after stent placements, cannabis use disorder, and vascular surgery and telemedicine—critically important in this year of COVID-19— have been presented at recent editions of VAM. Though particular topics differ from year to year, surgeon-scientists offer data and insights they hope vascular surgeons find valuable. The abstract submission site for the 2021 VAM will open in mid-November for the June 2021 meeting.

“This is the chance for SVS members to present their research, on peripheral arterial disease, thoracic outlet syndrome, on complications, on all aspects of care of all vascular diseases,”

said Matthew Eagleton, MD, co-chair of the SVS Program Committee, which oversees scientific programming at the meeting.

Co-chair Andres Schanzer, MD, and the entire Program Committee also seek research on issues that impact surgeons themselves, such as wellness, surgery and its effect on posture and surgeon health, practice management, and more.

“We continue to plan full speed ahead for an in-person, high-impact meeting where colleagues can once again connect and learn from each other,” said Schanzer. “We’re hoping it won’t be necessary, but if it is, we will be ready to convert the meeting to an innovative and engaging virtual format.” Abstract guidelines will be posted online in late October.

VAM 2021 to mark 75th anniversary of SVS The 2021 VAM will be June 2 to 5, 2021, at the San Diego Convention Center in San Diego and will be a celebration as well as an educational and networking event, as members break out the party hats and noisemakers to celebrate the 75th anniversary of the Society. Plan now to join in the festivities.

Educational sessions are to be held daily. Podium-based scientific sessions are to run from June 3 to 5. The Society for Vascular Ultrasound (SVU) is holding its meeting from June 3 to 4 in conjunction with VAM, at the same location.

The joint SVS-SVU Exhibit Hall also will be open June 3 to 4. An integrated housing and registration system is expected to open up in early March.

With an eye on the past, SVS Foundation looking ahead to stable future Dear colleagues:

Before we can look to where we’re going, we need to look to where we’ve been. And we do just that, in the pages of the Society for Vascular Surgery (SVS) Foundation Annual Report, available at vsweb.org/ FoundationReport2020.

This has been a challenging year for the SVS Foundation, the SVS and all its members. A year that began with promise and excitement over the second annual “Vascular Spectacular” gala became the Year of the Pandemic instead. COVID-19 halted elective—but medically necessary—surgeries, upended our members’ practices and created economic uncertainty.

22 • Vascular Specialist

The pandemic is not yet tamed, though some equilibrium has returned with the resumption of elective surgeries and the training of our future colleagues.

We remain not only hopeful, but excited, in looking ahead to the future of the SVS Foundation.

We have done some major restructuring, including the addition of board members from outside the SVS itself. New voices offer alternatives and put us in touch with a greater number of people and initiatives. We have additional stability. Yet we have the same ultimate goal: to improve patient care through public education and awareness, and through research with the support of Foundation grants and

scholarships. As chair, I hope to promote prospective research, in particular device research that could lead to better treatment options for our patients. Such research is difficult to conduct, but necessary to be able to make the best decisions on treatment.

We will also review all current and existing programs, and consider new programs in both education and research.

I congratulate and thank all who have donated to the SVS Foundation in the past, particularly this past year. And I want to encourage anyone who has never donated to make 2020 the year that changes.

Become a first-time donor! After all, the need is as great as ever.

Foundations are mission-driven and thrive with the support of donations. We can change and enhance vascular health and knowledge, and ultimately, as always is our goal, improve patient care. I ask all of you to be generous in supporting your Foundation and allowing it to continue to find better solutions in treating vascular disease.

Yours truly, Peter F. Lawrence, MD SVS Foundation chair

OCTOBER 2020

MEMBERSHIP

SVS: Building bridges between twin tracks of academic and private practice

BY BETH BALES

For Laurel Hadley Hastings, MD, membership in the Society for Vascular Surgery (SVS) provides a great collection of valuable benefits.

kind of bridges the gap between academic and private practice. It gives me access to the whole realm of vascular surgery. That’s one of the nicest things for me.”

While a Candidate Member, she said, training consumed so much of her time and attention, she didn’t feel she had the extra bandwidth to become more involved with the Society as a whole. That’s changed. She thoroughly enjoys the camaraderie—not to mention answers to important clinical questions—via a couple of SVS online discussion groups that were created shortly after the start of the pandemic. She also hopes to become part of an SVS committee next year, to volunteer within the Society itself.

Hastings is looking forward to feeding her interest in research, hoping to become a reviewer with the JVS publications. “The more literature and research you’re exposed to, the better researcher you can become,” she said. And she’s keenly aware that the SVS Foundation offers many award opportunities for young researchers.

As is the case with many Candidate members and trainees, Hastings has attended several previous iterations of the Vascular Annual Meeting (VAM), including the 2017 session in San Diego, the site for the upcoming 2021

THEY INCLUDE AN ONGOING CONNECTION to academia and research, potential mentoring, interacting and working with more experienced surgeons and with leaders, camaraderie, the Journal of Vascular Surgery (JVS) publications that keep her up to date with the latest research and developments and the SVSConnect message board.

“I’m enjoying being an Active Member,” said Hastings, previously a Candidate Member who became an Active Member in July.

“I’m in private practice in central Louisiana and I wanted to still have some academic ties,” she said. “SVS

Laurel Hadley Hastings

“The more literature and research you’re exposed to, the better researcher you can become”— Laurel Hadley Hastings

Renewal reminder: 2021 SVS membership due by end of year

BY BETH BALES

The end of the year is fast approaching, and SVS memberships are now up for 2021 renewals.

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ues invoices have been distributed to all members via email and must be paid by Dec. 31 to maintain SVS membership and access to the Journal of Vascular Surgery, JVS-Venous & Lymphatic Disorders and SVSConnect. Statements will be mailed in early November, for those who need hard-copy invoices.

The SVS is constantly working to improve the value of membership and add new benefits. “This past year has really brought home to our colleagues just how valuable membership is,” said Membership Committee chair Afshin Molkara, MD. “When the pandemic upended vascular surgery, SVS was there with advice, resources and Town Halls to help us through. “Not only have we continued our members-only initiatives—our robust community on SVSConnect, leadership courses, the surgeon wellness initiative and mentoring opportunities—we also are about to launch our branding initiative to help us let referral sources know who we are and what we do. We’re working to update our website. There will be more.”

Membership confers many additional benefits, including an upcoming branding initiative to position vascular specialists as the experts for the care of circulatory diseases; a growing stable of peer-reviewed publications; and clinical practice guidelines and reporting standards to facilitate exemplary patient care. Read all about benefits at vsweb.org/Benefits. Meanwhile, aspiring members have one more chance this year to apply to become part of the preeminent professional home for vascular surgeons. Membership applications are due by Dec. 1. See vsweb.org/Join for more information and to apply.

OCTOBER 2020

version. She’s excited to return to the West Coast city and to VAM itself.

After all, she pointed out, her involvement in the worldwide discussion board has introduced her—and other members—to colleagues around the world. “If you need help at 2 a.m., there’s probably someone in South Africa or Hong Kong who can help,” she explained. “It’s the best thing that will ever come out of this COVID crisis.”

VAM 2021, she said, means a chance for these presences on her computer to become real. “It’s going to be great to see each other in person,” she said.

A CALL TO ACTION

Visit, re-visit SVS ONLINE

BY BETH BALES

There’s still time to view presentations from this past summer’s SVS ONLINE: “New Advances and Discoveries in Vascular Surgery,” held virtually from late June to early July. Credits for sessions that offer them are available through Oct. 31.

REGISTRATION IS REQUIRED; those who registered during or before the meeting do not need to register again. Separate registrations are required for the Society for Vascular Nursing’s annual conference and the Vascular Quality Initiative’s virtual meeting.

Visit vsweb.org/RegisterONLINE. Registrants may view, listen and/or download post-live and pre-recorded lectures at their own convenience, and, where offered, may claim Continuing Medical Education (CME) and Maintenance of Certification (MOC) credits.

Those credits claimed for

sessions attended during the live event may not be claimed a second time.

Registrants also may view live and OnDemand industry presentations and browse the industry Virtual Trade Show and Product Showcase (industry presentations are not eligible for credit).

To access all materials, log in at vsweb.org/Planner2020. Use the left-hand panel to navigate to sessions of choice.

For more information email education@vascularsociety.org.

vascularspecialistonline.com • 23

Quality Payment Program: The proposed updates slated for 2021

Interoperability (PI) (25%) and Improvement Activities (IA) (15%) performance categories have remained unchanged % Quality in weight since the 2020 proposed rule. Maximum negative [down 5%] and positive payment adjustments remain at -9 and 9%, respectively; Medicare physicians who do not perform adequately in an APM or MIPS in 2021 will be subject to as much as a 9% reimbursement penalty in 2023.

The Cost category was primarily impacted by % the addition of measures related to telehealth Cost [up 5%] services. Minor changes are proposed for the PI and IA categories, primarily involving the pathways for nominating a new measure and/or activity.

Given the disruption in care from COVID-19, Quality measures will be scored by performance period, not Proposed performance category weights historical benchmarks. In terms of scoring flexibility, there will also be an expanded list of reasons impacting quality measure performance as well as a revised policy pathways, the MIPS Value Pathways (MVP) and the APM regarding truncation of the performance period to nine Performance Pathway (APP). CMS instead proposes months or suppression of the measure if nine months of changes to guiding principles and development criteria data is unavailable. Additionally, in light of the COVID-19 for MVPs and changes to the APP option that will help emergency, CMS is using the Extreme and Uncontrollable facilitate ultimate transition. The CMS web interface will Circumstances policy to allow participants to request a be phased out in 2021 as part of the transition towards reweighting of one or more MIPS performance for the these new pathways; organizations reporting through this 2020 performance year. mechanism should identify another method.

The SVS will compose a comment letter in response The proposed rule also would modify performance to the proposed changes, advocating on behalf of its thresholds. The minimum performance threshold to avoid members to maintain the weighting of the Quality and a penalty is proposed to increase from 45 to 50 points, 10 Cost categories and the minimum performance threshold points less than anticipated. at the same level as performance year four, in order to The threshold for exceptional performance remains minimize additional burden on providers during the at 85 points. The Quality performance category would COVID-19 pandemic. be weighted at 40% (decreased by 5%), while the Cost performance category’s weight is proposed at 20% (increased 5%).

Jeniann A. Yi and Ashley K. Vavra These changes reflect the requirement for equal are members of the SVS weighting of those two performance categories at Quality and Performance Measures Committee.

30% by the 2022 performance period. The Promoting

40

BY JENIANN A. YI, MD, AND ASHLEY K. VAVRA, MD

The COVID-19 pandemic’s impact on surgery and medicine continues, prompting the Centers for Medicare and Medicaid Services (CMS) to propose changes in year five of the CMS Quality Payment Program (QPP). These changes were to take effect Jan. 1, 2021.

THE SOCIETY FOR VASCULAR SURGERY (SVS) will compose a comment letter in response to the proposed changes, advocating on behalf of its members.

CMS released its proposed updates for year five in August. The rule acknowledges the impact of COVID-19 and the need for more gradual implementation of originally planned changes.

The QPP was created following passage of the 2015 Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA). The legislation repealed the Medicare sustainable growth rate formula and created the QPP. The program is a value-based reimbursement model, which requires Medicare providers to participate in the Merit Based Incentive Payment System (MIPS) or an Alternative Payment Model (APM) to avoid penalties.

In the wake of the ongoing pandemic, CMS’ proposed rule delays introduction of two new participation

➺

➺

CMS

We know who you are—do you know who we are?

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membership donating to the PAC. We need your support now more than ever. The PAC is an annual donation program.

We urge all members to keep your SVS PAC donations current by making a 2020 donation to SVS PAC. You can easily make your SVS PAC donation online at www. svspac.org. Additionally, please email Moe Malek at mmalek@vascularsociety.org

to check on your PAC anniversary date.

Resolving to donate can rest on an impulse as simple as this: “I am responsible for protecting the specialty.”

Mark A. Mattos and Peter H. Connolly are SVS PAC members.

BY MARK A. MATTOS, MD, AND PETER H. CONNOLLY, MD

Let’s start with our mission statement: We at the SVS Political Action Committee (PAC) exist as the fundraising arm for the advancement of the legislative priorities of the SVS. Through education and advocacy, we interface with legislators regarding key issues and legislation impacting all vascular surgeons and the patients for whom we care.

T

he SVS PAC provides monetary support to the political campaigns of incumbents and challengers alike, whose votes and legislation are in line with the vision of the SVS. A donation to the PAC influences policy outcomes that will continue to support the practice of vascular surgery.

The SVS PAC provides a direct link to legislators; we create an interface platform and dialogue that can affect the way you practice vascular surgery.

We know that these past several months have been hard—our clinical volumes have declined and many of our patients and friends have succumbed to COVID-19. But 24 • Vascular Specialist

the last thing we should do is stick our heads in the sand and expect that things will return to normal.

What can you do? In this new election cycle, we face a series of cutbacks and legislative reform that will lead to 7% cuts in Medicare payments. If this goes through, you can imagine that it would be extrapolated to broad payment cuts across all procedure codes regardless of payer. And if you think you are protected because you are a hospital employee, think again. We have small pockets but big ideas.

We are working for you. We hope that you will support the PAC with a donation.

We still only have about 6% of our SVS

7% 6% cuts

contribute

OCTOBER 2020

DIVERSITY

BY BETH BALES

Following a year of study and including more than 40 separate goals, objectives and requested actions, the SVS Executive Board has received, reviewed and embraced the report of the SVS Diversity, Equity and Inclusion (DEI) Task Force as a blueprint for response and change.

IT NOW HAS BEGUN THE TASK OF implementing the report and its recommendations, which means integrating it throughout the structure of the Society. The plan, said SVS president Ronald L. Dalman, MD, must be comprehensive and “worthy of the detail included in the report.”

Creating a new Diversity Committee as part of the SVS governance structure is the highest priority and “will be essential in helping to guide and serve as a

resource to the Executive Board and Strategic Board of Directors, as well as many other councils, committees, sections and task forces,” said Dalman. The SVS already is selecting committee volunteers from among the applications received.

The SVS will publish the Task Force report along with the plan for implementation to make it available to all members.

Dalman will give progress statements as recommendations are approved and implemented.

One objective is well under way for implementation: increasing editorial positions for women and minorities in Journal of Vascular Surgery (JVS) publications. JVS is considering applicants for a new associate editor for clinical research with a focus on diversity, equity and inclusion.

Women and members of underrepresented groups in medicine were strongly encouraged to apply.

The Executive Board also is expected to approve an SVS diversity position statement. The statement—the new Diversity Committee’s first task—will clearly articulate the SVS’ commitment to diversity, equity and inclusion related to gender,

Help diversity effort by completing member survey

BY BETH BALES

To know where to go, you first have to know the starting point.

“WE CANNOT ADEQUATELY measure our progress in the SVS on diversity, equity and inclusion if we do not have the requisite data to measure,” said Society for Vascular Surgery president Ronald L. Dalman, MD. He is asking all SVS members to take the simple action of completing the upcoming member census and survey in November/December and help the SVS build a more robust database regarding demographics, and member interests and priorities.

It will provide a snapshot of current representation across the Society. “One of the most important findings of the SVS (Diversity, Equity and Inclusion) Task Force report … is that we as an organization don’t know enough about our membership,” said Dalman. “Full participation in the 2020 census will help us get a more complete understanding of our membership today.”

Immediate past president Kim Hodgson, MD, created the Task Force relatively early in his presidency. He asked

26 • Vascular Specialist

co-chairs Bernadette Aulivola, MD, and John F. Edit, MD, to look at the issues broadly, “to focus not just on gender or racial disparities, but also those related to sexual orientation or identity, age, or, the group that I think is most discriminated against, foreign medical graduates.”

And shortly before his term ended, he presented statistics on representation on a wide variety of Society groups, from the overall membership, to councils, committees, task forces, leadership, the Vascular Self-Assessment and Education Program editors and authors, and more.

The Task Force has presented its report to the SVS Executive Board (see story, above), and Aulivola looks forward to forward movement. “Change will happen,” she said, in a post on the members-only SVSConnect messageboard.

The Task Force is working with Dawn M. Coleman, MD, and Joseph Mills, MD, on a Journal of Vascular Surgery supplement that will focus solely on issues related to diversity, equity and inclusion, she said. Task Force recommendations

race, ethnicity and sexual identity in the field of vascular surgery and within the Society.

Other recommendations expected to receive early attention are the appointment of a liaison to each SVS council and key committees to provide perspective on diversity and inclusion, as well as encouraging all members to update their profile information in the SVS database through the upcoming annual member census survey.

The comprehensive report and plan address training, working with regional and national societies, as well as the Association of Program Directors in Vascular Surgery (APDVS), to develop DEI policies.

New sessions at the 2021 Vascular Annual Meeting (VAM) form another plank, in addition to extending the new branding toolkit and campaign to include diversity and inclusion, and developing a program for practice support for minority vascular surgeons.

The Executive Board will mandate discussion and action over the course of the next year for all Society-related boards, councils, committees and task forces.

“Creating a new SVS Diversity Committee is the highest priority and “will be essential in helping to guide and serve as a resource to the Executive Board and Strategic Board”— Ronald L. Dalman

include investing not only and offers equal opportunity in recruitment of a diverse and voice to all its members group of individuals to the regardless of gender, race, vascular surgery field, but religion or sexual orientation/ also in providing support identity,” she said. and resources throughout She and Eidt thanked “the their careers. “This many students, trainees and includes opportunities for vascular surgeons who have leadership within the SVS reached out to help with the and transparency of the Bernadette Aulivola work of the Task Force as well appointment process,” as SVS support staff member she said.

Sarah Murphy, whose hard work has Aulivola briefly mentioned the been a true asset to the progress we have controversy in August over a JVS article made. We are grateful for the widespread on social media and professionalism, enthusiasm for change.” which resulted in viral posts from all Dalman thanked Hodgson for his realms of the medical field. Those events “foresight last summer in chartering “have strongly reinforced the need for the the DEI Task Force, which has provided SVS to take a proactive stand in assuring us with timely guidance as to how that our Society and our field is inclusive to proceed.”

“[The JVS events] have strongly reinforced the need for the SVS to take a proactive stand in assuring that our Society and our field is inclusive and offers equal opportunity and voice to all its members regardless of gender, race, religion or sexual orientation/identity”—Bernadette Aulivola OCTOBER 2020

ELANABS / ISTOCK / GETTY IMAGES PLUS

SVS makes commitment to diversity, equity and inclusion

MILITARY MEDICINE

Vietnam War-era vascular trauma pioneer honored by department he founded

BY BRYAN KAY

During a storied career, Norman M. Rich, MD, carved out a reputation as a pioneering vascular surgeon—drawing distinction for the creation of the Vietnam Vascular Registry database of vascular trauma injuries.

COURTESY DR. NORMAN RICH

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s a major during the Vietnam War, he was an emerging young surgeon who performed the role of chief of surgery in the Mobile Army Surgical Hospital (MASH) unit, where his emphasis on the need for arterial and venous repairs would help save scores of lives and limbs.

It’s perhaps no wonder then that the university department of surgery Rich founded would form a new named chair in his honor. So it is that the Uniformed Services University (USU) created the Norman M. Rich chair in surgery, a title assumed by current department chair, Navy Capt. Eric Elster, MD. USU described Rich as a significant contributor to the institution itself, military medicine and surgery throughout the more than half a century he operated as a vascular surgeon. During the hostilities in Vietnam, he would refine vascular surgical techniques, in particular for arteriovenous injuries to the extremity.

Rich’s injury database contained more than 7,500 people, a development he ranked as one of his proudest achievements in an interview with Vascular Specialist published in November 2018.

“He is exceptionally worthy of this

Awards and honors LYSSA OCHOA, MD, FOUNDER of the San Antonio Vascular and Endovascular Clinic (the SAVE Clinic), has received the Women’s Leadership Award from the San Antonio Business Journal. The SAVE Clinic’s mission is to reduce the number of diabetesrelated amputations.

Meanwhile, Christopher LeSar, MD, of the Vascular Institute of Chattanooga, Tennessee, has been named the president of the American Heart Association’s Chattanooga Board of Directors.

OCTOBER 2020

honor for his tireless commitment and dedication to the School of Medicine and the Uniformed Services University,” said Arthur Kellermann, MD, dean of USU’s School of Medicine.

For a read on what drew Rich to vascular surgery, we must delve back in time to the horrors of World War I. It was through the words of Otto Utzinger, MD, the doctor who had delivered him, that as a boy he heard about the horrors of amputations carried out during the Great War. The seed was planted.

Others from whom Rich drew inspiration include surgical titans like Michael DeBakey, MD, Carl Hughes, MD, Frank Spencer, MD, and Emile Holman, MD. His Vietnam registry found inspiration from Hughes, who had himself cataloged the vascular cases he treated during the Korean War. The registry saw Rich document the details of injuries as closely as possible, and then obtain and add long-term follow-up to each entry to establish whether procedures had worked.

It has had a lasting impact on the practice of vascular trauma, though he downplayed his role, quoted as saying he was “merely a scribe for 600,000 young American physicians who served during an

eight-year period in Vietnam.” Elsewhere, Rich was the first vascular surgery fellow at Walter Reed General Hospital in

Washington, D.C. He took on his role in USU’s department of surgery in 1977, stepping down in 2002. He was responsible for the first edition of “Vascular Trauma,” written with Spencer, and a further two subsequent editions of the textbook. He has also served on the editorial board of the Journal of Vascular Surgery.

“From this point forward, every surgeon who is given the honor of leading USU’s department of surgery and concurrently holding the Norman M. Rich chair of surgery at USU will have a direct connection to one of academic surgery’s most influential leaders in the 20th century and well into the 21st,” added Kellermann. “On behalf of the Uniformed Services University and ‘America’s Medical School,’ I offer heartfelt thanks to Dr. Norman M. Rich for a lifetime of service to USU and our nation, and congratulations to both Dr. Rich and Capt. Elster on this distinct honor.”

“He is exceptionally worthy of this honor for his tireless commitment and dedication to the School of Medicine and the Uniformed Services University”—Arthur Kellermann

George Williams (1930–2020) George Melville “Mel” Williams, MD, a giant of the pioneering generation of vascular surgeons, who was credited with establishing and modernizing transplant and vascular surgery at John Hopkins Hospital, died Aug. 26. He was 89.

The shortage of organs for transplant inspired him to help form the United Network for Organ Sharing, and he would serve as its first president.

vascularspecialistonline.com • 27