Vascular Specialist, July 2020

8–10 SVS ONLINE Conference news: Reports from the digital VAM alternative, including on rates of suicidal ideation

Vol.16 No.7 JULY 2020

Featured in this issue:

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NEW VICE PRESIDENT Michael C. Dalsing joins line of succession

JENS ELDRUP-JORGENSEN ACC and SVS join forces on single vascular registry

SPECIAL REPORT

Cultural reckoning: Confronting systemic racism

BY MALACHI SHEAHAN III, MD

panelists immediately expressed concern.

He would take this drive alone as a young Black male? Osa responded that his mother was also worried for his well-being. Black parents have to fear for their children in a way that never would occur to me as a father of white boys. That fear persists even if their children are surgeons. We all need to consider our roles in ending racial inequity in vascular surgery. It’s not enough to say, “I would have more black trainees/faculty if there were more qualified Black applicants.”

We also need to ask why. Why are there not more applicants? Is it because there

Vascular Specialist 9400 W. Higgins Road, Suite 315 Rosemont, IL 60018

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KNOW IT’S ALL A BIT EXHAUSTING. A pandemic, a recession and now racism.

Do we need to deal with this now? If you’ve listened to your Black colleagues in the recent podcasts and town halls, you already know the answer. The least we can do is unburden them of the stress that comes with feeling alone.

Of all the things I’ve learned the past few weeks, one vignette struck me as particularly poignant. On a recent Audible Bleeding podcast, Osarumen Okunbor, a new general surgery graduate, described his plan to drive cross-country to begin his vascular fellowship in Seattle. The other

To ensure we train more Black vascular surgeons, we must engage in active recruitment. We can no longer wait for them to come to us

are disproportionately fewer Black medical students. But why? As you drill down, your answer either becomes “because there is systemic injustice”—or something very problematic. Among the voices in this issue, you will hear from two young Black men who I attempted to mentor through the recent vascular match. But supporting them was only passive action on my part.

These men had come to me. To ensure we train more Black vascular surgeons, we must engage in active recruitment. We can’t simply wait for them to come to us.

See page 4–6

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GUEST EDITORIAL

Time, money and marginal utility

more, value relationships, and thereby reduce stress.

Unfortunately, children are usually born when surgeons are either in training or busy starting a career and practice.

Later, we may be able to spend hard-earned money to buy time.

BY BHAGWAN SATIANI, MD

Like most older surgeons, my residency and trauma fellowship years at Grady Hospital— part of Emory University School of Medicine—remain a blur. With frequent, every-other-day 24-hour call, this coincided with the first three years of my oldest child's life.

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s I recall, the term work-life balance was not yet born. But it appears that my instinct to value time over money upon starting practice was spot-on. My epiphany—which came much later in life—that I was choosing time over money is not new.

Benjamin Franklin is famously supposed to have said, “Time is money,” although the context was probably different.

I have written before about having prematurely added three partners in private practice, dismissing advice that loss of income would be consequential. We mutually agreed to free each other for family events during the day or on call, even during a procedure. Operative consents were obtained for all four surgeons. Patients understood prior to surgery that we were interchangeable unless otherwise requested.

One associate would substitute for another midway through an endarterectomy, for instance, and then take on the role of speaking to the family. This mode required us to have complete trust in one other, in addition to reciprocity.

As senior partner, my actions were intentional. This then allowed us more time with our families and to see our children grow up. We took eight weeks of vacation, working hard while one of the other surgeons was away.

Times have changed, and it may not be possible to duplicate this practice as an employed surgeon. Yet, none of us has regretted our decision.

It is no secret that physicians are burning out, partly because there is not enough time in an average workday to care for patients, complete medical records, answer emails, fight with insurance carriers, finish mandatory computerbased learning modules, complete continuing medical education hours, and serve on local and specialty society committees.

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

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ADDED FACTORS Furthermore, if we are in academic surgery, our duties also include teaching, lecturing, writing grants, working on promotions and doing clinical research, among other tasks.

When physicians are asked if they are frequently rushed, 78% of hospital/corporate-owned and 70% of physicianowned/independents agree. I am surprised it is not closer to 100%. The heightened demand for data reporting to support quality metrics and the push to generate revenues for employers in healthcare is taking the joy out of practicing medicine. Why is it that the sacrifice of time is always on the personal side?

We know that time and money are fungible, but extra time spent at work is irrevocably taken from our families. A recent Gallup survey asked people about whether they have enough time or what social scientists call “time affluence.”

The survey showed that 80% of Americans lack the time they need to accomplish their goals each day. Some 40% of physicians in a burnout survey claimed that their work did not leave them enough personal or family time.1 Some physicians can afford to “buy” time with money.

The use of babysitters and nannies are examples of this.

However, research such as a study of 800 Dutch millionaires informs us that although buying time is correlated with well-being, almost half did not spend money to buy time.

Interestingly, the least wealthy participants benefited the most from spending money on time-saving purchases.2 The authors also maintain that reports of greater overall well-being cannot be explained by income, education, age, marital status, number of children living at home, or number of hours worked per week. The bottom line is that money does allow us to hire time-saving services, socialize

AFFECTIVE Of course, many people have both time affluence Bhagwan Satiani and money. This may not be true for the average active surgeon paid essentially by the hour (work RVU per hour). But does more money provide more happiness? Is it logarithmic? Nobel Prize winner Daniel Kahneman, PhD, and colleagues at Princeton University, looking at affective measures, only noted that emotional well-being does rise with log income but did not increase beyond an annual household income of about $75,000.3 Affective happiness considers positive or negative emotions such as peace and joy experienced daily or in the recent past. Beyond that, more happiness may be experienced if additional time is being added to daily life.

There are suggestions to deal with the consequences of burnout other than the tired term “resilience.” I would favor a dose of preventive medicine. One thought has been to offer physicians time as an alternative to money. Stanford University researchers reported a pilot time-banking study in which physicians were rewarded with vouchers only for “time-saving” services. Voucher recipients related better work-life balance and described themselves as less likely to quit compared to other physicians.4 Gregory Gilbert, MD, author of the study, tells me that for a modest investment from the department, faculty can choose services like laundry or cleaning when they bank time put in for teaching responsibilities, for instance. Systems can still base it off wRVUs, although I have objected to the wRVU measure previously as a sole metric of compensating us. Financial incentives based entirely upon wRVU production is a step in the wrong direction.

AMPLE TIME Taking enough time off from work is important. The

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JULY 2020

2020 Medscape General Surgeon survey showed only 20% of physicians take five or more weeks of vacation and a third only take one to two weeks off annually.5 In the 2019 survey, 6% of burned out physicians took two weeks or less of vacation each year. If surgeons are negotiating a new job, asking for more time off rather than money is worth considering. In another Medscape survey, about 50% of physicians would take a salary reduction to achieve a better work-life balance, with women and millennials more likely to do so.

Economists use the term marginal utility to determine how satisfaction levels influence consumer choices. The idea being that the consumer buys more of a product or service until there is no further need, or declining satisfaction for each additional unit of the product or service. In other words, there is zero marginal utility when more money gives us no further satisfaction. When we reach zero is entirely up to us, because our priorities—such as paying off debt, wants and needs—are different.

Over one-third of surgical residents and the average medical student carry an educational debt of over $200,000.

Foregoing additional income may not be realistic until a significant part of the debt has been paid off. What is helpful in the long term is maintaining a modest lifestyle and keeping wants under control till there is recognition of zero marginal utility.

Having made plenty of mistakes early in my career, I am satisfied that, for me, the extra time—rather than income— was worth it. If you are undecided, ask and then listen to your children, spouse or partner. The answer may also lie in the mirror.

When physicians are asked if they are frequently rushed, 78% of hospital/corporate-owned and 70% of physician-owned/ independent physicians agree

78% 70%

SVS vice president, treasurer announced on SVS ONLINE opening day

BY BETH BALES AND BRYAN KAY

Michael C. Dalsing, MD, has been chosen as the next SVS vice president, joining a line of succession that now includes new president Ronald L. Dalman, MD, and president-elect Ali AbuRahma, MD, while Keith Calligaro, MD, is the new SVS treasurer, succeeding Samuel R. Money, MD. THE RESULTS WERE ANNOUNCED during the second session of the SVS Annual Business Meeting Saturday, June 20, when Dalman officially became SVS president, succeeding Kim Hodgson, MD. The meeting took place at the close of the opening day of the SVS ONLINE digital conference. Hodgson opened proceedings with a State of the SVS address, which was followed by the William J. von Liebig Forum, the first of the scientific sessions on the slate of the digital alternative to the Vascular Annual Meeting (VAM), and the E. Stanley Crawford Critical Issues Forum, put together by Dalman—and this year focused on the future of vascular surgery.

Dalsing is the director of vascular surgery at the Indiana University School of Medicine. He is currently professor emeritus of surgery within the division of vascular surgery and is the medical director of the IU Health Non-invasive Vascular Laboratory, which has been accredited since 1993 under JULY 2020

References 1. S hanafelt T. et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Available at https://jamanetwork.com/ journals/jamainternalmedicine/fullarticle/1351351.

2. Smeets P., Whillans A.V., Bekkers R., Norton M.I. Social Psychological & Personality Science. (Pre-published online June 25, 2019). https://doi.org/10.1177/1948550619854751.

3. Kahneman D., Deaton A. (2010). High income improves evaluation of life but not emotional well-being.

Proceedings of the National Academy of Sciences, 107(38), 16489-16493. doi: 10.1073/1) pnas.1011492107 4. Schulte B. Time in the bank: A Stanford plan to save doctors from burnout. Available at https://www.washingtonpost.com/ news/inspired-life/wp/2015/08/20/the-innovative-stanfordprogram-thats-saving-emergency-room-doctors-from-burnout/ 5. https://www.medscape.com/slideshow/2020lifestyle-general-surgeon-6012497

his direction. He is based in Indianapolis, and currently chairs the SVS Political Action Committee, Steering Committee and is a member of the SVS Policy and Advocacy Council.

Calligaro is chief of the section of

The bylaw changes subsequently passed, with 98.2% of voting members approving. They had been under consideration for a approximately a year

vascular surgery and director of the Vascular Surgery Fellowship at Pennsylvania Hospital and clinical professor of surgery at the University of Pennsylvania School of Medicine, Philadelphia. He is a member of the SVS Appropriateness, Audit, Conflict of Interest and Professional Conduct, and Document Oversight committees.

SVS members voted during the first Annual Business Meeting on Monday, June 15, to amend bylaws to not only permit voting virtually but also to provide for choosing from a slate of candidates for open officer positions.

The bylaw changes subsequently passed, with 98.2% of voting members approving.

They had been under consideration for approximately a year, with opening up the election process a key initiative of Hodgson.

Bhagwan Satiani is professor of clinical surgery in the division of vascular surgery, the department of surgery, in the Ohio State College of Medicine at Ohio State University in Columbus.

He is an associate medical editor of Vascular Specialist.

Voting opened that same evening and closed at 9 a.m. Saturday, June 20. SVS Nominating chair Ronald Fairman, MD, announced the results during the second Annual Business Meeting on June 20.

A total of 482—15.6%—of eligible members cast votes during the period.

“I can’t begin to say how grateful and humbled I am to become president,” said Dalman, especially “on the verge of celebrating our 75th anniversary.”

“I’m not sure what the future will hold this year,” he added, but it will include efforts to maintain momentum on ongoing initiatives mentioned throughout the meeting and to “figure out the best ways to support our members in a time of great uncertainty. I encourage everyone to reach out to me if they have ideas on how to do our jobs better.”

Michael C. Dalsing

vascularspecialistonline.com • 3

COVER STORY

CULTURAL RECKONING

‘I cannot remove my black skin’: Perspective of a vascular surgery resident

BY REGINALD NKANSAH, MD

For each of the past 10 days, I’ve woken up and asked myself the same questions: Do I matter? Does my life have as much value as that of anyone else?

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haven’t had positive answers to these questions. Not any that I could be confident in anyway. For me, at times being a Black man in America has been more difficult than the journey I’ve taken thus far to become a physician, one of my greatest life goals. Throughout my education, when I was deficient in a skill or lacked adequate knowledge, I could practice and study to progress towards proficiency.

As a Black man, this opportunity often doesn’t exist. I cannot remove my black skin, and no amount of education, professional clothing, social expertise, discernment or humility can overcome the intrinsic systematic and personal discrimination I face daily. All this simply on the basis of the way I was born, something out of my control.

At my graduation nearly three weeks ago, it was said that, “You’re always a physician, whether at work, home or elsewhere.” But for me, I often feel like a 5-foot-8 to 5-foot11-inch Black man wearing nondescript clothing with no name, face, identity or value. I live in a chronic state of fear and discomfort that at any moment I may be a victim of any number of unfortunate incidents.

For example, in 2008, as my friend and I played catch in the park near our brothers’ elementary school at dusk, waiting for a cub scouts meeting to end, a police vehicle jumped the curve and drove directly towards me with his front headlights on. The officer exited his vehicle and

“I live in a chronic state of fear and discomfort that at any moment I may be a victim of any number of unfortunate incidents”— Reginald Nkansah aggressively asked us what we were doing there. We indicated why we were there and subsequently had to accompany him into the school to confirm that we were not trespassing in the park.

In the summer of 2012, police officers came to my home while my parents were at work and questioned whether or not I lived there. They asked to step inside my house and for confirmation that I lived in my own home. This was the result of a morning pulling weeds at my mother’s request, and the overzealous call of a neighbor who said she saw a trespasser. My family moved into the home in 2004, and I had lived there consecutively for six years before leaving for

college. In 2013, while eating a family dinner at Bear’s Den at Washington University in St. Louis, I watched as one of my best friends (now a physician), was detained and questioned by campus police in reference to a submitted police profile that neither fit Reginald Nkansah his height nor clothing (an inadequate and erroneous tip). This stood on top of the custom we had as Black men on campus to always have a backpack, lest you be detained and questioned about the validity of your presence.

It’s not my job to teach individuals and institutions to treat me as an equally valued human being. However, I do strongly believe that it is our collective responsibility to create a better, more equitable society to preserve the future for our posterity, our profession and our country.

Racism isn’t your fault or mine, but it unequivocally exists. It’s salience has simply once again increased. We were born into a set of circumstances that enabled the systematic racism and structural violence against various vulnerable groups. If we perpetuate this inequity we are complicit in the prejudices of our ancestors.

We need to have the courage to be better, to engage with this struggle each and every day, and step-by-step build a better future. This shouldn’t be through only thoughts, prayers, conversation, statements and social media posts, but also tangible changes and actionable items. I’m confident that the SVS, other leading organizations in vascular surgery, educational institutions and individuals can demonstrate significant leadership in changing our country for the better.

Reginald Nkansah, a graduate of Tulane University in New Orleans, is an integrated vascular surgery resident at the University of Washington in Seattle.

Vascular fellow: ‘Keeping your head down does not save you from inequality’

BY OSARUMEN OKUNBOR, MD

Pain is often fully experienced in isolation. It’s these experiences that serve as some of the most defining moments in life. The history of race cannot be recounted without sorrow. It remains a constant reminder of our differences, a difference that has forged a unique experience in the inequality of humanity—the Black experience.

FOR SOME, THE RECORDED VIDEOS of Black lives being taken so maliciously without regard for another human’s life is new and shocking. Unfortunately, these events are all too familiar for Black families.

This Black experience is one that has been lived in isolation for years. These moments define and reinforce the idea that we are inferior and, even worse, less than human when compared to another. These ideas have been passed down the generations.

One thing that is new and unfamiliar in recent months are those people who have offered their voice for change. This collective voice is no longer just Black voices 4 • Vascular Specialist

in the shadows of our culture. It is voices of different backgrounds, races and religions.

Protests and empathy are no longer segregated. There has been a conscious decision to no longer allow the pain from inequality in another human being to be experienced in isolation. This new, unfamiliar place is part of the story that is needed to make change. I’ve been struggling with this thought often: What responsibility do I have in all of this? And what kind of intention should I grant my voice?

As an aspiring vascular surgeon, I’ve made a commitment to learn this craft and reach my full potential. My purpose to serve

Osarumen Okunbor

people feels as if it is explicitly implied by its title. This is a huge life commitment, and balancing other responsibilities can be very challenging. However, I cannot ignore that also implied in my title—as well as those of my colleagues—is the power that it lends itself in any community. Everyday people trust us with their lives in a very vulnerable way. Patients come into our hospitals from all walks of life seeking support, guidance and our tools for healing. When it comes to race relations within healthcare, there are still conversations to be had about disparities and misrepresentation. Our healthcare system still needs work, and

at times it mirrors the same systems and prejudices that have let minorities down and instilled fear, not security. Maybe our role as providers is to challenge our implicit biases that allow us to continue to perpetuate these failings in our system when dealing with vulnerable populations.

When I was asked to write a piece for Vascular Specialist on this topic, I wasn’t sure what to say or what I should write. It is not very often that the topic of race in society, outside of the topic of healthcare, is brought up explicitly in a professional platform such as this one. The idea of writing this was an uncomfortable one that tapped into a place of fear. We all want to be respected and remembered for our great work in the field, not about what has made us different and challenged our equity.

Some of us feel like we just want to exist by keeping our head down and working hard, but we often reach the realization that keeping your head down does not save you from inequality. As I took a step back, I was able to see that it is this fear—and feelings of discomfort—that can hinder change.

Osarumen Okunbor is a vascular surgery fellow at the University of Washington in Seattle.

JULY 2020

Outgoing SVS president outlines state of Society diversity

BY BRYAN KAY

Outgoing Society for Vascular Surgery (SVS) president Kim Hodgson, MD, delivered a datadriven insight into diversity within the organization during his June 20 State of the SVS address at the start of SVS ONLINE, one of his final acts atop the organizational chart.

DELIVERING DATA DEMONSTRATING the composition of the SVS along age, gender and ethnic lines, he indicated work remained to be done to achieve a more diverse organization, telling the Vascular Annual Meeting (VAM) replacement that “we ought to be able to do better.”

Last year, the SVS Executive Board established an Equity, Diversity & Inclusion Task Force, co-chaired by John Eidt, MD, and Bernadette Aulivola, MD, charging them with looking at the issue broadly, explained Hodgson, “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.”

SVS DIVERSITY Broadly, he said, the SVS is only 15% female.

“But clearly this is not what is reflected in all of the different facets of our Society. For example, as you can see, women make up 38% of those of us younger than 39 years, 24% between 40–49 years, 11% between

50–59 years, and only 3.5% of members 60 years old or greater. This is important to keep in mind since different positions within the organization typically require different levels of prior experience, which usually correlates with age. [It's similar] with [the composition of] our organizational ethnic diversity, for which age had no impact.”

The relevant statistics read: 73% white, 15% Asian/Indian, 6% Hispanic/Latino, 2% African American and 4% other.

While the Executive Board is entirely white, Hodgson said “the Strategic Board doesn’t look too bad when comparing it against the ethnic make-up of our society but Hispanics and African Americans, while admittedly in short supply in the pool, could be better represented,” he told viewers of the address.

“Hispanic and African Americans are more commonly seen on the slopes of Aspen, Colorado, than in our meeting halls”— Kim Hodgson The statistics to which Hodgson refers demonstrate an SVS Strategic Board (n=25) composed of 80% white members, 12% Indian/Asian, 6% Hispanic/Latino and 4% other.

MEMBERSHIP At the council level, Hodgson continued: “Obviously it’s difficult if not impossible to completely mirror your membership, particularly poorly represented cohorts thereof, on all councils and committees, but perhaps we could do better here.”

The ethnic diversity of the SVS councils were recorded as (n=50) 74% white, 20% Asian/Indian and 6% other.

“Things look a little better at the

SVS issues statement abhorring injustice and violence amid unrest in US

BY BRYAN KAY

JULY 2020

committee level, but please career, I have only once had note that the larger, the ‘n’ the the opportunity to train an more unknowns and 'others' we African American vascular have,” Hodgson said. “Again, fellow, an outstanding young we can serve you better if man who I would trust with we know more about you, so my own care,” he continued. “I please plan to tell us so in the noticed that over the two years fall.” he was with me, that many The SVS committee statistics of my Black patients actually (n=346) read: 58% white, 20% started following my advice.

Asian/Indian, 3% Hispanic/ Kim Hodgson And I came to realize that they Latino, 3% African American, believed it when it came from 8% unknown and 8% other. him or in his presence, but they didn’t really Continuing, Hodgson said: “Rutherford trust me on my own. associate editors, typically a group 50 years “Think about that for a minute. A large old or over, were 17% female for the 9th proportion of our patients struggle to edition and will be 42% female for the 10th. be sure that their doctor’s interests are in And while the 9th edition had virtually their best interests. Good outcomes for the no ethnic diversity at the associate editor population we serve requires trusting in level—even the international editors were patient engagement, and sometimes that Caucasian—the 10th edition is looking takes having a doctor that looks and talks much better.” like you.”

Said 10th edition editors break down as follows: 50% white, 25% international, 8% UNDERREPRESENTED Hispanic/Latino, 8% African American But Hodgson went on to argue that a and 8% other. There were no Asian/Indian lack of diversity on SVS committees, associate editors on the 10th edition. councils and boards was not “indicative” “I’ve looked at the gender and ethnic of discrimination under the prism diversity for the VESAP4 editors and of the appointments process “during question authors, VESAP5 editors, the which we constantly strive for APDVS [Association of Program Directors diversity.” Rather, he continued, this in Vascular Surgery] executive council, the was reflective of a lack of diversity in Vascular Surgery Board, the JVS [Journal the membership body as a whole. of Vascular Surgery] and JVS-VL [Journal “While underrepresented in all of medicine, of Vascular Surgery-Venous and Lymphatic but especially in the surgical specialties, Disorders] editors and editorial boards, and Hispanic and African Americans are more all the data tell a similar tale,” Hodgson commonly seen on the slopes of Aspen, went on.

Colorado, than in our meeting halls.”

“While different contingents may debate Achieving greater diversity within the whether the gender data represent a glass SVS ranks needn't be a forlorn journey, half empty, half full or even too full, I will Hodgson pointed out. The Society has been stay out of that debate and say that the data down a similar road before. are what they are. However, no one can Hodgson concluded: “As a society we argue that, particularly with regard to the have had outreach efforts directed at other Hispanic and African American contingent, underrepresented groups in the past, and we ought to be able to do better on ethnic much of the data I have just shown you diversity. Not just in vascular surgery but in indicates that such efforts can be successful. medicine as a whole.”

“The Task Force has documented who we are today. We now need to ask how do we EXPERIENCE address our remaining diversity challenges, Hodgson provided some insight from a and I am encouraged that the Task Force personal point of view. “In my 35-year has proposals to tackle just that.”

In the aftermath of the protests that erupted across the U.S. after African American George Floyd died at the hands of police in Minneapolis, on June 2 the Society for Vascular Surgery (SVS) and the Association of Program Directors in Vascular Surgery (APDVS) issued a joint statement in support of diversity.

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oining other bodies of medical professionals, the two organizations highlighted the sacred oath taken by physicians to “save and extend the quality of life” of all people. They went on to state that as membership groups they abhorred “injustice and violence of any kind.”

Medical bodies had come under renewed pressure to take action to help address systemic racism as it exists in the medical profession and healthcare.

The full statement reads: “The Society for Vascular Surgery (SVS) and the Association of Program Directors in Vascular Surgery (APDVS) embrace the core values of diversity, inclusion, fairness and equity.

“As organizations of physicians and healthcare practitioners, we value human life, and have taken a sacred oath to save and extend quality of life for all of our patients. Racism, discrimination and inequity of any kind undermines public health and our healthcare delivery systems. The SVS and APDVS abhor injustice and violence of any kind, wherever and whenever it occurs. We are horrified by the events surrounding the death of George Floyd as well as the subsequent acts of violence that have come amidst peaceful protest for change across our nation.

We must come together with wisdom and meaningful action to address these events. The SVS stands firmly with all of its members, who stand with their patients, their families and their communities. We hope for peace, calm, wisdom and positive action in the coming days.”

vascularspecialistonline.com • 5

CULTURAL RECKONING

Opening up a difficult conversation

BY BRYAN KAY

Recent times have wrought a potent cocktail of cultural disarray on the psyche of the United States. In medicine and vascular surgery, this confluence of events has been acute. First COVID-19 halted elective surgery, bringing the specialty to a near standstill and anxiety to the wider medical sphere. Then the cultural moment quickly melded with the harsh reality of systemic racism suffered by people of color, including within the healthcare system, following the killing of African American George Floyd by police.

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s a set of events, they combined to confront and confuse. Normal life evaporated with the coming of the novel coronavirus. Passivity in the face of racism also disappeared after Floyd’s killing in Minneapolis. Difficult questions started to be asked.

Including of those who work in medicine, often around the role they may or may not play in the system—but also the kind of healthcare disparities exposed by COVID-19.

It was a moment that struck Dawn M. Coleman, MD, associate professor of surgery at the University of Michigan in Ann Arbor, Michigan, hard. During the worst moments of COVID-19 in her workplace, Coleman—an active member of the military—was part of an effort to put together an emergency field hospital.

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Then came Floyd’s death in Minneapolis, and the U.S. started to boil. Medical professionals and societies were challenged to step up.

As she puts it, she’s incapable of sitting back in silence, and felt compelled to take action. So wearing her hat as co-chair of the Society for Vascular Surgery (SVS) Wellness Task Force, she recently staged a Dawn M. Coleman webinar in conjunction with the SVS Equity, Diversity and Inclusion Task Force aimed at giving voice to the realities faced by her colleagues of color.

“I’m not an expert in COVID, I’m not an expert in racism, I’m not an expert in putting together a field hospital. I think I have just found myself in a position where there’s a lot of really heavy, complicated problems right now. Some days it feels really overwhelming,” Coleman told Vascular Specialist.

“I try very carefully to listen, and I try to be readily available to vascular surgeons in the space of wellness. I think it’s a volatile time right now for everybody in the U.S. for a lot of different reasons. COVID may be new but a lot of things we are experiencing right now so sharply are not. I think COVID has really clarified in a very acute way disparities that were already well in existence. There has been recurrent evidence of such, concurrent with mounting civil unrest. I feel at times really ignorant. I'm really trying to learn a lot, now more than ever. I think people are feeling a lot right now. You wake up and there’s a lot of bad news.

There’s tremendous human suffering. There are a lot of wrongs being performed. I think as surgeons, as fixers, we are naturally always trying to do our best to help, and I think we carry this weight. I think it’s increasingly difficult to steward your compassion and to compartmentalize certain things.”

That’s when Coleman realized a conversation had to be initiated. Hearing stories of injustice, watching matters unfold amid the healthcare disparities given fresh exposure by the coronavirus pandemic, she got to work. “With the Wellness Task Force, I feel at least there is a space we can

use to bring people together, and maintain a focus on active support of our diverse workforce and membership—and also this ongoing commitment we have made to our patients—focusing on our vulnerables, our trainees.

“Change is desperately needed, large-scale change, bigger change than any one of us can accomplish. But I think if we don’t start someplace, that change will never happen.”

It’s a long road, Coleman observed. Some of the correspondence she has received laid bare the challenge.

One particularly poignant, raw piece of communication from a dear friend brought the reality into sharp focus. “It’s hard to hear that suffering, that emotion, and not have any understanding about what that feels like, what that injustice feels like, what racism feels like,” she explained. In that vein, Coleman wanted to cultivate openness. The webinar, she says, was about giving people a platform to talk and

“You wake up and there's a lot of bad news. There's tremendous human suffering.

There are a lot of wrongs being performed.”— Dawn M. Coleman share—but also to enable those motivated to listen. “How can any of my peers and partners and trainees thrive as surgeons of color—or any of our minority surgeons—when they are afraid. Some of them, many of them? They don’t feel supported locally, or even higher. It’s a lot to unpack. I have a really hard time sitting silent. This was the one thing I thought I could do, quickly, urgently with the hat that I wear—the Wellness Task Force seemed to be a good place to start. I hope it will complement the work the SVS is already doing with the Equity, Diversity and Inclusion Task Force because there are people already thinking about this.”

JULY 2020

SVS ONLINE

Crawford Forum sets the stage for vascular surgery future xxxxx xxxx

BY BRYAN KAY

It was an encapsulation of the existential questions surrounding vascular surgery.

And it was just as the newly installed Society for Vascular Surgery (SVS) president Ronald L. Dalman, MD, had designed.

T

he Stanford University, California, vascular chief had intended it to be constructed this way. As is custom, the at-that-point SVS president-elect had been charged with devising the coveted E. Stanley Crawford Critical Issues Forum.

This year, of course, it took place during SVS ONLINE, the digital alternative to the Vascular Annual Meeting, canceled in the face of the ravages of the COVID-19 pandemic. It was part of the conference’s opening day, a pivotal session aimed at guiding the vascular specialty into the future.

Dalman took the approach of returning the forum to its baseline, as former SVS president Crawford envisaged: charting the course of vascular surgery going forward.

Dalman’s forum contained a very deliberate narrative flow, all of which coalesced around the direction to which vascular surgery is headed. The bottom line: What is vascular surgery and what is its future within the U.S. healthcare system?

Joseph Mills, MD, professor and chief at Baylor College of Medicine in Houston, highlighted the work being carried out to establish vascular surgery as a respected part of the medical firmament, setting the stage for the overarching theme of this year’s iteration of the forum.

“I want to create a vision for our members, I want to be able to position the SVS as leader in this space,” he said. “Ultimately, we want to promote better outcomes in

8 • Vascular Specialist

management of vascular care and vascular health for our patients.”

The mantra of vascular surgery—as vascular specialists providing comprehensive care—at this stage comes into clear view. “We hold ourselves to be comprehensive vascular leaders and partners, and many of us have built practices based on this,” Mills said. “But, in many instances, we are viewed as highly technical surgeons who are relied upon for episodic interventions.

“So, to brand ourselves properly, we have to do what we say we do, which is to provide comprehensive and longitudinal care.”

That tack neatly segued into the work of Richard Powell, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, who carried on the theme of the forum with a talk on how the vascular specialty is valued within the U.S. healthcare system.

Vascular surgeons are of critical importance to ensuring a safe operating room environment, he told viewers of the event. “How does the hospital administrator view vascular surgery?” was the core question posed by Powell.

“Our patients tend to be complicated. The average hospital administrator frequently has no idea what vascular surgeons do. I was surprised that this was the case. I have been on the Board of Trustees with Dartmouth for over 10 years and knew all the C-suite executives quite well.

When I asked our own chief strategy officer, CFO and

chief clinical officer and others what we do, they did not appreciate how frequently we help other services with both elective and, more importantly, with emergent surgical assists.”

The backdrop to much of this reality in which vascular surgeons operate is the specter of burnout. The SVS Wellness Task Force was set up to ameliorate and investigate what ails vascular specialists. The very genesis of the group came in response to data suggesting vascular surgeons were at higher risk than other specialties to burnout, said Dawn M. Coleman, MD, co-chair of the Wellness Task Force. “This was considered a critical issue in the face of a threatened workforce. We have approached proactively this uncomfortable space to destigmatize a culture of complacent suffering, specifically to optimize our recruitment and retention.”

Coleman made the link between lowered productivity and burnout, leading to the sort of decreased revenue incurred by hospitals and quality of care suffered by patients that medicine seeks to avoid.

The bottom line here, as envisaged by Dalman as he set up the Crawford Forum, was to draw into view the idiosyncrasies of vascular surgery and its central role in the healthcare system.

Which led to the session’s final speaker: Ben Harder, managing editor and chief of health analysis at U.S. News & World Report, publisher of respected national healthcare rankings.

The backdrop to Harder’s inclusion on the Crawford Forum slate involves the existential questions that surround vascular surgery. In short, it is not listed as a distinct specialism in the platform’s analysis of the U.S. healthcare system, a situation Dalman would like to remedy.

But Harder outlined why vascular surgery as a separate listing won’t be forthcoming during his turn at the interface of the digital podium. “Going back to 1990, we identified about a dozen different areas of complex specialty care to evaluate hospitals,” he said. “It has never been our mission to evaluate each department or each service of a broad healthcare organization separately.

So, I want to be clear that the cardiovascular rankings that we publish evaluates care that’s provided by medical cardiologists, interventional cardiologists, by vascular surgeons as well as cardiothoracic surgeons. All of that is encompassed in that one specialty that we rank and publish. The reason for that is these disparate specialties and services provide care for overlapping patients.”

“The average hospital administrator frequently has no idea what vascular surgeons do”— Richard Powell For his part, Dalman pressed Harder further. “Vascular surgery works with a lot of other specialties, and if we quantify our contributions only in the framework of the cardiovascular service line, that’s missing a significant contribution vascular surgeons make to health systems and patient outcomes. So, how do we more broadly capture what vascular surgeons bring to a health system?”

Harder demurred, again explaining that U.S. News & World Report does not deviate from its core ranking parameters. Yet, Dalman had a final salvo. He asked whether participation in registries such as the Vascular Quality Initiative (VQI) was a ranking criterion.

To which the answer came back in the negative. Not to be deterred, the new SVS president pushed further “I would encourage you to use the VQI for that purpose,” Dalman added.

JULY 2020

‘Poor long-term survival’ following explantation of an infected endograft

BY DAWN POWELL

Paolo Perini, MD, of the University Hospital of Parma, Italy, told the opening day audience of SVS ONLINE on June 20 that explantation of an infected abdominal aortic endograft is associated with high postoperative mortality and poor long-term survival. Furthermore, there was a high rate of reinfection.

ACCORDING TO PERINI AND colleagues, infection of an abdominal aortic endograft is a rare but “devastating complication” that is associated with high mortality. He told the SVS ONLINE audience that the aim of the present study—a multicenter review of endograft explantations performed over a 20-year period (1999–2019)—was to analyze factors “that may have influenced 30-day mortality, 30-day morbidity, and long-term survival.”

The investigators identified 257 patients who had undergone endograft explantation at 11 centers over the study period. Of these, 49 (19%) had an infected endograft.

“The mean age of patients was 73 years and there was a clear male preponderance [90% of patients]. This was a high-risk population. In fact, 86% of patients had an American Society of Anesthesiologist (ASA) score higher than 3,” Perini observed.

He added that one finding was that explantation for infection “generally occurred” earlier than explantation for endoleak correction (13 vs. 46 months, respectively; p<0.001). Furthermore, 35% of patients had previously undergone endovascular correction. Perini stated that prior endovascular correction did not present a risk factor for infection because

“explantation for other reasons presented a similar rate of endovascular correction.”

All patients underwent complete endograft explantation, with 63% subsequently undergoing anatomic reconstruction and 37% undergoing extraanatomic reconstruction. While anatomic reconstruction was more common overall, Perini noted that extra-anatomic reconstruction was “a common solution for patients operated on in an urgent setting.”

Some 22% of infections were found intraoperatively. Additionally, the most commonly identified micro-organisms were Gram positive and multiple causative agents were found in two thirds of cases.

At 30 days, mortality was 25% and this

“This was a high-risk population. In fact, 86% of patients had an American Society of Anesthesiologist (ASA) score higher than 3”—Paolo Perini

rose to 35% when in-hospital mortality was taken into considerations. Perini commented: “We did not find any specific risk factors for higher mortality.

The presentation of aortoenteric fistula [40% of cases] was associated with a higher mortality rate but the difference [compared with other presentations] was not statistically significant. Morbidity rates were high, especially in terms of renal injury [27%], respiratory failure (33%) and gastrointestinal complications (18%).”

During long-term follow-up (mean 31.2±47.8 months), there were four aneurysm-related deaths and 20% of patients went on to have another infection.

The one-year and five-year survival rates were 57% and 32%, respectively, and these rates were significantly lower than for patients who underwent explantation for another reason (83% and 65%, respectively; p=0.035). One-year survival rates were also significantly lower in patients who underwent extra-anatomic reconstruction than those who underwent anatomical reconstruction (33.3% vs. 72.2%, respectively; p=0.0014).

Perini concluded that explantation was “technically challenging” and associated with “high postoperative mortality and morbidity rates.” He also noted that longterm survival was “poor.”

Alarming rate of suicidal ideation among female vascular surgeons warrants urgent intervention, researchers find

BY BRYAN KAY

Gender-based differences driving career dissatisfaction and burnout exist, viewers of the SVS ONLINE virtual conference heard during the William J. von Liebig Forum June 20, the first scientific session held on opening day. And an “alarming rate of suicidal ideation amongst women” warrants urgent intervention to identify and support those at risk, Laura Marie Drudi, MD, a vascular surgery resident at McGill University in Montreal, told attendees.

“THE PREVALENCE OF BURNOUT AMONG vascular surgeons is high,” she said. Indeed, work-related pain is a significant factor for both men and women, and programs that help mitigate pain in surgeons should be helpful to all vascular surgeons, Drudi went on to state.

She was presenting evidence from a study entitled, “Predictors and sequela of burnout amongst practicing American vascular surgeons: A gender-based analysis, on behalf of the SVS Wellness Task Force”—an initiative set up by the Society in 2017 in response to an apparent high risk for burnout in the vascular surgery specialty.

“Burnout is a mental state characterized by emotional exhaustion, depersonalization and a diminished sense of personal accomplishment,” Drudi said. The epidemic of physician burnout has reached sobering levels and, indeed, vascular surgeons appear to be at high risk, she noted.

Drudi et al cited as a backdrop the one-third of practicing vascular surgeons who self-report burnout and depression.

Their study sought to identify gender-specific predictors for burnout to guide future interventions.

During 2018, active SVS members were surveyed

JULY 2020

confidentially using the Maslach Burnout Index. This was embedded in a questionnaire that captured demographic and practice-related characteristics, with results stratified by gender, Drudi explained.

Univariate and multivariate logistic regression models were developed to identify predictors for the endpoints Laura Marie Drudi of burnout and suicidal ideation.

The survey had an overall response rate of 34.3% of practicing vascular surgeons. A higher percentage of women responded (19%) than comprise SVS membership (13.7%), the researchers found. Burnout prevalence was similar for women and men (42.3% and 40.9% [NS]) but the prevalence of suicidal ideation was significantly higher in women (12.9% vs. 6.6%; p<.007).

“While there was no difference in mean hours worked or call taken, women were more likely to have had a recent conflict between work and home responsibilities (68.5% vs. 57.4%; p<.01) and to have resolved this conflict in

Women were less likely to selfreport a recent malpractice suit (10.5% vs. 20.3%; p<.005)

or to feel that a fair resolution was reached (57.3% vs. 93.3%; p<.05)

favor of work (57.5 vs 42.8%; p <.005),” Drudi said. “Women spent more time working at home on EMR [electronic medical record] (6.4 vs.

4.7 hours; p<.0001) or other work-related tasks (6.5 vs. 5.4 hours; p<.05); however, men were more likely to be very dissatisfied with their EMR (23% vs. 11.2%; p<.05).

Although men and women had the same incidence of reported recent medical errors, women were less likely to self-report a recent malpractice suit (10.5% vs. 20.3%; p<.005) or to feel that a fair resolution was reached (57.3% vs. 93.3%; p <.05). There was no gender difference in reported work-related pain. Multivariate analysis revealed work-related pain as an independent predictor for burnout and suicidal ideation for the entire cohort, and work/life imbalance as an independent predictor for burnout. EMR dissatisfaction was an additional burnout predictor in men.”

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SVS ONLINE

How remote support systems will transform medical care

BY BRYAN KAY

The prospect of remote stroke intervention may be the most exciting clinical application among the suite of benefits emerging from the ongoing transformation in surgical practice and education delivery, Alan Lumsden MD, the medical director of Houston Methodist DeBakey Heart & Vascular Center in Houston, told viewers during this year’s iteration of the Roy Greenberg Distinguished Lecture.

L

umsden gave the address—entitled “TeleWhat? Beyond the office: How remote support systems will transform education, case support and care delivery”—on the second day of SVS ONLINE, on June 23, as the digital alternative to the canceled Vascular Annual Meeting (VAM) moved onto Scientific Session 2 and its first Invited Session, “American Venous Forum Debates 2020: Are DVT & PE interventions unnecessary?”

Having the ability to perform a procedure from afar is the holy grail among these remote support systems, said the professor of cardiovascular surgery, against the backdrop of a COVID-19 pandemic that not only caused VAM 2020’s cancellation but also a surge of interest in telemedicine.

Lumsden connected the dots that unite a modern era in which boundaries are being pushed in the delivery of education, case support and care.

“The COVID-19 epidemic dramatically increased interest in telemedicine,” he told Vascular Specialist in the days leading up to the start of SVS ONLINE. “However, for most, this simply means teleconsultation in an office-based environment. In this presentation, we’re going to study some of the more advanced applications that are specific to surgical practice. Specifically, how remote audiovisual platforms can be employed for case support, remote monitoring, remote education and

potentially perform remote interventions.”

Lumsden pointed to an old picture published on the cover of TMC Pulse in July 2018—depicting the operating room of the late vascular surgeon Michael DeBakey, MD—as a yardstick of progress.

“In this black and white picture from Dr. DeBakey’s operating room, you see old-style surgical education with people crowding around,” he said. “If you look up

Zoom. There is now a plethora of online offerings associated with the rapid development of Zoom fatigue. This makes it hard to differentiate oneself from the crowd. It is particularly a challenge in developing a hands-on curriculum. We recently designed an online hands-on curriculum for the upcoming vascular intern class.”

The hands-on tradition was something Lumsden and his colleagues wanted to continue. “For the first time ever, we believe, a remote course focusing on basic suture skills was conducted, in which

“Education has clearly been transformed, in some ways for the better and many others for the worse by the COVID-19 crisis”—Alan Lumsden above the field, there is a huge television camera with someone lying on the boom to record the case. If you look even higher, there are viewing domes where folks could attempt to see down into the wound.

Clearly, technology has moved on, and contemporary audiovisual communications systems potentially allow us to transform case support.” Lumsden first trained his focus on advances in medical education.

“Education has clearly been transformed, in some ways for the better and many others for the worse by the COVID-19 crisis,” he continued. “Everyone has discovered

SVS Foundation Board structure changed

BY BETH BALES

The SVS Foundation Board of Directors has altered its infrastructure, including expanding the board and adding seats specifically for public members and changing the term of the Foundation chair to a three-year instead of a one-year term.

JULY 2020

Alan Lumsden

sewing kits were distributed to all 57 participants,” he explained. “Demonstration by and supervision from remote proctors was achieved in small classes of four to five students. Optimization of a CT [computerized tomography] image and working in the MPR [multiplanar reformation] environment was performed by distributing standardized CT scans and software to all the students. These are but two examples of how surgical training may have to adapt to our new reality.” Support for acute cases, meanwhile, was brisk.

“When the epidemic hit, we could

immediately deploy many of the remote systems in support of acute cases,” said Lumsden. “We had requested that the device reps familiarize themselves with remote support, practice with the interface and gain an understanding of the benefits and limitations of this technology. Although many of these systems are fairly easy to use, it is important that users familiarize themselves with the interface through practice before covering emergent cases.

Remote support was used in at least three emergent cases during the COVID-19 crisis. This led to a degree of acceptance, which has now extended into elective cases.”

Lessons have been learned, too.

“With use, it has become apparent that optimization requires attention to bandwidth, camera positioning, the audio communication system and the format of verbal communications,” Lumsden added.

“In addition, the number of video feeds which are necessary is case-specific.”

It is remote support’s “holy grail,” though, that gets the Houston Methodist Walter W. Fondren III Distinguished Endowed Chair particularly excited: the carrying out of actual procedures. “This has been successfully demonstrated, with the first case being remote coronary intervention in India, and the second being a neurointervention in Toronto.

“Many of the prerequisites for good audiovisual communication are also intrinsic to remote catheter control. We will demonstrate early data on performing remote endovascular interventions in a simulated environment. Remote stroke intervention may be the most exciting clinical application—a high public health need where the efficacy of early intervention can have massive health and economic implications. In the end, it is all about speed of data transmission, reliable audiovisual communication and case choreography between observer/operator and the patient.”

EXPANDING THE BOARD PROVIDES FOR development of criteria for evaluation of current broader representation while the three-year term and future programs; and amended bylaws to for the chair provides continuity, said Michel S. enact the changes.

Makaroun, MD, whose term as chair ended June Besides Lawrence, other members of the 20. The changes as a whole “position the SVS Foundation Board of Directors are SVS president Foundation Board for further growth,” he said.

Ronald L. Dalman, MD; president-elect Ali In addition, the immediate past president AbuRahma, MD; immediate past president Kim of the SVS will no longer succeed to the chair Hodgson, MD; SVS treasurer Keith Calligaro, position, but will serve on the Foundation board.

MD; Edith Tzeng, MD, chair of the Research In announcing these changes at the first SVS Peter Lawrence Council; and SVS members William Shutze, Annual Business Meeting on Monday, June 15, MD, Richard Lynn, MD, Matt Eagleton, MD, Makaroun named Peter Lawrence, MD, who chaired the and Joseph Hart, MD, as well as non-SVS members Nasim Foundation in 2015–16, as the new chair.

Hedayati, MD, Sylvain, and Neupert.

New public members are “friends of the SVS” Marty Outgoing president Hodgson thanked Makaroun for Sylvain and James Neupert. his work, particularly with adding the SVS Foundation Other infrastructure changes include the creation of “Vascular Spectacular” Gala to the Vascular Annual Meeting. three-year terms for board members, with the exception of Hodgson called the restructuring “an outstanding idea and staggered terms for the first cycle to provide continuity; the an outstanding accomplishment.” vascularspecialistonline.com • 11

AWARDS

Vascular pioneer

BY BETH BALES

His was the golden age of vascular surgery, said Robert B. Smith III, MD, recipient of this year’s SVS Lifetime Achievement Award. And he enjoyed every moment of it, including getting in on the ground floor of the specialty by training under vascular pioneer Arthur Voorhees, MD, in New York City.

SMITH’S WORK—AS A SURGEON, scientist, teacher, mentor and leader—has left a lasting impact on the vascular world.

Smith interned and did his residency at Columbia Presbyterian Hospital in New York City (interrupted by two years in the Army), where he became immersed in vascular surgery with Voorhees. “My career overlapped with the growth and maturation of vascular surgery as a distinct specialty. It’s amazing what happened in those decades,” he said. And, with the endovascular revolution, “it’s still going on.”

In 1966, Smith returned to Emory University in Atlanta, where he’d attended college and medical school, as a faculty member. He spent the rest of his career there. With his senior partner, Garland Perdue, MD, Smith performed Georgia’s first successful renal transplant. He collaborated with Dean Warren, MD, to

help refine the distal splenorenal shunt, a major innovation in the care of patients with portal hypertension. Surgeons from across the country visited Emory to observe the liver team performing shunt procedures.

Smith was the first to describe, in 1977, the creation of an axillo-popliteal bypass and its utility as an extra-anatomic bypass for the management of patients presenting with an infected aortobifemoral bypass. That and many other contributions to the clinical practice of vascular surgery have been reported in more than 225 peer-reviewed publications, as well as four co-edited textbooks In 1969, just three years after his return to Emory, he helped launch one of the country’s first accredited vascular surgery fellowship programs. Now in its 50th year, nearly 90 board-certified vascular surgeons have trained there—including a number of SVS members—who are well-respected leaders in vascular surgery in a variety of community and academic settings throughout the U.S. and abroad. Sixty came through during Smith’s tenure, including one now practicing in Egypt.

Those trainees and colleagues heap praise on him, saying he was known as “both a master surgeon and the go-to vascular surgeon at Emory,” and that he actively “recruited and developed surgeonscientists.”

Besides surgeon, clinician and teacher, he has donned many other hats: in administrative roles, including medical director of Emory University Hospital and associate dean for clinical affairs; in surgical roles, including being on the American College of Surgeons’ Board of Governors and a representative of the College on the Joint Commission, plus involvement in regional and national vascular surgical

SVS Foundation announces awards, grants

BY BETH BALES AND BRYAN KAY

The SVS Foundation honored its 2020 grant recipients during the first SVS Annual Business Meeting, held virtually on Monday, June 15.

T

hey included the SVS Foundation and American College of Surgeons Mentored Clinical Scientist Research Career Development Award (K08), presented to Areck A. Ucuzian, MD, of the University of Maryland School of Medicine, for the project “Mechanisms of aortopathy in LRP1 deficiency”; the E.J. Wylie Traveling Fellowship, which was bestowed on Cassius Iyad Ochoa Chaar, MD, of Yale University School of Medicine, for “Building a vascular and endovascular surgery outcomes research center (VESOReC) at Yale”; and the Research Career Development Travel Award, won by John Byrne, MD, at the University of Toronto.

Mohammad Qadura, MD, of the University of Toronto, meanwhile picked up a Clinical Research Seed Grant for 12 • Vascular Specialist

organizations.

In 1996, as president of the North American Chapter of the International Society for Cardiovascular Surgery, Smith helped James Robert B. Smith III Stanley, MD, then SVS president, to initiate action that eventually resulted in the establishment of the American Board of Vascular Surgery.

“Bob Smith is a thoughtful person, a true gentleman, and one of those individuals who have made us who we are today,” said one surgeon. “Dr. Smith set an example of integrity, humility, compassion and surgical excellence that has had indisputable salutary effects on his many trainees,” another said.

“His influence continues to be felt to this day by a new generation being trained by his trainees. It is an honor to be able to pay forward the many lessons learned from Dr. Smith.”

“My career overlapped with the growth and maturation of vascular surgery as a distinct specialty. It’s amazing what happened in those decades”— Robert B. Smith

“Combating anti-platelet resistance through personalized medicine.” Other awardees included a Community Awareness and Prevention Project Grant for Kelly Kempe, MD, of the University of Oklahoma School of Community Medicine for a project called “Realizing primary care barriers to limb salvage in Oklahoma.”

A Bridge Grant was allocated to BEST-CLI investigators Matthew Menard, MD, of Brigham and Women's Hospital in Boston, and Alik Farber, MD, of Boston University Medical Center.

A Vascular Research Initiatives Conference (VRIC) Trainee Award was presented to Derek Afflu, MD, of the University of Pittsburgh Medical Center. Mentored by Ryan McEnaney, MD, he tackled research entitled, “Elastic fibers of the internal elastic lamina are unraveled but not created with expanding arterial diameter in arteriogenesis.”

Frank Davis, MD, of the University of Michigan Medical School, was another recipient. Guided by mentor Katherine Gallagher, MD, he tackled the project, “Epigenetic modifications influence macrophage-mediated inflammation in abdominal aortic aneurysms.” Katherine Hekman, MD, of the Northwestern University Feinberg School of Medicine, also claimed a VRIC prize for “Autophagy remodels mitochondria during differentiation and enhances longevity through Ulk1 kinase signaling of induced pluripotent stem cell-derived endothelial cells,” under the mentorship of Jason Wertheim, MD. Likewise, “Downregulation of inflammation and a cascade of pro-angiogenic signals mediate the beneficial effects of gene-modified stem cell therapy in hindlimb ischemia,” landed Hallie Quiroz, MD, of

Fellow surgeons also point out that he was way ahead of his time in the quest for work-life balance, now gaining prominence in the SVS via its Wellness Task Force.

“This is something I advised our trainees about over the years,” Smith said. “Vascular surgery can be an all-consuming career. You want to try to arrange your life, if you have a family, so you don’t miss too many recitals and soccer games. Even with my best efforts, I think our kids remember me as an absent dad for many events.”

In fact, despite their laments that “Dad was never home,” all three children have been involved in medicine: daughter Victoria in nursing, son Robert, in management positions related to medicine and youngest Scott Smith as a physician’s assistant in anesthesia, a position that requires on-call work and irregular hours, Smith noted.

“The boys swore for years they’d never be in medicine,” he laughed. Meanwhile, he and wife Flo now enjoy grandchildren and great-grandchildren, all living relatively close by.

He performed an estimated 10,000 procedures during his career. “I really enjoyed patient care. I loved the operating room and surgical procedures. And during the peak of my career, that was the most important business I was involved in,” he said. However, now 10 years into retirement, Smith's viewpoint has changed.

“Now the most satisfying and gratifying were all those marvelous young people we trained,” he said.

“Those 60 have now trained so many other young surgeons that it’s allowed me to touch the lives of people that I’ve never seen or heard of. I think in many ways that is more important than the patients I actually operated on myself.”

the University of Miami Miller School of Medicine, a VRIC Trainee Award. She was mentored by Omaida Velazquez, MD. There was also a series of Student Research Fellowship Awards. Kamran Ali, of the University of Chicago, sponsored by Ross Milner, MD, collected one for the project, “Development of a mixed-mode ductile fracture cohesive zone model for use in evaluating aortic neck-endograft seal behavior.”

Thomas Wen-Tao Cheng, of Boston University School of Medicine, claimed another for “Analysis of presentation for dialysis and dialysis access outcomes in the immigrant and refugee population.” He was sponsored by Jeffrey Siracuse, MD, and was awarded an SVS General Surgery Resident/ Medical Student VAM Travel Scholarship.

Natasha Ilyana Edman of the University of Washington, was another recipient. She claimed the award for “Assessment of the causes for lower intervention rates among women with thoracoabdominal aortic aneurysms” under the sponsorship of Matthew Penn Sweet, MD. Louis Hinkle, of Houston Methodist Research Institute, sponsored by Maham Rahimi, MD, received one for “Nanoparticle delivery of a hybrid NO donor/ROS scavenger for the treatment of ischemia-reperfusion injury.”

And Yiyuan David Hu, of Harborview Medical Center— sponsored by Benjamin W. Starnes, MD—for “Understanding secondary intervention in ruptured abdominal aortic aneurysms following open repair vs. EVAR” was among the other recipients to receive an SVS General Surgery Resident/ Medical Student VAM Travel Scholarship.

JULY 2020

CODING

We got you covered

BY FRANCESCO AIELLO, MD, AND RAVI HASANADKA, MD

The Society for Vascular Surgery (SVS) Coding Committee is best known for its work developing CPT (Current Procedural Terminology) codes, recommending physician work relative value units (RVUs) as well as working to address Medicare payment issues.

However, the committee also represents the SVS and its members with coverage issues.

U

nderstanding third-party payor coverage policies is essential to ensuring reimbursement for your services. Coverage polices are confusing and highly variable between third-party payors and even between regions for the same payor. This article provides information about this issue for Medicare fee-for-service (i.e., traditional Medicare), Medicare Advantage and commercial payors—as well as what the committee can do to help.

Medicare rules and regulations are the basis for most Medicare coverage policies, and commercial payors often follow Medicare policies. The program is a federal one, but claims are processed by commercial health insurers, known as Medicare Administrative Contractors (MAC), who cover two distinct geographic jurisdictions. Although MACs can individually determine what is and what is not covered, they must follow certain Medicare guidelines. The Medicare Coverage Database provides beneficiaries and clinicians access to coverage policies.

These are in the form of National and Local Coverage Determinations (NCD and LCD).

The NCDs and LCDs may provide a list of inclusive diagnosis codes for coverage or

rely on a description of what constitutes “medical necessity.” These coverage decisions, which can change annually, serve as the basis for reimbursement for services within a MAC’s jurisdiction.

Medicare Advantage (Part C) must cover the same Medicare Part A and Part B services as are covered by traditional Medicare fee-for-service.

However, Medicare Advantage, administered by commercial payors, often offers additional services and also often has additional rules and policies. Medicare Advantage plans can require “in-house” referrals, restrict access to specialists and require prior authorization (PA) for many services, which is not required for most traditional Medicare services.

Differences between traditional Medicare and Medicare Advantage in coverage policies, deductibles and annual out-of-pocket caps can impact the care beneficiaries receive.

Commercial payors also have coverage policies that may include a time-consuming “precertification process” for some services, requiring input of multiple medical parameters into an automated medical review algorithm to determine if a patient meets clinical indications.

Commercial payors also may create their own version of an LCD by providing a list of services and acceptable diagnosis codes as well as inclusion and exclusion criteria for coverage.

Sadly, even if all the steps are followed and a preauthorization is obtained, reimbursement is not assured, as the claim may be denied for any number of reasons.

Doctors and surgeons do have several avenues of recourse. However, if a pattern of denied coverage or reimbursement doesn’t pass the sniff test, the SVS Coding Committee is a valuable resource.

Once the member provides background information, including copies of policies, denials, appeals and more, the committee will process the issue through a coverage decision tree. For example, is the denial appropriate? Was proper documentation

If a pattern of denied coverage or reimbursement doesn’t pass the sniff test, the SVS Coding Committee is a valuable resource submitted with the claim? Has an appeal been processed? How widespread is the issue? It can then respond accordingly.

The Coding Committee also addresses coverage issues through a collection of external information and payor engagement. These may include LCDs, the Carrier Advisory Committees (CAC), the Center for Medicare and Medicaid Services

(CMS) national regulations, CMS NCDs and private payor policies. The committee will send letters and/or have meetings with payors to advocate for appropriate coverage for vascular surgery services.

The committee also works with other societies on coverage issues when indicated.

For example, SVS recently worked with the Society for Vascular Ultrasound (SVU) on an Aetna physiologic studies policy and with the Society for Interventional Radiology, the Society for Cardiovascular Angiography and Interventions and the American College of Cardiology on a United Health lower extremity coverage issue.

Once a medically inappropriate policy takes hold in a state or region, it is often then adopted by other carriers in locations around the country.

To mitigate development of undesirable vascular surgery coverage policies, the SVS Coding Committee pre-emptively develops model policies as a means to efficiently communicate what SVS believes to be correct coverage for vascular surgery services, based on current evidence and professional society guidelines.

These model policies do not serve as clinical guidelines but instead are a way to be ready in order to address coverage issues as they arise. The SVS Coding Committee is currently working with SVU on a model vascular studies policy.

A key to success is to get out in front of coverage issues early. A primary SVS Coding Committee goal is to reduce the administrative burden and increase the timeliness of payments so the membership can then turn its focus onto providing excellent comprehensive vascular care.

The next time you encounter a coverage issue, please contact the SVS Coding Committee, housed within the Advocacy Council, by emailing mmalek@ vascularsociety.org.

CODING COURSE

What you don’t know can cost you money

BY BETH BALES

How is your coding knowledge shaping up at present? Are you up to date on modifiers and how to apply them, changes in CPT (Current Procedure Terminology) and Medicare? Do you know the correct coding for key endovascular and open vascular procedures?

DON’T LEAVE REIMBURSEMENT money on the table. Plan to attend—or have a staff member or two attend—the 2020 Society for Vascular Surgery (SVS) Coding and Reimbursement Workshop. This year’s workshop, with an optional session on evaluation and management (EM) codes, will be held Friday and Saturday, Sept. 25

JULY 2020

and 26, at the Hyatt Rosemont in Rosemont, Illinois, near O’Hare International Airport.

The optional session will be from 8 a.m. to noon Sept. 25, with the main workshop set for 1 to 5 p.m. Sept. 25 and from 7:30 a.m. to 4:30 p.m. Sept. 26.

The intensive program is designed to address updates, including changes to

endovascular stent placement outside are reported and paid, which could impact the lower extremity and PQRS, as well as reimbursement negatively, course managers coding for intravascular embolization and have said. retrograde intrathoracic carotid stenting.

An attendee from 2019 explains why the Vascular surgery is a complex specialty, course is valuable. “I am a vascular surgeon requiring a large number of codes, plus who now is required to enter my own codes has seen a great many code changes in the into a hospital billing/coding app and need past five-plus years, according to faculty to know the codes. My RVUs (relative value members. units) are also based The optional on this so I want them workshop will to be accurate, so as focus on coding and to optimize my RVUs The workshop is planned as documentation rules for to be recognized for a live meeting. However, SVS choosing a correct EM the enormous amount will consider adjusting the category and level of of work a vascular meeting to include a virtual service specifically for surgeon does during component, depending on the vascular surgeon. the day. And it is never local or national restrictions on live gatherings in effect Because this is still an eight-hour day. in September. a significant area of Ever. Seven days a audits for payors, both week.”

For more information, Medicare and CPT have Visit vsweb.org/ please email education@ proposed major changes Coding2020 for more vascularsociety.org. to the way EM codes information.

Workshop

vascularspecialistonline.com • 13

VQI

ACC, SVS join forces on single vascular registry

BY BETH BALES

The American College of Cardiology (ACC) and Society for Vascular Surgery (SVS) are collaborating on a single vascular registry to harness the strengths of both organizations in improving care and outcomes of patients with vascular disease. The Vascular Quality Initiative (VQI) announced the new registry as its first session of the VQI Virtual Meeting on Tuesday, June 23. “The combined strengths of ACC and SVS will provide a clear choice for clinicians, researchers, industry and the Food and Drug Administration when looking for data on the management of vascular diseases,” said Fred Masoudi, MD, ACC National Cardiovascular Data Registry (NCDR) Management Board chair and chief scientific advisor.

EFFECTIVE JANUARY 2021, THE ACC’S NCDR will collaborate with the SVS Vascular Quality Initiative (VQI) to support and steer a single vascular registry. SVS will operate the registry, creating a cobranded VQI program that will be a unique, comprehensive resource for measuring and improving the care provided to a growing population of patients with vascular diseases.

“The ACC NCDR and the SVS VQI are the two leading clinical registries in the peripheral vascular space. A single registry combines the resources and expertise from

14 • Vascular Specialist

both organizations. We are merging the best elements of both registries to create the premier vascular clinical registry,” said VQI medical director Jens Eldrup-Jorgensen, MD. “We look forward to working with the ACC and other medical society collaborators that will allow us to enrich the VQI and improve the care of vascular patients.”

Originating as the CARE Registry in 2006 and expanding scope in 2014 to include lower extremity, vascular catheter-based interventions, the ACC’s Peripheral Vascular Intervention (PVI) Registry assesses the prevalence, demographics, management

and outcomes of patients undergoing percutaneous treatment for peripheral vascular disease. To date, the PVI Registry includes patient data from more than 200 Jens Eldrupinstitutions.

Jorgensen VQI began in 2010 as an expansion of the Vascular Study Group of New England, which originated in 2003. More than 675 centers participate in VQI, which has 13 procedural-based registries encompassing the treatment of arterial and venous disease as well as a disease-based registry collecting data on the medical management of aneurysms, carotid stenosis and lower extremity arterial occlusive disease.

“The ACC is committed to working with all of our partners in cardiovascular care to create a cohesive source of vascular disease data,” said ACC president Athena Poppas, MD. “In combining our registry with that of SVS, we are providing uniform, actionable information for physicians and health systems.”

The new registry collaboration will provide greater opportunities to evaluate new and emerging technologies, pharmacologic therapies, and medical and lifestyle management. It will also provide a rich source of data for academicians, the FDA and industry looking to answer

scientific questions about patient characteristics and outcomes and the use and effectiveness of different treatments.

“The SVS is proud of its history of working with other medical societies, government agencies and industry when developing quality improvement programs to improve the quality of vascular care,” said SVS president Ronald Dalman, MD. “Working with the ACC on this initiative is another example of how collaboration and inclusion can improve the services we offer to caregivers and our patients.”

“The ACC NCDR and the SVS VQI are the two leading clinical registries in the peripheral vascular space. A single registry combines the resources and expertise from both organizations”— Jens Eldrup-Jorgensen

JULY 2020

LEADERSHIP A. As I mentioned, daily reminders of how we can do

better are necessary to make the change stick. It is also very helpful to have the support from our Society administrators, who are very engaged in supporting ways to bring change/ diversity in our field. As a leader, you also need to be scanning the horizon to see what is out there and how you can apply it to your situation, your challenge.

Q. As a female leader in a male-dominated field, I certainly see you as a role model.

Have you seen and experienced change within the field during your career?

A. Yes, definitely. The composition of people coming

into the field has changed. I have seen attempts to fill the pipeline. In fact, the integrated program has attracted a larger pool of women interested in vascular surgery.

Secondly, social media has played a very large role and has popularized the field. It is an excellent way to find a mentor/become a mentor to the new generation of medical students that are already networking in social media.

Thirdly, the increase of women in the field has prompted more women to get involved in local societies, which influences the people behind you as role models. Having the ability to network, and find sponsors and mentors, are key to increasing the visibility of women in our field.

Spotlight on Amy Reed, MD

BY YOUNG ERBEN, MD

This interview continues our series of conversations with national vascular surgery leaders based on topics from the Kouznes and Pozner book “The Truth About Leadership.” This column highlights evidence-based behaviors on how to make a change stick.

A

my Reed, MD, is director of vascular service for M Health Fairview’s 11-hospital system and professor and chief of vascular and endovascular surgery at University of Minnesota. She also is immediate past-president of the Association of Program Directors in Vascular Surgery (APDVS) and secretary of the Society for Vascular Surgery. (SVS) She served on the Vascular Surgery Board for seven years, is a current member of the University of Minnesota Physicians Board of Directors, co-editor of VESAP4 (Vascular Educational SelfAssessment Program) and VESAP5, and an associate editor of the Annals of Vascular Surgery.

Q. During this COVID-19 pandemic, how do you remain a thoughtful and poised leader and care for our vascular patients?

A. I try to understand each unique scenario in which the

patient finds himself/herself and how I would personally like to be cared for, and apply the same strategies with all of our vascular patients, staff. We all have anxiety, grief, loss—a whole slew of emotions—during this time. Compassion is paramount.

We have been fortunate to have embraced telemedicine, which has helped tremendously, especially seeing patients, and reassuring them through the video/phone interactions has been rewarding for us and for the patients. The pandemic has placed both patients and physicians on equal footing dealing with all the problems surrounding the pandemic. Across all 11 hospitals that we cover, we have been able to reach out to our patients and share with them the concerns that are touching us all, especially how to deal with their vascular disease process and the COVID-19 pandemic.

Q. With recent events in Minneapolis, how do you remain a positive female leader as a role model?

A. It is important to acknowledge the tragedy, the loss and

the sadness, let alone it happened in my own backyard, in an area of the country labeled “Minnesota Nice.” It has made us realize we are all imperfect. We all have biases and blind JULY 2020

spots. To see this happen is heartbreaking.

However, it highlights an opportunity for ongoing change and reform. I can see similar patterns of biases and disparities within our field of surgery. Examples of that are the tolerance of bad behavior of certain individuals in the operating room, not having the right gender or accepted sexuality, not being from the right race, not looking the right way, not having the right skin color. However, it takes standing up to that to cause change; which is Amy Reed not popular. Even further, one cannot assume that the problem is solved by just standing up to it. This is an area/topic that requires ongoing scrutiny and pressure for change. We cannot take our foot off the accelerator when it comes to equity and diversity. It requires attention every single day. Everyone needs to get involved. It is a struggle. I believe persistence is the key component to prompt change that is lasting. Our first SVS female officer— Dr. Julie Freischlag—was first elected only a decade ago.

It took another 10 years before another woman would be elected. We need to continue promoting diversity throughout our specialty.

Q. What steps do you think are important to enact lasting change?

“It is important to acknowledge the tragedy, the loss and the sadness, let alone it happened in my own backyard, in an area of the country labeled as ‘Minnesota Nice’”— Amy Reed

Q. What would you say to your younger self after finishing up vascular surgery fellowship?

A. Understand what you know and what you have. You

are not the only one with the issues you are facing. Being vulnerable is OK. Admitting and understanding that it is not only you is OK. Don’t be afraid to ask for help; it is not a sign of weakness. You can have a work buddy, or it can be somebody at another institution with whom you can talk things out, and he/she can help you understand what you are going through.

There are social groups at the SVS that are excellent networking opportunities to discuss and understand the very same issues that you may be going through. You are not alone, especially with personal life struggles. Don’t beat yourself up.

Q. What would you say to young women in medical school contemplating vascular surgery as a field of practice?

A. This is a wonderful career. I would do it all over again,

even with all the trials and tribulations I have been through.

Vascular surgery has such a variety of careers opportunities.

You can reinvent yourself in your career many times over.

You have the opportunity to have a malleable and flexible career. It can fit you. You can do open operations, you can do stenting, you can do balloon angioplasties, you can take care of critically ill patients, you can do in-office procedures, you can be an administrator, etc. The opportunity to have lifelong interaction with patients really adds incredible depth to our specialty.

Having grown up on a dairy farm, I know personally how life can throw significant challenges at you. I have a great role model in my mom. She is the ultimate example of perseverance. She survived a financial disaster, loss of home and farm, and family break-up. She picked herself up, went back to school and re-invented herself. Role models like her drive my perseverance to keep moving forward and to be a good example for my own daughter. I wouldn’t be where I am today without the support of my husband, who helps me keep things in perspective.

Young Erben was writing on behalf of the SVS Leadership Development and Diversity Committee.

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DIALYSIS ACCESS

CX 2020 LIVE

CX 2020 LIVE vascular access session features debate on place of endovascular fistula creation

BY JOCELYN HUDSON AND SUZIE MARSHALL

The CX 2020 LIVE Vascular Access Consensus session sparked global interest, with chair Nick Inston, MD, of Birmingham, England, and moderator Domenico Valenti, MD, of London, taking questions from 17 countries, spanning South America to Southeast Asia. The session pinpointed the latest developments in this fast-moving field, including cutting-edge technologies, such as endovascular arteriovenous fistula (endoAVF) creation, the use of covered stents in dialysis access, and the advantages of external support.

Jennifer Hanko, MD, of Belfast, Northern Ireland, opened with the benefits and drawbacks of peritoneal dialysis compared to hemodialysis, stressing the importance of choosing “the right access, for the right patient, at the right time.” Polling revealed that audience members were split on whether endovascular fistula creation is the future, with Inston concluding that the topic is “still up for debate.”

“A

ll modalities must be considered” when planning access, Hanko began, including peritoneal access, hemodialysis, conservative care “as appropriate,” and the patient’s suitability for kidney transplantation.

She suggested that more patients could benefit from peritoneal dialysis if they had it first, but also stressed that this approach is only recommended for certain patients. Indeed, while hemodialysis requires frequent hospitalization and peritoneal dialysis can be managed at home, the latter does carry with it a risk of infection.

Among the factors that preclude peritoneal dialysis are the presence of cardiovascular disease, low serum albumin, and age greater than 75 years.

Furthermore, Hanko noted that there is “no consensus” on when a patient should proceed to both peritoneal dialysis catheter and back-up fistula creation.

Patients with no fistula options “should be encouraged to do peritoneal dialysis if possible,” Hanko advised the CX 2020 LIVE audience.

“Traditionally, we have advocated radiocephalic fistula first.” However, Hanko acknowledged that there are situations in which this may not be appropriate. She pointed out that patient choice is also an important factor, summarizing that the approach at the Belfast City Hospital “is no longer fistula first. It is the right access, for the

16 • Vascular Specialist

right patient, at the right time.” Valenti opened the discussion after Hanko’s presentation, asking how patient choice influences her decision-making in fistula creation. “I think it is a partnership,” Hanko replied, adding that “it is about working with [patients] to get to a solution.”

Inston asked whether it is common practice to insert a peritoneal dialysis tube at the same time as creating a fistula, to which Hanko responded that it is not something she would advocate for most patients. But she acknowledged that a “small subset, probably less than 5%” would benefit. “I think we can all testify to the fact that when patients fail peritoneal dialysis, we are not always that great at having their vascular access ready.”

In response to a question from the U.K., about what to do if fistula formation is not what the patient wishes, Hanko said she would still strongly recommend it, and get additional education for the patient on the risks versus benefits of a catheter over a fistula. However, she noted that “it is the patient’s choice in the end”.

New era David Kingsmore, MD, of Glasgow, Scotland, also advocated a patient-tailored outlook to vascular access, describing in his presentation the “old era” approach of “fistula provision for all”—typified, he said, by European Society for Vascular Surgery (ESVS) 2018 guidelines on vascular access—as being

ripe for change, in particular through greater use of early cannulation arteriovenous grafts (ecAVGs).

Kingsmore made the point that while, for some patients, fistulas remain the ideal treatment option, “for half [of patients] they are not.”

Likewise, catheters for some patients are ideal, he commented, but for most they are not. “You have to consider what the patient aim is, and how to incorporate transplant with our vascular access planning. Overall, early cannulation grafts are certainly under-utilized and they can be optimized.

We have an opportunity for a new era, to integrate and tailor optimal practices to patients’ aims, choices, and needs.”

Following his presentation, Valenti asked Kingsmore whether the “fistula first” approach has contributed to the underutilization of grafts, to which he replied: “We are victims of looking at procedures rather than patients, [and] not integrating with other services and patient outcomes. Nick [Inston] has talked before about the outcomes and the changing success rate. We have got to bear in mind that dialysis has evolved substantially over the years, and transplant has evolved even more.”

Support still limited Developments in the use of external support devices were outlined by Robert Shahverdyan, MD, of Hamburg, Germany, who put forward a mechanical solution for fistula failure.

And, although an online poll of participants found that only 17% are currently using these devices to improve fistula outcomes, Inston was confident that the numbers would grow following Shahverdyan’s presentation on VasQ (Laminate Medical).

“The VasQ device improves the likelihood of an AVF becoming functional by addressing both hemodynamic and mechanical factors of failure.

It produces consistent clinical benefits to patients, and also improves outcomes for an individual clinic when adopted as the standard of care for AVF creation.

“Several studies have been performed and more are underway to validate the clinical benefits of VasQ. So far, we are observing consistently high AVF usability and patency outcomes across the studies: 80–90% usability, with roughly 80% primary patency at six months for VasQ. [This] compares favorably with most other published results for standard AVF creations.”

Data needed Robert Jones, MD, of Birmingham, England, provided a technology update on endoAVF, looking at the performance of two catheter systems— Ellipsys (Avenu Medical) and WavelinQ (BD).

One of the major benefits with this approach is the lack of surgical trauma, “therefore potentially less intimal hyperplasia and stenosis formation.”

Jones also highlighted: “Both of these catheter systems utilize the forearm vascular anatomy to create an endoAVF, an area that is not typically used for surgical fistula creation.”

He added: “Multiple specialty operators can use

JULY 2020

The CX 2020 LIVE Vascular Access Consensus session poll statistics:

17% CX 2020 LIVE’s Vascular Access Consensus panel, including (clockwise from top left): Roger Greenhalgh, Nick Inston, Domenico Valenti, Robert Jones, Robert Shahverdyan and Jennifer Hanko

both devices to create successful fistulas and this potentially can lead to a decreased waiting time for definitive access. Of utmost importance is patient preference.”

Fistula creation Polling of the online audience revealed that only 46% agreed with the statement: “Endovascular creation of a fistula is the way forward.”

However, if a role for durability of the fistula can be established, consensus may be reached. In the discussion that followed the presentation, a participant from Buenos Aires in Argentina raised the issue of the difference in cost between endoAVF formation and a standard surgical procedure. Jones conceded that “the upfront cost of an endoAVF device is higher in most countries than it is for surgical fistula.” But he pointed out: “The evidence to date has demonstrated that these endoAVFs require less reinterventions.” Jones pointed to the potential for longer-term savings, citing an American study published in the Journal of Vascular

“The evidence to date has demonstrated that these endoAVFs require less reinterventions”— Robert Jones Access that compared collective WavelinQ data with retrospective Medicare data that “demonstrated that there was a saving to be made in each patient over a period of time. The upfront costs are certainly more expensive with these devices but, overall, in a long period of time, according to the evidence, it suggests there is a cost saving.”

Panagiotis M. Kitrou, MD, of Patras, Greece,

JULY 2020

demonstrated an edited case on the endovascular creation of an arteriovenous fistula using WavelinQ. The device consists of two rapid change catheters, with the arterial catheter inserted first.

Kitrou detailed the steps involved in preparing the patient, as well as the other devices required for the procedure. The issue of costs associated with endoAVF was raised again in the discussion that followed, with a question from Johannesburg in South Africa. Other queries on time-to-fistula maturation in endoAVF, and whether it is necessary to coil deep veins, were submitted from as far afield as Argentina and Pakistan.

Use of external support for vascular access: Yes 17% No 83%

83%

‘The gold standard’ A second edited case was presented by Matteo Tozzi, MD, of Varese, Italy, on the use of a selfexpanding covered endoprosthesis—Viabahn (Gore)—to treat AVF failure at the venous anastomosis. Tozzi reviewed the case of a 69-yearold male receiving hemodialysis for diabetic nephropathy, starting the dialysis with a tunneled central venous catheter filter for a bloodstream infection.

Following the edited case, Tozzi then fielded questions from the global audience, including one from India to which Tozzi responded by outlining that “in the cephalic arch, the stent graft is the first option for the stenosis because all other techniques such as drug-coated balloon, plain balloon or highpressure balloon fail very fast.” Here, a covered stent graft is “the gold standard.” Tozzi added that he “chose this terrible case to demonstrate the ability to maintain patency in the functionality of the early cannulation graft,” and, following a question from a physician in Malaysia, about the use of cutting or scoring balloons before deploying the stent graft, Tozzi noted that “I prefer scoring balloons for predilatation of arch stenosis like the prosthetic venous anastomosis. I do not use cutting [balloons] because the blade damages the elasticity of the internal lamina of the vessel and therefore increases the intimal hyperplasia.”

46% Split on whether endovascular fistula creation is the future: Yes 46% No 54%

54% *D isclaimer: All data was gathered via the CX LIVE 2020 digital platform and was factually correct at time of going to press

vascularspecialistonline.com • 17

COMMENTARY

Making virtual education hands-on with 'Jump Start: PreIntern Training' program

BY ALAN LUMSDEN, MD

How do you hold a hands-on training program during a pandemic? For the last seven years, Houston Methodist DeBakey CV Education has hosted “Jump Start: PreIntern Training” in Houston, Texas, a crash course designed to ease the transition from medical student to integrated vascular surgery resident. Typically, this was a largely hands-on experience, with sessions covering ultrasound, suturing skills, cadaver dissection and orientation to the hybrid operating room. However, with this year’s COVID-19 crisis and resulting travel restrictions and social distancing measures, we realized the usual format wasn’t possible. After extensive discussion about whether to cancel the event, we decided to proceed in a virtual format, while still finding a way to retain the critical hands-on component. Although, to our knowledge, this kind of remote hands-on training hadn’t been done before, our team was eager to take on the challenge.

A TEAM OF HOUSTON METHODIST VASCULAR surgery faculty, outgoing SVS president Kim Hodgson, MD (Southern Illinois University Medicine), John Eidt, MD (Baylor Heart & Vascular Hospital), and Carlos Bechara, MD (Loyola Medicine), worked with DeBakey CV Education to put together the virtual program. The core interactive lectures—how to perform a vascular history and physical, gross vascular, and imaging anatomy—were held over Zoom, with opportunities for quizzing trainees to keep them on their toes. Hodgson reviewed vascular surgical instruments, Zsolt Garami, MD, introduced the ultrasound machine and discussed ultrasound-guided access, and recent vascular surgery interns shared the top 10 calls and consults incoming residents could expect in their first month.

The highlights were the new virtual hands-on sessions covering suturing and imaging. Each learner and faculty member were sent a kit with suture boards, grafts, sutures and hemostats; tripod supports for cell phones; and a thumb drive with medical images. The group was split in half, going into either suturing or imaging sessions one day, then switching the next. To create an intimate experience, we broke the session into groups of five students per proctor.

During the suturing skills breakout sessions, on-camera instructors demonstrated skills such as vertical mattress sutures, hand tying, graft anastomoses and patching, giving step-by-step instructions and real-time feedback to the students who were following along at home. Instructors 18 • Vascular Specialist

Kim Hodgson (bottom left) and John Eidt (middle right) teach suturing skills over Zoom to trainees using suture boards at home.

Rebecca Barnes demonstrates the components of a hybrid operating room over a live video feed from the Houston Methodist Institute for Technology, Innovation & Education

Videographer George Tripsas films Alan Lumsden’s live suturing demonstration

We leaned on our experience producing advanced cardiovascular education and training events, and explored new technical frontiers, creating a valuable experience John Eidt teaches vascular anatomy over Zoom

could focus on one student at a time to inspect their work, offer suggestions to improve technique, answer questions, and generally have one-on-one interactions.

While some students practiced suturing, a parallel group of students learned key vascular imaging skills.

Using standardized CT patient data sets on the thumb drive from their training kits, students learned how to optimize views by windowing the CT, how to work in the multiplanar reconstruction environment, and how to confirm measurements of vascular structures—all on their personal computers. Houston Methodist faculty taught radiation safety from a hybrid operating room, using 360° cameras and real-time radiation sensors to demonstrate how culmination COM positioning and wheeling the appropriate protection apparatus could reduce radiation exposure. The immediate feedback on this course has been overwhelmingly positive. In pulling off this program, we leaned on our experience producing advanced cardiovascular

education and training events, and explored new technical frontiers, creating a valuable experience.

We strongly believe that interactive virtual educational programs that can retain learner attention and impart meaningful hands-on skills training will be necessary both in the immediate future of social distancing and looking forward where telelearning will reach learners around the world who would not otherwise be able to travel to a training event. I look forward to exploring this new horizon in cardiovascular education—the possibilities are limitless.

Alan Lumsden is the medical director of Houston Methodist DeBakey Heart & Vascular Center in Houston.

JULY 2020

AAA

Researchers: No benefit for doxycycline used to avoid surgery for AAA

BY JOCELYN HUDSON

A new study by researchers at the University of Maryland School of Medicine (UMSOM) in Baltimore found that patients with an abdominal aortic aneurysm (AAA) received no benefits from taking a common antibiotic drug to reduce inflammation.

PATIENTS WHO TOOK THE antibiotic doxycycline experienced no reduction in the growth of their aneurysm over two years compared to those who took a placebo, according to the study published recently in the Journal of the American Medical Association (JAMA).

“This study provides strong evidence that doxycycline is of no benefit for patients with small abdominal aortic aneurysms in terms of preventing their growth. Healthcare providers should take note of the finding and stop using this as a prophylactic treatment,” said corresponding author Michael Terrin, MD, professor of epidemiology and public health at UMSOM. Researchers from the University of

JULY 2020

“This study provides strong evidence that doxycycline is of no benefit for patients with small abdominal aortic aneurysms in terms of preventing their growth”— Michael Terrin

Nebraska Medical Center in Omaha, Nebraska, the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin, and Vanderbilt University School of Medicine in Nashville also had leadership roles in the study.

The JAMA study involved 254 patients with small aneurysms who were randomly assigned to take either 100 milligrams of doxycycline twice daily or a placebo for two years; CT scans performed at the beginning of the study and on followup found no differences in aneurysm growth between those who took the drug

and those who took the placebo. Study participants were mostly white and male with an average age of 71 years.

“Randomized clinical trials are essential when it comes to answering important clinical questions,” said E. Albert Reece, MD, executive vice president for Medical Affairs, UM Baltimore, and the John Z. and Akiko K. Bowers distinguished professor, University of Maryland School of Medicine. “This finding will help guide doctors to avoid an unnecessary treatment for a common condition associated with aging.”

254

100

patients

milligrams of doxycycline

vascularspecialistonline.com • 19