Vascular Specialist–January 2021

20 COVID-19 Vascular complications Participants in global vascular registry, VASCC, continue probe of virus as they confront and tackle winter surge

Vol.17 No.01 JANUARY 2021

Featured in this issue:

2

12

GUEST EDITORIAL INTERTWINING WAVES OF EMOTION AND VIRUS

LEADERSHIP PROGRAM INAUGURAL COHORT ON UNIQUE CHALLENGE

22

Deaths among CLTI patients:

33.4%

33.1%

Drug-coated

Uncoated

device group

device group

[249 patients]

[243 patients]

SWEDEPAD NEW PACLITAXEL ANALYSIS

COMMITTEES

+

POSITIVITY

Target 2021 SVS councils and committees drill down on key goals for the year ahead

BY MALACHI SHEAHAN III, MD, BETH BALES AND BRYAN KAY

See page 4

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

CHANGE SERVICE REQUESTED

Presorted Standard U.S. Postage PAID Permit No. 384 Lebanon Jct. KY

GUEST EDITORIAL

A healing touch

BY LAURA MARIE DRUDI, MD

SINCE MARCH 2020, MY LIFE HAS LITERALLY spiraled out of control both personally and professionally.

The COVID-19 pandemic shattered my life, and I am still left picking up the pieces, wondering if it will ever be put back together again. Mid-March in Montreal, my licensing exam—for which I spent months preparing and taking time away from my year as chief resident— was postponed a week before I was supposed to write.

After spending roughly three weeks in my own study quarantine, diligently reading my Rutherford textbooks, I was somewhat oblivious to the raging COVID-19 virus.

I quickly realized the severity of the pandemic when the Royal College of Physicians and Surgeons of Canada postponed all exams for the first time in its history. The day I found out my exam was postponed, I called my supervisors telling them I would be returning to clinical duties immediately and asking how I could help. I was assigned to one of the COVID-designated hospitals, and assisted any way I could.

Given I was helping in one of the these hospitals, I felt somewhat like a leper to family and society—I couldn’t physically be with those I loved and couldn’t even go grocery shopping, as most stores initially wouldn’t allow those in contact with the virus—including healthcare professionals—to shop. This proved to be an emotional challenge and my first taste of social isolation. My residency in vascular surgery ended in a way I could never have imagined—no graduation, no team dinner, no farewell parties with all allied healthcare professionals on our vascular units, and certainly no farewell hugs. Those who know me know how I love to give hugs—an act of two hearts literally coming together and, in my mind, a place of courage and vulnerability.

It was certainly not the goodbye I foresaw for a group of individuals I came to call family—a relationship spanning roughly a decade, especially for those who knew me as a keen, enthusiastic, and energetic medical student. Without much of a goodbye, I left my home and family in Montreal and embarked on a solo journey on an international flight to Belgium. I was off to pursue a fellowship before

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

2 • Vascular Specialist

Laura Marie Drudi

The monkey mind is a Buddhist term describing unsettled, restless and uncontrollable thoughts, like a monkey whimsically swinging from branch to branch international borders closed again. I quickly found myself physically and emotionally isolated. The Belgian response to COVID-19 was similar to that seen in Canada. Masks were mandatory, social distancing was respected. Despite these efforts, Belgium was hit hard in a second wave as the European Union nation with the highest rate of COVID-19 infections. The country locked down for a second time in

November, and operating rooms were likewise ramped down as well. Plans of seeing loved ones back home in Montreal or having family come to see me in Belgium were quickly abandoned. Firm restrictions in both countries and ongoing lockdowns made sure of this.

These somber emotions of isolation, disconnection and vulnerability are not unique to me, but rather a collective feeling, consciously or unconsciously. Along with these feelings of isolation come lack of control, anxiety and overwhelming thoughts as we turn more and more inwards into ourselves. As I write, I sit alone in my apartment, in full lockdown like most areas in the world; it’s just me and my monkey mind, as the author Jay Shetty puts it in his book, “Think Like a Monk.” The monkey mind is a Buddhist term describing unsettled, restless and uncontrollable thoughts, like a monkey whimsically swinging from branch to branch.

Thoughts flash across my mind, and, for whatever reason, they seem busier than ever with scheduled webinars, zoom meetings, papers, grants and presentations.

I feel pulled in almost every direction and a distinct lack of direction sitting behind a screen. Although I am virtually connected, I feel as lonely as I have ever been before.

Radical ideas settle in. Ideas that suggest giving it all up and trying to go find some inner peace in some ashram in India like my friend, Jay—my monkey mind in full swing now.

Pressure sets in over my chest and heart as if a drum were beating against it, growing louder and louder. And just like I have no control over my own panging heartbeat, I feel like I have lost all form of control in my life as well.

As I sit alone and reflect, I think I overestimated the healing power of community and touch—of how the touch of a comforting hand on mine, a warm hug, a kiss, could just dissipate all worries and anxieties, but also bring clarity and heal the mind. I look to my patients who are alone, isolated with even bigger existential worries, and how they must long for a healing touch, whether they know it or not. I long for the day our healing hands could unapologetically and unfearfully reach out, touch, and heal.

Laura Marie Drudi is a limb salvage fellow at Az Sint Blasius hospital in Dendermonde, Belgium. She is the resident/fellow editor for Vascular Specialist.

Published by BIBA Publishing, which is a subsidiary of BIBA Medical Ltd.

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

POSTMASTER: Send changes of address (with old mailing label) to Vascular Specialist, Subscription Services, 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher. The Society for Vascular Surgery and BIBA Publishing will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services, or the quality or endorsement of advertised products or services, mentioned herein.

For missing issue claims, e-mail subscriptions@bibamedical.com.

Design Terry Hawes

Vascular Specialist (ISSN 1558-0148) is published monthly for the Society for Vascular Surgery by BIBA Publishing.

Letters to the editor vascularspecialist@vascularsociety.org

The Society for Vascular Surgery headquarters is located at 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018.

RECIPIENT: To change your address, e-mail subscriptions@bibamedical.com.

Printed by Elk Grove Graphics

©Copyright 2021 by the Society for Vascular Surgery

Publisher Roger Greenhalgh Content Director Urmila Kerslake Managing Editor Bryan Kay bryan@bibamedical.com Editorial contribution Jocelyn Hudson, Suzie Marshall, Will Date Advertising Nicole Schmitz nicole@bibamedical.com

BIBA Medical, Europe 526 Fulham Road, London SW6 5NR, United Kingdom BIBA Medical, North America 155 North Wacker Drive – Suite 4250, Chicago, IL 60606, USA

January 2021

COMMITTEES

+ POSITIVITY

COVER STORY

While there is little doubt the pandemic has impacted each vascular surgeon and the SVS as a Society in numerous ways, the commitment and dedication of SVS committee, council and task force members to deliver on the mission has remained undaunted. Thanks to outstanding leadership by the Executive Board and Strategic Board, and impeccable stewardship and professional support by our staff, the SVS has not lost a beat, and, if anything, is poised to step on the gas as some semblance of normalcy reappears. Despite incredible challenges in local practice conditions across the country, councils, committees and task forces kept meeting, thinking and producing results for members and patients.

SVS even generated some new committees and task forces during this challenging time, such as the Diversity Committee and the Population Health Task Force—reflective of the new opportunities for change on our horizon. I would like to take this opportunity to thank all of our SVS leaders, volunteers and staff for their steadfast commitment to our higher mission and cause as a Society. The reports presented in the following pages show a vibrant, forward-looking Society, positioned to embrace whatever comes.— Ronald L. Dalman, MD, SVS president

Quality Council zeroes in on Appropriate Use Criteria The Quality Council has written in 2021. earmarked a major initiative The Vascular Quality Initiative for 2021, and it will involve (VQI) is also part of the Quality sponsorship of the first official Council. An ongoing major set of SVS Appropriate Use objective will be to harmonize Criteria guidelines, focusing on both sets of guidelines with claudication. the VQI in a way that VQI The criteria are intended to participants can demonstrate provide guidance for decisioncompliance, Kraiss elaborates. making in real-world clinical “We want to position the scenarios.

SVS as a model professional SVS created the Quality society with regard to the close Council—which is chaired by coordination of data-driven Larry Kraiss, MD—in 2018 Clinical Practice Guidelines and to coordinate and integrate Appropriate Use Criteria, along the quality-related activities occurring in various places within the Society.

Clinical Practice Guidelines are a close relative of the HODGSON: criteria, and their BRINGING development was APPROPRIATENESS recently added to INTO SHARPER the council portfolio, FOCUS Kraiss explains.

This allows the SVS to closely coordinate Appropriateness featured as part of our October cover creation of both Clinical Practice Guidelines and the Appropriate with the ability to use the VQI Use Criteria guidelines for to measure whether compliance important vascular topics. with those guidelines produces An update to the former for better patient outcomes,” claudication will also be adds Kraiss.—Beth Bales 4 • Vascular Specialist

Appropriateness Committee seeks to push ahead with new guidelines It was a central plank of the presidential agenda set out by immediate past president Kim Hodgson, MD. And now the SVS Appropriateness Committee has targeted further development of the Society’s first set of Appropriate Use Criteria guidelines. The SVS defines appropriateness as “the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.”

Developing the appropriate use guidelines requires a commissioned literature. Appropriateness Committee chair Jeffrey Siracuse, MD, said: “Our goal for the year is to evaluate the review, finish the Writing Panel’s scenarios and to assemble the Rating Panel to review them for two rounds. As this process moves forward and develops, future topics will be considered.”—Beth Bales and Bryan Kay

New link-up for the Document Oversight Committee The SVS Document Oversight Committee—or the DOC—will be aligning with the SVS Quality Council in order to further its crucial work during the course of 2021.

This will include improving congruency between clinical practice guideline recommendations and the Vascular Quality Initiative (VQI).

Not only will this new direction lead to better collaboration and communication, it should result in more widespread adoption of Clinical Practice Guidelines and reporting, both of which will result in improved quality of care and, subsequently, improved patient outcomes, say committee chair Ruth L. Bush, MD, and vice chair Marc L. Schermerhorn, MD. The DOC, composed of 16 members, already works closely with the rest of the SVS, including the Executive Board. “Our purpose is to review, critique and promote internally and externally generated Clinical Practice Guidelines, white papers, mobile tools and calculators, all of which support patient care for SVS members,” explain Bush and Schermerhorn.

“The DOC also maintains a regular schedule of reviewing guidelines every five years looking for new literature and data to support or revise recommendations.”

The alignment with the Quality Council will see immediate results during the first six months of 2021, with the DOC due to issue Clinical Practice Guidelines on the management of extracranial cerebrovascular disease, the management of popliteal artery aneurysms and enhanced recovery after surgery for vascular operations, they add.—Beth Bales and Bryan Kay

January 2021

New committee to deliver diversity position statement

Keeping a close watch for QPP developments The Quality and Performance Medicaid Services (CMS) plans Measures Committee (QPMC) to implement in 2022 the is tasked with monitoring and Merit-Based Incentive Payment creating national performance System (MIPS) Value Programs measures that are relevant to (MVPs). That will see the vascular surgeons.

QPMC make a major push to Ever since the Quality create a vascular surgery Performance Program MVP proposal for CMS (QPP) was to consider, Woo implemented in explains.

2016, a major focus The committee of the QPMC has accomplished been advocating for significant work vascular surgeons on on this proposal QPP requirements, in 2020, with the educating the SVS development Karen Woo membership about of performance QPP and working to create measures and data analysis mechanisms for vascular to support their validity. This surgeons to be successful in work will continue in 2021 it—all physicians who bill with a focus on publishing a Medicare are required to white paper on the topic of participate adequately in QPP patient-reported outcomes or face a financial penalty. relevant to vascular surgeons, With Karen Woo, MD, as on which CMS has placed chair, in 2021 the QPMC will great emphasis. “The QPMC continue to monitor for QPP has always and will continue developments that may affect to work tirelessly to optimize vascular surgeons and address performance measures for them to the extent possible. vascular surgeons and the As of the final rule for 2021, delivery of care to our vascular the Centers for Medicare and patients,” says Woo.—Beth Bales

The newly formed Diversity, Equity and Inclusion (DEI) Committee plans to implement the recommendations from the DEI Task Force. Under the guidance of chair Vincent Rowe, MD, the committee’s primary focus for the upcoming year will be to create an SVS diversity position statement, revise the SVS’ mission and core values, initiate collaborative relationships with key SVS councils and committees, and enrich diversity educational programs at the Vascular Annual Meeting (see page 25 for more on the DEI Committee).—Beth Bales

Preparing for VAM—with alternative options on deck The Postgraduate Education Committee is hard at work to try to provide the most compelling, timely educational material for SVS members this year, chair Vikram Kashyap, MD, tells Vascular Specialist. Given the fluid situation regarding the pandemic, the committee is planning for multiple options for the 2021 iteration of the Vascular Annual Meeting (VAM): an in-person VAM, a hybrid meeting or virtual only.

“We instituted a change for VAM 2021, slating postgraduate education courses on three separate days, instead of clustering them all on Wednesday,” explains Kashyap.

“This will allow SVS members to attend more sessions with less parallel, competing programming. Some of our sessions will be carry-overs from those that could not be presented in 2020, including postgrad courses on pediatric and emergency vascular care. We also have a lineup of concurrent and ‘Ask the Expert’ sessions for all interests and career stages. Topics include, but are not limited to, the value of a vascular surgeon, occupational hazards, the digital transformation of healthcare, how to prevent complications and leadership. We are hopeful of being able to see you in person in San Diego.”—Beth Bales

“We instituted a change for VAM 2021, slating postgraduate education courses on three separate days, instead of clustering them all on Wednesday”—Vikram Kashyap

SVS births brand new Communications Committee

Filling the pipeline: Establishing VSIGs and making them work to ensure vascular future

Vol.16 No.8 AUGUST 2020

Featured in this issue:

2

10

PROFESSIONALISM The social media conduct conundrum

DEPRESSION Women with HIV and atherosclerosis

680

Gender disparities SPECIAL ISSUE

Diversity, equity and inclusion: Disparities in medicine and vascular surgery

13 VQI A vascular VISION into EVAR patient care

Black/minority surgeons

Black/minority patients

- inequality of opportunity

- underinvestment - underrepresentation in leadership positions - racial profiling

- food deserts - higher rates of lower extremity complications

BY BRYAN KAY

R

ECENT MONTHS HAVE yielded a conversation on systemic racism perhaps unlike any other before. We’ve learned about how it manifests across society, how it impacts those on the receiving end, and how it can appear in subtle guises, including in healthcare. In the wake of the killing of George Floyd and the racial disparities exposed by the COVID-19 pandemic, last month Vascular Specialist explored what role the vascular specialty might play in this crucible, and looked at what that conversation should look like within vascular profession.

Events since have reminded everyone of another recurring area of disparity: that of inequity across gender. Unfortunately,

Presorted Standard U.S. Postage PAID Permit No. 384 Lebanon Jct. KY

January 2021

16–17 MED SCHOOL

CHANGE SERVICE REQUESTED

The new-look Vascular Specialist now falls under the auspices of the new SVS Communications Committee

Committee and the Patient Safety Organization, which operates the Vascular Quality Initiative (VQI).

The three sub-committees cover social media engagement, PPO and the website oversight.

Committee composition is set to be announced early in the year.—Beth Bales

vascular surgery itself grabbed the international spotlight under this aegis. A paper published in the Society for Vascular Surgery (SVS) peer-reviewed publication, the Journal of Vascular Surgery, sparked widespread derision for the nature of its classification of so-called “unprofessional” social media content among young vascular surgeons. Its primary target was generally interpreted to be female members of the specialty, garnering the viral moniker #Medbikini on, of all places, social media.

This month, Vascular Specialist continues its focus on systemic racism, broadening coverage with a special issue that explores matters of diversity, equity and inclusion across race, ethnicity and gender. Among

Vascular disease

Outcomes

our coverage, from SVS ONLINE we hear about the latest scientific findings in studies that investigate demographic disparities in peripheral arterial disease (PAD) and carotid revascularization.

From within the vascular surgery ranks, we hear from four African American practitioners who detail their personal experiences of racism as well as their clinical and research interests in the arena of healthcare disparities. And we hear about the research that gave rise to the SVS Diversity, Equity and Inclusion Task Force.

All of it nourishes a conversation that, unlike others before, doesn’t look like it will fade away anytime soon.

See page 3–9

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

The SVS Communications Committee, equipped with three subcommittees, is a new addition for 2021.

Chaired by the SVS secretary, Amy Reed, MD, the committee consists of leadership from Pulse; Vascular Specialist; Audible Bleeding; and the SVS Membership, Public and Professional Outreach (PPO) and Program committees; COVERS (Coalition for Optimization of Vascular Surgery Trainees and Students); SVS Town Halls; the Wellness Task Force; and the Journal of Vascular Surgery diversity, equity and inclusion editor.

It will help shape and align member communication topics and improve engagement across all Society for Vascular Surgery channels and communications vehicles.

The overall Communications Committee will focus on highlevel strategy and will help integrate communications across all SVS entities, including the Society itself, the SVS Foundation, the Political Action

continued on page 6 vascularspecialistonline.com • 5

COMMITTEES

COVER STORY

New Year will bring new SVS online education portal

+

As part of the Education Council (see related story, below), the Education Committee is breaking new ground in 2021. Now more than ever, members need a place to go where all the educational programming of the SVS is available for them on one convenient, searchable website, says committee chair Kellie Brown, MD. Starting in January 2021, the SVS will launch an online education portal, containing links to educational content developed through the SVS. This will be a one-stop place to find content from live and online events, Continuing Medical Education (CME) programs, and a video repository of surgical techniques peer-reviewed and curated by SVS members.

The portal will include links to several other websites, including a separate video library offering members a wide variety of videos on surgical techniques; and an SVS OnDemand site (see stories below and on page 19). The mobile-friendly SVS OnDemand will be accessible via single sign-on using SVS login credentials. Members will be encouraged to submit video and educational programs for sharing. This platform will grow over time to be the place to go for quality, peer-reviewed vascular content on the web.—Beth Bales

POSITIVITY

The Education Committee is encouraging members to submit video and educational programs to be shared

Education Council plans slew of advances—including new LMS The Education Council—the umbrella for the Education, Leadership Development, Postgraduate Education, Resident and Student Outreach, VAM Program and VAM Video committees— has at least five goals for 2021, chair Rabih Chaer, MD, explains.

These include planning and designing the next comprehensive member needs assessment for evaluation of results in 2021. This will be an all-encompassing survey designed to guide the strategic focus on the SVS based on the top priorities of the membership.

The council also expects to release the inaugural version of the new learning management system (LMS), SVS OnDemand, to the membership, which is set to include repurposed VAM materials, hybrid education and a vascular atlas.

The LMS has been built by the hard work of the Education Committee with guidance from the Education Council. It will be a work in progress to enhance the vascular atlas, as well as the non-clinical sections, including leadership, wellness, and coding and billing. An editorial board for the new learning platform will be considered for maintenance and content update. This project is to launch this month (see news story on page 19).

There are also plans to develop a standardized methodology—as best practices—for the planning, development and implementation of skills courses, Chaer continues.

This is designed to ensure that the quality of the skills training remains high and reproducible. The council will oversee the effort of the SVS to implement skills courses, such as the peripheral arterial disease (PAD) and venous versions.

Chaer also drew reference to efforts being made to enhance educational platform offerings to include webinars and a virtual version of the PAD course. This will include webinars by highly sought-after experts on hot topics, and the virtual PAD course will be an abridged version of a future in-person course.

Finally, Chaer pointed to a multidisciplinary white paper of best practices in perioperative care—including vascular surgery, vascular medicine, anesthesia, SVS physician assistants and the Society for Vascular Nursing—that the council plans to release.

A draft of this document is in progress, and is designed to serve as a guide for practitioners on the perioperative care of different vascular pathologies and procedures. A mobile app version is also being developed and is aimed at acting as an easy reference resource.—Beth Bales and Bryan Kay

Going global: Society gets new International Mentorship Program The International Relations Committee has launched a new International Mentorship Program to provide experienced SVS academic mentors for members outside the United States who do not have access to individuals who can assist them in professional growth.

Mentors will assist their mentees in clinical research design, abstract submission, manuscript preparation and scientific meeting presentations.

Mentorship will not include specific patient care recommendations.

Outcomes of this effort include the mentee’s participation in presentations and publications, participation in the SVS International Scholars program and annual surveys sent to participants to evaluate process and success, says committee chair Palma Shaw, MD. “Continuous feedback can allow for improved process and outcomes,” she explains. “This effort will strengthen the visibility and interaction of the international membership, and generate academic productivity of higher quality. Interactions between the mentor and mentee can occur via Skype or other media platforms.”

The SVS website now includes an International Mentor Program toolbox for global members.

The tools include guidelines for standardized curriculum vitae (SUNY Upstate Medical University) and a quick guide to American Medical Association (AMA) citation style, Shaw reports. It also contains the Case Report Guidelines (CARE) checklist of information to include when writing a case report; guidelines for writing an abstract; the STROBE (Strengthening the reporting of observational studies in epidemiology) statement on observational studies; as well as case‐control, cohort and cross‐ sectional studies, Shaw adds.

Furthermore, the CONSORT (Consolidated standards of reporting trials) 2010 statement­—updated guidelines for reporting parallel group randomized trials is in the toolbox, along with CONSORT for abstracts—a checklist; the PRISMA (Preferred reporting items for systematic reviews and meta-analyses) checklist; practical non‐clinical skills for surgeons; a surgery trainee’s guide to writing a manuscript; and Journal of Vascular Surgery author information.

For information on the mentor program and toolbox, visit vsweb.org/ InternationalMentors.—Beth Bales continued on page 8

Responsible for

6

committees in 2021; plans 5

key initiatives

6 • Vascular Specialist

January 2021

COMMITTEES

COVER STORY

Furthering diversity goals in SVS appointments

+

POSITIVITY

20192020

UP

The SVS Appointments Committee has made great efforts to be more transparent, diverse and equitable in recent years—a process its chair and members plan to continue.

Improvements undertaken in the last four years include requiring more specific interest statements from candidate volunteers, leveraging chair and staff evaluations to judge performance and the fit of existing appointments, and enhanced attention to SVS diversity and inclusion metrics in the appointments process, committee member and SVS president Ronald L. Dalman recently noted.

Traditionally, the committee consists of three members including the president, president-elect (Ali AbuRahma, MD) and vice president (Michael C. Dalsing, MD), with the president-elect as chair.

However, the Executive Board has expanded the committee’s composition to reflect diversity, equality and inclusion. So three members were added to the present composition: one from the Diversity, Equity and Inclusion Committee, one from the Community Practice Committee, and one representing the younger generation of the SVS membership. Among its appointments process activities, the committee works to ensure no single member is burdened with too many assignments. “Our goal is to make the process as transparent, inclusive and equitable as possible,” Dalman said. “Great progress has been made towards these goals, but there still is much more to do.”—Bryan Kay and Beth Bales

408 positions to be filled, held by 277 unique members across 29 councils and committees

DOWN

20202021 451 positions to be filled, held by 630 unique members across 30 councils and committees

2020 SVS appointments by the numbers

8 • Vascular Specialist

Overseeing governance and expanding SVS footprint

SVS PAC seeks more contributors

The Policy and Advocacy Council is composed of the leaders of the Coding and Reimbursement, Government Relations, PAC, Quality and Performance Measures, and VA Vascular Surgeons committees.

In effect, the umbrella body supports each of the committees, coordinating efforts across them and communicating on their behalf to the Executive Board, says council chair Matthew Sideman, MD. In 2021, the council aims to actively pursue expanding the footprint of the Society for Vascular Surgery (SVS) as Matthew influential leaders in healthcare policy.

Sideman “We will identify national volunteer leadership opportunities for our members and advocate for their placements to achieve this goal,” explains Sideman.—Beth Bales

The SVS Political Action Steering Committee (PAC) looks to protect your future and hopes. This year the PAC hopes to have at least 10% of SVS members contributing. The committee has had an unprecedented year, co-chairs Peter H. Connolly, MD, and Mark A. Mattos, MD, point out. Despite the ongoing ravages of COVID on our patients and practices and the new Centers for Medicare & Medicaid Services (CMS) reimbursement cuts that began Jan. 1, only 7% of the SVS membership participated in donations to the PAC. By doing the simple math, the co-chairs say, that means only 383 individuals out of 5,471 SVS members felt the necessity to donate time and money to push through SVS legislative priorities. “It would seem that our message has fallen on deaf ears.

Membership’s inaction to understand and recognize the role of the PAC as our voice in Congress will have devastating consequences on the way we practice medicine,” Connolly and Mattos continue.

“At the beginning of 2021, we need an all-hands-on-deck mentality from SVS members. We all need to take responsibility and take a stand in protecting our specialty by supporting the SVS PAC and its mission. Supporting the PAC is supporting your patients, your practice, your future and our specialty! It is clear CMS is not interested in helping us.”

Connolly and Mattos are optimistic: “The SVS PAC Steering Committee would like to encourage all SVS members to make 2021 a year to remember,” they say, “a year in which we overcome COVID, overturn the CMS Medicare cuts and protect the viability and growth of our specialty. So please join the SVS PAC and donate to help save our future.”— Beth Bales

Advocating for ‘fair and equitable coverage’ of vascular services Partnering with SVS PAC in fight over payment cuts As 2020 brought both the prospect of significant reimbursement challenges for surgical services as well as the tremendous clinical and financial challenges of the pandemic, the SVS Government Relations Committee focused intensely on efforts to head off implementation of steep cuts to 2021 Medicare reimbursements.

In 2021, chair Margaret Tracci, MD and the committee will continue to work closely with the SVS PAC and partners at the Surgical Care Coalition for appropriate reimbursement for vascular surgery care—a fight bound to continue even in the event of a “fix” in the final days of the 2020 legislative session, says Tracci. “We will also continue to advocate for policies that impact the quality of life and well-being of vascular surgeons, including pushing back against prior authorization and other administrative burdens, and to ensure that our role and mission are represented in any of the broader healthcare reform efforts that may emerge in a new administration,” she says.—Beth Bales and Bryan Kay

Among the many projects of the SVS Coding and Reimbursement Committee, advocating appropriate coverage for vascular services continues to be a major focus.

In 2021, the committee, led by chair Sunita Srivastava, MD, will continue to increase its coverage initiatives, working with government and private payers.

The committee will advocate for fair and equitable coverage of vascular services in a variety of sites of service by review of policies and commitment to upholding the SVS practice guidelines.

Srivastava says: “Through collaborative work with several multidisciplinary professional societies, we aim to provide timely review and response to new coverage determinations, alternate G code proposals and work valuation issues.

“The committee will work closely with vascular specialists to ensure appropriate coding, reimbursement and coverage policies for our members and patients.”—Beth Bales

The SVS PAC would like to make 2021 a year to remember by overcoming both COVID-19 and cuts to Medicare

383 of Sunita Srivastava

PAC contributors

5,471 members January 2021

Council moves SVS into vascular population health vacuum The Clinical Practice Council, chaired by William Shutze, MD, has numerous ongoing and new projects and initiatives, including the new SVS Population Health Initiative.

There are several definitions that might clarify the concept of population health.

One is: “The health outcomes of a group of individuals, including the distribution of such outcomes within a group.” Another: “The health of a population as measured by health status indicators and as influenced by social, economic, and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services.” Several factors contributed to the pursuit of this initiative. “It is well recognized that there are racial, social and geographic disparities in healthcare delivery—including for vascular disease,” explains Shutze.

The reimbursement climate is in the middle of a pivot towards value-based reimbursement. There is currently no other entity addressing vascular population health, and the SVS is the appropriate entity to move into this space. The project will describe and delineate vascular health disparities, optimize a value-based care model, and supplement this with education for patients and healthcare providers. The SVS has partnered with the Southern Illinois University School of Medicine’s department of population science and policy. It will develop a guide and then conduct focus groups with the SVS membership to understand vascular population health challenges and innovations.—Beth Bales

January 2021

Continuing the cause of the SVS Branding Toolkit A new SVS Branding Toolkit is the culmination of hard work over the past two years by the Public and Professional Outreach (PPO) Committee, according to campaign spearhead and committee chair Joseph L. Mills, MD. And there’s more to come for 2021.

The vascular surgery branding initiative was identified by SVS members two years ago as one of their highest priorities. The major branding themes developed include “surgery is only part of our story” and the “comprehensive vascular care” that vascular surgeons provide in a longitudinal fashion.

“The well-received Branding Toolkit is the result of these efforts,” says Mills. This toolkit includes individually customizable full videos, video clips, as well as referral and condition-specific flyers. The three fliers currently completed and available for use by members cover abdominal aortic aneurysms, chronic limbthreatening ischemia and diabetic foot ulcers.

Based on the excellent reception, the PPO plans to complete additional condition fliers. These fliers (which can be printed or linked, and are downloadable) will address other major conditions vascular surgeons commonly treat, including carotid disease and stroke, dialysis access, thoracic outlet syndrome, acute and chronic venous disease, claudication and peripheral arterial disease, peripheral aneurysms, and visceral and renal artery occlusive disease. The committee will also organize video clips and virtual interactive sessions to teach SVS members how to use the Branding Toolkit in their individual practices and will actively seek feedback to improve the utility of the toolkit.—Beth Bales

The vascular surgery branding initiative was identified by SVS members two years ago as one of their highest priorities

Gaining stronger representation for community practice surgeons Since its inception, the Community Practice Committee has been a valuable resource for surgeons working in settings that serve local communities. It has provided educational opportunities at Vascular Annual Meetings and, more recently, webinars in order to keep members upto-date on important topics.

As an SVS committee, it has been successful beyond the expectations of the leadership.

The SVS aims to make sure that community practice physicians continue to enjoy the full support of the Society (the December cover story of Vascular Specialist focused on some community practice concerns in the setting of the office-based lab).

In 2021, the chair Daniel McDevitt, MD, and the Community Practice Committee will undergo an unprecedented and exciting change, becoming a true section of the Clinical Practice Council. As a section, community practice

physicians will enjoy stronger representation in the SVS leadership, including positions on the SVS Board and on the Nominating Committee.

The section will continue to provide educational resources through in-person events at VAM and via webinars and other newer electronic media.

Society members will also be able to specifically identify themselves as members of this Section. As Section membership grows, we will eventually enjoy the benefit of choosing our own leaders.

The SVS has made a strong commitment to community practice surgeons with the conversion of the Committee to a Section. We are looking forward to continued growth and the sincere involvement of our interested community physicians.—Beth Bales and Bryan Kay

continued on page 10

vascularspecialistonline.com • 9

COMMITTEES

COVER STORY

Health tech task force aims for SVS SET pilot program expansion The SVS Health Information Technology Task Force was established to analyze the potential application of digital health, virtual care, clinical informatics and augmented intelligence within the specialty of vascular surgery. Current dysfunction in healthcare drives administrative burdens, physician burnout, persistent health inequity, patient disengagement and rising costs, says Judith Lin, MD, task force chair. The task force seeks to identify current applications of health information technology that can reduce the administrative burden plus engage patients, support vascular surgeons and reduce costs as well as promote equity.

In addition to supporting and educating members in health information technology, the task force will also focus on overseeing SVS SET, a first-of-its-kind mobile phonebased exercise therapy program for management of claudication. A pilot program is underway to evaluate the feasibility, efficacy and potential impact of SVS SET. To date, 14 clinics from 11 states have joined the pilot, with further expansion in 2021 expected.

This all follows a busy inaugural year, which also included several presentations on telehealth and technology initiatives. A Town Hall in the spring aimed to help our members stay safe while providing care to vascular patients. Manuscripts were published online as an SVS Telemedicine Primer for Vascular Surgeons (visit vsweb.org/TelemedicinePrimer) and in the Journal of Vascular Surgery. In 2021, task force members also will actively identify speakers in the digital health and clinics technology arena, and develop CME sessions.— Beth Bales

14

Foundation looks to up contribution levels in 2021 Led by chair Peter Nelson, MD, the SVS Foundation Development Committee works with Foundation chair Peter Lawrence, MD, and the SVS Foundation Board to develop strategies to promote SVS member donations. The active membership contribution percentage continues to grow, with last fiscal year hitting 17.5%, Nelson says. “Our goal is to have 100% support from SVS members and leaders in advancing our field.”

Giving tends to be more weighted toward the end of the tax year, he continues. “However, the Committee is working on ways to encourage donation more continuously throughout the year by approaching specific audiences and creating seasonal promotions. This starts with peer-to-peer solicitation and encouraging the SVS leadership to lead by example. We can then appeal to younger and senior members, among others, to encourage participation with matching programs and other incentives.”— Beth Bales 10 • Vascular Specialist

Pushing forward VA facilities for the betterment of vascular surgery

+

POSITIVITY

Vascular policing: Developing a ‘robust’ internal evaluation program

11 states

17.5% active members currently contribute, but Foundation shooting for 100%

The Conflict of Interest and Professional Conduct Committee occupies an important role in the SVS polity. “One of our committee’s charges is to evaluate the actual or potential conflicts of interest of its members who serve in leadership positions,” chair O. William Brown, MD, tells Vascular Specialist.

“For 2021, we want to develop a robust internal evaluation program and encourage members to report any actions they believe are code of ethics violations.

As per protocol, the committee routinely evaluates such conflicts each year and forwards its recommendations to the Executive Committee.”

However, the second charge—to evaluate concerns regarding the professional conduct of the SVS membership—is rarely performed, Brown explains.

This has most often been a result of the membership’s reluctance to report cases of misconduct, and the Society’s reluctance to review cases it believes most often are the result of local politics, he says. However, the SVS code of conduct states that a “member shall not participate in any activity that is not in the best interest of the patient.”

Today, as evidenced by articles in national newspapers like the Wall Street Journal and the New York Times, the vascular community is under siege, Brown goes on to argue.

Vascular surgeons have been accused of practicing medicine purely for their own benefit—and not for the benefit of the patients they treat, he points out.

“Accordingly, it is clear that when a physician places his or her income above the quality of patient care, it falls under the auspices of the SVS,” Brown continues.

A committee goal this year is to encourage all members to report any activities they see within the vascular community that they believe rise to the level of a code of ethics violation.

Vascular surgeons are being evaluated by the public, insurance companies and the legal community, Brown argues. “However, vascular surgeons are the most capable of evaluating the actions of other vascular surgeons. If we do not assume this role now, as noted, others will take our place,” he explains.

“I believe that the last thing vascular surgeons want is to have lay people evaluate the medical treatment that a vascular surgeon provides to his/her patient. Physicians agree that such an approach has not been very successful or satisfying when applied in the field of medical malpractice litigation.

“If vascular surgeons do not police themselves lay people or—even worse—the government will assume that role. The committee’s goal is to develop a robust internal evaluation program and avoid others from assuming a duty that we are most suited to perform.”—Beth Bales and Bryan Kay

The SVS VA Vascular Surgeons Committee is looking ahead this year to reclaim procedural volume at Department of Veterans Affairs (VA) facilities—ravaged by COVID-19—and to facilitate construction of hybrid suites.

The VA committee focuses on improving the vascular surgery community by spurring gains in the resources available for vascular surgeons and by maintaining and improving the training and research environment for the specialty, both at the trainee and the junior faculty level within the VA. “Maintaining the VA as a robust environment for vascular surgery helps maintain the pipeline for training future SVS members as well as allows the use of VA resources to accomplish vascular surgerybased research,” explains committee chair Gale Tang, MD. “The VA remains an extremely fertile training environment for bread-and-butter vascular surgery, because of the heavy burden of vascular disease among veterans. However, COVID-19 has had a profound impact within the VA, significantly decreasing vascular surgery procedural and clinic volumes, heavily damaging the trainee experience.”

Most VA offices, in fact, are lagging behind their academic affiliates in terms of recovering volume. In addition to the committee’s plan to develop strategies to maintain appropriate vascular surgical case volumes within the VA, it will also include analyzing the effect of COVID-19 on vascular surgery referrals outside of the VA. The committee plans to develop

“The VA remains an extremely fertile training environment for bread-and-butter vascular surgery, because of the heavy burden of vascular disease among veterans”— Gale Tang strategies to maintain appropriate vascular surgical case volumes. This will also include facilitating best practices to improve trainee participation in telehealth.

Updating aging infrastructure within the VA to include hybrid suites remains a priority, as currently only 50% of VA vascular surgeons have access, says Tang.

By establishing what has worked for the successful facilities, the committee hopes to establish more uniform access to appropriate resources to facilitate vascular care within the VA, which will help facilitate the important role of the VA for vascular surgery training, research and careers for SVS members.— Beth Bales

January 2021

Forging ahead with a new identity and planning for VRIC 2021

Emphasizing the necessity of basic and translational science The SVS Research Council oversees the research mission of the SVS through the functions of the Basic and Translational Research Committee and the Clinical Research Committee. In 2021, a key goal is to continue to emphasize the essential nature of basic and translational research in understanding the pathogenesis of vascular diseases and developing novel therapies.

Central to this is supporting the development of young vascular surgeon-investigators who will dedicate their careers to delving into the unanswered questions behind the diseases treated by the specialty, explains council chair Edith Tzeng, MD.

Another significant goal for 2021 is to update SVS clinical research priorities. The original priorities were developed in 2010 through a survey of SVS membership and opinion leaders. Over the past decade, several of these priorities have been the focus of multicenter clinical trials that will provide guidance on the management of vascular diseases. Given the exponential growth of clinical investigations and sophisticated analysis of big data, significant knowledge has been gained.

“Thus, it is time to update these clinical research priorities so that vascular surgeons can stay contemporary with the needs of the specialty and of patients,” Tzeng says.— Beth Bales

The Basic and Translational Research Committee (BTRC) is the new name of the former Research and Education Committee.

The name change reflects the charge to help encourage surgeon applicants dedicated to basic and translational discovery in vascular science. “We are a diverse group of young and established vascular surgeon-investigators with broad expertise in vascular science,” says committee chair Luke P. Brewster, MD. “For 2021, we are very excited to bring our Vascular Research Initiatives Conference (VRIC) to our SVS constituents and the vascular science community broadly in a virtual platform.”

This will occur in two, two-hour sessions, and all accepted abstracts have the opportunity to be published in JVS-Vascular Science.

The committee has been preparing for this pivot to a virtual platform, setting the dates for Wednesday, April 28, and Thursday, May 6.

Both sessions will be from 7 to 9 p.m. Central Time.

“In addition to highlighting important advances in vascular science, we will be emphasizing trainee presentations. Please consider submitting your science and attending our Virtual VRIC 2021,” adds Brewster.—Beth Bales

Publications Committee braced for major change in year ahead The Publications Committee is responsible for overseeing, among others, the Journal of Vascular Surgery (JVS) family, the Rutherford textbook and Seminars in Vascular Surgery. After conducting reviews and interviews, committee members as a group put forth candidates for the editorship of JVS and Rutherford to the SVS Executive Committee for its final decisions, according to committee chair Peter Henke, MD. “This next year is a big year for us,” he relates. “We have been charged with performing a full review of the journal as it relates to the Elsevier (publisher) contract, and the journal as it stands in processes and impact. We have hired the esteemed consulting group, Clarke and Esposito, to accomplish this.

“Over the years, the JVS has been a part of the SVS bottom line, and the journal contract is a major financial issue. Moreover, the academic publishing world is in a state of significant change, not the least of which is the future of Open Access.

“We have a timeline of about 15 months to complete this charge, and will hopefully set the stage for the next decade or so.

Intertwined with this will be creating a vision for how best dissemination of scholarly information occurs, in the short- and long-term, for SVS members and vascular disease caregivers overall.”—Beth Bales JVS-Vascular Science, the latest addition to SVS' family of journals

AAA

Pre-emptive embolization of aneurysm sac side branches prevents post-EVAR type II endoleak, study finds

BY JOCELYN HUDSON

According to Daniela Branzan, MD, a senior vascular surgeon at University Hospital Leipzig, in Leipzig, Germany, and colleagues, pre-emptive embolization of aneurysm sac side branches for patients with abdominal aortic aneurysm (AAA) is “safe and effective” in preventing type II endoleak after endovascular aneurysm repair (EVAR) and results in aneurysm sac shrinkage.

WRITING IN THE JOURNAL OF Vascular Surgery (JVS), Branzan et al write that type II endoleak is the most common endoleak after EVAR, yet its optimal management is hotly debated.

They note that preliminary selective embolization of aneurysm sac side

January 2021

branches has been adopted to prevent type II endoleak, and so the investigators’ goal with this study was to determine the rate of type II endoleak and diameter decrease of AAA after EVAR following pre-emptive embolization of aneurysm sac side branches. The authors detail

that, between September cause mortality. Branzan 2014 and September 2019, 139 and colleagues specify that patients with AAA underwent mean follow-up was 23±16 percutaneous aneurysm sac months and that patients side branch embolization had a median of five patent before EVAR. Imaging followaneurysm sac side branches. up was performed at one After completion of and six months, then yearly. embolization, the authors Endpoints included freedom report in JVS that 76.4% of from type II endoleak, Daniela Branzan initially patent aneurysm AAA sac shrinkage, type II sac side branches were endoleak-related reinterventions, and alloccluded, with no major procedurerelated complications. They note that follow-up imaging showed type II endoleak in seven (5%) patients and that an increase of the aneurysm sac was seen in six. They also report six type II endoleak-related reinterventions during follow-up. Branzen et al add that the majority of patients (86.7%) exhibited aneurysm sac shrinkage and a mean diameter reduction was 9.2mm (p<0.001).

They also report one aneurysm-related death within 30 days after EVAR.

“After completion of embolization, the authors report in JVS that 76.4% of initially patent aneurysm sac side branches were occluded”

SOURCE: DOI.ORG/10.1016/J. JVS.2020.11.032

vascularspecialistonline.com • 11

VASCULAR LEADERS

Inaugural leadership program overcomes pandemic difficulties

BY BRYAN KAY

The inaugural cohort of the Society for Vascular Surgery (SVS) Leadership Development Program had to show some resilience early. Not long after the initiative’s maiden run, COVID-19 struck, and a program meant to take place in person went digital.

F

or the group of 25 vascular surgeon-leaders who took part, the pandemic—and the switch— afforded impromptu leadership lessons. Program faculty member Vikram Kashyap, MD, chief in the division of vascular surgery and endovascular therapy at University Hospitals Cleveland Medical Center in Cleveland, explained how the Leadership Development Program had grown out of a stated need for educational leadership and, specifically, an SVSbranded course relevant to practicing vascular surgeons. “Overall, it has been a hit,” he said. “Clearly, the challenges with COVID changed what we envisioned with the program, which included in-person meetings in Chicago, a challenge project, and recognition at the VAM [Vascular Annual Meeting]. It pivoted—just like the VAM—to a virtual-only program that went on throughout 2020.” Fatemeh Malekpour, MD, a University of Texas (UT) Southwestern, Dallas, assistant professor of vascular and endovascular surgery, was one of those first cohort members navigating the unintended digital structure.

“None of us knew in the second half of the program that the world would be upside down; COVID changed the

agenda,” said Malekpour, whose own leadership credentials include becoming the first-ever female vascular surgeon in her home country of Iran before arriving in the U.S. “The Chicago in-person workshop was canceled, and all lectures were stopped.”

With the next crop due to participate in the interactive program from January to May with self-study and monthly online education, the hope remains it culminate in a recognition event in June at VAM. Still, Malekpour expounded the virtues of the digitized version, saying the rearranged program and agenda led to useful leadership strategizing among participants.

This unique aspect helped connect her with a diverse group of vascular surgeons as well as the experiences and problems they encounter at their institutions, she explained. “The course is diverse in participants and organizers. It switches to small practice groups in the second part of each session. These smaller groups get to know each other more, and there is time for everyone to share their points of view, ask other people’s opinion and comment on newly discussed strategies.”

Nicolas Mouawad, MD, chief of vascular and endovascular surgery in the McLaren Health System-Bay Region in Bay City,

Deadlines near for Society, Foundation awards

BY BETH BALES

Applications are due early in 2021 for a number of Society for Vascular Surgery (SVS) and SVS Foundation awards, honors and grants.

INFORMATION ON ALL AWARDS AND scholarships is available at vsweb.org/Awards.

January: Applications are due Jan. 13 for the Resident Research Award, which includes a $5,000 award and the opportunity to present at the 2021 Vascular Annual Meeting (VAM). The award, open to surgery residents and vascular surgery residents and fellows enrolled in training programs in the United States or Canada, is intended to motivate early-career physicians to pursue their interest in research that explores the biology of vascular disease and potential translational therapies.

February: Undergraduate and medical school students in the U.S. and Canada have until Feb. 1 to apply for the Student Research Fellowship. This award introduces students to the application of rigorous scientific methods

12 • Vascular Specialist

Michigan, was another member of the last cohort. “[The program] provided an in-depth and engaging forum to learn from leaders in the field and from one another, understanding and discussing challenges and offering practical solutions,” he said. Melissa Kirkwood, Vikram MD, chief in the division of Kashyap vascular and endovascular surgery at UT Southwestern Medical Center in Dallas, another faculty member, explained how they had dropped the capstone element of the program amid the pandemic, but then refocused on COVID-19 as a leadership crisis. “In the Nicolas upcoming course, we’re still Mouawad hoping to have a live event, but we’ve mapped out how to have these webinars.”

Malekpour touched on how the program and the pandemic interacted. “If nothing, it made me realize how many of us deal with similar situations,” she added. “It was sometimes like a support group during the COVID crisis.” Mouawad described how he melded the program elements around day-to-day practice. “The course is very manageable with our busy clinical practices,” he said. “The information was relevant and impactful, learning not only how to lead teams of people but also how to lead yourself. Personal reflections and assessment was key, and the course allowed for this introspection and 360 evaluations.”

In a virtual environment, Kashyap observed, some of the leadership skills and assessments can take a little time to

to clinical problems and underlying biologic processes important to patients with vascular disease. Awardees receive $3,000 and a complimentary subscription to the Journal of Vascular Surgery.

March: Six awards carry March 1 deadlines.

SVS Awards include: n Lifetime Achievement Award, the highest honor SVS bestows on a member. This recognizes an individual’s outstanding and sustained contributions to the professions and SVS, and their exemplary professional practice and leadership. Robert Smith, MD, of Georgia, received this honor in 2020. n Medal for Innovation in Vascular Surgery, honoring an individual whose contribution has had a transformative impact on the practice or science of vascular surgery.

The most recent recipient was venous surgery pioneer Robert Kistner, MD, in 2019. n Excellence in Community Service Award, honoring members who have exhibited outstanding leadership within their communities as a practicing vascular surgeon.

Email awards@vascularsociety.org with questions.

SVS Foundation Awards with the March 1 deadline include: n Community Awareness and Prevent Project Grant, to help surgeons conduct community-based projects in

Fatemeh Malekpour

Melissa Kirkwood

sink in. He anticipated members of the first cohort returning to act as mentors during the program undertaken by cohort two this year. “Leadership is a lifelong journey,” he added. “We cannot do this enough. We really need these types of programs at multiple levels for trainees, tenured faculty, mid-level faculty. In my own personal experience, I learn so much each time I take a course, read a book, or, as a faculty, I learn so much just from participants about their challenges. That provides insight for me about how to navigate things better.”

Looking ahead, Kirkwood looks forward to a full-fledged program slate re-entering the fray: “Hopefully, by cohort three, we’ll be back to a more live, in-person course where we will have a full capstone project people will work through on their own.”

vascular health, wellness or disease prevention. n Clinical Research Seed Grants, providing direct support for pilot clinical projects that could potentially become larger studies funded by industry or government sources. n E.J. Wylie Traveling Fellowship, providing the recipient the opportunity to visit a number of vascular surgery centers around the world.

In addition, applications for the Distinguished Fellow designation also are due March 1. This designation goes to Active, International or Senior members who are vascular surgeons and who have made substantial contributions in two of the three categories of research, service and education. Visit vsweb.org/DistinguishedFellow for more information.

Current Treatments

Necroptotic Cells

RIPK3

Thrombin

Deep Vein Thrombosis

GSK'074 Diagram depicting last year's Resident Research Award-winning paper

January 2021

SVS PAC

Avoiding the ‘tragedy of the unprepared’

BY SHAHRAM AARABI, MD, AND KENNETH MADSEN, MD

AT THE CONCLUSION OF A challenging 2020, we at the Society for Vascular Surgery (SVS) have a clear mission ahead: We must work with the U.S. Congress to avoid what military experts refer to as a “tragedy of the unprepared.”

We all know too well as surgeons the critical importance of preparedness.

Our success hinges on removing or controlling as many known variables as possible. The critical importance of preparation, mobilization and response is key in health policy.

In “The Art of War,” Sun Tzu noted: “Now the general who wins a battle makes many calculations in his temple before the battle is fought. The general who loses a battle makes but few calculations beforehand. Thus do many calculations lead to victory, and few calculations to defeat. It is by

January 2021

attention to this point that I can foresee who is likely to win or lose.” The message here is that the majority of SVS members (93%, to be exact) and nearly all elected political officials are either uneducated, and/or misinformed about the coming Centers for Medicare & Medicaid Services (CMS) cuts to Medicare. Few vascular surgeons (or politicians) seemed to realize that a 7–10% loss of revenue was due to begin Jan. 1. At this juncture—writing in the middle of December—the situation truly looks to be a “tragedy of the unprepared” waiting to become a reality. The PAC is spending the final weeks of the year urging SVS members and lawmakers to support a bill to prevent cuts to all specialties. To the 7% of the SVS membership supporting the PAC, we thank you. To the remainder of our colleagues, please consider the impact your participation could have for our profession. The charge, “I am responsible for protecting the specialty” is a call for us all to engage in this battle to reverse the CMS cuts, protect our specialty—and to avoid our own tragedy of the unprepared!

Few vascular surgeons realize that a 7–10% loss of revenue began Jan. 1

Please donate at vsweb.org/SVSPAC. Shahram Aarabi and Kenneth Madsen are members of the SVS PAC Steering Committee.

New SVS learning platform goes live this month Educational content will soon be as close as the nearest Internet connection.

SVS ONDEMAND IS EXPECTED TO DEBUT IN mid-January, along with a new Education section/portal on the SVS website through which to access not only the ondemand materials, but also other SVS-developed educational content. The searchable website (vsweb.org/Education), will be the one-stop shop for SVS-related materials, with links to information on SVS-developed educational products.

It will provide information on live meetings and courses, plus information and links to surgical technical guides, a video library, publications such as the Journal of Vascular Surgery; Audible Bleeding podcasts; the Vascular Educational Self-Assessment Program (VESAP); and guidelines, reporting standards and consensus documents.

A key feature of the new site is SVS OnDemand, which is a state-of-the-art education resource for vascular surgeons, residents and allied health professionals. SVS OnDemand will house a wealth of educational videos and presentations, surgical technique guides and full courses from the 2019 VAM and the 2020 SVS ONLINE virtual meeting.

During this inaugural launch, SVS members in good standing will be able to access VAM 2019 meeting content free. SVS ONLINE meeting content will be free to attendees.

Others must purchase access to that content via member/ non-member pricing. “This has been in the planning and ‘construction’ phases for quite some time and we think the final product is worth the wait,” said Kellie Brown, MD, chair of the SVS Education Committee.—Beth Bales

vascularspecialistonline.com • 19

PANDEMIC

Vascular surgery COVID-19 registry participants probe state of practice amid winter surge

BY BRYAN KAY

The question of the COVID-19 pandemic’s effect on vascular practice continues to occupy members of the specialty.

Contributors to a global vascular surgery registry collecting data on its impact on scheduled operations and virus-related thrombotic complications detailed a series of practice experiences as the pandemic entered the winter surge.

T

he Vascular Surgery COVID-19 Collaborative (VASCC) aims to catalogue how the coronavirus has affected procedures across the five major areas of vascular practice and conditions to include carotid, aortic, peripheral, venous and hemodialysis modules (project one). VASCC’s second focus on thrombotic complications is investigating the virus’ connections to acute limb ischemia, acute mesenteric ischemia, stroke and symptomatic venous thromboembolism (project two).

“The winter surge is hitting the U.S. and Europe hard,” notes registry co-founder Max Wohlauer, MD, assistant professor of surgery in the division of vascular surgery at the University of Colorado School of Medicine in Aurora. “Hospitals are placing severe limitations on scheduled surgeries and vascular surgeons are seeing increases in thrombotic complications of COVID.” As VASCC continues to collect data and enroll new sites both inside the U.S. and internationally, fellow co-founder Robert F. Cuff, MD, program director for integrated vascular surgery residency at Spectrum Health-Michigan State University in Grand Rapids, emphasizes how far-reaching the registry has been. “VASCC is truly a worldwide international effort with sites in Europe, Australia, Asia, the Middle East and the U.S. It truly has been as wide an effort as the Pandemic itself.”

At the beginning of December, Vascular Specialist spoke with some of the VASCC contributors at a number of sites and heard about how the winter surge was impacting on practice and thrombotic complications.

Probing questions Jens Eldrup-Jorgensen, MD, of the division of vascular and endovascular surgery, at Maine Medical Center in Portland, Maine, pointed to the kind of questions he’s asking in light of COVID-19’s association with arterial and venous thrombotic events. “What extent will this virus impact vascular patients who are predisposed to thrombotic events, i.e., pre-existing arterial occlusive disease or thrombogenic surfaces, e.g., stents or grafts?” he pondered.

20 • Vascular Specialist

“How will the COVID-19 virus impact treatment of arterial disease, for example increased postoperative thrombotic events affecting stent or graft patency, coronary artery thrombosis, cerebrovascular thrombosis, or venous thromboembolic events and other postoperative complications—such as pulmonary complications—all of which could occur early or late.”

Eldrup-Jorgensen added: “Patients are reluctant to come to the [emergency room] or hospital. How will this delay impact pre-existing arterial disease? For example, will untreated carotid stenosis progress to [a cerebrovascular accident], will untreated AAA [abdominal aortic aneurysm] rupture—and will untreated lower-extremity occlusive disease—progress to gangrene, sepsis and limb loss?”

In Dallas, Fatemeh Malekpour, MD, an assistant professor of vascular and endovascular surgery at the University of Texas (UT) Southwestern, Dallas, contrasted the initial March–May 2020 period with June–August, and the months up to the beginning of December.

As the intial period unfolded, she said, “we started to make a list of patients who were affected by the pandemic: an elective AAA that ruptured and [the patient] died at home, an SMA [superior mesenteric artery] open thrombectomy patient who was eventually discharged, COVID toes, deep vein thromboses. VASCC was solidifying and UT Southwestern joined the collaborative.”

Then, from June to August, new cases were slowing down, Malekpour stated, and operating rooms started to re-open.

“Summer and fall revealed that Texas is having more cases every day, and soon it took over New York, Florida and California,” she continued. “Even though

the death rate was not as high, we still had ongoing high daily new cases and deaths.

“In the couple of months till now, which is December, Texas remained number one at total case number, and most of the times daily new deaths.

We are still doing scheduled elective procedures at Parkland Memorial Hospital and the university hospital.

All patients should have a COVID test to come to pre-op, and this has been the rule for more than four months. After both hospitals agreed to participate in VASCC, and we obtained access to the UT Southwestern COVID registry, our team completed project one of VASCC. We are about to start project two using the institution registry,” Malekpour added.

Learning curve Brigitte K. Smith, MD, program director of the vascular surgery fellowship at the University of Utah School of Medicine in Salt Lake City, speaks of how, during the second wave, she and colleagues have been able to “fine-tune” what is canceled or rescheduled.

“For example, a patient presenting with limb ischemia that we might previously have approached with lysis, we wouldn’t offer lysis because it takes multiple days, multiple trips to the operating room—lots of personal protective equipment—and an intensive care unit [ICU] bed,” she says. “The patient with critical limb ischemia that was 2a would either get thrombectomy/ bypass, or be sent home with a very low ankle-brachial index [ABI], albeit not an immediately threatened limb. Now we have our supply chain for PPE [personal protective equipment] figured out so that isn’t a consideration.”

Cheong Jun Lee, MD, division chief of vascular surgery at NorthShore University Health System in the Chicago area, said VASCC project one might yield “help with coordinating a more appropriate, datadriven postponement for certain disease conditions in this second surge we are experiencing.”

Meanwhile, Lee sees timeliness with VASCC project two on thrombotic complications, which went live on Nov. 19.

“As we saw in the first surge in spring, we at NorthShore are seeing another wave of serious thromboembolic issues associated with COVID-19­—three serious arterial occlusion events were recently seen by our team since the beginning of this second surge, one patient with a carotid occlusion

and transient ischemic attack who is doing well with anticoagulation, and two patients with acute aortic thrombosis; one who underwent thrombolysis for distal embolization of the thrombus and who responded well, except will lose a toe; and one with complete infrarenal occlusion, resulting in paralysis and lower-limb ischemia who underwent open thrombectomy and is recovering in the ICU, but has renal and hepatic dysfunction.”

Of note, Lee added, none of those patients presented with the serious respiratory issues anticipated with COVID on presentation. “Although these patients had underlying medical comorbidities, the profound hypercoagulability realized with COVID-19 certainly is a clinical driver for these events,” he said. “VASCC project two aims to capture important data from these challenging—but valuable—experiences of vascular surgeons handling serious thrombotic complications of COVID-19 patients, and it is critical we get a robust participation from our vascular surgery community.”

Italian experience Gabriele Piffaretti, MD, associate professor of vascular surgery at University of Insubria School of Medicine in Varese, Italy, said he and colleagues had experienced two very different situations over the course of the pandemic. “During the first wave, here in Varese we saw very few vascular complications, more frequently in the form of massive pulmonary embolism that indeed jeopardized a potentially good clinical outcome after weeks of noninvasive ventilation, or ICU treatment.

“In the second phase, Varese has been and still is the area with the greatest incidence of infection and number of hospitalized COVID patients in the entire national territory. However, information gained from the first phase, as well as the ability to treat these patients at the very early onset of the respiratory insufficiency, most likely allowed us to smooth the incidence of vascular complications in our area.

“Acute limb ischemia, mesenteric ischemia, and carotid thrombosis remain the main vascular complications observed since Oct. 18, the date of the start of the second wave in our area.”

Drawing from her experience, Laura Nicolai, MD, of the vascular surgery unit at Cà Foncello Hospital in Teviso, Italy, described thrombosis of the small vessels and pedal arch as the main problem encountered.

“In two middle-aged patients with COVID-19 who presented with acute lower-limb ischemia, we performed a transpopliteal balloon embolectomy, but the acute limb ischemia recurred, despite anticoagulation,” she said. “In both of them, the problem was solved performing an arteriovenous fistula between anterior tibial vein and artery and posterior tibial vein and artery at the ankle, because there was no run off due to thrombosis of small vessels and pedal arch.”

January 2021

VASCULAR PRACTICE

COVID-related hypercoagulability linked to elevated malfunction rate in temporary hemodialysis catheters

BY BRYAN KAY

Hypercoagulability in COVID-19 patients leads to an increase in the malfunction rate of temporary hemodialysis catheters—but heparin locking of the catheters is linked to decreased malfunction rates.

THOSE ARE AMONG THE FINDINGS OF A STUDY recently published in the Journal of Vascular Surgery.

The research sought to address the subset of COVID-19 patients with acute kidney injury who require hemodialysis. With temporary catheters being the mainstay in their treatment and up to 96% of COVID-19 patients experiencing dialysis circuit clotting, the investigators identified a paucity of data and guidelines to address the problem.

John J. Kanitra, MD, a general surgery resident in the

department of surgery at Ascension St. John Hospital in Detroit, and colleagues carried out a retrospective cohort study via chart review at their institution— a large urban hospital.

The study included patients who needed a temporary catheter placed between Feb. 1 to April 30, with follow-up for outcomes continued between May 1 and May 12.

A total of 48 patients with a mortality rate of 71% were identified. Malfunction occurred in 31.3% of patients.

Thirty-seven patients (77.1%) received heparin locking, 22 (45.8%) received systemic anticoagulation and 38 (79.1%) received venous thromboembolism prophylaxis. The overall rate of malfunction was lower at a trend level of significance, with heparin vs. saline locking (24.3% vs. 54.6%; p=0.058), Kanitra et al found.

Meanwhile, systemic anticoagulation

did not affect temporary catheter malfunction rate (p=0.240). Higher D-dimer levels were related to greater mortality (HR 3.28, 95% CI 1.16–9.28; p=0.025), but were not significantly associated with temporary catheter malfunction (HR 1.79, 95% CI 0.42–7.71; p=0.434).

“The high malfunction rate is likely a result of the hypercoagulability that has been suggested in COVID-19 patients,” the authors write.

“Reports describe COVID-19 patients without predisposing factors developing thromboembolic events. The etiology of this is thought to be endothelial damage driven by the cytokine storm, leading to excess thrombin formation in addition to increased blood viscosity from hypoxemia.”

The authors noted the need for prospective, randomized studies in order to confirm their findings—chiefly so that locking the temporary catheters with heparin in COVID-19 patients can be recommended.

“Increased [venous thromboembolism] prophylaxis suggested a possible association with improved [temporary hemodialysis catheter] patency, though the comparison lacked sufficient statistical power,” Kanitra and colleagues write.

“Additionally, the current study found an 71% mortality rate in COVID-19 patients requiring acute HD, which has important implications for planning and resource delegation for future coronaviral infections.”

Malfunction occurred in

31.3%

of patients

“The high malfunction rate is likely a result of the hypercoagulability that has been suggested in COVID-19 patients”— John J. Kanitra et al

SOURCE: DOI.ORG/10.1016/J.JVS.2020.11.033

Lower-extremity revascularization ‘improves’ walking performance and quality of life in claudicating PAD patients

BY BRYAN KAY

Revascularization of the lower extremity improves hemodynamics, walking performance, quality of life and calfmuscle pathology in claudicating patients with peripheral artery disease (PAD), researchers in Nebraska found.

FURTHERMORE, BASELINE systolic pressure in the foot, at 15 seconds after relief of arterial occlusion (SPP15sec) predicts which claudicating patients will improve by more than 20m of six-minute walking distance (SMWD) according to Shuai Li, MD, a postdoctoral researcher in the group of Iraklis I. Pipinos, MD, and George Casale, PhD, at the University of Nebraska Medical Center. Li and colleagues presented the findings of a study looking at prediction of walking performance after revascularization of the lower extremity for PAD patients suffering from claudication.

“Baseline SPP15sec represents both the severity of macrovascular blockages and the function of resistance arteries,” he explained during a presentation of the data at the annual meeting of the Midwestern Vascular Surgical Society (MVSS), held virtually Sept. 9–12, 2020.

January 2021

“SPP15sec is lower in patients with severe macrovascular blockage and wellpreserved resistance arteries—better Shuai Li, MD vasodilation.”

Further explaining the research team’s theory about the prediction value of baseline SPP15sec, Li said that when revascularization relieves macrovascular blockage, patients with lower baseline SPP15sec show more improvement in their clinical function. “Our data suggest that patients who, at the time of initial presentation have well-preserved muscle with relatively healthy resistance arteries, respond best to revascularization operations,” he added.

The researchers evaluated a cohort of 41 claudicating patients.

vascularspecialistonline.com • 21

PAD

SWEDEPAD unplanned interim analysis shows no difference in all-cause mortality for paclitaxel devices

BY JOCELYN HUDSON

AN UNPLANNED INTERIM ANALYSIS OF THE registry-based SWEDEPAD clinical trial, in which patients with peripheral arterial disease (PAD) received treatment with paclitaxel-coated (drug-coated balloons or drug-eluting stents) or uncoated endovascular devices, “did not show a difference between the groups in the incidence of death” during one to four years of followup.

This conclusion was published by Mårten Falkenberg, MD, Joakim Nordanstig, MD, of Gothenburg University, Gothenburg, Sweden, and colleagues in the New England Journal of Medicine (NEJM).

Falkenberg et al conducted the analysis against a backdrop of “concern about an increased risk of death associated with the use of paclitaxel-coated angioplasty balloons and stents in lower-limb endovascular interventions for symptomatic peripheral arterial disease.” They relay that data for the analysis was from the multicenter, randomized, open-label, registry-based SWEDEPAD (Swedish drug elution trial in peripheral arterial disease) clinical trial.

At the time of their analysis, the authors detail, 2,289 patients had been randomly assigned to treatment with either drug-coated devices (the drug-coated device group, 1,149 patients) or treatment with uncoated devices (the uncoated device group, 1,140). They state that paclitaxel was used as the coating agent for all the drug-coated devices.

Falkenberg et al detail that randomization was stratified according to disease severity on the basis of whether patients had chronic limb-threatening ischemia (1,480 patients) or intermittent claudication (809 patients), and that the single endpoint for this interim analysis was all-cause mortality.

Writing in NEJM, the authors communicate that no patients were lost in the mean 2.49-year follow-up period, during which 574 patients died, including 293 patients (25.5%) in the drug-coated device group and 281 patients (24.6%) in the uncoated device group (hazard ratio, 1.06; 95% confidence interval, 0.92–1.22).

At one year, Falkenberg and colleagues write that all-cause mortality was 10.2% (117 patients) in the drug-coated device group and 9.9% (113 patients) in the uncoated device group. During the entire follow-

22 • Vascular Specialist

up period, they found that there was “no significant difference in the incidence of death between the treatment groups” among patients with chronic limbthreatening ischemia (33.4% [249 patients] in the drug-coated device group and 33.1% [243 patients] in the uncoated device group) or among those with intermittent claudication (10.9% [44 patients] and 9.4% [38 patients], respectively).

In the discussion of their findings, the authors acknowledge that this interim analysis “was not a prespecified part of the trial protocol.” They respond to this limitation by noting a twofold rationale behind publishing these total mortality data ahead of completion of the trial: “First, we sought to reduce patients’ and physicians’ concerns regarding the safety of paclitaxelcoated devices, and second, we considered the data to be important to support completion of ongoing trials investigating the efficacy of such devices in peripheral arterial disease.” They add that this analysis was recommended by an independent data and safety monitoring committee “in order to alleviate patients’ and physicians’ concerns” surrounding paclitaxel safety.

Falkenberg and colleagues recognize a number of other limitations to their unplanned interim analysis, including the fact that the open-label design “could have the potential to introduce bias.” However, they point out that the endpoint of all-cause mortality used “is less sensitive to this particular limitation than more subjective outcomes.”

Another drawback the authors recognize relates to the fact that there were few deaths among patients with

An unplanned interim analysis found that PAD patients treated with either a paclitaxel-coated or uncoated device did not show a difference in mortality

intermittent claudication, resulting in the confidence interval for that particular group of patients being wide (ranging from 0.72 to 1.93). As a result of this, the investigators write that they “cannot completely exclude the possibility of a difference in mortality in this subgroup.”

Falkenberg et al identify the use of ‘low-dose’ (rather than ‘high-dose’) paclitaxel-coated devices being “relatively common” in the trial as another limitation, which “may have influenced” their results.

In addition, they note that there was variation in the treatment effect among centers, although they write that it “seems likely that this variation is due to chance rather than to variation in centre characteristics.”

Finally, they highlight that no analysis of the efficacy of paclitaxel-coated devices is included in this interim report. They write: “These data are planned to be provided in the final clinical trial report after formal completion of the trial.”

At the end of their discussion, Falkenberg and colleagues stress that the SWEDEPAD trial “was not primarily intended for analysis of total mortality,” pointing out that the main purpose was “to determine whether drug-coating technology ultimately improves the lives of patients with symptomatic peripheral arterial disease by preventing amputation and improving healthrelated quality of life.”

Because this interim analysis “does not show a significantly higher incidence of death resulting from the use of paclitaxel-coated devices,” the authors conclude with their belief that “equipoise remains,” detailing that recruitment has been resumed with enrollment of patients in both the chronic limb-threatening ischemia cohort and the intermittent claudication cohort.

The authors write that the trial is funded by grants from the Swedish Research Council, the Swedish HeartLung Foundation, and Region Västra Götaland.

They also communicate that “all the companies that provide drug-coated balloons and drug-coated stents for patients in Sweden with peripheral arterial disease are supporting the trial by providing price discounts on their devices.”

SOURCE: DOI:10.1056/NEJMOA2005206

Deaths among CLTI patients

33.4%

33.1%

Drug-coated

Uncoated

device group

device group

[249 patients]

[243 patients]

January 2021

CODING

Outpatient evaluation and management codes extensively revised

BY ROBERT M. ZWOLAK, MD

For the first time since 1992, office/outpatient evaluation and management (E/M) Current Procedural Terminology (CPT) codes have been extensively revised. As of Jan. 1, the lowest level new patient visit code 99201 will be deleted, and the remaining new patient visits 99202–99205, along with the established patient office visits 99211–99215 will be revised to eliminate mandatory history and physical exam elements (H&P).

O

nly a “medically appropriate history and/ or examination” will be required for all office/ outpatient E/M codes.

The number of body systems/ areas reviewed and examined need only be performed and documented to the extent medically necessary and clinically appropriate, and the levels of H&P documentation will no longer count for, or against, the office code level. This change was based on Medicare efforts to reduce documentation burden. It should be

January 2021

noted, however, that this policy may be different for non-Medicare private payors.

Beginning in 2021, physicians may also choose to use medical decisionmaking (MDM) or total time for selection of the appropriate new and established patient office visit code level. Time has been redefined for this set of codes from “typical faceto-face time” to the sum of both faceto-face and non-face-to-face services of the physician or qualified health professional (QHP) on the date of the encounter. In addition, time may be

used to select a code level for office/ outpatient EM services, whether or not counseling and/or coordination of care dominates the service.

Each revised code includes a range of time for use when reporting a code using total time. In addition, for the total time that exceeds the highest level of code 99205 or 99215, a new code (99417) has been established to report each additional 15 minutes of incremental time.

Surgeons may choose to report total time for instances where MDM is straightforward or low, but the encounter required significant time.

This could be a situation such as if a language barrier slowed the discussion, or the patient and family had numerous questions.

The original four levels of MDM (straightforward, low, moderate, high) have not changed for 2021. However, since 99201 and 99202 both described “straightforward” MDM, code 99201 will be deleted and reported using 99202 beginning in 2021.

MDM continues to have the same three elements (presenting problem, data reviewed/analyzed, risk). The level of MDM for office/outpatient E/Ms will continue to be based on two out of three elements.

In addition to all of these changes, the guidelines for office/outpatient E/M reporting have been extensively revised, including the addition of definitions for many new terms that have been introduced for 2021.

Details about these changes— “CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202–99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes”—can be found at vsweb.org/E/MChanges2021. Please note that code 99XXX has formally been published as 99417.

Code descriptors and reporting requirements for all other non-office/ outpatient E/M codes have not changed for 2021.

This means that the legacy 1995 and 1997 E/M documentation guidelines still apply for all inpatient visits, emergency department visits and all consultation codes.

Robert M. Zwolak is a member of the SVS Coding Committee and was recently named the American Medical Association (AMA) alternative representative to the organization’s RVS Update Committee (RUC), and alternative vice chair.

vascularspecialistonline.com • 23

DIVERSITY

Executive Board commits to DEI changes

BY BETH BALES

The Society for Vascular Surgery (SVS) Diversity, Equity and Inclusion (DEI) Task Force’s findings and recommendations are taking shape, with some already implemented.

AFTER MORE THAN A YEAR OF study and information-gathering, the task force presented its findings and recommendations to the SVS Executive Board in late summer.

After enthusiastically embracing the task force’s conclusions, the board has completed an implementation plan to assure that all the recommendations are accomplished. The issues identified by the task force are “significant and compelling … and demand our attention at this moment in time,” the board said.

“Your Executive Board commits to the changes necessary to implement its more than 40 recommendations, objectives and requested actions. The in-depth response is the board’s action plan for change.

Recommendations and plans are divided into several domains: such as governance and leadership; research; representation and engagement; programs, publications and communications; and recruitment and outreach.”

One of the task force’s top priorities was creation of a new standing committee,

the DEI Committee, reporting directly to leadership. That has been accomplished.

One of that committee’s first duties and a focus for 2021 will be to create an SVS diversity position statement. It also will work to establish collaborative relationships with SVS councils and committees.

The task force also recommended, and the board implemented, the just-completed Physician Member Census, with the report repeatedly citing the lack of comprehensive membership demographics as a “significant impediment to change.”

Kim Hodgson, MD, the 2019–20 SVS president, established the DEI Task Force in September 2019, charging it with envisioning a more diverse and inclusive SVS and vascular surgery workforce, and to make recommendations to strengthen the Society’s alignment to its core value on diversity, equity and inclusion.

Bernadette Aulivola, MD, and Matthew Smeds, MD, had proposed a group be formed to analyze potential gender bias and harassment in vascular surgery; this

SVS creates muchanticipated DEI Committee

BY BETH BALES

Fulfilling one of the first recommendations—and the highest priority—of the Diversity, Equity and Inclusion (DEI) Task Force, the Society for Vascular Surgery (SVS) has created and appointed members to the new Diversity Committee.

A

s is the case with the Finance and Audit committees, this new standing committee will report directly to the SVS Executive Board.

The DEI Committee will, among other charges, work across the SVS to implement the Task Force’s top-priority recommendations and actions and determine the need for organizational policies and positions to align DEI initiatives.

Top priority recommendations the committee will undertake over the next six months include creating a diversity position statement, revising the SVS’ mission

January 2021

Bernadette Aulivola

“Your Executive Board commits to the changes necessary to implement its more than 40 recommendations, objectives and requested actions”— SVS Executive Board was based on the doctors’ then-recent research findings of high prevalence of gender bias and sexual harassment of

and core values, appointing DEI liaisons to key SVS committees, councils and task forces, and producing an annual dashboard of DEI metrics.

The committee creation and incorporation into the SVS governance structure “is essential in helping guide and serve the Society,” said SVS president Ronald L. Dalman. “This committee will be a resource to the Executive Board and the SVS Strategic Board of Directors as well as for all the other councils, committees, sections and task forces,” he said.

Vincent Rowe, MD, will chair the new committee.

Members include the DEI Task Force vice chair Bernadette Aulivola, MD, plus members Steven Abramowitz, MD, Kwame Amankwah, MD, Young Erben, MD, and Matthew Smeds, MD. Also on the committee are: Rana Afifi, MD, Kathryn Bowser, Laura Marie Drudi, MD, Garietta Falls, Andrew

vascular surgery faculty at academic vascular surgery programs. That report can be found at vsweb.org/TBD. Interestingly, the task force presented its report shortly after a firestorm occurred over the publication—and later retraction— in the Journal of Vascular Surgery of a peer-reviewed paper on “Prevalence of unprofessional social media content among young vascular surgeons.” The article prompted worldwide comment and much derision, particularly on social media. At the same time, pointed out SVS president Ronald L. Dalman, MD, the situation “represents an opportunity for the Society—and all of its members—to embrace the moment and fully commit to working together to solidify positive change for the future.”

In announcing its implementation plan, the board also looked to the future. “This is our moment to maximize opportunity for all, both within the SVS and in the larger communities we serve, … extending throughout all facets of our organization,” the Executive Board said.

The August 2020 issue of Vascular Specialist was dedicated to exploring diversity, equity and inclusion. Read the edition—including an article on the survey referenced above—at vsweb.org/ SpecialistAugust2020. The full task force report, as well as the board’s response, will be published in an upcoming issue of the Journal of Vascular Surgery. They are now available online at vsweb.org/DEIreport and vsweb.org/DEIresponse.

Gonzalez, MD, Omid Jazaeri, MD, Lee Kirksey, MD, Erin Koelling, MD, Rishi Kundi, MD, Kedar Lavingia, MD, Danielle Pineda, MD, Rebeca Reachi-Lugo, MD, and, as a liaison to the SVS Foundation, Nasim Hedayati, MD. Ulka Sachdev-Ost, MD, is liaison from the Journal of Vascular Surgery.

As befits its goals and charge, the committee’s membership is diverse, said Dalman. “You can’t address issues of inclusion and equity, not to mention diversity, unless you bring to the table points of view informed by different backgrounds and experiences,” he said.

“You can’t address issues of inclusion and equity, not to mention diversity, unless you bring to the table points of view informed by different backgrounds and experiences”— Ronald L. Dalman Vincent Rowe

vascularspecialistonline.com • 25

NEWS BRIEFS

Missing your journals? Be sure your dues are paid Have you paid your 2021 Society for Vascular Surgery dues? If you haven’t, you’re missing access to all of the latest research in the Journal of Vascular Surgery publications.

CMS confirms Physician Fee Schedule cuts; SVS members asked to contact lawmakers

BY BRYAN KAY AND BETH BALES

The Centers for Medicare and Medicaid Services’ (CMS) has delivered a blow to vascular surgery in the form of a 7% cut in total payment for the services it provides. The cuts are included in the agency’s final rule for Medicare payments under the Physician Fee Schedule (PFS), and were slated to take effect Jan.1, 2021.

News of the payment reductions came Dec. 1, as CMS announced what it called “a broader administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.”

The final PFS conversion factor for 2021 is $32.41, a decrease of $3.68 from 2020’s $36.09.

Earlier this year, Margaret C. Tracci, MD, chair of the Society for Vascular Surgery (SVS) Government Relations Committee, and Matthew J. Sideman, MD, chair of SVS’ Policy and Advocacy Council, spoke of the high stakes involved, should CMS not amend the rule. Their warnings have come to pass.

“What will this look like on Jan. 1?” Tracci and Sideman wrote in the September issue of Vascular Specialist, as the SVS sought to help lobbying efforts against the cuts.

“The conversion factor (CF), or dollar amount per work RVU, will drop nearly 11% – by $3.83 – from this year’s CF of $36.09 to $32.26.

“Pause for a moment to reflect on the fact that this is less in actual, noninflation adjusted dollars than we were paid back in 1998. In fact, had 1998

26 • Vascular Specialist

payment levels kept up with inflation over the past 27 years, the CF for 2021 should be $57 per RVU, representing an inflation-adjusted loss of more than 43%. This amounts to an acute collapse layered on top of a long-term devaluation of physician services that has gone on—essentially unchecked—for 27 years.”

U.S. Reps. Ami Bera (CA-7) and Larry Buschon (IN-8) introduced “Holding Providers Harmless from Medicare Cuts During Covid-19 Act of 2020” in a bid to stave off the cuts.

There were 54 co-sponsors of the bill, and SVS members were urged to contact their lawmakers in an effort to stop the cuts before adjournment of Congress at the end of the year.

As the year was coming to a close, SVS president Ronald L. Dalman, MD, said, “The bill introduced by Reps.

Bera and Bucshon is a win for patients and a win for physicians, and I urge all members of Congress to support it.

“Our healthcare system is under extraordinary pressure, and now is the time for Congress to act and protect our patients.”

Sideman, meanwhile, urged all SVS members to contact their lawmakers via Voter Voice to ask them to act.

And that’s not all. SVS membership confers an array of benefits. Only members can use the new SVS Branding Toolkit, with videos, referral brochure and fliers, vascular condition fliers and ads, to help vascular surgeons tell their story about the comprehensive care they provide. The SVSConnect online community is for members only as well.

Take advantage of these benefits and everything else SVS has to offer. Renew your dues today at vsweb.org/SVSDues.

Those members in year four of their “graduated candidate” membership must now transition to Active membership.

Those who did not apply for such membership by Dec. 1, 2020, could also see their benefits interrupted. March 1 is the first application deadline for 2021.

Visit vsweb.org/Join.—Beth Bales

Quality initiative: New pocket guides now available New pocket guides of the Society for Vascular Surgery (SVS) clinical practice guidelines and reporting standards are now available, with printed guides sent to all members.

SVS guidelines and reporting standards are extensively researched and written by leading vascular experts. Members are known to consider these documents as very useful resources.

Pocket versions will be sent to members in the mail. They include guides on abdominal aortic aneurysm, chronic limb-threatening ischemia (in the form of the Global Vascular Guidelines, published in 2019 by the SVS, the European Society for Vascular Surgery and the World Federation of Vascular Societies), the management of visceral artery aneurysms, and type B aortic dissections (Reporting Standards).

The SVS members have been mailed free printed copies of the spiral-bound guides.

Members can download free digital version and purchase additional printed copies online at vsweb.org/PocketGuides. Nonmembers also may visit the site to purchase digital or printed editions.

Printing and distribution of these guides was supported by a block grant from W.L. Gore and Associates, Inc. All content was solely developed by the Society for Vascular Surgery.

With these new topics, SVS now has eight pocket guides available on a variety of vascular conditions.—Beth Bales

VIVID trial sees first enrollment Vesper Medical recently announced initiation of its Food and Drug Administration (FDA) investigational device exemption (IDE) study, VIVID (Venous stent for the iliofemoral vein investigational clinical trial using the Vesper Duo venous stent system).

The VIVID trial is a prospective, multicenter, single-arm study to evaluate the safety and efficacy of the Vesper Duo stent system in the treatment of patients with iliofemoral occlusive disease. According to Vesper Medical, the Duo stent system is designed to be the next generation venous stent technology, uniquely engineered to address the challenges of deep vein obstruction. The modular portfolio is intended to provide physicians clinical versatility with both the Duo Hybrid and Duo Extend stent options in a full range of lengths and diameters to customize therapy for each patient.—Jocelyn Hudson and Bryan Kay

January 2021

Dalman to trainees: ‘Vascular surgery is a tremendously rewarding career’

BY BRYAN KAY

For aspiring vascular trainees, interview season is a time of great stress as well as opportunity. Graduating medical students and residents prepare the pitches of a lifetime. But during these arduous times of social distancing, the process of securing vascular residency and fellowships comes with an added, virtual barrier.

The prospect of negotiating a remote interview process is a challenge shared by vascular chiefs, SVS president Ronald L. Dalman, MD, told Vascular Specialist as the interview season was in full swing.

And the chief of vascular surgery at Stanford University in Stanford, California, told potential trainees to bear with the process for what would ultimately be “a tremendously rewarding career.”

“We’re right in the middle of the interviews this year for our prospective trainees, and again, it’s obviously challenging, with the pandemic situation,” Dalman explained in an interview late last year. “I want to emphasize to anyone that vascular surgery is a tremendously rewarding career, and has proven itself to be, really, one of the cornerstones of the American medical system.

“The patients we care for, the challenges that we’re presented with, are very professionally rewarding, and it makes for a great career option for people who really want to take care of important problems—significant clinical challenges that really measure themselves against the moment.”

Dalman lamented the absence of face-to-face contact with candidates this time round but stressed the efforts made to elucidate the vascular story.

“Vascular surgery is a great career choice,” he continued. “It’s just unfortunate that we’re not able to have in-person interviews, and have the appropriate introduction for potential trainees. We’re doing everything we can in partnership with APDVS [the Association of Program Directors in Vascular Surgery] in our new COVERS collaboration between the various national societies to try to tell our story.

“All I can say is: You’re just going to have to trust us. It’s a great career opportunity, and we hope that we get an enthusiastic and highly-interested cross section of trainees this year for our training programs.”

WIfI score found to be accurate across racial groups

Increased odds of amputation were related to a more advanced WIfI score at initial presentation amongst Blacks (odd ratio [OR] 1.34, 95% confidence interval [CI] 1.10–1.63; p<0.003), D’Andrea noted.

“The odds of more advanced WIfI stage The wound, ischemia and was 1.3 times higher for Black patients as compared to white patients,” she said. foot infection (WIfI) score is D’Andrea and colleagues concluded: as accurate a predictor of risk “Higher amputation rates amongst blacks for limb loss in Black people with CLTI may be attributable to more as it is among whites, an SVS advanced disease severity at time of initial Foundation-supported presentation.

“In order to reduce disparities in study found. [peripheral arterial disease] outcomes, The research on patients with chronic targeted efforts at improved screening, limb-threatening ischemia (CLTI) was early diagnosis and expeditious carried out by Melissa D’Andrea, BA, a referral to a vascular specialist should fourth-year medical student from Loyola be implemented in vulnerable racial University Chicago Stritch School of populations.” The research was supported Medicine in Maywood, Illinois, et al, led by the SVS Foundation Student Research

by Bernadette Aulivola, Loyola’s director Fellowship award. of the division of vascular surgery and Vascular Specialist explored healthcare endovascular therapy. disparities in-depth in a The results were series of news articles presented at the covering new science and Midwestern Vascular profiles of key vascular Surgical Society virtual leaders last year. During annual meeting (Sept.

SVS ONLINE in the 9–12). summer, researchers in A total of 2,630 limbs in Texas found disparities in 2,543 patients with CLTI those undergoing early were analyzed, with 404 carotid revascularization limbs (15.8%) undergoing along gender, race and Melissa D'Andrea major amputation. ethnic lines.—Bryan Kay

“I want to emphasize to anyone that vascular surgery is a tremendously rewarding career”—Ronald L. Dalman

RelayPlus thoracic stent graft shows low operative mortality Terumo Aortic has announced the midterm results from the RelayPlus thoracic stent graft system post-approval study, revealing low operative mortality and morbidity— supporting its use as a "safe and effective" thoracic aortic aneurysm treatment.

January 2021

Over a three-year period, the RelayPlus stent graft was implanted in a total of 45 patients and showed 95.6% freedom from thoracic endovascular aortic repair (TEVAR)-related mortality, 84% freedom from all-cause mortality, and 97.2% freedom from reintervention. The results were published in the Journal of Vascular Surgery (JVS) in June.

The purpose of the multicenter, nonrandomized, prospective study was to report realworld outcomes of patients with thoracic aortic aneurysms and penetrating atherosclerotic ulcers TEVAR.—Bryan Kay

vascularspecialistonline.com • 27