Vascular Specialist–April 2021

Vol.17 No.04 APRIL 2021

health system 27. Characterizing electronic health record usage patterns of inpatient medicine residents using event log data 28. Evolutionary Pressures on the Electronic Health Record: Caring for Complexity 29. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review.

30. A resolution for the new year: Responding to a call to organize against burnoutcrisis 31. The Association Between Perceived Electronic 1. Burnout and Career Satisfaction in Women Health Record Usability and Professional Neurologists in the United States.

BurnoutAmong US Physicians 2. Cross-sectional survey of workplace stressors 32. Perceived Electronic Health Record Usability associated with physician burnout measured by the as a Predictor of Task Load and Burnout Among US Mini-Z and the Maslach Burnout Inventory.

Physicians: Mediation Analysis 3. A National Survey of Burnout and Depression Among 33. Electronic Health Record Effects on WorkFellows Training in Pulmonary and Critical Care Life Balance and Burnout Within the I(3) Population Medicine Collaborative 4. Job Satisfaction Among Academic Family Physicians 34. Estimating the association between burnout and 5. Burnout Among United States Orthopaedic Surgery electronic health record-related stress among ELECTRONIC HEALTH RECORDS Residents. advanced practice registered nurses.

6. High Burden of Burnout on Rheumatology 35. Association of Electronic Health Record Design Practitioners and Use Factors With Clinician Stress and Burnout.

7. The Pros and Cons of Electronic Health Records 36. Association of Electronic Health Record Use With 8. The electronic elephant in the room: Physicians and Physician Fatigue and Efficiency the electronic health record.

37. Resident Indentified Violations of Usability 9. In Pursuit of the Fourth Aim in Health Care: The Joy Heuristic Principles in Local Electronic Health of Practice Records 10. Physician stress and burnout: the impact of health 38. Seeing the Patient Is the Joy:" A Focus Group information technology. 11. Electronic health record Analysis of Burnout in Outpatient Providers associated stress: A survey study of adult congenital 39. A mixed-methods evaluation framework for heart disease specialists. 12. Physicians' Well-Being electronic health records usability studies Linked To In-Basket Messages Generated By Algorithms 40. Pajama Time: Working After Work in the Electronic In Electronic Health Records Health Record 13. Relationship Between Clerical Burden and 41. Technology as friend or foe? Do electronic health Characteristics of the ElectronicEnvironment With records increase burnout?

Physician Burnout and Professional Satisfaction. 14.

42. The Influence of Electronic Health Record Use on Use of Health Information Technology by Rhode Island Physician Burnout: Cross-Sectional Survey Physicians and Advanced Practice Providers 43. Electronic Medical Record Documentation and 15. Worklife and Wellness in Academic General Internal Provider Burnout Medicine: Results from a National Survey 44. Physician burnout: A neurologic crisis.

16. Professional Satisfaction and the Career Plans of 45. Artificial Intelligence and Surgical DecisionUS Physicians making 17. Physician Burnout in the Electronic Health Record 46. Beyond Burnout - Redesigning Care to Restore Era: Are We Ignoring the Real Cause?

Meaning and Sanity for Physicians 18. The Burden and Burnout in Documenting Patient Care: 47. Protecting healing relationships in the age An Integrative Literature Review of electronic health records: report from an 19. The complex case of EHRs: examining the factors international conference. impacting the EHR user experience.

48. "D/C the CC (Carbon Copy)" - Improving the EHR 20. Perceived Burden of EHRs on Physicians at Different Signal-to-Noise Ratio for Clinicians by Selective Stages of Their Career.

Feature De-Implementation.

21. The burden of inbox-messaging systems and its 49. Electronic health record innovations: Helping effect on work-life balance in dermatology physicians - One less click at a time.

22. Electronic health records and burnout: Time spent 50. Novel electronic health record (EHR) education on the electronic healthrecord after hours and intervention in large healthcare organization message volume associated with exhaustion but not with improves quality, efficiency, time, and impact on cynicism among primary care clinicians burnout 23. Nurses' Stress Associated with Nursing Activities 51. Physician Order Entry Clerical Support Improves and Electronic HealthRecords: Data Triangulation from Physician Satisfaction and Productivity Continuous Stress Monitoring, Perceived and 52.MD, Addressing Burnout From aMDCritical BYWorkload, GABRIELA VELAZQUEZ, LONDON C. GUIDRY, MD, Syndrome AND AMIT CHAWLA, SeeCare page 6 a Time Motion Study.

Specialty Organization Perspective 24. Electronic medicacords and physician stress in 53. The burden of the digital environment: a primary care: results from the MEMO Study systematic review on organization-directed workplace 25. Exploring the Association Between Electronic interventions to mitigate physician burnout Health Record Use and BurnoutAmong Psychiatry 54. Have you got the time? Challenges using vendor Residents and Faculty: a Pilot Survey Study electronic health recordmetrics of provider 26. Rethinking the electronic health record through efficiency the quadruple aim: time to align its value with the 55. Feeling and thinking: can theories of human motivation explain how EHR design impacts clinician burnout?

56. Conceptual considerations for using EHR-based activity logs to measure clinician burnout and its effects.

57. Practicing Clinicians' Recommendations to Reduce Burden from the ElectronicHealth Record Inbox: a Mixed-Methods Study.

58. Frontline Perspectives on Physician Burnout and Strategies to Improve Well-Being: Interviews with Physicians and Health System Leaders.

59. Electronic health records: a critical appraisal of strengths and limitations.

60. Organizational strategies to reduce physician burnout and improve professional fulfillment[ENDS.]

SETTLED SCIENCE The indisputable link between EHR and burnout

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

When there are none: Why manels are out

BY KAREN WOO, MD

constitute the majority of vascular surgeons, academic vascular surgery faculty and leadership. At the same time, manels are the disease in that they send a message that “you must look like this to be a vascular surgeon,” particularly a vascular surgeon that is considered an expert. This discourages young people to pursue vascular surgery, and junior faculty to pursue certain subspecialties—such as aortic surgery—that may be less inclusive. Further, speaking invitations are a major part of the currency required to achieve academic promotion, leadership positions, industry partnerships, research opportunities and future speaking invitations.

When speaking invitations only go to men, the cycle of underrepresentation and disparity is perpetuated.

ON JUNE 12, 2019, THE DIRECTOR OF THE National Institutes of Health, Francis Collins, MD, made a public commitment to decline to take part in panels that “do not fairly evaluate scientists of all backgrounds for speaking opportunities.”1 Collins referred to “manels”, a term describing all-male speaking panels. When taken to the extreme, the result is a “manference”—an entire conference composed of male speakers. If you think these are rare events, think again. In a study examining 98 medical conferences, representing 20 specialties held during 2017 and 2018, 36.6% of 5,409 panel sessions were manels and only four of the 98 conferences did not have a single manel.2

How did we get here?

So what’s the big deal?

Why does this keep happening?

The proportion of women in all Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs in 2016 was 44%, whereas the proportion of women in vascular surgery training programs was 33%.3 Women comprise a minority (18.6%) of academic vascular surgery faculty, with only 6.8% of women holding vascular surgery division chief positions compared to 13.7% of men. The proportion of women vascular surgeons who hold the rank of full professor is half that of men (10.7% vs 26.2%).2 As long as women continue to be underrepresented in public-facing forums, we continue to broadcast to students and trainees that women are not welcome in vascular surgery—and women cannot achieve their goals as vascular surgeons. Manels are a symptom of the underlying disparity in that it is easy to tap the men who

Additional well-described psychosocial phenomena perpetuate the creation of manels.

The “Matthew/Matilda effect” is a bias against

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

4 • Vascular Specialist

In the 1900s, medicine was considered a “high status” occupation with systematic discrimination against women.4 In 1970, the Women’s Equity Action League filed a class action lawsuit against every U.S. medical school alleging abuses in admissions. Consequently, affirmative action resulted in an increase in women enrolled in medical schools. What followed was a phenomenon called occupational segregation, in which women are pushed to work in specialties perceived as acceptable for women (such as pediatrics or family practice) while other specialties (such as surgery) were regarded as the domains of men.5

When speaking invitations only go to men, the cycle of underrepresentation and disparity is perpetuated continued continued onon page page 8 8

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 and 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

April 2021

COMMENTARY

COVER STORY

–––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– ______ ______ ssertS yteixnA eugitaf mrah - fleS seicnednet ladicius meetse fles wol ytivitagen lareneg peels roop snrettap ssensseltseR tbuod- fles ______ –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– –––– ––––

SETTLED SCIENCE The indisputable

link between EHR and burnout

The CEO of Epic, Judith Faulkner, recently made a statement questioning whether there was any evidence tying the EHR (electronic health record) to physician burnout. Here, as Gabriela Velazquez, MD, London C. Guidry, MD, and Amit Chawla, MD, detail, 60 peer-reviewed papers say otherwise.

T

ype the word “burnout” into PubMed, and 11,719 citations appear for just the past 10 years. Drill it down to “burnout and electronic medical record,” and 212 titles stare at you with an invitation to fall down the rabbit hole of why the abbreviation EHR—or the interchangeable EMR (electronic medical record)— elicits feelings of PTSD for so many healthcare workers.

With a quick scroll, the buzzwords appear in neon lights: “effects on work-life balance,” “click fatigue” and “pajama time,” to the really bad players of “burden,” “depression” 6 • Vascular Specialist

and “suicide.” These are becoming the vernacular of all physicians, regardless of the title of medical doctor, surgeon, fellow or resident-in-training.

Unfortunately, the EHR is truly an equal opportunist affecting all healthcare providers, including frontline nurses and physician extenders. After reviewing 212 titles, we narrowed down our search to 73 that associated the EHR with burnout. From there, we created the following four categories and assigned articles into the category for best fit, ultimately vetting 62 articles relating EHR to burnout.

We looked at EHR usability and association with burnout; factors affecting physician professional satisfaction and their implications for patient care health systems, and health policy; specialty-specific EHR-related burnout; and, finally, solutions and innovations to EHR-related burnout. It is clear that physicians, healthcare workers, and healthcare systems know there is a problem. What is also clear is that despite the evolving merger of healthcare systems, we have yet to find an applicable and feasible solution to the ongoing stress and burden EHR is bringing to our community.

It sounds great in theory—an electronic account of a patient’s medical history able to be accessed across multiple hospital systems in multiple states, no longer held hostage by the whims of shoddy penmanship and fax machines.

Although saying that the EHR was invented solely to improve patient outcomes is about as disingenuous as saying it was devised to save trees. Both things may be true to some extent, but they are secondary to making a profit—from the EHR companies selling the products, to the hospitals claiming every last cent from the insurance companies and patients. The HITECH Act of 2009 incentivized the adoption of the EHR while punishing non-adopters. Since then, more than $30 billion has been invested, resulting in 96% of hospitals utilizing an EMR.59 (A full list of references for this commentary are available at vascularspecialistonline.com.)

THE POSITIVES It’s not all bad. As expected, 77.6% of physicians in one study stated that the EHR improved billing processes.10 Multiple studies have shown that physicians feel that the April 2021

EHR has led to improved communication within the hospital.10,34 Some feel that it has even increased their clinical workflow.13 The EHR allows for remote access for those clinicians technologically inclined. Knowing whether you have to go to the operating room after scrolling through a computed tomography angiography (CTA) at home can save precious time. Medication errors have also decreased drastically because of the EHR.59 No matter how many times you try to convince yourself—or others try to convince you—that EHR is the best integration we have seen in decades, it is still dauntingly bad. All of those advantages can be converted into cons, unfortunately—mostly to the detriment of the physician. The physician’s note is no longer a document containing essential facts pertinent to patient care, but is now an itemized receipt with reimbursement documentation embedded within.17 The good news is that if you can’t finish all of your billing… I mean documentation… at work, you can now work from home. “Pajama-time” documenting has increased and is agnostic of training status (resident versus attending).33 The paralyzing dread that comes with watching the number on your inbox rapidly approach four digits is at least one thing that comes free with the EHR. One study indicated that almost half of all weekly in-basket messages came from EHR algorithms.12 Excessive inbox messages have been correlated with loss of situational awareness due to information overload.57 Note bloat; the inability of various EHRs communicating effectively with one another, leading to gaps in information; the perceived shift from patient care to computer documentation; and the physical manifestations of this shift (i.e., posture-related pain). These have all been linked to decreasing physician satisfaction, which has been associated with increased burnout.35

THE ISSUE IS REAL While we are not trying to depict an “all-time-low” of documentation, clearly this has been an issue for many years, and almost every single specialty has reported on its effects. Contemporary data suggest that this ongoing and growing issue has forced physicians to relocate, seek parttime opportunities and alternative employment.44 One could say that maybe they were not cut out to do medicine after all. However, we have all witnessed the repercussions and long-term effects among our close circles of physician friends, family and colleagues.

Once passionate and enthusiastic, they become slaves of EHRs and documentation demands until they have had enough. Physicians have lost their ability to control their documentation workload and focus on actual patient care.

Organizational structures and cultures are now dictating how many hours you will be spending in front of a computer, which, inevitably, will decrease the high-quality time spent in personal encounters, which we know is incredibly important in job satisfaction.1,2 Another interesting fact is that practitioners in group practices were less likely to report burnout compared to hospital-employed or academic practices. One of the theories is that the surveyed group practices found a way to become more productive by increasing the use of precharting by nurse navigators, scribes, or use of artificial intelligence.2,6 This makes us wonder why are we not being heard by our leadership? Why do we continue to be punished for lack of checking boxes rather than increasing efforts to support the workforce in this pressing matter?

Although professional dissatisfaction can be attributed to many factors, paper after paper associated dissatisfaction with the EMR to physician burnout. The Mayo Clinic found that dissatisfaction with the EMR was an independent risk factor for providers to likely or definitely reduce clinical work hours in the next 12 months, or leave their current job in the following 24 months.16 As medicine is seeing burnout rates twice as high as those in other fields, there should be concern for physicians leaving medicine altogether.16,46 April 2021

THE SEEDS ARE PLANTED EARLY Unfortunately, lack of job satisfaction comes well before attending-level practice. Chest published survey results from pulmonary critical care fellows showing more than 40% surveyed felt the EHR impacted their joy in medicine in a negative way. This correlated to higher odds of burnout.3 Advanced practice practitioners (APPs) are not exempt from EHR-related frustration and burnout. Lack of time to document and daily frustration with the EHR was significantly associated with burnout in APPs.34 So what is it about the EHR that reduces professional satisfaction and increases burnout? A chronic theme seems to be time. Face-to-face contact with patients is being eaten up with face-to-computer time instead. When an EHR reduces time with a patient, physicians report reduced personal satisfaction.7 The problem of time has many facets. The mandated documentation must be completed to avoid punishment from one’s institution, insurance companies and governmental agencies.

There is just not enough time in the workday to care for patients, document, and deal with all of the other mandatory inbox requirements. This leads to the necessity of doing homework nights, along with weekends and holidays.35 Physicians spending a moderate, high or excessive amount of time at home completing EHR-related tasks were associated with higher odds of depressive symptoms.3 Professional satisfaction

Unfortunately, the EHR is truly an equal opportunist affecting all healthcare providers, including our frontline nurses and physician extenders also decreased when physicians felt their inboxes were filled with tasks that could be assigned to others. The complexity of the EHR also had a negative impact on overall professional satisfaction.7 Processing large amounts of data has led to “cognitive overload,” exacerbated by the numerous clicks required to prove you did the work.26 Many assumed that younger doctors would not experience the same deleterious effects from the EHR; however, the EHR does not discriminate by age. The Mayo Clinic surveyed more than 6,000 physicians: Those under 40 still reported a 55% dissatisfaction rate with the EHR compared to 66% in those 60 and above.13 Stanford was able to use EHR software provider Epic to look at the time spent in the EHR by first-year residents versus those in their second year and higher. The mean daily average was 5.6 hours of computer time. Considering a medicine resident typically works a 10- to 12-hour day, this is approximately half of the residents’ time spent looking at a computer. This percentage does not change significantly as one becomes an attending. One study showed attending physicians spend 37–49% of the workday at a computer screen with an average of oneto-two hours of screen time at home.27 Improved overall professional satisfaction with regards to the EHR only happens when the EHR is perceived as improving quality of care for patients.7

POSSIBLE REMEDIES So what can be done from a healthcare systems perspective? Physicians with burnout are twice as likely to leave an organization. Since the estimated cost of replacing a physician is between $500,000 and $1 million, the health and well-being of our current and future physicians should be paramount, with hospital systems taking an active role in protecting them from EHRassociated burnout and burnout in general.46

A common goal reported by physicians to reduce burnout is having value-alignment with leadership.2,15,24 Hospitals and healthcare organizations need to be able to enhance or restructure their existing EHRs to reduce burnout while still complying with Centers for Medicare & Medicaid Services (CMS) rules and regulations. One aim has been for better EHR education opportunities.

Kaiser Permanente instituted a three-day intensive EHR education intervention for EHR documentation and physician well-being. Some 98% of the attendees reported they would recommend the training to their colleagues. Although they could not show a direct link to decreased burnout, the trend was toward decreasing time spent in the EHR, improved clinical accuracy of the documentation and fewer medical errors.50 Simple management of the physician inbox by removing tasks such as prescription refills, and re-delegating to appropriate support staff, or stopping the automatic cc’ing of notes unless intentional are small steps toward reducing the clerical burden.48 Fixing the EHR is a band-aid on a bullet hole: Regulatory reform is ultimately needed. The documentation burden is linked directly to billing and reimbursement.53 Until this changes, the burden will continue to fall upon the healthcare provider. In 2017, CMS launched a “patients over paperwork” campaign in an attempt to evaluate and streamline documentation regulations. A small portion of this initiative is to decrease the amount of redundant documentation and be more focused on the interval history of the patient. The National Academy of Medicine along with the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education (ACGME) also launched a collaborative effort with regards to physician burnout.30 Although there is an increasing amount of research being aimed at EHR and burnout, there still is no industry standard across EHR platforms to be able to study effectively.54 This creates difficulty in obtaining meaningful data to create change. Temporary patches will continue to be developed in an attempt to mitigate burnout. Scribe implementation has increased and been found to decrease physician documentation hours at work as well as after hours. 53 Most recently, artificial intelligence (AI) has come to the forefront as a solution to the EHR documentation burden.

The ability to have a computer program listen, create a usable note and bill correctly is being done by companies like Suki. Will this be a game changer and allow medicine to again become a contact sport, where the physician actually gets to look at the patient instead of a screen?

And, if so, what is the cost and who will pay for it?

Most vascular surgeons are optimistic pessimists, thinking the third bypass will definitely be the one that saves the leg, while penciling in the inevitable amputation into next week’s schedule. We are also a self-reliant bunch.

We will try and mitigate the onslaught of extra work by various workarounds, but all of this comes at a cost. The depersonalization of the patient encounter due to data entry is felt by the provider and the patient. The extra pajama time is felt by the provider and provider’s family.

Until the system stops using the EHR as a receipt for services and uses it as a tool to augment patient care, we will continue to burnout. We need good leadership to make that happen. We need to protect our future physicians from going down the same path.

Gabriela Velazquez, MD London C. Guidry, MD and Amit Chawla, MD, are vascular surgeons based in Winston-Salem, North Carolina; Baton Rouge, Louisiana; and New Orleans, respectively.

vascularspecialistonline.com • 7

GUEST EDITORIAL

When there are none: Why manels are out Continued from page 4

acknowledging the achievements of women scientists, whose work is instead attributed to male colleagues, leading to undervaluation of women’s accomplishments.6 Maternal bias is the assumption that women are less competent and less committed to their careers because they are preoccupied by children and family, and thus not interested in speaking. The “backlash effect” is the visceral response to a perceived violation of expected gender norms (women entering “masculine” specialties). This manifests in the “competence-likability trade-off,” where men are more well-liked when they are successful but the opposite is true for women. And who’s going to invite someone that’s not well-liked to speak on a panel?

How do we fix it?

Organizers: Starting with a diverse group of organizers has been shown to increase the diversity of speakers.

Organizers should commit to creating panels with representation of experts

argument that there are no women or diverse experts.

Responsibility Speakers: Before agreeing to a speaking invitation, inquire about representation on the panel. If there is not adequate representation, decline the invitation and make the reasons clear to the organizers.

Even better, suggest a woman or another individual that would increase the diversity of the panel to take your place.

Attendees: When you receive an invitation to attend a manel, decline the invitation and make the reasons clear to the organizers. For program directors and other leaders, when asked to distribute an invitation to a manel to your trainees or your colleagues, decline to distribute and again make the reasons clear.

Women in vascular surgery are acutely aware of the disparities, and, as a result, we work extra hard to prove we’re worth our salt. Next time you’re organizing a panel, make the savvy choice of a woman vascular surgeon.

Trust me, she will give a spectacular talk that you haven’t already heard 12 times before—and you’ll be delighted.

References 1. Rubin R. NIH Director Takes Stand Against “Manels”. JAMA 2019;322:295.

2. Arora A., Kaur Y., Dossa F., Nisenbaum R., Little D., Baxter N.N. Proportion of Female Speakers at Academic Medical Conferences Across Multiple Specialties and Regions. JAMA Network Open 2020;3:e2018127–e.

Organizers: Starting with a diverse group of organizers has been shown to increase the diversity of speakers from all backgrounds. This can require more effort on the organizers’ part than is typically afforded. As Ellen Dillavou, MD, associate professor of vascular surgery at Duke University School of Medicine in Durham, North Carolina, tweeted, “Sometimes you need to dig deeper than your speed dial.”

Organizers, in a rush to address diversity, will sometimes add a woman as a moderator, or have one woman among 10 men panelists.

This is “tokenism,” and it doesn’t undo a manel. While one woman technically makes it not an all-male panel, what we are striving for is not just circumventing a technicality, but a panel representative of all the experts in the field.

Further, tokenism can be harmful when it places an individual in a very visible position and asks them to present outside their area of expertise. This places the speaker in a position of potential weakness and strengthens the 8 • Vascular Specialist

3. Shin S.H., Tang G.L., Shalhub S. Integrated residency is associated with an increase in women among vascular surgery trainees. J Vasc Surg 2020;71:609–15.

4. Walsh M.R. Doctors wanted: No women need apply: Sexual barriers in the medical profession, 1835–1975. 1977.

5. Bergmann B.R. The economic risks of being a housewife. The American Economic Review 1981;71:81–6.

6. Silver J.K., Slocum C.S., Bank A.M., et al. Where Are the Women? The Underrepresentation of Women Physicians Among Recognition Award Recipients From Medical Specialty Societies.

PM & R : Journal of Injury, Function, and Rehabilitation 2017;9:804–15.

Karen Woo is associate professor of surgery at the University of California, Los Angeles (UCLA). She is also associate director of the Vascular Low Frequency Disease Consortium.

APDVS honors Jack L. Cronenwett with inaugural Lifetime Achievement in Education Award

BY BRYAN KAY

The Association of Program Directors in Vascular Surgery (APDVS) bestowed its first-ever Lifetime Achievement in Education Award on the association’s one-time president Jack L. Cronenwett, MD, during its annual Spring Meeting (March 26–27).

Making the presentation, APDVS immediate past president Amy Reed, MD, described the new award as the highest honor the association will confer on an individual.

“This award recognizes an individual’s outstanding and sustained contributions in the education of our next generation of vascular surgeons,” she told the meeting.

The award grew out of discussions held at last year’s APDVS Business Meeting. The association then developed an accolade designed to honor vascular surgeon-leaders who have exhibited “outstanding achievement in education of vascular trainees and vascular surgeons as well as leaders in our field,” Reed said.

“This individual would have experienced lifelong commitment to education and vascular education, and possesses an incredibly high level of integrity and the highest standards.”

Cronenwett is an active emeritus professor of surgery at the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. He is also a past president of the Society for Vascular Surgery (SVS), as well as the New England Society for Vascular Surgery (NESVS).

“I met him first when he was a visiting professor and I was a junior faculty at the University of Cincinnati, and he got me interested in the [Vascular Quality Initiative (VQI)] outcome data, which we use today in our hospitals and in our systems,” Reed revealed.

“He was one of the founding fathers of the integrated program for vascular surgery residency, and I was honored to be a very small part of that when I was a member of the APDVS Education Committee. His commitment to education of vascular trainees and vascular surgeons in practice is unparalleled, and I can think of no one more deserving than our inaugural recipient for the 2021 APDVS Lifetime Achievement than Dr. Jack Cronenwett.”

Cronenwett said he thought it apt that the award exist under the aegis of the APDVS. “I have a strong place in my heart for the APDVS,” he said.

Cronenwett explained that he was around at the start of the association, and served on the Executive Council for more than a decade.

“During that time, I was also fortunate to be appointed to the RRC (Residency Review Committee) for surgery, and was able, in at least a small way, to influence the views around a separate, free-standing vascular surgery residency.”

In 2006, when the Accreditation Council for Graduate Medical Education (AGCME) approved the concept of an integrated vascular surgery residency, “I was in a good position to apply, and I did in the spring about 15 years ago right about now for the Dartmouth program,” he continued.

The accreditation was approved, and Cronenwett announced the development at that year’s SVS Vascular Annual Meeting (VAM), encouraging others to follow suit. He said he has been impressed by the growth of the APDVS in the years since he last attended a meeting in 2003. “I’ve been excited to watch the growth and adoption of vascular integrated training programs in many centers.”

Cronenwett recalled the materials available back when he and colleagues were getting started, contrasting them with the current constitution of the APDVS website, the agenda for this year’s meeting, and the materials currently available. “Things have really come a long way, and all of you who have done so much in these later years to mature this organization should feel really proud of what you’ve done,” he added.

April 2021

VETERANS AFFAIRS

Lessons in PAD care from VA vascular surgeons

BY MARK EID, MD, AND PHILIP P. GOODNEY, MD

The care of patients with peripheral arterial disease (PAD) is challenging and costly. Every practicing vascular surgeon knows that when patients present with ulcerations, infection, ischemia and comorbidities, we can accomplish amazing things. In an ideal world, our approaches universally entail (1) treatment of ischemia with reperfusion, (2) management of infection with debridement and antibiotics, and (3) treatment of the entire patient with patient-centered care, from comorbidities to family support to mobility and pain management.

HOWEVER, WE KNOW THAT this idealized description often fails to materialize in the real world. There is controversy about the types and methods of revascularization we will offer.

Managing the non-vascular aspects of chronic limb-threatening ischemia (CLTI), especially in regions of the United States where wound care experts are unavailable, can be challenging. Finally, getting the best treatments—both medical and surgical— can be costly and limited by a patient’s insurance and access to care.

We can learn much from healthcare systems that regularly care for large numbers of patients with CLTI, even in cost-efficient healthcare settings with significant regulation. More than 180,000 veterans receive care for PAD in Department of Veterans Affairs (VA) hospitals, and many of these patients are more aged with more comorbidities than similar populations outside of the VA. Yet, despite these challenges, lessons in PAD care abound in VA vascular surgery care.1

First, VA vascular surgeons offer veterans participation in the latest studies to guide effective, evidence-based care. Of the 117 U.S. sites in the BEST-CLI (Best endovascular versus best surgical therapy in patients with critical limb ischemia) trial, 18 are VA hospitals.2 VA facilities had 10,000

5,000

0 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 FY20 FY21

Figure 1: Overall amputation rates within the VA by fiscal year

half the number of investigators per site but enrolled the same number of patients per month as non-VA vascular centers, as Matthew Koopmann, MD, of the Portland VA Medical Center shared at the Pacific Northwest Vascular Society meeting in 2019.

Second, the teamwork available for veterans in a multidisciplinary setting offers

Higher frailty scores linked to increased postoperative complications and mortality in veterans undergoing EVAR for AAA

BY BRYAN KAY

Higher frailty scores were associated with higher rates of postoperative complications and mortality among a national cohort of veteran patients who underwent endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) or dissection. This was one of the findings of a retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database using the Risk Analysis Index (RAI).

April 2021

significant benefits when treating PAD. Katherine Reitz, MD, and Edith Tzeng, MD, and colleagues at the Pittsburgh VA have studied more than 2,500 patients across the country, in a quality improvement project aimed at optimizing medical management of every veteran with PAD using a simple checklist. Other multidisciplinary measures include the Prevention of Amputation in Veterans Everywhere (PAVE) program led by Jesse Jean-Claudee, MD, and colleagues nationwide; this has focused on providing systematic approaches to wound care and amputation prevention for more than 20 years.3 Limiting variation and encouraging systematic and proven approaches are key foundations underlying each of these efforts, as demonstrated by the overall consistency in amputation rates over the past 21 years (Figure 1).

Finally, advanced technology and new approaches abound when veterans present with severe CLTI. Teams from vascular surgery groups from across the country

perform advanced limb salvage procedures.

This is not a unique occurrence, and teams across the country provide similar treatments in a veteran-focused manner aimed towards optimizing limb- and patient-centered outcomes. For instance, radial-to-peripheral interventions, which offer expanded endovascular options for patients with complex peripheral vascular

THE DATA WERE PRESENTED BY WAYNE TSE, MD, a resident in the department of surgery at Virginia Commonwealth University in Richmond, Virginia, at the Society for Clinical Vascular Surgery (SCVS) Annual Symposium (March 13–17), held as a hybrid meeting from Miami.

Opening his presentation, entitled “Using the Risk Analysis Index to assess frailty in a veteran cohort undergoing endovascular aortic aneurysm repair,” Tse pointed to the growing importance of surgical frailty assessment in perioperative management as the elderly share of the population increases.

The RAI tool—calculated from 12 different preoperative variables and weighted risk factors to yield a score between 0–81—previously has been shown “to be associated with worse short- and long-term outcomes in multiple procedures and subspecialties,” Tse said.

“More frail patients had more medical comorbidities; more frail patients were also more likely to have cancer and less likely to be independent”—Wayne Tse

history, have become more widely used within VA vascular practices. This puts VA vascular surgeons at the forefront of these less morbid techniques for high-risk patients.

Additionally, the employment of telehealth technologies, long before COVID-19 made this popular, has allowed the delivery of specialized vascular care to veterans who often live in remote locations.

In summary, few will argue that systematic approaches to the care of patients with PAD are not challenging, but important, pursuits. As surgeons who care for patients with PAD in both VA and nonVA hospitals, we believe lessons through clinical trials, teamwork and technology can help us improve the care for patients with PAD nationwide.

References 1. W illey J., Mentias A., Vaughan-Sarrazin M., et al. Epidemiology of lower extremity peripheral artery disease in veterans. J Vasc Surg. 2018;68(2):527–535 e525.

2. M enard M.T., Farber A., Assmann S.F., et al. Design and Rationale of the Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BESTCLI) Trial. J Am Heart Assoc. 2016;5(7).

3. G abel J., Bianchi C., Possagnoli I., et al.

Multidisciplinary approach achieves limb salvage without revascularization in patients with mild to moderate ischemia and tissue loss.

J Vasc Surg. 2020;71(6):2073–2080.e2071.

Mark Eid is a graduate research fellow and Philip P. Goodney is co-director of the VA Outcomes Group at White River Junction VA Medical Center in Vermont. Goodney is a member of the SVS VA Vascular Surgeons Committee.

The VASQIP database was queried for cases that took place between 2001 and 2018. A total of 5,878 patients who underwent EVAR were identified, with an average age of 71. They were placed into three cohorts: those who were non-frail (classified as a score up to 20), frail (21–34) and very frail (35 and up). Some 36.2% were recorded as nonfrail, 56% as frail and 7.7% as very frail.

“More frail patients had more medical comorbidities; more frail patients were also more likely to have cancer and less likely to be independent,” Tse told SCVS 2021.

Additionally, they were also more likely to undergo emergent surgery, he added.

“After univariate analysis, we can see the rates of postoperative complications are increasing as the frailty index score is also increasing,” Tse continued.

“There are increasing rates of death, cardiac, pulmonary and renal complications. Frail and very frail patients were up to seven and three times more likely to experience 30day mortality and a complication within 30 days.”

Tse acknowledged limitations such as the retrospective nature of the data, the fact that the researchers dealt with only 30-day outcomes, and that there were no procedurespecific outcomes.

“Higher frailty scores were associated with higher rates of postoperative complications and mortality. Riskadjusted scores were also associated with these findings,” he concluded.

“In the future, we hope to use this RAI score to implement and aid in the discussion of postoperative outcomes during the informed consent process.” vascularspecialistonline.com • 9

COMMENTARY

‘Latinx’: How to understand and use the generalneutral term in correct manner

While there are many historic differences between Mexicans, Puerto Ricans and Cubans, for instance, terms such as Latino, Hispanic, and Spanish-speaking were coined to describe their language as part of a collective unit.

The term Hispanic was first used broadly in the 1970s, and appeared in the United States census in 1980. It was recognized to be too limiting, and the term Latino was added to the census in 2000.

While the extensive history describing the use of these terms is too long to describe in this article, it nevertheless represents proof of how difficult it is to verbally define this multifaceted community.

Use in medical literature

BY DANIELLE PINEDA, MD, GARIETTA FALLS, MD, AND REBECA REACHI LUGO, MD

Three members of the Society for Vascular Surgery (SVS) Diversity, Equity and Inclusion (DEI) Committee, chaired by Vincent M. Rowe, MD, explain how to go about using and understanding the term Latinx.

HAVE YOU EVER HEARD OR READ the term Latinx? For the purposes of medical literature, we will try to explain how to understand the descriptor and also how to use it.

Latinx is used as an alternative to the gender binary that is inherent to formulations such as Latina/o and Latin@, and is used by and for Latinos who do not identify as either male or female, or more broadly as a genderneutral term for anyone Latin American descent.

The term Latinx has been used increasingly in the literature, with over 800 articles on one PubMed search including the term. It is acceptable to use the term Latinx in the demographic section to allow for a non-binary description of Hispanic heritage.

Most recently, when describing COVID-19 impact the American Medical Association utilized the term Latinx, solidifying its applicability.

Within the Cochrane Library, there are 80 trials

Garietta Falls

SVS PAC has weathered the storm of 2020

BY MARK MATTOS, MD, AND PETER CONNOLLY, MD

The year 2020 was one of firsts and of resilience. We had a plague of biblical proportions; civil unrest; fiery political and racial tensions; riots; polar vortices, where it was literally freezing in the Southwest; and, last but not least, the looming threat of Medicare cuts, limiting our patients’ access to care and fee cuts to all of our practices. All of this within the last year.

BY AND LARGE, IT SEEMS VASCULAR surgeons have weathered things quite well—testament to the human spirit and perseverance in the face of adversity. But, of course, this is not the time to sit back on our laurels for too long, as the reprieve in Medicare cuts is only for a year. With the rollout of the vaccines, things may be getting closer to normal by the fall.

Despite the adversity we have all faced, and the distressing current political climate, we feel that it is necessary to update you, the SVS membership, on the recent accomplishments of the Political Action Committee (PAC).

April 2021

Use in mainstream society While Latinx has gained traction in the academic literature, its widespread use across mainstream society is lagging. Multiple surveys have found that the primary users of the term tend to be younger, English-speaking or bilingual—and also born in the United States.

The Pew Research Center published a survey that showed just 25% of Latinos in the U.S. have heard of the term, but only 3% use it to describe themselves. Latinx was officially added to the Merriam-Webster dictionary in 2018.

According to the Merriam-Webster website, “Though Latinx is becoming common in social media and in academic writing, it is unclear whether it will catch on in mainstream use. Nevertheless, it is gaining noticeable traction among the general public as a gender-inclusive term for Latin Americans of diverse identities and orientations.”

While the use of Latinx is not well delineated in mainstream society, it is the opinion of the authors that it is acceptable to use Latinx as a non-binary descriptor of the Hispanic demographic in medical literature.

Danielle Pineda, MD, is assistant professor of surgery at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. Garietta Falls, MD, is an assistant professor at Case Western Reserve University School of Medicine in Cleveland.

Rebeca Reachi Lugo, MD, is a vascular surgeon at the Hospital Beneficencia Española in San Luis Potosí, Mexico.

of

Danielle Pineda

containing the word Latinx—most of them in 2020.

They are focused on the cultural area, family roles and lifestyles, as well as its effect on smoking, drinking and pregnancy in young people.

We are thrilled at the number of SVS members who gave to the PAC in 2020. We have nearly doubled our SVS membership participation in the SVS PAC. A total of 403 unique members (7% of the membership) donated to the PAC in the 2019–20 election cycle. With PAC donations and Voter Voice engagement, we helped to stop the 7% overall reduction in Medicare revenue to vascular surgery in 2021. The PAC was represented at nearly 10 regional society meetings. The annual SVS Membership Survey included five PAC Committee questions. We launched two outreach and solicitation campaigns—“Leading from the

Rebeca Reachi Lugo

Front,” to protect the specialty, and “I am Responsible,” for protecting the specialty.

The PAC Steering Committee submitted nine articles to Vascular Specialist in 2020 As we move onward in 2021, we at the SVS PAC have our work cut out for us.

We will continue to tirelessly advocate on your behalf for the support of our patients as well as the best interest of the SVS membership. We will not sit idle.

As we all look forward to this “new year,” we want to let you know some of our goals and objectives: We want to continue to build upon the outstanding relationships we have forged with our elected officials who supported our legislative priorities.

We had great support for our virtual

A total of 403 unique members (7% of the SVS membership) donated to the PAC in the 2019–20 election cycle

gatherings with lawmakers. These were intimate conversations with SVS members and members of Congress that helped to highlight many of the current problems our patients face and gave members a voice in the politics of medicine.

Some of our targeted legislative priorities for passage in 2021 and beyond include: holding providers harmless from cuts, physician wellness and raising awareness of peripheral arterial disease.

We want to achieve our goal of 20% SVS membership participation in the PAC during the 2021–2022 election cycle.

We want to show exactly where and how our PAC dollars are going to work. Our core working premise is that we typically give to politicians who have supported SVS issues, and are on committees or in leadership that work on healthcare policies.

To this end, we have devised a SVS PAC Political Scorecard that is now available on the SVS website. The scorecard highlights the PAC activities over the past year, the policies we support and the candidates and elected officials to whom we have donated.

Mark Mattos and Peter Connolly are co-chairs of the SVS PAC.

vascularspecialistonline.com • 11

VAM

Emerging picture: VAM 2021 line-up shaping up into blockbuster event

from vascular leaders at all levels,” including multidisciplinary teams; recruiting strategies; a dean’s perspective; and the view from the top n “Last-ditch effort at limb salvage: How to manage what seems unsalvageable,” intended to help vascular surgeons manage patients at the edge of the mainstream with options to limb amputation

Saturday, 6:30 to 8 a.m.

BY BETH BALES

The moving pieces that comprise the 2021 Vascular Annual Meeting (VAM), set to take place Aug. 18–21, are being assembled into a blockbuster whole.

THOUGH PLENARY SESSIONS HAVE YET TO BE structured, all of the invited sessions—“Ask the Experts,” breakfast and concurrent sessions, as well as postgraduate courses—are mapped out.

The goal for the invited sessions is, as always, “to have the most compelling and timely information for our SVS members,” said Vikram Kashyap, MD, chair of the SVS Postgraduate Education Committee, which puts together the invited sessions.

“We want to make sure we’re getting information to them to help them—on a daily basis—in their practices and with their patients.”

Most exciting, said SVS Program Committee co-chair Andres Schanzer, MD, “The outstanding postgraduate courses will be featured over the entire meeting, Wednesday through Saturday, and not solely on Wednesday, as in the past.”

This year presented a challenge in considering not only those sessions suggested for 2021, but also those that had been slated to be part of the canceled 2020 meeting in Toronto. The committee met this task successfully, he said, and the result is “a blockbuster setup of didactics.”

The agenda includes a postgraduate session on pediatric vascular surgery, probably the first such session in nearly a decade. Another postgraduate course, on vascular emergencies in community hospitals, “is very relevant to our members in non-academic centers. What patients do I take care of and who do I get to another center?”

New guidelines on aortic dissection will be highlighted at the third postgraduate session, important because “all of us are seeing more dissection patients with its greater recognition as a cause of cardiovascular symptoms,” said Kashyap.

The 2021 VAM also will include a number of collaborative programs, including one with the Society for Vascular Ultrasound. “We’ll have technologists and surgeons together in one room presenting both the ultrasound images and clinical issues of common vascular problems. I think that’s critical to getting a holistic view,” Kashyap added.

The session presented in collaboration with the American Venous Forum, meanwhile, will include “the stars of venous disease on the podium.” The Society of Thoracic Surgeons is collaborating with SVS on the Aortic Summit, to be held from 3:30 to 5:30 p.m. on Friday.

ASK THE EXPERTS returns for its fourth year, after debuting to great popularity and overflow crowds in Boston in 2018.

as community leaders in vascular disease,” including defining and demonstrating vascular surgeons’ value; branding; and succeeding in a competitive market, 4 to 5 p.m. Wednesday n “Quality reporting for a payment world, case studies and best practices,” including federal quality programs such as the Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorization Act of 2015 (MACRA) and the Quality Payment Program (QPP); the Alternative Payment Model system and its benefits, with case experiences; 3:30 to 4:30 p.m. Thursday n “Occupational hazards to the vascular surgeon,” including radiation safety, risks to pregnant surgeons, and ergonomic challenges, 4:30 to 5:30 p.m. Thursday n “Mesenteric artery revascularization,” including pre-procedural decisionmaking and selecting the appropriate treatment option for both acute and chronic revascularization; and intraoperative challenges and algorithms for treating both chronic and acute mesenteric artery ischemia; 3:30 to 4:30 p.m. Friday n “Clinical trials,” covering experiences with the National Heart, Lung and When: Aug. 18 to 21 Blood Institute (NHLBI), obtaining Where: San Diego Convention external funding and both getting a trial Center, San Diego, California off the ground and running it, 4:30 to 5:30 p.m. Friday Four full days of educational

VAM details

BREAKFAST SESSIONS are held from 6:30 to 8:30 a.m.

Friday and Saturday. (Industrysponsored sessions occur in that same timeframe on Thursday.)

Friday, 6:30 to 8 a.m. n “Wound complications and management in vascular surgery,” including laparotomy closure techniques; using abdominal wall meshes for prophylaxis against incisional hernias; closure techniques of groin incisions; adjusting to prevent or manage groin wound complications; and fasciotomy closure techniques n “Lessons learned

Topics include: n “Explanting endografts: When, why, how?,” 3 to 4 p.m.

Wednesday n “Positioning vascular surgeons for success

12 • Vascular Specialist

n “Malpractice 101,” including malpractice issues every beginning vascular surgeon should know; geographic variances in lawsuits; and documentation pitfalls n “Kidney Disease Outcomes Quality Initiative [KDOQI],” including its guidelines development; vascular access; flow-related dysfunction; and nonflow-related dysfunction. n “Career optimization tips and tricks for young surgeons,” with the top five tips to: success in the first three years after training in both the academic and private practice settings; sustained success in both settings; and longevity in vascular surgery with a focus on wellness, mentorship and camaraderie

Vikram Kashyap

programming

Exhibits: Aug. 19 to 20, with more than 125 companies showcasing the latest technology and services related to vascular surgery. The Exhibit Hall also will feature the Opening Reception, Scavenger Hunt, Vascular Live industry presentations, plus coffee breaks and box lunches.

Registration and housing will open in early May. Learn more at vascular.org/VAM. * The SVS continues to plan full speed ahead for an in-person, high-impact, meeting where colleagues can once again connect and learn from each other. The Society is hoping it won’t be necessary, but if it is, it will be ready to convert the meeting to an innovative and engaging virtual format.

The protection and safety of attendees remains the top priority.

A total of six CONCURRENT SESSIONS are planned for 2021.

Concurrent sessions n “Evolution and transformation of the [Journal of Vascular Surgery] JVS journals,” including the current status of JVS and future directions in medical publishing; diversity, equity and inclusion issues in scientific journals; the “why” of the new JVS-Vascular Science; reporting standards, guidelines and appropriate use criteria; registry papers; and COVID-19 and vascular disease in the JVS, 1 to 2:30 p.m. Wednesday n “Complication management,” covering 10 situations, such as steal syndrome and dialysis access; superficial venous interventions; carotid endarterectomy; transcarotid revascularization; and abdominal aortic aneurysms, 5 to 6:30 p.m. Wednesday n “Value of a vascular surgeon,” including organizing a service line; the clinical and financial impact as well as that of the office-based lab on the healthcare system; strategic planning; and negotiating with the C-suite, 1:30 to 3 p.m.

Thursday n “Back to the future: Patient selection and techniques in open infrainguinal revascularization,” including choosing procedures based on the new Global Vascular Guidelines; arterial anatomy; in situ vs. reversed vs. nonreversed transposed bypass; alternatives when the ipsilateral greater saphenous vein is not available; antiplatelet and anti-thrombotics after bypass; isolated and concomitant

April 2021

revascularization of common femoral and profunda femoris arteries; and venous arterialization for limb salvage; 1:30 to 3 p.m. Friday n “New solutions for old problems in vascular ultrasound,” in collaboration with the Society for Vascular Ultrasound, 1:30 to 3 p.m. Saturday.

Topics include balloon-assisted maturation procedures; carotid stenting; iliac vein stenting; peripheral artery angioplasty, and stenting and pedal access n “Digital transformation,” discussing changes in telemedicine and its place in the medical world today, 3:30 to 5 p.m.

Saturday

Postgraduate classes n “Clinical update in the management of aortic dissections,” which includes an update on the following: SVS Reporting Standards for aortic dissection; uncomplicated and complicated acute aortic dissection; complicated type A dissection and dealing with visceral/ limb malperfusion in acute aortic dissection, 1:30 to 4:30 p.m. Thursday n “Pediatric vascular care,” including venous thromboembolism; congenital vascular anomalies; arteriovenous access (AV) access in children; extracorporeal membrane oxygenation

Wednesday is the new Thursday Those planning to attend the 2021 Vascular Annual Meeting (VAM) in August need to keep in mind that the conference's structure has changed.

POSTGRADUATE CONTENT previously presented only on Wednesday is now dispersed throughout the meeting. And Wednesday is the new Thursday.

Organizers have moved the Opening Ceremony, the E. Stanley Crawford Critical Issues and William J. von Liebig forums, as well as the first plenary sessions, from Thursday to Wednesday.

“This really changes how one approaches the VAM, with content now equally spread out from Wednesday to Saturday,” according to Vikram Kashyap, MD, chair of the SVS Postgraduate Education Committee, which plans the postgraduate courses and the “Ask the Expert,” concurrent and breakfast sessions.

VAM opens at 7:30 a.m. on Wednesday with the Opening Ceremony. The final postgraduate session and Poster Championship both end at 4:30 p.m. on

April 2021

(ECMO) cannulation and perfusion consideration in neonates, infants and children; pediatric renovascular hypertension and arterial aneurysms; sports-related deep vein thrombosis/ compressive syndrome in children; iatrogenic femoral arterial aortic injuries; management of pediatric aortic injury; and current pediatric vascular surgery practice patterns and the role for cross-disciplinary team training, 1:30 to 4:30 p.m. Friday n “Emergency vascular care in the community hospital: What is safe and reasonable,” exploring questions of treatment versus transferring and handling various injuries in a community hospital, 1:30 to 4:30 p.m.

Saturday

VRIC to be held at VAM

Other sessions

The agenda includes four sessions, on: n “Arterial remodeling and discovery science for venous disease” n “Atherosclerosis and the role of the immune system” n “Aortopathies and novel vascular devices” n “ Vascular regeneration, stem cells and wound healing”

n “Bringing what’s new in venous to you!,” which is a collaboration with the American Venous Forum (AVF). The session includes “virtual venous education” in 2021, updates on CEAP classifications, and a series of tips and tricks for venous stenting, 4 to 5 p.m. Wednesday n The Aortic Summit, in collaboration with the Society of Thoracic Surgeons, 3:30 to 5:30 p.m.

Friday, Saturday Saturday, while the Registered Physician in Vascular Interpretation (RPVI) review course and final concurrent session both end at 5 p.m. Saturday.

And to permit attendees to attend as many sessions as possible, the plenaries are being presented in the mornings, with no competing sessions. “The whole audience can come into one room and listen to the best science we have to offer,” said Kashyap.

Afternoons, meanwhile, will present no more than three concurrent programs, to avoid overwhelming the audience with too many choices, as well as providing the ability to attend as many programs as possible.

“This new format comes in direct response to consistent member feedback requesting a solid morning of plenary programming every day, with all members together,” said Program Committee co-chair Andres Schanzer, MD. The Vascular Quality Initiative (VQI) will once again hold its annual meeting on Tuesday afternoon (12 to 6:30 p.m.) and from 8 a.m. to 5 p.m. on Wednesday.

Meanwhile, the Society for Vascular Nursing, as is its custom, will hold its annual conference from 8 a.m. to 5 p.m.

Wednesday and Thursday.

The Society for Vascular Ultrasound will also hold its annual meeting in partnership with VAM for the first time in many years, from 7 a.m. to 6 p.m. on Thursday and Friday.

For more information on VAM visit vascular.org/VAM.—Beth Bales

In celebration of the 75th year of the SVS, the Vascular Research Initiatives Conference (VRIC), typically held in early May, is moving this year to be held during the 2021 VAM in August. In a year when so much has been challenging, SVS president Ronald Dalman, MD, and VAM leadership considered how VAM could serve as a “homecoming” for all vascular surgeons.

The VRIC sessions will be live, held from 1 to 3 p.m. Thursday and Friday, Aug. 19 and 20, during VAM. All VAM registrants may attend VRIC sessions.

Those who want to attend VRIC only will be able to pay just the VRIC-only fee. The conference emphasizes basic and translational vascular science.

A hallmark of the meeting is the give-and-take among presenters and attendees, with discussion that helps motivate participants to discover solutions to important problems affecting vascular patients.

VRIC also features the annual Alexander W. Clowes Distinguished Lecture.

Philip S. Tsao, PhD, of Stanford University, will present the lecture, “Molecular and genetic approaches to understanding abdominal aortic aneurysm disease.” Many VRIC presenters are early-career surgeon-scientists, explained Dalman. Presenting at the conference long ago helped him get his own career started, he said. And for those just starting out, the in-person feedback is important. Attendees will follow up a VRIC registration research presentation up with questions fees for those who such as “Why did you do that? What else do not also wish to did you consider? You should talk to Max attend VAM are: who has a similar interest in that area.

“The indirect benefit of that interaction • SVS member: $100 is almost as valuable as the science • SVS Candidate member: $75 presented, if not more so,” he said.

• SVS Candidate memberin-training (residents and “In science, it’s all about trying to fellows): $50 get as much feedback as possible on • Non-member physician: $200 your ideas. Interaction, face-to-face, • Non-member vascular and comparing notes, probing for alternative general surgery resident: $50 explanations to data, questions and • Allied health professional answers—those are all a really important (SVS/SVN/SVU member and part of the process.” non-member): $75 Moving VRIC to the VAM umbrella is • Candidate member-in-training partially a result of the cancellation of student and non-member the 2021 American Heart Association’s medical student: $25 Vascular Discovery science sessions, which for several years have been held in conjunction with each other. With Discovery not taking place this year, the Basic and Translational Research Committee and SVS leadership made the proposition of holding VRIC as part of VAM this year, to promote the in-person interaction considered so important. SVS leaders anticipate a return to the traditional AHA partnership in 2022. Committee Chair Luke Brewster, MD, called VRIC@VAM a chance to come together a broader SVS membership.

“We are grateful to Drs. Dalman and Tzeng, and our VAM program directors, Andy Schanzer and Matt Eagleton, for providing us with this great opportunity to meet face-to-face and share cutting edge basic and translational research with each other,” he said.

To an extent, holding the two meetings together underscores the SVS branding messages of comprehensive vascular care and “Surgery is only part of our story,” Dalman added. “We're not just technicians,” he said. Those conducting translational research are working to understand the fundamental basis of disease and to manage it. “We’re pushing the frontiers of the disease; we’re understanding who gets the disease, why and novel ways to prevent and treat it.” For more information, visit vascular.org/VRIC21.

vascularspecialistonline.com • 13

VALUE IN CARE

'Highly implementable' price sheet leads to cost reductions in vascular Greatest procedures cost reduction:

BY BRYAN KAY

A simple cost reduction strategy implemented among providers in an academic vascular surgery practice yielded data demonstrating sometimes significant cost savings— in the case of common femoral endarterectomy, of nearly 70%.

endarterectomy, and combined endovascular aneurysm repairs (EVARs) and thoracic endovascular aneurysm repairs (TEVARs).

The data showed that greatest total operative cost reductions during the study period were recorded for common femoral endarterectomy (-68.6%; p= 0.0107), abdominal aortic aneurysm (AAA) repair (-17%; p=0.037), and carotid endarterectomy (-10.3%; p= 0.012).

“The total supply cost alone—which is important to assess because of the dilutional effects of expensive device implant cost—demonstrated significant decreasing costs for common femoral endarterectomy, with a cost change of 42% [p<0.0001],” Goldberg said.

“Interestingly, temporal artery biopsy saw a two-fold increase, which was also significant [99.5%; p=0.0003].”

In terms of cost per time, which Goldberg identified as “an important standardization for differences in complexity of procedures,” data similarly showed significant decreases for carotid endarterectomy (-8.9%; p=0.001), AAA repair (-16.2%; p=0.019), and carotidsubclavian bypass grafting (-9.9%), with a “trend toward significance” for common femoral endarterectomy (-41.2%; p=0.06).

Additionally, Goldberg et al recorded nonsignificant cost reductions for arteriovenous grafting and rib resections. Relative price increases of 31%, 8% and 3% were calculated for temporal artery biopsy, vein transposition and distal bypass, respectively.

Meanwhile, the research team discovered large total operative cost increases with minimal changes in supply cost, and non-significant changes in cost per time, for a composite of all endovascular procedures (EVARs and TEVARs).

“We demonstrate that a low-cost, highly implementable cost sheet is effective at reducing cost in vascular surgery,” Goldberg concluded. “Further investigations should assess how and why surgeons choose supplies and implants in order to target further intraoperative cost savings.”

Common femoral endarterectomy

-68%

HE RESEARCHERS BEHIND THE STUDY found significant savings made across a composite of open vascular procedures in three areas—total supply and implant cost (-17.5%; p=0.008), supply cost (-2%; p=0.049), and total cost per minute (-28.2%; p=0.015)—during the 2105–2018 study period.

Findings from the study were delivered by Drew Goldberg, MD, a general surgery resident at the Hospital of the University of Pennsylvania in Philadelphia during a scientific session at the Society for Clinical Vascular Surgery (SCVS) Annual Symposium in Miami (March 13–17).

Goldberg and colleagues set out to assess whether preoperatively distributing a surgical supply cost sheet could both increase financial awareness among surgeons and reduce overall cost.

“Surgical care comprises of approximately 30% of the expanding and growing healthcare costs in today’s economy,” Goldberg told the hybrid SCVS gathering.

“Unsurprisingly, vascular surgery contributes significantly to this expenditure as its patients are a cohort of increasing age, comorbidities, complexity of operation, need for reoperations and use of relatively expensive devices.”

Goldberg noted that various vascular surgery groups had assessed costsaving strategies in the vascular surgery domain, highlighting a need for novel methods to mitigate costs.

T

”Further investigations should assess how and why surgeons choose supplies and implants in order to target further intraoperative cost savings”— Drew Goldberg

Cost calculation The research team’s retrospective analysis recorded supply and implant costs both before and after the study period, with total operative cost defined as the accumulated implant and supply costs during a procedure.

“We assessed total implant and disposable supply cost, supply cost alone, and cost per time. Cost was analyzed over two periods: the 24 months prior to the tool implementation and 24 months following, with a 1-month washout,” Goldberg explained.

From the 1,372 included procedures, the authors found varying numbers for each, with the highest being carotid endarterectomy, common femoral

14 • Vascular Specialist

Under scrutiny

Moderating the session, Johann M. Lohr, MD, a general and vascular surgeon at Wm. Jennings Bryan Dorn VA Medical Center in Columbia, South Carolina, asked Goldberg how the study findings had changed practice at his institution.

“Feedback at the attending level was that in seeing the cost of some of the more routinely used devices, attendings were no longer having scrub techs open certain things, like wires, rubber shots, things of that nature, and it was driving costs down,” he revealed. “There is certainly a behavioral effect to be cognizant of the prices of each of these, not only the expensive devices, but the cheaper disposable items intraopertively.”

Alan Lumsden, MD, medical director at Houston Methodist DeBakey Heart and Vascular Center at The Methodist Hospital, Houston, asked whether the cost data was available in real-time or after the completion of procedures.

“Because I really want to know real-time, when I pull a guidewire off the shelf, how much it costs,” he elaborated. “I don’t really see why that information is not available to us.”

Goldberg responded: “With the integration of the electronic health record, with the ORs [operating rooms] today, the way that it works is when a device is used or opened, it gets scanned, and at that point it gets registered in the electronic health record; then after the fact, after the case, there’s a cost sheet that’s generated so that an attending or a surgeon can review that, and then have that knowledge for the next case. That’s how it would be implemented in a prospective manner.”

April 2021

Study identifies ‘critical need’ for guidelines on appropriate use of atherectomy

BY BRYAN KAY

No data currently exist to support the use of atherectomy over other technologies for the treatment of peripheral arterial disease (PAD), and the healthcare expenditure associated with the procedure is substantial, write Caitlin W. Hicks MD, assistant professor of surgery at John Hopkins Medicine in Baltimore, et al in a newly published study of physician practice patterns during peripheral vascular interventions (PVI) that appeared in JACC: Cardiovascular Interventions.

HICKS AND COLLEAGUES PLUMBED MEDICARE beneficiaries undergoing first-time femoropopliteal PVI— including angioplasty, stenting, and atherectomy—for PAD between Jan. 1, 2019, and Dec. 31, 2019, in their analysis.

Of 58,552 patients who underwent index

April 2021

femoropopliteal PVI during the study period, 31,476 calcification compared with those without diabetes, (53.8%) were treated with atherectomy, they found. suggesting that angioplasty and stenting technologies, Patients who underwent atherectomy were similar to which cause plaque disruption and displacement within those in the non-atherectomy group in terms of age and the arterial wall, may not be as effective as debulking sex but were more frequently Black (17.1% vs. 13.9%) with atherectomy,” they comment. or Hispanic (4.6% vs. 2.6%) with a p<0.001, the authors “The association of atherectomy with claudication is discovered. “Patients undergoing atherectomy were more troublesome. Invasive interventions for claudication more frequently being treated for claudication (29.3% have not been shown to have better long-term outcomes vs. 23.3%; p<0.001) and had a lower prevalence compared with medical best medical of end-stage renal disease (36.5% vs. 40.8%; management and supervised exercised p<0.001) and ever smoking (29.4% vs. 31.8%) therapy (SET) and, indeed, may be than those in the non-atherectomy group.” substantially worse.”

A total of 1,627 physicians were included Yet, Hicks and colleagues found a in the study. Their use of femoropopliteal subset of physicians with a high rate of atherectomy during index PVI ranged from intervention following an initial diagnosis 0% to 100%, Hicks et al reported. Some 420 of claudication. Acknowledging limitations, physicians, or 25.8%, performed atherectomy in Caitlin W. Hicks the authors note their study’s data being 87.5%-plus of their cases. Another 133 physicians limited to Medicare beneficiaries as (8.2%) performed atherectomy in 100% of their index therefore not applicable to other populations. They also femoropopliteal PVI cases. “High users of atherectomy state they have not reported patient outcomes following were more frequently cardiologists (38.3% vs. 34.2%) or intervention, writing, “the aim of our study was to radiologists (14.1% vs. 6.9%) and less frequently vascular describe practice patterns in the use of atherectomy for surgeons (34.1% vs. 48.2%) compared with atherectomy index femoropopliteal PVI rather than outcomes that users in quartiles 1 to 3 (p<0.001),” they write. have been previously described.”

“High atherectomy users had a higher median Concluding, Hicks et al point out a wide distribution percentage of services delivered in an [ambulatory pattern for atherectomy use in index PVI, with surgery center (ASC)] or [office-based lab (OBL)] (78.4% atherectomy used “more frequently for treating patients vs. 49.5%; p<0.001) and a higher median Medicarewith claudication and diabetes and by non-vascular allowed payment amount for index femoropopliteal PVI surgery specialists and physicians working primarily in per patient ($11,071 vs. $532; p<0.001).”

ASCs and OBLs.” They add: “There is a critical need for In discussion, Hicks and colleagues noted patient professional guidelines outlining the appropriate use of characteristics associated with atherectomy use included atherectomy to prevent overutilization of this technology, claudication—rather than chronic limb-threatening particularly in high-reimbursement settings.” ischemia (CLTI)—and diabetes. “Patients with diabetes SOURCE: DOI.ORG/10.1016/J.JCIN.2021.01.004 tend to have PAD with higher degrees of medial

vascularspecialistonline.com • 15

SVS SET

Vantage point: The SET coach's perspective

The integral role of coaches to SET app program success

BY BETH BALES

“A good coach will make his players see what they can be rather than what they are.” Those are words ascribed to football coach Ara Parseghian, who guided the University of Notre Dame to two national championships in the 1960s and 70s. And that’s exactly what the coaches involved with the testing of the SVS Supervised Exercise Therapy (SET) app, designed to help treat peripheral arterial disease (PAD), do. It turns out an app’s bells and whistles, and trackers and counters, can do only so much— the coach who helps patients through is integral.

I

n fact, coaching is much more important than app developer Oliver Aalami, MD, a clinical associate professor of surgery and the director of Biodesign for Digital Health at Stanford University, ever envisioned. His theory was that “technology would solve everything.” Now, with the app in use, “I’m learning to be more patient-centric, because that’s what the app is,” he said.

The program, which emphasizes education, nutrition and exercise, is now in pilot testing at 13 sites across the country, with other trials set to start soon.

Approximately 100 people participated in round one.

Key to the coaching aspect is knowing what patients want to achieve and why.

Coaches help each of their learnerpatients set a SMART—specific/ measurable/achievable/realistic/timely— goal, and then check in weekly about the obstacles patients are encountering and how they can overcome those challenges.

These personal goals are critical, said coaches Waukecha Wilkerson, Amy Davis-Bruner, as well as Aalami.

“Goals make this program powerful and personal,” added Aalami.

Whether the goal is to be able to walk more than 73 steps in one day, stay out of an assisted living facility, go dancing, or walk again after an amputation, a self-defined goal provides the impetus to change behavior.

And in so doing, to change lives.

16 • Vascular Specialist

“We’ve learned that in our initial conversations, it’s really about understanding and acknowledging what the starting point is for that individual, what is reality for him or her and meaningful for the life they live every day,” said Davis-Bruner.

“What would be different for their lives through meeting their own goals. It has to be meaningful for the patient—or there’s no motivation to walk.

These are true personalized SMART goals.”

“The app and coaching are the tools to empower the patient to be his or her own health advocate going forward, to be the architects of their own healthy lifestyles,” said Wilkerson. It works as well as it does, because “embedded in our coaching model are best practices and cognitive behavior science,” said Davis-Bruner.

The two coaches estimate 98% of those so far enrolled are excited to make this first step and start the program. “They feel like this is the path to recovery and to prevent further worsening of their condition,” said Wilkerson.

Patient goals have included to go to Great America amusement park, go ice fishing, help a spouse around the house again, wander the landscape and take photographs, and give the gift of hiking with grandchildren.

Wilkerson said her patient-learners have given mostly positive feedback, and have said the app itself is valuable in helping them monitor their daily activities and keeping them accountable.

But, she said, “It’s not just the technology responsible for keeping them on track. It is also the human coach with onboarding, and building that rapport and expectation of accountability through the 12-week program.”

In their weekly conversations, coaches sometimes must help their patients work through challenges they face.

For example, snow or ice prevents a patient from going to the mall to walk? “What other solutions have you considered,” coaches respond. Answers may be using an exercise bike instead, or walking around the house. “They think of their own solutions.” Others walk one floor in their apartment building, get on the elevator, and go to another floor to walk some more.

“The program is effective because the patient has control over the where and the how,” said Wilkerson. The coach’s role, added Davis-Bruner, is to help participants “resolve challenges to get to the success they want.

Education, such as presenting research showing what has proven to be effective in decreasing PAD symptoms and nutrition information, are also part of the program.

For one patient, education that explained the “how” of exercise therapy—the role of blood traveling to the arteries and what smoking does to that route—was critical to stopping smoking and continuing to walk.

And there are successes.

One patient got a job and moved into independent living. “He opens the app and continues to walk. It keeps him optimistic that it will all work out,” said Davis-Bruner.

Coaches and patients assess progress at the six-week mark. The patient who wanted to walk more than 73 steps a day? She’s at 1,100. An amputee, “feeling pretty down about life after amputation below the knee,” has noticed pain levels decreasing after walking on a treadmill.

The value patients find in the program and the victories many of them have had do not, however, mean a 100% success rate. In the first 100-patient cohort, seven had to leave because of surgeries or exacerbation of other problems.

But they want to start again in the spring, said Davis-Bruner. “They want to keep the app because they’re getting results. They’re building a healthy habit around the app itself and the app is a cue for a habit routine.”

“This is not a program for everybody,” said Aalami. “We have some really, really sick patients. All kinds of things can surface,” including a patient who walked so much she aggravated her arthritis and had to cut back. “Many conditions affect mobility,” he said.

Other physicians involved in these patients’ care are not only impressed with their patients’ health changes but also have called the app team to find out more. The other providers tell their patients, “Whatever you’re doing, keep doing it!” said Davis-Bruner.

What happens when coaching ends? By then, say Wilkerson and Davis-Bruner, the motivation to make the changes lasting must come from within. “Lasting change must be intrinsically motivated. Highfiving only lasts so long,” said Wilkerson.

She acknowledged the appreciation the patients have for the coaches. But the patients themselves have to be the ones driving the change, she said. “Ultimately, they are the hero of their story—the story that is most meaningful to them. That’s how it has to be if it’s going to be longlasting change. We coach with a model that uses what is most meaningful to that person’s life, and have him or her be the champion of that life.”

Coaches estimate 98% of app enrollees are excited to take the first step in the app program

”The program is effective because of the where and the how”—Waukecha Wilkerson April 2021

From the SET front: Through a patient's eyes

PAD patient walks away from pain

BY BETH BALES

Winter time is never easy in the north. Ice, cold and snow make it tough to walk outside in Lansing, Michigan, during those bitter, dark months. So there is another, somewhat unavoidable obstacle in the way of SVS Supervised Exercise Therapy (SET) app users as they bid to tackle their peripheral arterial disease (PAD) head on.

April 2021

DOUG GILLER JOKES THAT, INSTEAD, he is wearing a path in his carpeting. For 45 minutes each evening, he walks a path throughout his house while watching television, all to keep up with his SVS SET app activities.

The program, he said, “has been wonderful.

I’d recommend it to anybody. And even when this program ends, I’ll continue to walk for the rest of my life.”

He’s always been a man on his feet, working 30 years for General Motors and roller-skating several times a week.

When attending his grandchildren’s sporting events, he’d deliberately park farther away to get a little exercise.

But then, one day, a sharp pain in his calf while walking to a ballfield stopped him cold. When it continued, always in the same leg and always in the same spot, he went to the doctor. His cardiovascular surgeon told him he was a candidate for a stent, and then mentioned a program he’d been following in Europe that involved walking as a treatment for PAD. Giller was interested, but enrollment was full.

He began walking with his son, and the situation improved, “but I still wanted to get into that program!” he said. And when he was admitted, he started on his own, three weeks ahead of time. Misunderstanding the goal of walking five days a week, the self-described type A personality walked seven, instead.

He likes all elements of the program, including the nutritional information and the

daily messages that remind him to “go as hard as you can, but don’t hurt yourself.” One message in particular resonated: “You don’t have to be perfect.”

“That was the best one for me,” he said. “I don’t have to walk the same time every day. That helped me relax a bit.”

He called the leg pain a big wake-up call. “When I couldn’t walk a quartermile without hurting, that was a big signal to me,” he said. “I went from no pain to big pain.”

The prospect of surgery, meanwhile, propels him forward. “If you tell me, ‘if you walk, you don’t have to do surgery,’ I’m going to walk.

I know it’s minor surgery, but I don’t want it if I don’t have to have it. It’s been an incentive to get back in shape.”

He will return to his surgeon in June and hopes to hear good news on a variety of markers. “I’m a resultsdriven person,” he said.

Beyond changing his diet and walking, he also makes sure to incorporate breaks from sitting every 15 to 20 minutes, as the program has suggested.

“It’s changed me,” he said. “Even when this program ends, I’ll continue to walk for the rest of my life. I have such a sense of accomplishment when I’m done. I feel energized.”

vascularspecialistonline.com • 17

NEWS BRIEFS

First patient treated in the BeGraft FEVAR study aimed at providing evidence for on-label use

MEET THE EXPERTS

SVS introduces ‘Meet the Experts’ Webinar Series

BY BETH BALES

The Society for Vascular Surgery (SVS) is introducing a new webinar series, with the first installment set to take place this month.

Benjamin Jackson

THE “MEET THE EXPERTS” Webinar Series will feature expert faculty and attendees interacting in small groups for shared learning and an intimate feel. The four onehour webinars will focus on topics that are relevant and timely to vascular surgeons who are operating in vascular practice.

“We wanted topics that would be of interest to the vast majority of our membership, that would be compelling and useful to them,” said Benjamin Jackson, MD, associate professor of surgery at the Hospital of the University of Pennsylvania in Philadelphia. Jackson is slated to moderate one of the sessions.

The webinars will be from 7 to 8 p.m. Central Daylight Time on April 22, May 20, June 10 and July 15. Attendance will be limited to 100 people. The series is supported in part through an unrestricted educational grant provided by Gore.

They’re modeled after the “Ask the Experts” sessions at the Vascular Annual Meeting (VAM), an event that has proven so popular people have been turned away for lack of space.

“Those are relatively small groups, with significant interaction between the leader and the audience,” explained Jackson. Amidst the pandemic, members of the Education Committee, which is planning the series, thought such education would be useful.

“After all,” said Jackson, “with everything virtual, and communication and contact so significantly curtailed, this interaction is probably more valuable than usual.”

All four webinars will be case-based, with attendees presenting brief cases or clinical scenarios, asking for input from the experts, leading to constructive, productive and interesting conversations, he said. He and Kellie Brown, MD, Education Committee chair, hope the webinars, or sessions similar to them, can be conducted in the future, with different topics, even when the pandemic is over and inperson learning returns.

SVS members and residents and trainees may attend free of charge. Non-members will pay $35 for each webinar.

Continuing Medical Education credit will be available for each webinar and will be awarded after the attendee has completed the individual activity evaluation.

The sessions cover hemodialysis access aneurysms, redo carotid revascularization, advanced techniques for IVC filter removal and type 2 endoleak prevention and management. For more information, visit vascular.org/MeetExperts. * The Society for Vascular Surgery is accredited by the Accreditation Council for Continuing Medical Education (CME) to provide CME for physicians. The Society designates this live activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

18 • Vascular Specialist

The first patient has been included in the BeGraft fenestrated endovascular aneurysm repair (FEVAR) study investigating the Bentley BeGraft peripheral balloon expandable covered stent in complex aortic aneurysms.

THE PATIENT WAS REFERRED FOR FEVAR with a 6cm juxtarenal abdominal aortic aneurysm, explained the coordinating investigator and study lead, Eric Verhoeven, MD, of General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany. “This patient has an absolute indication due to the diameter and we cannot use standard EVAR to seal below the renal arteries because there is no sealing zone available,” he explained.

A further two patients are planned in the next week, added Verhoeven, who announced the launch of the open-label BeGraft FEVAR study.

The study aims to investigate the safety and performance of the BeGraft peripheral stent graft system as a bridging stent in FEVAR for complex aortic aneurysms.

The research, which is approved by the German competent authority BfArM, is being

Physician assistant community launches ‘PA Case of the Month’

BY ANNA VECCHIO

To help broaden its physician assistant (PA) members’ knowledge of vascular care and help them engage and interact with each other virtually, the Society for Vascular Surgery (SVS) PA Section has introduced the “PA Case of the Month.”

THE MONTHLY INITIATIVE WILL PROVIDE PA members an interactive resource to learn about clinical topics and treatments for vascular conditions. PAs can expect to see a variety of topics. Cases planned for the upcoming months include cerebrovascular disease, dialysis access management and lower-extremity vascular disease.

Cases will be posted via SVSConnect and will include a short writeup of a case study, followed

run in collaboration with Bentley and the Foundation for Cardiovascular Research and Education (FCRE).

Participating centers in the study include Nuremberg, Munster, Munich, Regensburg, Aachen, Stuttgart and Giessen, all in Germany. A total of 100 patients will be included to generate data on approximately 250–300 BeGrafts in fenestrations. Recruitment is set to take 12 months, with 24 months follow-up.

The main outcomes will be technical success (successful introduction and deployment), bridging stent patency at 12 months, as well as the absence of procedure-related complications and bridging stent-related endoleaks at 12 months. Overall clinical outcomes—including 30-day mortality, and health-related quality of life—will also be assessed alongside adverse events.—Bryan Kay by a short number of multiple-choice questions, and then in-depth answers. SVSConnect will serve as the main hub of communication and engagement for the cases. Members of the PA community are encouraged to take part in the survey, and share their thoughts and questions through topic threads.

The initiative began last spring, as PA members began searching for ways to add engaging educational resources into their membership community.

Connor Westfall, a PA in the department of general and vascular surgery at Good Samaritan Hospital in Boston, is one of the project leaders.

“Educational value is a big part of joining a society. We want to present interesting clinical cases that will spur critical thinking, and provide a different perspective and approach to patient care,” said Westfall, an SVS PA Section Executive Board member.

He has high hopes that the platform will grow over time through community engagement and word-of-mouth.

The group is optimistic that the launch will encourage more members of the PA community to submit new clinical cases; the platform includes a mechanism for PA Section members to indicate an interest in participating.

The overarching goal of the initiative is to expand PAs’ knowledge in vascular care.

Tracci elected Southern Vascular recorder THE SOUTHERN ASSOCIATION FOR VASCULAR SURGERY (SAVS) HAS ANNOUNCED the election of Margaret (Megan) Tracci, MD, as its next recorder.

Tracci is currently associate professor of vascular and endovascular surgery at UVA Health in Charlottesville, Virginia, and a past president of the Virginia Vascular Society.

The current SAVS president is William A. Marston, MD, who recently took over the chair from the outgoing Gilbert R. Upchurch Jr., MD. Marston is currently chief of the division of vascular surgery at the University of North Carolina at Chapel Hill, North Carolina.—Bryan Kay

April 2021

French study: Cervical artery lesions found to be frequent among vascular Ehlers-Danlos syndrome patients

VENOUS2021

Vetex Medical's ReVene thrombectomy catheter

Vetex Medical announces positive one-year outcomes for ReVene thrombectomy catheter Vetex Medical has announced positive one-year outcomes from a European clinical study of the ReVene thrombectomy catheter. In patients with iliofemoral vein thrombus, the device was found to significantly improve symptoms and quality of life, while reducing leg swelling.

Cervical artery lesions are frequent and mostly asymptomatic in patients with vascular Ehlers-Danlos syndrome, investigators seeking to systematically assess arterial complications in the region found.

“LOCAL DISSECTIONS AND aneurysms are the most frequent type of lesions, but transient ischemic attack or stroke seem rare,” the France-based research team concluded in a paper entitled “Spontaneous cervical artery dissection in vascular Ehlers-Danlos syndrome,” recently published in Stroke.

The researchers, led by Salma Adham, MD, of Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges Pompidou, in Paris set out to

establish the first systematic assessment of cervical artery lesions.

“Vascular Ehlers-Danlos syndrome is a rare inherited connective tissue disorder because of pathogenic variants in the COL3A1 gene,” Adham et al write.

“Arterial complications can affect all anatomic areas and about 25% involve supra-aortic trunks (SATs) but no systematic assessment of cervical artery lesions has been made.”

The researchers carried out a retrospective review of patients with molecularly proven vascular Ehlers-Danlos syndrome at a tertiary referral center during the 2000–2017 study period.

Of 144 patients in the cohort analyzed, 56.9% (n=82) had SAT lesions: 64.6% female and 74.4% index-case patients.

Most lesions were identified in early arterial assessment—48% at first work-up, the investigators found.

“Cumulative incidence of a first identification of a SAT lesion was 41.7% at 40 years old,” the note. “On the complete period of survey, 183 SAT lesions (with 132 dissections and 33 aneurysms) were identified, mainly in internal carotid arteries (56.3%) and vertebral arteries (28.9%), more rarely in patients with COL3A1 null mutations (p=0.008). Transient ischemic attack or stroke were reported in n=16 (19.5%) of the 82 patients with SAT lesions without relation with age, sex, treatment, or hypertension.”—Bryan Kay

SOURCE: DOI.ORG/10.1161/ STROKEAHA.120.032106

RESULTS WERE PRESENTED AT (DVT), the majority of whom had Venous2021, the annual meeting of severe disease. The primary endpoint the American Venous Forum (March was met—100% procedural success 17–20), by principal investigator Stephen and achievement of Grade II lysis in A. Black, MD, a vascular surgeon at the target vessel, with no instances of Guy’s and St. Thomas’ Hospital NHS procedure- or device-related adverse Foundation Trust and Kings College events or complications, including major Hospital, London, England. bleeding, the authors reported.

ReVene uses dual-action The median Villalta score technology designed to dedecreased from 15 at baseline clot peripheral vessels through to two at 12 months (p<0.001). wall-to-wall contact in a single The median Venous Clinical session with or without the use of Severity Score (VCSS) decreased thrombolytics. from nine at baseline to two at “In this study, we saw a very 12 months, demonstrating a low rate of post-thrombotic durable outcome out to one year syndrome at 12 months, with all (p<0.001). The median VEINES patients seeing improvements quality of life (QoL) score in symptoms and quality of Clinical study: increased from 57 at baseline VCSS decreased to 98 at 12 months (p<0.001). life, and no safety concerns,” from nine to two, said Black. “I found the Additionally, the median demonstrating a ReVene device very effective durable outcome thrombectomy time (including at removing clot and very imaging assessments) was only out to one year straightforward to use. These 23 minutes, and as short as outcomes are really very exciting three minutes, Black revealed. and show a great deal of promise in The ReVene device is designed improving outcomes in the management to remove clot with a dual-action of clot in the peripheral vasculature approach: a dynamic cage separates for the benefit of both patients and the clot from vessel walls through wallhealthcare system.” to-wall contact, while the catheter The multicenter, VETEX European simultaneously draws clot into the study of the ReVene thrombectomy device, where it is macerated and catheter enrolled patients with acute transported out of the body.— iliofemoral deep vein thrombosis Bryan Kay and Jocelyn Hudson

nine two

April 2021

vascularspecialistonline.com • 19