Vascular Specialist–May 2021

19 TRAINEES Corner Stitch Laura Marie Drudi introduces a brand new monthly column by and for students, residents and fellows

Vol.17 No.05 MAY 2021

Featured in this issue:

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FROM THE EDITOR AN OPEN LETTER TO EHR BEHEMOTH EPIC

EVAR IN THE OBL OFFICE-BASED AAA PROCEDURES

VASCULAR ACCESS SMARTPATCH DEVICE PILOT

Latest VAM news

Registration to open for VAM 2021

CRITICAL ISSUES AMERICA

Hitting the spot: EVAR for rAAA should be ‘treatment of choice’ in 2021

BY BETH BALES

morbidity from standard open surgical repair.

“It minimizes dissection, cuts blood loss, avoids hypothermia, avoids vessel injury and avoids coagulopathy,” Veith explained.

“It’s so obvious, one wonders why endografts were not used sooner to treat ruptured AAAs. Well, the answer was simple: In the beginning, it took time to procure

REGISTRATION AND HOUSING are set to open in mid-May for the 2021 Vascular Annual Meeting (VAM), which takes place Aug. 18–21 in San Diego.

Educational programming is ready to run across all four days, with exhibits open Thursday and Friday.

The meeting will be subject to safety and health protocols likely to change between now and August.

With the 2020 meeting canceled because of the COVID-19 pandemic, SVS leaders hope all those members not subject to ongoing institutional travel bans will attend.

“We know from talking to our members that they deeply miss the energy, enthusiasm and camaraderie that are part of live meetings,” said SVS Program Committee co-chair Matthew Eagleton, MD. The Program Committee—with Andres Schanzer, MD, as fellow co-chair—oversees the educational programming presented at VAM. “We are looking forward to welcoming everyone to San Diego, talking with friends and colleagues, and enjoying the program we have spent months putting together.”

Continued on page 6

See related VAM storiesSee on page page12 9

If the equipment and requisite skillset are available, and a patient’s anatomy is suitable, endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (rAAAs) “should be the treatment of choice in 2021 and beyond,” vascular titan Frank Veith, MD, argued during the keynote address at the 2021 Critical Issues America (CIA) meeting in Miami last month.

BY BRYAN KAY

aortic endografting conference (April 16–17).

In a talk entitled, “The evolution of EVAR for ruptured AAAs: From black sheep to the treatment of choice,” the man behind the first EVAR performed in the United States back in 1992 said the minimally invasive procedure is “intuitively better,” with the reason to pursue it the high mortality and

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low mortality rate of around 20% “and the many inoperable cases that can be treated successfully with EVAR” show that the procedure is “a better way to treat rAAAs in anatomically suited patients,” Veith, professor of surgery at NYU Grossman School of Medicine and the Cleveland Clinic, told the

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FROM THE EDITOR

An open letter to Epic Systems

action. Sir Ronald Fisher, the father of modern medical statistics, devoted his dying years arguing that cigarettes didn’t cause lung cancer. Rather, he opined, lung cancer patients developed a craving for cigarettes to soothe the irritation in their lungs.

I am concerned about the role physician wellness has played in Epic’s decision-making over the last decade.

Interoperability has been an abject failure of the EHR era. Physicians were promised seamless communication between offices and hospitals. Our patients’ records available everywhere at our fingertips. Four years after my hospital converted to Epic, we still cannot integrate our office notes. While it’s fun to stand at our fax machine

Dear Epic, I AM NOT WRITING TO YOU TODAY AS A customer, but rather on behalf of your users. More specifically, I am representative of the 870 American Medical Association (AMA) physicians who gave their electronic health record (EHR) an average grade of F on a recent survey published in the Mayo Clinic Proceedings.1 I also represent 72% of the 860 vascular surgeons I queried who reported being unsatisfied with their EHR.2 In fact, if you review nearly any recent study of physicians and their relationship to their EHR, you will see that I represent the overwhelming majority. We are not happy, and we would like change.

There are two reasons why I am writing my comments to Epic directly and not to the EHR industry as a whole.

First, it seems we are stuck with each other. Epic is used by nearly every major medical institution. More than half of the U.S. population have their medical records on an Epic system. Epic’s massive market share and the closed nature of its system mean that your programmers essentially set the standard for EHR usability. For better or for worse.

Second, I am concerned about recent comments made

by Epic executives regarding physician burnout. While most EHR companies are happy to stick their heads in the sand or offer useless platitudes toward the blight of physician burnout, I believe you have taken it one step further. Epic’s leadership appears to outright deny the established correlation between the EHR and burnout.

In an interview with Healthcare IT News,3 CEO of Epic Systems, Judith Faulkner, stated: “Here is something I wish the press would do. And that is, the latest studies I’ve seen are showing that there’s not a high correlation between happiness with the EHR and happiness with their job and

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

2 | Vascular Specialist

Statistics can always be used to sell doubt. Outlier studies are frequently deployed to prevent consensus, because consensus demands action

Malachi Sheahan III

the problem of burnout. I think it would really help if the media understands that and helps everyone else know it.”

I honestly don’t know what this statement even means. It seems like Ms. Faulkner is asserting that while doctors may hate Epic, they also hate their jobs, so maybe the two are unrelated?

I have no idea if Ms. Faulkner truly believes her statement, but if Epic’s corporate policy is that the EHR is unrelated to burnout, then we have a problem. The science connecting the EHR to burnout is not only overwhelming, it is also logical. Major triggers to burnout are barriers to doing your job. Doctors want to care for patients.

Unfortunately, that now means we must spend countless hours on the computer, far more than we spent on paper charts. All EHR vendors must immediately look for steps that can be taken to decrease the time physicians devote to using their products to care for patients.

Statistics The easiest way to defend a product’s role in causing harm is to deny the very relationship. Blur the lines. As doctors, we have seen this tactic time and time again. Cigarette maker Philip Morris nearly perfected it. Statistics can always be used to sell doubt. Outlier studies are frequently deployed to prevent consensus because consensus demands

pretending to be Don Draper sending a hot new ad copy to Lucky Strike headquarters, there has to be a better way.

On Sept. 15, 2008, Rep. Pete Stark (D-CA) introduced HR 6898, which could have provided an open-source health IT system for the entire country. Everyone on a single free EHR with third-party app developers able to innovate at will. The EHR industry helped to kill this effort with lobbyists and money. In its place, the HITECH Act passed in 2009, further fracturing our healthcare system. Epic’s CEO was appointed to the U.S. Health IT Policy Committee, which then pushed for rapid implementation of the law. Suddenly, it seemed every hospital and physician’s office needed an electronic health system. As the entire U.S. healthcare system rushed to become compliant, Epic offered something few could. An all-in-one package. Epic’s comprehensive nature was an easy sell to hospital CEOs who were overwhelmed by the new federal regulations. In my opinion, the key to Epic’s massive market share lies in the all-encompassing nature of its software suite and not necessarily in its quality.

Seemingly no company has fought the promise of interoperability more than Epic. In 2013, the CommonWell Health Alliance was formed to ease information exchange continued on page 4

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May 2021

FROM THE EDITOR

An open letter to Epic Systems continued from page 2

between EHRs. This non-profit association consisted of 28 members, but Epic declined to join. Instead, you created an interoperability network for hospitals, but only if all of the hospitals used Epic. In a statement to the U.S. Senate,4 Epic’s director of interoperability, Peter DeVault, defended these actions. He stated that Epic users could link with non-users but admittedly only through a possibly lengthy process where the systems were linked manually by Epic, for an hourly fee and a per-patient surcharge. Due to outside pressure, Epic later suspended the per-patient cost.

A 2014 RAND report5 named Epic a singular roadblock to interoperability.

Privacy In 2019, Epic again came out against interoperability. Your CEO’s letter6 to health system executives asked them to contact Alex Azar, then Health and Human Services (HHS) secretary, and oppose two proposed rulings designed to give patients increased access to their health records.

Privacy concerns were cited as the primary motivation.

Seema Verma, Centers for Medicare & Medicaid Services (CMS) administrator, later responded, “The disingenuous efforts by certain private actors to use privacy, as vital as it is, as a pretext for holding patient data hostage is an embarrassment to the industry.”

While Epic’s stated goal was to protect patient privacy, I suspect your motives were fiscal. Tommy Thompson, former HHS secretary and Wisconsin governor, seems to agree with me. In his editorial defending Epic,7 he wrote, “These rules would unfairly harm Wisconsin’s health IT industry and, along with it, the Wisconsin economy. These rules would compel Epic to give its trade secrets away to venture capitalists, Big Tech, Silicon Valley interests, and overseas competitors for little or no compensation.” It is not a crime to protect your profits; some would say that is the point of being in business. Those of us in the healthcare field, however, have to learn to balance financial priorities with the greater good.

Perhaps Epic has gotten too big. The company is now involved in far more than EHR development. It runs the EpicShare platform, the Boost consulting service, and the data mining research service Cosmos. Epic also offers public health surveillance, benchmarking for healthcare systems, and numerous resources for hospital CEOs and insurance companies. Of course, all of these function with proprietary access to patient data. And the larger and more exclusive that database is, the better. So while Epic has admirably refrained from selling patient data to outside businesses, in reality, it seems you can profit from it all on your own.

I believe no aspect of the EHR contributes more to burnout than the pure amount of time it requires of doctors. A 2019 JAMA study8 found that interns were spending more than 10 hours per day on electronic records. The study gained a lot of attention, and I’m sure it didn’t go unnoticed by Epic. Your software can now track physicians’ time. Surprisingly though, data acquired through Epic tells a dramatically different story. In one recent study,9 Epic reported U.S. physicians were spending about 90 minutes per day on electronic records. A far more 4 | Vascular Specialist

reasonable number, although it comes with a catch. Epic only records physicians’ time interacting with the EHR if they click the mouse or perform a keystroke every 5 seconds. Otherwise, you simply stop the clock. My kids wish the screen time parental controls on their devices were this forgiving.

Epic costs EHR vendors often argue that physician dissatisfaction with their product is really just frustration with U.S. government regulations. So what happens when an EHR is deployed in another country? Denmark has a national health system and high levels of physician satisfaction. A recent Epic rollout in a large region of the country left mixed reviews at best. A poll of their physicians found only 12% were satisfied with the new EHR, while 60% reported deep dissatisfaction.10 Henrik Flyger, MD, a premier breast surgeon, lamented, “You have exported burnout.”

Epic can also be very expensive to initiate. Mayo Clinic and Partners HealthCare spent more than $1 billion each on Epic implementation, according to reports. Kaiser Permanente spent $4 billion. A Peer60 survey11 showed that Epic also had significantly higher down-the-road costs than either Cerner or Allscripts, competitor EHR firms.

Not every hospital can afford these top-level installations, but CEOs are terrified of picking the wrong EHR. A common saying in the industry is that no one is ever fired for choosing Epic. Therefore, many hospitals end up purchasing inferior versions with less support. And their physicians suffer. I’m sure you know that ease of use and level of support can reduce physician stress. But this process is now monetized. So congratulations to those physicians who work at an institution that can afford top-level support and software. Thoughts

A Peer60 survey showed that Epic also had significantly higher down-the-road costs than either Cerner or Allscripts and prayers to the rest of us. In describing your efforts to improve the physician experience, Epic often cites the specialty boards12 that you set up to interact with doctors directly. I spoke with several members of your Vascular Surgery Surgical Steering Board. They all relayed frustration with the process of improving the Epic interface for vascular surgeons. I have provided them anonymity so as not damage their relationship with your company. I began by asking them about compensation for their time. One told me, “We have never been offered reimbursement for our time or ideas.” Another added: “No. You’re basically a free software developer for them.”

When asked about the process of improving the software,

I was told, “Vascular was an afterthought for Epic and it shows in how poorly integrated our workflows are.” “The process is very slow and laborious. [I] could not get them to figure out how to mitigate the click-to-death nature of EMR [electronic medical record].” Another highlighted the hierarchal nature of Epic implementations. “I can see other institutions that have made the investment in bettering the lives of their physicians with the updates, specializations, order sets, templates, etc.... then I see my version and it magnifies everything that it lacks.”

Epic reply In preparing this letter, I wrote to Epic and submitted the above remarks from the Epic Vascular Surgery Steering Board and also asked for Epic’s comment on Judith Faulkner’s assertion denying the association between the EHR and physician burnout. Here is the complete statement I received from Epic’s vice president of clinical informatics, Chris Mast, MD: “We work closely with our customers to develop software that saves physicians time and adapts to their preferred practice styles. Ideas and input from physicians have always been integral to the design process, whether from steering boards of specialists or from developers meeting with physicians. Mobile apps, speechdriven workflows, and a built-in virtual assistant give physicians more control over how they interact with the system and quicker access to information.

“This helps healthcare organizations address key causes of physician burnout, according to independent research. In 2020, for example, a Medscape survey of 12,000+ physicians found that the three most common contributing factors to burnout were too many bureaucratic tasks (58%); spending too many hours at work (37%); and lack of respect from leaders or colleagues (37%). EHRs were sixth on the list.

“The EHR offers benefits that are not possible with paper-based records—like engaging patients through convenient web apps and offering widespread virtual care during the COVID-19 pandemic.

“Regulatory requirements also have a major effect on physician satisfaction.

“Just imagine trying to keep up in today’s regulatory climate without an EHR. Physicians would be buried in paper documentation and expected to search through charts and follow up on illegible or inaccessible information. EHRs allow organizations to automate or streamline many regulatory tasks and adapt quickly when regulations change.”

To be honest, I found this response to be outrageous. Ignoring the dozens of peer-reviewed studies13 that link the EHR to burnout, and presenting this flawed survey as evidence of the opposite is shameful.

I believe the kids call this gaslighting.

You have cherrypicked the Medscape survey from a pandemic year when doctors had quite a bit on their plates. If you check the same survey report from 2019 (and I suspect you did), you would see EHR sitting right at #3, just two percentage points behind “spending too many hours at work.”

Looking back through these annual Medscape surveys, the EHR is perennially in the top three to four reported causes of burnout.

In fact, the authors concluded,14 “Many factors can cause burnout, but by far, having too many administrative tasks as well as working long hours, working with EHRs, lack of respect and insufficient compensation are major players.” And since when is being the sixth-worst thing in medicine good? If I were voted the sixth-worst doctor, my first response wouldn’t be to gloat over Drs. Doom, Strangelove, Octopus, Frankenstein and Lector.

May 2021

Look Epic, I know you're not going anywhere, but neither are we. Put aside the science denial and join us at the table Devaluation Why am I asking you for accountability? Healthcare finances are a zero-sum game. Epic generates billions of dollars from this system. I know you are investing in artificial intelligence and other technologies that may decrease physician workload. But these are just future innovations that will take years to implement into newer versions of Epic.

The reality is we need you to focus effort and financing now to improve the existing interface and levels of support. I feel that you have displayed a consistent pattern of devaluing physicians. Over the past decade, Epic has seemingly resisted true interoperability, monetized support for nurses and doctors, distorted physician EHR time requirements, limited third-party innovations, and denied the science behind the role of EHR in burnout.

The doctors who want to help and serve on your steering boards go uncompensated—another indicator of the worth you place on physicians.

In an interview with Stephen Klasko, MD, the editorin-chief of Healthcare Transformation, your CEO Judith Faulkner said, “We have too many doctors who no longer like their professions.”15 I completely disagree. We don’t hate our jobs. We hate the barriers to doing our jobs. Your corporate motto has been reported16 as “Do good. Have fun. Make money.” While this might not have the same zing as Cobra Kai’s “Strike first. Strike hard. No mercy,” at least it’s honest and to the point. I can’t speak to the

money you’ve made or the fun you’ve had, but I know there is plenty of good left to do.

Look Epic, I know you’re not going anywhere, but neither are we. Put aside the science denial and join us at the table. Not through the steering committees under your control, but via high-level, bilateral negotiations. The EHR usability metrics17 published last year by Christine Sinsky, MD, and colleagues would be an excellent place to start. I sincerely hope you begin to accept the role of the EHR in burnout and work with us. If not, at least I’ve put something in your inbox for once.

Yours truly,

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

References 1. E dward R. Melnick, Liselotte N. Dyrbye, Christine A. Sinsky, Mickey Trockel, Colin P. West, Laurence Nedelec, Michael A. Tutty, Tait Shanafelt. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians.

Mayo Clinic Proceedings, Volume 95 Issue 3, 2020.

2. D .M. Coleman, S.R. Money, A.J. Meltzer, M. Wohlauer, L.M. Drudi, J.A. Freischlag, M.S. Hallbeck, B. Halloran, T.S. Huber, T. Shanafelt, M. Sheahan, Vascular Surgeon Wellness and Burnout: A Report from the SVS Wellness Task Force, Journal of Vascular Surgery, 2020.

Peer-to-peer coaching program created to strengthen wellness support

BY BETH BALES

The Society for Vascular Surgery (SVS) and the Academy for Surgical Coaching are developing a first-of-its-kind coaching program that strengthens wellness support for vascular surgeons. Studies show they—along with physicians across specialties—are experiencing an increase in burnout, anxiety, depression and suicidal ideation.

T

he partnership was announced in April. Coach selection is expected to occur in May or June, with training set for July.

Research conducted by the SVS Wellness Task Force has reinforced and replicated many of the studies’ findings within the specialty of vascular surgery.

With this new program, customized to vascular surgery, SVS aims to address the triggers of burnout and provide wellness support through coaching intervention.

“We are excited about our partnership … and consider it a shining example of how we are listening and responding to our members regarding wellness initiatives,” said Dawn Coleman, MD, co-chair of the SVS Wellness Task Force.

May 2021

“We believe we are one of the first medical societies to take the translational step from studying and discussing the issues to providing service and support for members.”

Initially, SVS hopes to recruit and train a dozen vascular surgeons to become certified surgical coaches, each of whom will be paired with as many as two vascular surgeons seeking support for a three-month period. Over the course of a year, it is hoped each surgical coach will work with up to four SVS members. SVS will expand the program if evaluation demonstrates success.

“Our experience shows surgeons love working with surgical coaches because it changes the way they think about their

3. h ttps://www.healthcareitnews.com/news/epic-ceo-judyfaulkner-apple-docs-who-actually-their-ehrs-and-warren-buffett 4. https://www.help.senate.gov/imo/media/doc/DeVault1.pdf 5. https://www.rand.org/content/dam/rand/pubs/research_ reports/RR300/RR308/RAND_RR308.casestudies.pdf 6. https://www.cnbc.com/2020/01/22/epic-ceo-sends-letterurging-hospitals-to-oppose-hhs-data-sharing-rule.html 7. https://madison.com/wsj/opinion/column/tommy-thompsonhhs-new-health-it-rule-would-hurt-epic-and-wisconsinseconomy/article_bb2a6ff2-2b4b-5148-a774-f763d0b8969f.html 8. C haiyachati K.H., Shea J.A., Asch D.A., et al. Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations.

JAMA Intern Med. 2019;179(6):760–767.

9. H olmgren A.J., Downing N.L., Bates D.W., et al. Assessment of Electronic Health Record Use Between U.S. and Non-U.S. Health Systems. JAMA Intern Med. 2021;181(2):251–259.

10. https://www.politico.com/story/2019/06/06/ epic-denmark-health-1510223 11. https://www.reactiondata.com/wp-content/ uploads/2015/01/Peer60TCO-online.pdf 12. https://www.epic.com/epic/post/specialty-steeringboards-improve-quality-on-a-global-scale 13. G abriela Velazquez, London C. Guidry and Amit Chawla.

Settled science: The indisputable link between EHR and burnout. Vascular Specialist, Vol 17, No. 4, April 2021.

14. https://www.medscape.com/slideshow/2019lifestyle-burnout-depression-6011056#5 15. https://www.liebertpub.com/doi/ full/10.1089/heat.2016.29026.jfa 16. https://www.forbes.com/sites/katiejennings/2021/04/08/ billionaire-judy-faulkner-epic-systems 17. C hristine A Sinsky, Adam Rule, Genna Cohen, Brian G Arndt, Tait D Shanafelt, Christopher D Sharp, Sally L Baxter, Ming Tai-Seale, Sherry Yan, You Chen, Julia Adler-Milstein, Michelle Hribar, Metrics for assessing physician activity using electronic health record log data, Journal of the American Medical Informatics Association, Volume 27, Issue 4, April 2020.

practice,” said Caprice Greenberg, MD, president and co-founder of the Academy for Surgical Coaching.

“The coaching sessions will focus on identifying challenges, setting goals and pushing for continuous improvement. Surgeons can discuss operative performance, leadership skills, clinical judgment or selfregulation. The surgical coach is there to support vascular surgeons to achieve their individualized and self-identified goals.”

As practicing vascular surgeons themselves, the surgical coaches will be well-positioned to help their colleagues manage professional challenges and ultimately increase job satisfaction.

Additionally, peer-to-peer support will help minimize the isolation associated with vascular surgery and destigmatize the culture of “complacent suffering.”

“We want to make sure we address the inherent issues, such as emotional exhaustion and depersonalization, that might be contributing to burnout among vascular surgeons,” said Niten Singh, MD, program co-designer and a task force member. “We will focus on these issues first.”

Funding support was produced in part by a grant from W. L. Gore & Associates, Inc., as part of the SVS Quality Practice Block Grant program.

“We want to make sure we address the inherent issues, such as emotional exhaustion and depersonalization, that might be contributing to burnout among vascular surgeons”— Niten Singh

vascularspecialistonline.com | 5

COVER STORY

Hitting the spot: EVAR for rAAA should be 'treatment of choice' in 2021 continued from page 1

endografts in emergent situations, we had the solution, our own surgeon-made MEGS [Montefiore Endovascular Grafts System] endograft, which could be prepared and kept sterile in our operating rooms to treat emergent situations.”

History Taking the CIA audience on a nearly 20-year historical retrospective, Veith discussed the evolution of EVAR and grafts. “Because this MEGS graft could be sterilized ahead of time, and kept in the operating room for urgent cases, we were able to do the first EVAR for a rAAA anywhere in the world in April 1994.”

The patient in question was inoperable, he pointed out, because of a hostile abdomen and bad heart. “He was in shock and severe pain. His angiogram showed clear evidence of free rupture, and we were able to treat him with our surgeon-made MEGS graft. His aneurysm was successfully excluded, and the patient survived for more than three years, only to die of his comorbidities.”

Through 1994 and 1995, Veith and colleagues treated another 11 patients considered at prohibitive risk for open repair.

“Surprisingly for us in these very sick patients, there were only two deaths, giving us a remarkable 17% operative mortality. These favorable early results in impossibly high-risk patients led us to the hypothesis in 1995 that endografts and other image-guided endo techniques should be employed to treat all rAAAs, even in good-risk patients. From 1994 to 2000, almost no one else in the world agreed with us. They almost all felt that open repair was the best treatment for all ruptured aneurysms.”

Onward to 2005, Veith said his institution and a few others produced results suggesting that EVAR improved outcomes for rAAAs. He noted, however, that other groups had experienced poor results deploying EVAR for rAAAs. “So it’s fair to say that as of 2009, EVAR for rAAAs remained controversial, and there were many who said we need a randomized controlled trial [RCT] comparing EVAR to open repair in this setting.”

Yet, Veith argued, it is the treatment strategies, adjuncts and techniques—outlined, he said, in a 2009 Annals of Surgery paper— that make a difference, “and may account for the better results, which some groups could achieve.”

Randomized trials The controversy persisted at least until 2016, Veith continued, culminating in continued calls for RCTs. Three such trials have been completed: ECAR (Endovasculaire ou chirugie dans les anévrysmes aorto-iliaques rompus) in France, AJAX (Amsterdam acute aneurysm trial) in the Netherlands, and IMPROVE (The immediate management of the patient with ruptured aneurysm: Open versus endovascular repair) in the U.K. “All three trials claimed no difference in 30-day mortality between EVAR and open repair,” said Veith. “However, that conclusion is, in my opinion, flawed, misleading and 6 | Vascular Specialist

just plain wrong. Here is why: The ECAR and AJAX trials excluded high-risk patients in shock and too sick for open repair, and those are precisely the patients most likely to benefit from EVAR.” The larger IMPROVE trial, Veith continued, concluded that a strategy of endovascular repair was not associated with significant reduction in 30-day or one-year mortality.

“Here is why this conclusion is misleading: Even though there was no 30-day mortality significant difference between the EVAR strategy group and the open repair group, one has to see the details to appreciate the flaws in IMPROVE,” he said.

“One key flaw is that of the 316 patients randomized to endovascular strategy, only 154 were actually treated by EVAR—that’s less than half. Their mortality was around 27%. While in the same group, those patients getting an open repair actually had a higher mortality of 38%.”

Veith added, “So, to me, it seems that the IMPROVE trial clearly shows that EVAR is the better treatment for rAAA patients, if it can be done. In addition, the most recent results from IMPROVE confirm EVAR’s superiority, with better long-term survival overall with EVAR and better short- and longterm survival in women.”

RCTs, he concluded, “are not always the infallible holy grail they are thought to be. As with everything else in this world, how you do EVAR for rAAAs matters, including some of the strategies and technical tips I have shown you today.”

NICE guidelines Later in the same session, Bijan Modarai, MB BS, a consultant vascular surgeon at Guy’s and St. Thomas’ NHS Foundation Trust in London, England, presented an update on the controversial NICE (National Institute for Health and Care Excellence) AAA guidelines published in March 2020 that recommended open repair for most patients.

Modarai revisited both the draft and finalized document. While discussing “highly critical feedback” to the initial draft, he pointed out stakeholders had commented that “one cannot provide EVAR for ruptured aneurysm if there is no elective service as the infrastructure would simply not be present.”

Session moderator Mark Farber, MD, chief of the division of vascular surgery at the University of North Carolina, Chapel Hill, probed Veith on the importance

“From 1994 to 2000, almost no one else in the world agreed with us. They almost all felt that open repair was the best treatment for all ruptured aneurysms” of education and access to expertise. “This gets back to the NICE guidelines,” Veith said. “If you’re not doing elective EVAR, you can’t do emergency EVARs. It’s really education all the way.”

Benjamin W. Starnes, MD, University of Washington, Seattle, chief of vascular surgery, added: “When the anesthesiologists finally saw that we could do these awake under local anesthesia, and they saw the outcomes, they were flabbergasted.”

CX rAAA debate Meanwhile, a debate at the recent 2021 Charing Cross Symposium (CX; April 19–22), featured a similar theme,

Frank Veith

focusing on the topic, “Emergency endovascular aneurysm repair is the standard of care for rAAA,” which was proposed by Hans-Henning Eckstein, MD, a professor of vascular and endovascular surgery at the Technical University of Munich, Germany.

“We all know that aortic rupture is a life-threatening condition, so survival is the therapeutic aim number one,” he said. “Since we know from trials that EVAR is safer than open aortic repair in elective rAAA therapy, the question arises whether emergency EVAR is also safer than open aortic repair for rAAAs.” The answer is yes, he said. “It’s more an issue of how to do emergency EVAR than simply inferiority or superiority,” Eckstein added.

“Current guidelines clearly recommend emergency EVAR over open aortic repair in anatomically suitable patients,” he said. “Emergency EVAR has significantly lower mortality and morbidity rates, and therefore emergency EVAR should be considered the new standard of care for rAAA.” Arguing against the motion, R. Clement Darling III, MD, chief in the division of vascular surgery at Albany Medical Center in New York, said: “What happens to those patients with hostile necks or unsuitable necks, or have poor access? Those patients might be better suited for open repair than endovascular repair, and I think that’s one of the limitations we have seen in single series studies.”

The standard of care for rAAAs requires that “you can stop the bleeding in an expeditious fashion, whether it is by clamping the aorta or by aortic occlusion balloons,” he continued.

“And don’t forget that 30% of the mortality for open aneurysms historically has been because of venous injuries trying to get proximal aortic control, so the balloon is truly a game changer. You need to reconstruct the aorta no matter whether you use EVAR or open [repair], and the goal really is to have a live, viable patient for discharge.”

Ruptured AAAs, Darling said, is a “systems problem”— and not merely a procedure solution. “We need a system that has access to both the surgical skills for open and endovascular care for optimal results. It is not EVAR that is the only answer for the best results in rAAA repair.”

A CX audience poll sided with Eckstein by 64% to 36%. “I think that [the poll result] reflects what’s going on in the community—granted, both speakers did a good job in presenting the case,” session moderator Gustavo S. Oderich, MD, professor and chief of vascular and endovascular surgery at the University of Texas Health Science Center at Houston, added.

May 2021

AAA

‘Radiation will be a thing of the past,’ CX 2021 aortic session hears

AAA patients with COVID-19 may need ‘more frequent surveillance’

BY JOCELYN HUDSON AND SUZIE MARSHALL

BY BRYAN KAY

Discussion during the opening day of the Charing Cross (CX) 2021 Digital Edition (April 19–22) emphasized the potential of Philips’ Fiber Optic RealShape (FORS) technology to reduce radiation and ease technical success, with moderator Gustavo Oderich, MD, professor and chief of vascular and endovascular surgery at the University of Texas’ McGovern Medical School in Houston, suggesting that “radiation will be a thing of the past” thanks to this new technology.

OTHER KEY TAKEAWAYS DURING A session on controversies in the abdominal aortic space included a ringing endorsement that endoanchors have a part to play in the treatment of challenging necks, and consensus among the panel that parallel grafts should be used as little as possible in this hostile anatomy.

Marc L. Schermerhorn, MD, chief of vascular and endovascular surgery at Beth Israel Deaconess Medical Center

in Boston, gave a presentation on the “disruptive” technology of FORS, which opened a panel discussion on the topic of radiation. Oderich stated that FORS “addresses a major area of need, which is the ability to look at the anatomy on any view we want without being radiated,” highlighting that the technology offers both an ease of technical success and parallel reduction of radiation. Looking ahead, he posited: “Radiation is going to be a thing of the past.”

A Charing Cross panel discusses controversies in the abdominal aortic space, including the treatment of challenging necks

Endoanchors In a Podium 1st presentation, William Jordan, MD, chief in the division of vascular surgery and endovascular therapy at Emory University School of Medicine in Atlanta, revealed preliminary five-year data from the primary arm of the ANCHOR registry (Aneurysm treatment using the Heli-FX EndoAnchor

“There is significant, successful innovation to ensure short-term sealing and prevent longterm complications”— Colin Bicknell system global registry). This is a multicenter, prospective study designed to capture real-world usage of the HeliFX EndoAnchor system in patients with challenging abdominal aortic aneurysm (AAA) anatomy, particularly those with hostile aortic necks. Jordan concluded that, out to five years, patients with such necks “may have acceptable durability when the EndoAnchor fixation method is used, particularly at the index operation.”

Showcasing the practical use of endoanchors in the challenging neck anatomy, Giovanni Pratesi, MD, a vascular surgeon in Genoa, Italy, presented an edited case, with postoperative computed tomography angiography (CTA) showing complete aneurysm exclusion in a challenging proximal aortic neck.

EVAR in challenging necks A CX debate addressed another pressing issue regarding hostile neck anatomy— that being whether standard endovascular aneurysm repair (EVAR) can be used in most challenging necks. Colin Bicknell, BM MD, a consultant vascular surgeon in London, England, stood for the motion, 8 | Vascular Specialist

while Vascular Society of Great Britain and Ireland (VSGBI) president Michael Jenkins, MBBS, also a consultant vascular surgeon in London, put forward the counterargument.

“There is significant, successful innovation to ensure short-term sealing and prevent long-term complications,” argued Bicknell, who resolved that EVAR is therefore appropriate for “most” patients with AAA who prefer this approach. Jenkins, on the other hand, contended that standard EVAR cannot be used in most challenging necks “because it does not work”. He elaborated: “It is outside IFU [instructions for use], aortic neck dilatation leads to loss of seal, and sac expansion causes positional change and effacement of seal zone.” He added that while adjuncts may help transiently, they are not durable. “What may have been heroic 10 years ago, perhaps maverick five years ago, now is criminal”, Jenkins concluded.

Following the debate, polling revealed that 71% of the CX 2021 audience disagreed with the motion that standard EVAR can be used in most challenging necks.

Parallel grafts Also addressing a challenging neck controversy, Alexander Zimmermann, MD, a vascular surgeon in Zürich, Switzerland, gave a presentation on parallel graft use in the anatomy of a hostile neck, focusing in particular on “disappointing” clinical results thus far.

He concluded that, in the majority of cases, he aims to “stay away” from using such grafts in challenging neck. Ian Loftus, MBChB, a consultant vascular surgeon in London, said that he would only use parallel grafts in “very selective emergency cases” and Roberto Chiesa, MD, a vascular surgeon in Milan, Italy, stated that he uses parallel grafts as infrequently as possible.

May 2021

Patients with known abdominal aortic aneurysms (AAAs) who may have had a COVID-19 infection might need to have more frequent or a different surveillance regimen until a better understanding of the relationship between the virus and potential symptomatic progression or rapid enlargement of aneurysms is achieved.

THOSE WERE AMONG THE CONCLUSIONS drawn by Ronald L. Dalman, MD, SVS president and chief of vascular surgery at Stanford University, California, during a discussion on the pandemic’s possible impact on the prevalence and progression of AAA worldwide at the Charing Cross (CX) 2021 Digital Edition (April 19–22).

Dalman had just presented details pointing to potential

Plans revealed for pilot study on performance of EVAR for AAA in officebased labs

BY BRYAN KAY

Details of a planned pilot study investigating the merits of performing endovascular aneurysm repair (EVAR) on abdominal aortic aneurysms (AAAs) in office-based labs (OBLs) and other free-standing ambulatory facilities emerged during the recent Critical Issues America annual meeting (April 16–17) held in Miami.

PRINCIPAL INVESTIGATOR ENRICO Ascher, MD, professor and chief of vascular surgery at NYU Langone HospitalBrooklyn, New York, and director of the Vascular Institute of New York, spoke of a need to revisit the little-explored prospect during a presentation entitled, “Developing a successful OBL EVAR program: Is it worth it? What does it take?”

Ascher—who disclosed a potential future relationship with medical device maker Endologix in connection with the pilot study—first took attendees on a journey May 2021

biologic links between the virus and AAA, describing “multiple lines of indirect evidence suggesting there may be some impact” across the globe.

His talk was part of the Abdominal Aortic Controversies session.

“Clearly, in experimental modeling, in a number of experiments, we’ve shown that S1 protein promotes experimental aneurysm progression,” he told CX 2021.

“There’s obviously questions regarding the potential impact of a few weeks of disease on a chronic condition such as aortic aneurysm disease that takes months or years to develop, but we also have this phenomenon of long-haul COVID.” Dalman posed some of the resulting conundrums: Does the virus cause aneurysms versus just accelerate aneurysms? What are the implications for screening and surveillance? And what other COVID-19-related vascular conditions become apparent down the line?

Session moderator Gustavo Oderich, MD, professor and chief of vascular and endovascular surgery at the University of Texas’ McGovern Medical School in Houston, raised the point of reduced numbers of patients reporting for AAA screening studies as well as an increase in those presenting with ruptures. Oderich asked whether any changes had been made at Stanford aimed at reversing this trend.

Dalman reported seeing somewhere in the order of a 20% reduction in new patient visits to clinic. In terms of Vascular Quality Initiative (VQI) requirements, he said they had struggled to meet 80% one-year follow-up.

“We are doing our best to try to reach out to patients,

through the development of ambulatory surgical care in the U.S. The OBL concept emerged in the mid-1960s to increase cost-effectiveness and patient comfort, he explained, and the first one opened in Phoenix in 1970. “There are now more than 5,500 centers across the U.S.” Ascher presented a series of studies demonstrating the shape of the shift away from the hospital to the ambulatory setting.

One used Medicare data to show that while the total number of procedures per 100,000 increased little in a five-year period (2006– 2011), the number performed in an office environment experienced a 50-fold increase.

Ascher detailed his own experience of office-based surgical practice after peripheral vascular interventions in the OBL began in earnest in 2008.

“Our group started fairly early and accumulated an experience that showed that arterial and venous procedures could be performed safely in an office setting,” he said.

From 2011–2015 at the Vascular Institute of New York, Ascher and colleagues carried out 6,201 procedures, 5,783 of them venous, 238 arterial, 129 arteriovenous (AV) access, and 51 inferior vena cava (IVC) filters.

He reported no mortalities, “very few complications and excellent patient satisfaction.” Further studies covering venous, arterial and vascular access procedures have produced similar findings, he said.

Ascher outlined some of the advantages of office-based surgery, including improved patient satisfaction, the avoidance of unnecessary hospital admission, decreased overall costs, and independence for vascular

assure them it is safe to visit the hospital, to remind them their vascular health components remain important, but there is only so much you can do. Until a majority of the population is vaccinated, I think that’s going to continue to be a barrier to care.”

Stéphan Haulon, MD, a vascular surgeon at Hôpital Marie Lannelongue, Paris, France, pondered the implications of the unusual complications he witnessed following aortic surgery at the end of the first wave of the pandemic. “What should be the delay between COVID infection and aortic surgery?” he asked.

Dalman reported experiencing similar incidences— "spontaneous arterial thromboses and strokes in young patients, and lower-extremity arterial occlusions in young people with no other risk factors.” He encouraged audience members to adhere to the emerging guidelines applicable to their particular cases.

In particular reference to what might be the true impact of long-haul COVID-19, Dalman referenced a National Institutes of Health (NIH) initiative looking into the consequences in all disease manifestations of the phenomenon.

“The important thing to keep in mind here is that patients, who have known aneurysms who may have had a COVID-19 infection, may need to have more frequent or a different surveillance regimen until we have a better understanding of what the relationship is,” he said.

“But no, at the current time, we have not recognized a relationship between the symptomatic progression or rapid enlargement of aneurysm in COVID-19 infection,” Dalman added.

surgeons. “They may also be lucrative for physicians,” he added.

But there are also some key guardrails, Ascher continued.

“Patient selection, surgeon experience and well-designed safety clinical pathways are crucial,” he said. “Currently, we are reviewing our data with high-risk patients undergoing peripheral arterial procedures in our office.”

So to the key question: What about the performance of EVAR in the OBL? “This is not an original question, and I’m sure many of you have thought about it,” Ascher told attendees.” He referenced two studies, one showing that median length-of-stay for EVAR was only two days, and another indicating that 92% of EVAR patients are not readmitted to the hospital within 30 days.

This raises the pursuit of criteria for EVAR carried out in the office environment that “can identify a sub-group of patients who can do well with 24-hour admission or no admission at all,” he added.

In this vein, Ascher drew attention to two recent studies with contrasting findings. A study carried out by a research group from Buffalo, which was published in the Journal of Vascular Surgery (JVS), “gave a thumbs down” to the idea of EVAR being performed in a free-standing ambulatory facility “because their ability to predict who can benefit from same-day discharge was not great.”

Yet, Ascher pointed out, surgeons from Chang Gung Memorial Hospital at Linkou, Taiwan, performed 168 EVARs in an outpatient facility, mostly under local anesthesia and sedation, reporting zero mortality, 95% same-day discharge, and a 2.4% rate of readmission within 30 days in a paper published in the Journal of Vascular and Interventional Radiology (JVIR).

In the U.S., little data exist to demonstrate that the concept is viable.

Ascher argued the time has now come to explore its potential use.

“As far as I know, Stuart Harlin was the first and only surgeon to have performed EVARs in an office setting,” he said.

“Although he never published the series of six cases, he did inform me they were selected, easy cases, and that they all did well. The reason he stopped doing them was because he moved from Florida to Texas, and no longer runs an office procedure lab.”

The pilot study planned by Ascher and colleagues is set to involve 10–15 patients who will undergo AAA EVAR using the Alto abdominal stent graft system (Endologix) in the surgical group’s current office operating room.

The research team hopes to produce early results from the study sometime next year, Ascher added.

“Patient selection, surgeon experience and well-designed safety clinical pathways are crucial”— Enrico Ascher vascularspecialistonline.com | 9

VASCULAR ACCESS

New wearable device for AV fistula remote monitoring shows promise—but faces commercial challenges

BY BRYAN KAY

A new wearable device designed to remotely monitor arteriovenous (AV) fistula function in dialysis access patients uncovered promising data, leading one set of researchers to conclude the technology offers hope for improved care and lower costs among a challenging patient population.

THE SMARTPATCH MONITORING system—which involves the extraction of real-time data through a series of multimodal sensors from a patch placed over an AV fistula, subsequent cloud-based machine learning and then actionable clinical alerts—is currently undergoing testing in a series of pilot studies aimed at tackling the healthcare burden of kidney failure and vascular access failure.

The first analyzed dataset demonstrated the device “has the ability to measure hemoglobin, volumetric flow, and hemodynamically significant stenosis in AV fistulas,” Richard F. Neville, MD, associate director of the Inova Heart and Vascular Institute in Falls Church, Virginia, recently revealed during the Society for Clinical Vascular Surgery (SCVS) annual meeting.

Neville and colleagues looked at 128 patients at three dialysis centers, with all study participants wearing a SmartPatch device over an AV fistula either in their upper or lower arm.

“In this particular study, we utilized state-of-the-art optical technology with a particular patented array that allows for better data acquisition,” explained Neville, who disclosed that he serves on the Scientific Board of the device’s developer, Alio Medical.

“This took into account position, motion, light, temperature and pulse of the patient. There was no need for patient interaction. This was all done remotely, and the clinical alerts are in real time.”

Parameters The intention of the study was to evaluate the ability of such a device to monitor AV fistula function, degree of stenosis, flow rate and the physiologic parameter of hemoglobin levels as a marker that impacts fluid management.

All participants wore a SmartPatch for a week. Each of the three clinical centers involved focused on one of the three metrics.

The location focused on hemoglobin analysis studied 57 patients, the facility looking at volumetric flow looked at 21, 10 | Vascular Specialist

and the center monitoring percentage stenosis evaluated 71 study participants.

For each metric, Neville said, machine training algorithms were developed using the first 116 data streams from the device sensors. The algorithms were subsequently tested and correlated on the next 157 data streams, correlating with hemoglobin standard measurement, transonic flowmeters and the standard fistulagram, he added.

The resulting data, Neville et al found, showed that hemoglobin was measured with comparative accuracy “and only a standard deviation of 0.41 as compared to hemoglobin measurement using standard techniques.”

A new wearable remote monitoring device known as the SmartPatch (Alio Medical) is currently undergoing pilot testing

metrics that the device might monitor include oxygen saturation, blood pressure, heart rate, and hemoglobin and sodium levels.

Discussion

Co-moderating the SCVS session in which Neville delivered his team’s findings, Jean Bismuth, MD, associate professor of cardiovascular surgery at Houston Methodist, Data Richard F. Neville Houston, queried how The SmartPatch detected placement of the patch might low volumetric impact on the The SmartPatch detected reliability of the data flow—a potential indicator for access collected. low volumetric flow—a failure—with 100% Neville explained potential indicator for sensitivity and 75% that Alio had “spent specificity, Neville a lot of time” on the access failure—with continued during his material involved in 100% sensitivity and presentation. the patch to ensure 75% specificity “Additionally, the it is not injurious to degree of stenosis skin, and that it can was also detected, be used and worn looking at hemodynamically significant for extended periods of time. stenosis of greater than 50%, with Meanwhile, W. Charles Sternbergh, 100% sensitivity and 100% sensitivity as MD, professor and chief of vascular and compared to subsequent fistulagrams, and endovascular surgery at Ochsner Health arteriographic and angiographic imaging.” in New Orleans, co-moderating alongside He commented: “Therefore, we Bismuth, raised the specter of potential concluded in this study that this initial pitfalls toward commercialization of dataset shows us that this remote wearable the device. Among Medicare patients, monitoring system has the ability to Sternbergh said, “evaluation of how their measure hemoglobin, volumetric flow fistula is doing is baked in” to evaluation and hemodynamically significant stenosis and management (E/M) services at dialysis in AV fistulas. We are also hopeful that centers. “Typically, it’s not allowed to have this remote monitoring system will allow prophylactic testing, and it would even be us—and shows promise to allow us—to suggested that that’s fraudulent, as some improve the care and lower the costs freestanding centers that do fistulagrams associated with other healthcare factors every three months no matter what have associated with this patient population.” found out.”

Neville said potential future biologic Sternbergh asked: “How might this

device intersect those issues?” Neville admitted this question got to the heart of the measured approach Alio has taken toward commercialization.

“The technology has evolved rapidly,” he said. “When we first started this project in the animal lab, there was one sensor, a photoacoustic sensor. Now there’s an array of sensors, and that’s why we’re able to generate the variety of information that I showed you.”

But, Neville continued, commercialization remains an important step yet to be thrashed out.

Options There are a number of possibilities, he said.

One option might involve the device being given away for free, with an in-app-based subscription fee then applied for the data, he said.

Another would necessitate approaching dialysis companies with the benefits of keeping dialysis access fistulas functioning and also keeping patients out of the emergency room, Neville stated.

“There were some initial cost savings shown in a dialysis population in the U.K. in the national health system [NHS] there, where just monitoring the hemoglobin accurately allowed [doctors] to adjust erythropoietin—which is a very expensive medication—and possibly decrease it, saving money just on the medications that are used on these folks.”

In the end, Neville added, he sees the device incorporated as a value-added part of care for the AV fistula patient population, as large dialysis companies realize close monitoring of access health and physiologic parameters “may actually save the overall cost of the patient in the long term.”

May 2021

Friday at VAM to feature session on diversity

BY BETH BALES

Racial and ethnically-based disparities exist in healthcare. To highlight these disparities, and what the Society for Vascular Surgery (SVS) is doing to address them, the 2021 Vascular Annual Meeting (VAM) will feature a special session on diversity, equity and inclusion (DEI). It will be held from 10 to 11 a.m. Friday, Aug. 20, and will immediately precede the 2021 Presidential Address from Ronald L. Dalman, MD, at 11 a.m.

DALMAN HAS TAKEN A LEAD ROLE IN PLANNING of Vascular Surgery, which includes a broad range of the session, which will include a talk by SVS member Lee perspectives on the challenges we face in improving Kirksey, MD, of the department of vascular surgery at opportunity and health outcomes for all. the Cleveland Clinic, plus the presentation of five DEI“Hopefully, the session and the supplement will spur related abstracts. Kirksey will provide his perspective as a a lot of discussion about what each of us can do to Black vascular surgeon member of the SVS. level the playing field DEI issues have influenced nearly every aspect of SVS for everybody,” said activities this year, said Dalman.

Dalman.

However, the challenges they present are not new.

Awareness of the social determinants of health has been building for years. “As the saying goes, ‘Your ZIP code is more likely to impact your health than your genetic code,’” he said.

“As the saying goes, The abstracts will highlight aspects of ‘your ZIP code healthcare disparities and will complement is more likely to what members have already learned in the past year in terms of understanding the impact your scope of the problem. “The flip side is ‘What health than your are we doing about it?’ Kirksey will address that question as well, including relating what genetic code’”— we have done in the past year,” said Dalman. Ronald L. Dalman The SVS DEI Committee has worked hard over the past several months to recommend concrete changes, he said, adding, “Our future depends on getting this right.”

The special session will complement the publication in August of the special DEI supplement to the Journal

In the room: Changes aplenty as VAM returns

BY BETH BALES

Register today

The Vascular Annual Meeting (VAM) is more anticipated than ever after the annus horribilis of 2020 and the pared-back, digital VAM alternative that was SVS ONLINE. WHILE ORGANIZERS HAVE previously relayed the changes made for this year’s meeting, Program Committee co-chair Matthew Eagleton, MD, took the opportunity to once again emphasize the significant changes to its structure for 2021, with educational programming presented across all four days— Wednesday through Saturday.

Between the large number of quality sessions available and attendee feedback decrying the overlap of such sessions, VAM organizers decided the best way to limit competing sessions was to substantially revamp the schedule.

“Wednesday is the new Thursday,” has become a recurring refrain in reference to VAM 2021.

“I hope you get tired of hearing that— because it’s important that people know that we have significant sessions scheduled from opening Wednesday to closing on Saturday,” said Eagleton.

12 | Vascular Specialist

Sessions formerly held on Thursday, but moved to Wednesday beginning this year include: n The Opening Ceremony, at 7:30 a.m. n The William J. von Liebig Forum (the first plenary) n The E. Stanley Crawford Critical Issues Forum (on multispecialty collaboration) Other sessions on Wednesday include two concurrent sessions: two “Ask the Expert” presentations; International Forum and International Fast Talk; a special 90-minute presentation on COVID-19, including abstracts; and a collaborative session with the American Venous Forum (AVF).

With the exception of breakfast sessions, mornings are presented conflict-free.

Afternoons have no more than three overlapping sessions.

Other changes include scheduling the three postgraduate courses over three days, instead of holding them all on Wednesday.

And, the Vascular Research Initiatives Conference (VRIC) will be held at VAM this year in a pair of two-hour sessions on Thursday and Friday afternoon.

VRIC registration is included with VAM registration; however, those interested in attending only VRIC may do so by paying the VRIC registration fee. The Society for Vascular Nursing and the Society for Vascular Ultrasound are both holding their annual meetings in conjunction with VAM.

This year, attendees have the additional option of viewing VAM remotely in streaming sessions (17 live sessions, with 15 total Continuing Medical Education credits available) as well as attending live. Both options include viewing the content on an On-Demand basis at no additional charge. Pricing is different for both options.

The meeting will feature a number of special events for which separate tickets—and, in some cases, additional fees—are required. All are listed on the registration form. Those requiring separate fees include the Vascular Quality Initiative Annual Meeting, the SVS/ Society of Thoracic Surgeons Aortic Summit, the Women’s Leadership Dinner, and the RPVI Exam Review Course.

See safety protocols at vascular.org/VAMProtocols.

To register, visit vascular.org/ VAM.

May 2021

YOUR SVS

PAD

#SVSTweetChat: Connecting to the online vascular community

Ahmed Kayssi, MD, Leigh Ann O’Banion, MD, and Allan Conway, MD, shared tips for success for new vascular surgeons, pitfalls to avoid in the first years of practice, how to manage a work-life balance, as well as some financial advice.

Participants tagged colleagues and friends in the discussion, which led to increased retweets, shares and notable mentions.

The April Tweet chat received more than 16,000 impressions—the number of times a user saw #SVSTweetChat in their timeline or search results, and 840 detail expands as users expanded #SVSTweetChat threads.

continue to garner a substantial amount of attention and engagement on social media,” said Logan. The next Tweet chat will kick off at 8 p.m. Central Daylight Time Thursday, May 20, with a new set of panelists to discuss “Radial Access for the Vascular Surgeon.”

With a growing community of technologically engaged vascular professionals, the possibilities for sharing interesting and timely content on social media are constantly evolving. Continue to follow the #SVSTweetChat conversation on Twitter and follow @ VascularSVS.

BY ANNA VECCHIO

SVS Twitter numbers: @VascularSVS has 8,000+ followers, up 500 since the start of 2021

With social media having such a prevalent presence today, it continues to play a significant role in connecting surgeons, prospective trainees and medical students throughout the vascular community.

THE SOCIETY FOR VASCULAR SURGERY (SVS) Social Media Committee has launched its newest initiative to keep members connected, the new monthly #SVSTweetChat series. Each month, expert panelists will share career advice, hot topics of debate, and innovations in the vascular field with the Twitter community.

Twitter continues to be a leading platform in the committee’s social media outreach efforts. The @ VascularSVS Twitter account hosts more than 8,000 followers and will be the forum for the series. Since January 2021, this account has gained more than 500 new followers and has generated more than 430,000 impressions.

“The benefit of Twitter is that users can navigate in and out of the discussion at any time. Since the hashtag will be embedded on Twitter, users can access the thread during and after the chat,” said Meryl Logan, MD, chair of the Social Media Committee.

The first #SVSTweetChat debuted April 15, with a discussion of "Early Career Advice.” Brigitte Smith, MD,

Tweet chats—each with its own topic—will take place on the third Thursday of each month. To participate, log in to Twitter at the time of the chat, search #SVSTweetChat in the upper right-hand search bar and look for the latest thread of tweets. To respond and engage with the chat, include the hashtag, #SVSTweetChat, in each response. “We have received great feedback from the panelists and participants so far. We are hopeful that the #SVSTweetChat series will

VAM: SVS PAC donors to be recognized at VAM

BY VIVIENNE HALPERN, MD

The SVS Political Action Committee (PAC) is critically important for our voices to be heard in the places where policies that affect all of our practices are being made. The PAC’s role is one of advocacy and influence—to educate Congress on the important policies and referendums that can have a direct effect on our patients and our practices.

THE PAC IS WORKING DILIGENTLY to move our voice forward by attending virtual Town Halls and stressing the importance of vascular surgery in the care of our patients.

PAC members attended a virtual event with U.S. Reps. Larry Bucshon MD (R-IN) and Lizzie Fletcher (D-TX), both members of the House Committee on Energy and Commerce and the

14 | Vascular Specialist

subcommittee on Health.

The subcommittee oversees many aspects of policy that affect our lives, including public (Medicare, Medicaid) and private health insurance; medical malpractice and medical malpractice insurance; public health and quarantine; hospital construction; biomedical research and development; health information technology; privacy; the

Department of Health and Human Services; the National Institutes of Health; the Centers for Disease Control; and the Indian Health Service. The committee also oversees other aspects of health policy.

The SVS PAC works to promote vascular surgeons and ensure that SVS members have access to U.S. representatives and senators in order to discuss issues that have a major impact on members and their practices.

As we all look forward to the Vascular Annual Meeting (VAM) this August, we want to remind you to donate before May 31 to be recognized at the

All members who donate between April 1, 2020, and May 31, 2021, will be recognized at VAM on signs

conference. All members who will have donated between April 1, 2020, and May 31, 2021, will be recognized at VAM on signs.

The regional society with the highest percentage of members who donate during that timeframe will be recognized at VAM at the Annual Business Meeting, and its name added to the SVS Regional Society plaque.

Office practices whose members all give during that timeframe will be recognized at the meeting.

We really do need to get our voices heard and understood.

Please donate to the PAC and be recognized for being a part of the force to improve our ability to care for our patients in the most effective and efficient way—one we all know that we can do with the proper practice environment.

VIVIENNE HALPERN is a member of the PAC Steering Committee.

May 2021

Intermittent claudication and exercise therapy: A poor SET-up

BY NEELIMA KATRAGUNTA, MD, AND KEVIN MARTIN, MD

M

any of you may have already heard about the controversial Comparative Billing Reports (CBRs) that have been received by some of our vascular surgery colleagues. In case you haven’t, this is your chance to catch up and to prepare for a possible insurance denial that may occur in the setting of a clinically-indicated intervention for debilitating claudication after a trial of exercise therapy and for critical limb ischemia (CLI).

The Centers for Medicare and Medicaid Services (CMS) sends a CBR document comparing procedures by a physician with those of others in the country. A flurry of CBRs has surprised some SVS members and seem to suggest that these physicians were not using any exercise therapy prior to performing interventions on patients with intermittent claudication.

The CBRs might seem reasonable if valid; however, the evaluation process was flawed. CMS hired an independent company to look at all the patients who had a peripheral vascular intervention with an ICD-10 code for intermittent claudication (IC) and whether there was a CPT code for Supervised Exercise Therapy (SET) within three months preceding the intervention. It did not matter if there was also an ICD-10 code for rest pain or tissue loss, or if the patients had received an adequate trial of exercise therapy but it hadn’t been billed as SET. The company employees did not take into consideration clinical settings in which exercise therapy would not be indicated, such as a failing bypass or stent with claudication.

Despite all of this, this group found very few physicians who were outliers

with the raw data. The company added criteria, and finally sent the billing reports to those above the 90th percentile or below the 10th percentile (per the CBR letters).

While the consulting company did have some consulting physician input, those doing the review did not seek the opinions or guidance from vascular surgeons in the development of this document, known as CBR202004. The timeframe was Dec. 1, 2018, to Nov. 30, 2019, and all the CBR202004 letters have been delivered.

In addition to CBRs, some private insurance companies have denied coverage for interventions for IC. Again, the basis of such denials seemed to be whether SET was billed, rather than whether exercise therapy was tried. These companies have instituted new policies that were not widely announced but posted to their websites and caught many off guard.1,2 SET is not required by CMS before a peripheral vascular intervention (PVI) for regular Medicare patients. However, patients enrolled in Medicare Advantage programs may be required to have SET or structured exercise therapy along with prior authorization for some IC interventions.

SET, as defined by CPT code 93668, is 45 to 60 minutes of rehabilitative physical exercise on a motorized treadmill or track supervised by an exercise physiologist or nurse. This can only be done in a hospital or a physician office setting and requires a supervising physician or physician extender trained in ACLS.3,4 This CPT code was not developed until 2017 and widespread payment was not available until 2018.

It is still not well-compensated, which is probably a reason why this service is

IC study: Interventions associated with poor two-year relief

BY BRYAN KAY

Peripheral vascular interventions for intermittent claudication (IC) were linked to poor two-year relief of symptoms in the Vascular Quality Initiative (VQI) database, a new study published in the May issue of the Journal of Vascular Surgery (JVS) found.

FIRST-NAMED AUTHOR JONATHAN BATH, MD, assistant professor of surgery in the division of vascular surgery at the University of Missouri in Columbia, Missouri, and colleagues analyzed the real-world practice patterns and outcomes of endovascular procedures to May 2021

neither widely known nor easily available.

In addition, there are numerous patient factors and logistical issues that prevent such a service from being used even if it were available. SET is not routinely ordered by physicians and thus not billed by them. Most such programs are run by cardiac rehabilitation centers.

In response, the SVS Coding Committee and others have sent letters to CMS about this CBR, pointing out how such an assessment could have been done in a more accurate manner if the specialty societies involved would have been consulted before the data were extracted. SVS strongly recommends exercise therapy for IC before interventions.5 SVS is involved in developing an app-based SET program that could overcome many logistical issues and make it easier for patients to use it.

There are a few steps that can be taken to avoid issues with reimbursement for IC interventions. Remember to use only the most specific ICD-10 code for vascular

The company employees did not take into consideration clinical settings in which exercise therapy would not be indicated, such as a failing bypass or stent with claudication disease for billing procedures. Do not use a generic claudication code if more advanced vascular disease is present (I70.22 family for rest pain, I70.23 family for ulceration, I70.26 family for gangrene), or if there is a failing bypass (T82.856A) or stent (T82.599A).6 Document clearly if a patient is simply not a candidate for exercise therapy due to other comorbidities. This may also be a good time to look into partnership with cardiac rehab programs in your area to see if they can offer SET for vascular patients with intermittent claudication by incorporating protocols

such as Gardner Skinner protocol.6 The attention of CMS to unwarranted peripheral interventions is both important and timely but the process by which the agency has sought to determine this is deeply flawed. Current practices and SVS guidelines for exercise therapy, including SET, are well-established. Physicians should be able to determine the most effective options for management of peripheral vascular disease in accordance with current guidelines and after careful consideration of individual patient factors.

References 1. https://www.anthem.com/dam/medpolicies/ abcbs/active/guidelines/gl_pw_c183076.html 2. https://www.uhcprovider.com/ content/dam/provider/docs/public/ policies/comm-medical-drug/lowerextremity-vascular-angiography.pdf 3. https://www.cms.gov/Outreachand-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/ Downloads/MM10295.pdf 4. https://www.cms.gov/medicare-coveragedatabase/details/nca-decision-memoaspx?N CAId=287&CoverageSelection=National&K eyWord=supervised+exercise+therapy&Ke yWordLookUp=Title&KeyWordSearchType= And&bc=gAAAACAACAAAAA%3D%3D& 5. C onte MS, Pomposelli FB, Clair DG, Geraghty PJ, McKinsey JF, Mills JL, Moneta GL, Murad MH, Powell RJ, Reed AB, Schanzer A, Sidawy AN. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication. J Vasc Surg. Volume 61, issue 3, supplement, 2s-41s.e1, March 01, 2015 6. T reat-Jacobson D, McDermott MM, Beckman JA, Burt MA, Creage MA, Ehrman JK, Gardner AW, Mays RJ, Regensteiner JG, Salisbury DL, Schorr EN, Walsh ME. Implementation of Supervised Exercise Therapy for Patients with Symptomatic Peripheral Artery Disease: A Science Advisory from the American Heart Association.

Circulation. Volume 140, Issue 13, 24 September 2019; Pages e700-e710 https:// doi.org/10.1161/CIR.0000000000000727

NEELIMA KATRAGUNTA and KEVIN MARTIN are members of the SVS Coding Committee.

treat IC in the VQI to determine whether The authors reported that adjusted analyses they met the Society of Vascular Surgery revealed that treatment of more than two (SVS) guidelines, which recommend that arteries was associated with a shorter time any treatment offered provide “reasonable to recurrence (hazard ratio [HR], 1.19; 95% likelihood of sustained benefit”—more than confidence interval [CI], 1.09–1.31) and a 50% likelihood of clinical efficacy for two or shorter time to repeat procedures (HR, 1.25; more years.

95% CI, 1.09–1.45). The use of atherectomy The VQI was accessed for patients treated was also associated with a shorter time to for IC between 2004 and 2017 for whom recurrence (HR, 1.29; 95% CI, 1.08–1.33) and “Most patients who had there was complete data and more than a shorter time to repeat procedures (HR, nine months of follow-up. The primary 1.31; 95% CI, 1.13–1.52). Discharge with undergone intervention for outcome measures were condition antiplatelet and statin medications was IC had not been medically recurrence and repeat procedures associated with a longer time to recurrence optimized before the performed within two years of the (HR, 0.84; 95% CI, 0.78–0.91). intervention” — initial treatment, the research team The researchers concluded that “most Jonathan Bath et al reported. patients who had undergone intervention for A total of 16,152 patients met the IC had not been medically optimized before inclusion criteria, with a mean age of the intervention, with high rates of smoking 66 years—61% were men, 45% were current and poor use of antiplatelet agents and statins.” smokers, and 28% had been discharged without antiplatelet or statin medication.

SOURCE: DOI.ORG/10.1016/J.JVS.2020.10.067 vascularspecialistonline.com | 15

VASCULAR PRACTICE

CONGRESS

SVS advocacy efforts help spark landmark change in research effort requirements

Surgeons react to reintroduction of bill aiming to increase access to PAD screening

surgeons are pursuing researchintensive careers. Regardless of the level of specialized skills and clinical commitment, all surgical specialties have been impacted with a progressive decline in the number of surgeon-scientists applying for K awards. While the RFI was issued

BY EDITH TZENG, MD by the NCI, we indicated that all Edith Tzeng NIH institutes should consider The recent decision from the National Heart, Lung, and Blood Institute (NHLBI) to reduce reducing the effort requirement for K awards and this should apply to all surgeons. the dedicated research effort from 75 to 50% for K awards is a landmark change and will In response to an overwhelming response to the Request have a tremendous impact on vascular surgeons. for Information, the NCI announced that it will allow THE DECISION AFFECTS THE JUNE 2021 investments in the form of independent national funding. the reduction in research effort for surgeon-scientists submission date and applies to vascular, cardiothoracic and Despite the great success of this program, there were applying for K08 awards to 50%. On March 22, the NHLBI trauma surgeons, as well as interventional. years where only a single K08 or K23 application was announced that, as of the June 2021 submission date, The change is a result both of advocacy from the Society submitted to the NIH. This problem is not unique to the vascular, cardiothoracic and trauma surgeons, as well as for Vascular Surgery (SVS), among other entities, and the vascular surgery community, with similarly low numbers interventional cardiologists, will also be able to reduce resulting responsiveness from the National Institutes of of K08/K23 applications by other surgical specialties. research effort to 50% for K08 and K23 applications. This Health to the surgical community and the National Cancer In response to these concerns, the National Cancer is a landmark change and highlights the responsiveness of Institute, which had sought out information from the Institute (NCI) issued a Request for Information (RFI, the NIH to the needs of the surgical community. surgical community.

NOT-CA-21-027) in January 2021 to Unfortunately, this change does The National Institutes of Health (NIH) has a long invite comments and suggestions not appear to be NIH-wide, with tradition of supporting early-career physician researchers in regard to the surgeonother institutes with high levels through the K08 and K23 Mentored Clinical Scientist scientist effort requirement of surgical investigators, such Development Award mechanisms that fund protected for K08 awards. The SVS as National Institute of General time for intensive, mentored research. This pathway to responded that these awards Medical Studies (NIGMS), not independence has been adopted by clinician-scientists, are a missed opportunity in the yet adopting the reduced effort reduction in but surgeon-scientists are reluctant to take advantage of career development of vascular requirement. The National Institute of research effort these awards because of the requirement for a significant surgeon-scientists due to the 75% effort Diabetes and Digestive and Kidney Diseases requirement 75% dedicated research effort and a level of compensation requirement. It has been roundly agreed (NIDDK) allows only urologic surgeons to request that is not commensurate with the level of training and within the surgical community that 50% 50% effort. We hope that the reduction in effort specialization of surgeon-scientists. effort is sufficient time commitment for active requirement for some surgeon-scientists at NCI and Surgical specialists, such as vascular surgeons, have surgeon-scientists to succeed in research and for career NHLBI will be adopted by all NIH institutes and will significant clinical demands and highly developed technical development. In the SVS response, we highlighted that broadly apply to all surgical specialties. skills that make this level of time commitment unrealistic. the 75% effort requirement was a deterrent for young This reduction in K award effort requirements by The limited salary support offered by K08 and K23 awards surgeons to pursue research-intensive careers because they NHLBI will have a tremendous impact on vascular for 75% of dedicated effort results in a financial burden on do not want to sacrifice that much of their clinical time, surgeons. It is now the time to act and for departments of the surgical departments and divisions supporting these with patient care the driving motivation behind both their surgery and divisions of vascular surgery to support our early-career faculty. Thus, many institutions are often career path and desire to conduct research. early-career faculty by encouraging them to apply for these not able or are unwilling to support that level of effort, This effort requirement reduces clinical productivity awards. We strongly voiced that this change would be especially in the current state of medical economics. and results in lower financial compensation for surgeonpivotal in the training of vascular surgeon-scientists—now The SVS has been a longstanding advocate for scientists compared to their peers. As a result, fewer we must show the NIH that it is. Finally, we must continue developing vascular surgeon-scientists. To offset the to advocate for uniform application of reduced effort financial burden of supporting young vascular surgeonrequirements at all institutes and for all surgeon-scientists.

We hope that the reduction in effort scientists, the SVS Foundation in 1999 created a supplemental award that provides additional funds to select requirement for some surgeonK08 and K23 awardees to offset research costs. These SVS EDITH TZENG is professor of surgery at the scientists at NCI and NHLBI will Foundation awards, in part co-sponsored by the American University of Pittsburgh Medical Center and be adopted by all NIH institutes College of Surgeons, have supported 39 vascular surgeonchief of vascular surgery for the VA Pittsburgh Healthcare scientists to date and yielded a nearly eight-fold return on System. She is chair of the SVS Research Council.

75%

VenoValve: Chronic venous insufficiency device gains brisk double of first US patent, IDE approval

BY BRYAN KAY AND JOCELYN HUDSON

Hancock Jaffe Laboratories recently revealed that the United States Patent and Trademark Office (USPTO) issued the first patent covering the company’s VenoValve.

The patent is entitled Implantable Vein Frame and is U.S. patent number 10,959,841.

16 | Vascular Specialist

>

50%

THE COMPANY RECENTLY announced that only 28 days after filing, the Food and Drug Administration (FDA) approved the company’s Investigational Device Exemption (IDE) application to begin the U.S. pivotal trial for the VenoValve. Known as the SAVVE study, the trial is a prospective, nonblinded, single-arm, multicenter study of 75 chronic venous insufficiency (CVI) patients to be enrolled at up to 20 U.S. centers.

“We will continue to work with agencies like the FDA and USPTO, and other regulatory authorities throughout the world towards our ultimate goal of reaching the millions

BY BRYAN KAY

The recent reintroduction of the bipartisan Amputation Reduction and Compassion (ARC) Act—aimed at improving peripheral arterial disease (PAD) education, increasing access to PAD screening, and preventing avoidable lower limb amputations—drew a mixed response from within the vascular surgeon community.

THE MOVE GAINED THE SUPPORT of the CardioVascular Coalition, a collection of physicians, care providers, advocates and manufacturers that says it is dedicated to “community-based solutions designed to improve awareness and prevention of PAD, reduce geographic disparities in access to care, and secure

patient access to high-quality, cost-effective interventional treatment across America.”

But some in the vascular community found fault in the bill.

“I (nor USPTF [United States Preventive Services Task Force]) am not aware of any evidence that screening for PAD reduces costs, anxiety, or amputations in any population,” wrote Westley Ohman, MD, assistant professor of vascular surgery at Washington University School of Medicine in St. Louis, in a Twitter exchange that followed a call for surgeons to encourage their lawmakers to co-sponsor the ARC Act. “There is ample evidence that overtreating ‘low grade’ PAD leads to CLTI and, thus, amputation.”

“Amputation reduction is a noble goal, and PAD education is a must. However, this bill (as written) does not accomplish that,” he added.

Joshua Balderman, MD, a vascular surgeon in Tucson, Arizona, voiced strong disagreement to the call’s sentiment.

“Keep clinical judgement in the hands of clinicians,” he wrote. “There’s a reason device companies are behind this bill, and it’s not out of the goodness of their own hearts.”

Guillermo Escobar, MD, associate professor of surgery in the division of vascular surgery and endovascular therapy at Emory University School of Medicine in Atlanta, described how near the bill comes to tackling the problem.

“It’s unfortunate—it almost gets to

where we would agree (fund screening), then veers away (don’t pay unless imaging is not done prior to amputation),” he wrote.

Bryan T. Fisher, MD, chief of vascular surgery and limb salvage expert at Tristar Centennial Medical Center in Nashville, related how he had contributed to the bill, and though it had been some time since he had read through it, he was concerned some were reacting without having looked over its current contents.

“My biggest issue is it tries to mandate clinical decision-making, reducing physician autonomy. Never a good thing,” responded Reid Ravin, MD, assistant professor of vascular surgery at Mount Sinai in New York. “It also

“Amputation reduction is a noble goal, and PAD education is a must.

However, this bill (as written) does not accomplish that” Westley Ohman

advocates reimbursing screening that may or may not be beneficial.

Nontargeted screening can be harmful, leading to overtreatment.”

The Society for Vascular Surgery (SVS) is engaged, Margaret (Megan) Tracci, MD, associate professor of vascular and endovascular surgery at UVA Health in Charlottesville, Virginia, noted. She described how a working group led by Lee Kirksey, MD, vice chair in the department of vascular surgery at the Cleveland Clinic, and Sean Lyden, MD, chair of the same department.

Together, they have been “working through both positives (raising awareness of PAD and amputation prevention) and concerns (specific provisions such as amputation coverage),” Tracci explained.

of patients suffering from CVI”, said Hancock Jaffe CEO, Robert Berman. “We believe that the VenoValve will set a new standard of care for CVI patients and will establish Hancock Jaffe as a leading provider of innovative medical devices for peripheral vascular disease”.

Leading hospitals and top vascular surgeons throughout the U.S. have expressed interest in participating in the SAVVE study. The company has begun the process of fulfilling conditions for study initiation outlined by the FDA and seeking Institutional Review Board (IRB) and other necessary approvals from potential SAVVE sites. The company expects to begin patient enrollment in the third quarter of 2021 and will provide periodic updates.

May 2021

May 2021

vascularspecialistonline.com | 17

NEWS BRIEFS

Voting on bylaws, vice president begins May 17

BY BETH BALES

Voting runs from May 17 to 24 on proposed bylaws amendments and for the position of vice president of the Society for Vascular Surgery.

IMMEDIATELY PRECEDING THE OPENING OF voting, SVS leaders will host a Town Hall from 6 to 8 p.m. Central Daylight Time, “Leading the Way in 2021: An Evening with the Appointments and Nominating Committees.” President Ronald L. Dalman, MD, will facilitate the Town Hall.

President-elect Ali AbuRahma, Appointments Committee chair (pictured above), will present an overview of the 2021 committee appointments “by the numbers” and outline the dramatic changes that have been made to this process in the Society’s efforts to increase member engagement and diversity, equity and inclusion.

Nominating Committee chair R. Clement Darling III, MD, will announce and introduce the 2021 candidates for vice president and moderate a question-and-answer session with the candidates.

That position is the sole one up for election this year.

Voting will run through 5 p.m. CDT May 24.

The new vice president will be announced at the Special Virtual Annual Business Meeting No. 1, beginning at 6 p.m. CDT on Monday, June 16. Attendees also will witness the transition of leadership from Dalman to AbuRahma as SVS president and see the entire SVS Officer and Strategic Board lineup. Members also will receive updates from officers.

The SVS Executive Board and Strategic Board of Directors proposed the bylaws changes. Visit vascular.org/ BylawsInfo2021 to view the proposed revisions, along with the rationales for the changes.

The traditional in-person passing of the gavel will occur during the Special Virtual Annual Business Meeting No. 2, taking place Saturday, Aug. 21, at the 2021 Vascular Annual Meeting in San Diego.

Registration is required for both business meetings; there is no charge to attend.

Attending and participating in the Annual Business Meeting is an essential civic responsibility of Active and Senior Members of the SVS. As noted elsewhere in this issue of Vascular Specialist, only Active and Senior members in good standing are permitted to vote.

Those members in arrears for their 2021 dues may not vote until their dues balance is up to date. To pay dues, visit vsweb.org/SVSDues.

In Memoriam Peter McDonnell, MD, 65, Oak Park, Illinois, died March 20, of injuries he received in a bicycle-car accident March 9.

Calvin E. Jones Jr., MD, 82, retired surgeon and faculty member at the Johns Hopkins School of Medicine, died April 16, after suffering a fall.

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COMMENTARY

PAD: Endologix acquires PQ Bypass

Apply for VAM travel scholarships by May 19 Medical students and general surgery residents have until May 19 to apply for Society for Vascular Surgery Vascular Annual Meeting travel scholarships.

THE SCHOLARSHIPS ARE THE SVS General Surgery Resident/Medical Student VAM Travel Scholarship and the SVS Diversity Medical Student VAM Travel Scholarship. Each provides not only a travel award to underwrite expenses to attend VAM, but also complimentary meeting registration, a mentorship program, and a dedicated educational and networking program.

Diversity scholarship winners also will participate in the Meet the Leaders Luncheon with members of the SVS Leadership Development and Resident and Student Outreach committees and mentors.

Students who live in the San Diego area will not receive the travel award portion of the scholarship. Students and residents may apply to each scholarship program but are eligible to receive only one award per year.

Priority will be given to those who have not previously received any type of SVS travel scholarship, are not presenting an abstract/poster at the meeting, and have not already matched into a vascular surgery training program. Scholarship notifications will occur in mid-June.—Beth Bales

Detour system for percutaneous bypass

Honor mentor with gift to SVS Foundation

More information is available at vascular. org/VAMTravel1 and vascular.org/ VAMTravelDiversity.

Register for ‘Meet the Experts’ webinars Register today for the remaining Society for Vascular Surgery (SVS) "Meet the Experts" webinars, including "Redo Carotoid Revascularization,” to be held May 20.

These webinars are free for SVS members and residents/trainees. Nonmembers will pay $35 for each webinar.

They are limited to 100 participants to permit an intimate feel and provide for faculty-audience conversations. Topics are: • May 20: Redo Carotid Revascularization • June 10: Advanced Techniques for IVC Filter Removal • July 15: Type 2 Endoleak Prevention and Management Continuing Medical Education (CME) credit will be available for each webinar and will be awarded after completing the individual activity evaluations. Learn more and register at vascular.org/ MeetExperts.—Beth Bales

ENDOLOGIX RECENTLY announced completing the acquisition of PQ Bypass, a medical technology company pioneering a first-of-itskind technology that addresses severe peripheral arterial disease (PAD).

PQ Bypass’ proprietary Detour platform for percutaneous femoropopliteal bypass has been designated by the Food and Drug Administration (FDA) as a Breakthrough Device. The Detour system consists of the TORUS stent graft and the PQ crossing device. The Detour system is currently being studied in a U.S. and European clinical trial, DETOUR2.

“The acquisition of PQ Bypass is a seminal moment in Endologix’s history, building upon our leadership in the treatment of abdominal aortic aneurysm to champion disruptive technologies for the treatment of vascular disease,” said Richard Mott, CEO and chair of Endologix.

“We intend to actively pursue new and innovative vascular technologies that are clinically relevant to surgeons, hospitals, and patients, with a commitment to world-class medical education, clinical research, and excellent procedural outcomes.”—Bryan Kay

$3,100 generated to mark National Doctors Day

Spotlight Ravi Chandra, MD, of Ocala, Florida, has been appointed to the Florida Board of Medicine, subject to Florida Senate confirmation.

Society for Vascular Surgery (SVS) members can honor their mentors in a wonderful and consequential way by making a donation to the SVS Foundation in their mentors’ honor.

Corner Stitch

Welcome to Corner Stitch, a brand new section by and for trainees. First up is outgoing Vascular Specialist residents and fellows editor Laura Marie Drudi, MD, who introduces this monthly column with a retrospective on her time representing medical students, residents and fellows in these pages. She takes us on a journey through her years as a trainee and explains how she found her writing voice.

A love for writing To the Vascular Specialist community: IT HAS BEEN SUCH A TREMENDOUS honor to serve this community through my position as a trainee editor since 2014. You all have seen the range of my writing—from opinion to creative and reflective pieces—as I matured from a young trainee to a fellow. It is now time to seek new voices for Vascular Specialist as I transition into a new role from trainee to faculty.

I would like to take this opportunity to reflect on these past eight years with a community I have come to call family. In 2014, I was deeply humbled at meeting Russell Samson, MD, at a local Canadian meeting in our nation’s capital, Ottawa.

As one of the few young trainees at the meeting, and somewhat timid, I got up the courage to go introduce myself to our keynote lecturer, Dr. Samson. I am ever so grateful to my younger self for taking that leap of faith just to say “hello”—that young Laura Drudi had no idea of the journey that was to follow.

I am immensely indebted to Dr. Samson, who took me under his wing and onboard his vision for Vascular Specialist, which grew to become the official newspaper of the Society for Vascular Surgery, and the publication you now know today. He later passed the baton on to the current medical editor, Malachi

SEVERAL MEMBERS DID JUST THAT for National Doctors’ Day, with $3,100 in contributions to recognize eight different SVS members.

“I cannot tell you how flattered and moved I am that a valued colleague honored me in this way on Doctors’ Day,” said SVS Foundation Chair Peter Lawrence, MD, one of the honorees.

“He knows how much the Foundation and its work mean to me, and I cannot think of a more meaningful tribute.”

Others similarly honored on National Doctors’ Day were: Alfio Carroccio, MD, Benjamin Chang, MD, Alan Dardik, MD, R. Clement Darling III, MD, Manish Mehta, MD, Philip Paty, MD, and Sean Roddy, MD. SVS members who would like to do the same may email the Foundation at SVSFoundation@vascularsociety.org for more information. When the Foundation’s new website—now in progress—is completed, honorarium gifts will be available online.— Beth Bales May 2021

This month: The positive effects of new blood

Sheahan III, MD. Both these editors have guided and mentored me through my writing, and given me the space to grow and be creative. From my very first piece, “Life as a hospital bed,” to my last as a trainee, “A healing touch,” I hope my words, intentionally crafted, transported you all into my world as I navigated and discovered myself in the process.

I have always had a love for writing, and found solace and peace in expressing myself through my handwritten stream of words. I believe my true voice has always been the words fashioned into reflections and stories—some of which have made it into print, and others that are not yet ready to be shared.

Growing as a writer in Vascular Specialist has opened doors through networking with fellow writers, editors, and vascular surgeons from across the world. I found strength and leadership through my crafted words. Looking back, initially I was always stronger with a pento-paper approach, and, if I was being honest, I hid behind my written words.

because no one else will do it for you.

Second, no matter what you think, you aren’t alone in the struggles you are experiencing. Lean on people you trust inside or outside of your institution, and create a community of people likeminded and spirited.

And, finally, be patient. It took me a long time to learn this one, and I honestly don’t think I have learned it fully yet.

Growing into the person and surgeon you will become will take time, and it requires patience.

Going back to lesson one—life and training isn’t a sprint. And although it is great crossing the finish line and getting the medal, what matters most is what you invested in the process. Enjoy the process and have faith in it.

Alas, the time for change has arrived.

It is long overdue that I pass my pen to

a new person—and voice—for our new trainee section, Corner Stitch. However, you will be sure to find my whimsical stream of words in other pieces for Vascular Specialist, and I will continue to serve and mentor our future trainee editors. For all inquiries for this position, you can send an email to Dr. Sheahan.

Thank you to the readers of Vascular Specialist for continuing to read my work and for supporting me through my journey. It has been an utmost pleasure.

Thank you all.

LAURA MARIE DRUDI recently completed a limb salvage fellowship at Sint Blasius Hospital, Dendermonde, Belgium. She is now a vascular surgeon at Centre Hospitalier de L’Universite de Montréal, Canada.

I found strength and leadership in my crafted words But Vascular Specialist enabled me to grow as a writer and as a person, and I also found strength and confidence in my own spoken voice through that process.

Through the years, Vascular Specialist has heard my unique voice through my own lived experiences, but I hope the trials and tribulations I experienced, and the lessons I learned along the way, resonated with readers and guided you from afar. Before I take my leave, I wanted to share some final wisdoms and lessons learned as a trainee.

First, training is hard. Treat it like a marathon, or a half-Iron(wo)man in my situation—a challenge in which I also consciously and intentionally chose to (foolishly) partake.

However, similar to my half-Ironman training, residency required training like an athlete (nurturing body, mind and soul). Take care of your whole self

May 2021

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