Vascular Specialist–June 2021

18 TRAINEES Corner Stitch Integrated resident offers pearls of wisdom for new batch of interns

Vol.17 No.06 JUNE 2021 Official Publication

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Featured in this issue:

www.vascularspecialistonline.com Mean unadjusted

ELECTION SVS SET TO UNVEIL NEXT VICE PRESIDENT

2011–2021 Reimbursement rates

Adjusted for inflation

-7.2% -20.1%

15

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REIMBURSEMENT VASCULAR BUYING POWER DECLINES

STENT RECALL MIGRATION SPARKS ACTION

Fiber Optic RealShape used in US for first time

BY BRYAN KAY

SPECIAL ISSUE

DEI One speciality, many voices, diverse perspectives

BY LAURA MARIE DRUDI, MD, REBECA REACHI LUGO, MD, AND KATHRYN BOWSER, MD on behalf of the SVS DEI Committee

OVER THE COURSE OF THE LAST YEAR, THE Society for Vascular Surgery (SVS) has been on a journey toward fostering greater diversity, equity and inclusion (DEI). From the nadir of #Medbikini almost a year ago, the SVS Executive Board has since embraced and published a report from the SVS DEI Task Force—now a full-fledged committee—that called for action and change. Here, as members of the new DEI Committee, we introduce a Vascular Specialist focused issue that probes what the world of vascular surgery looks like for minorities, women and those of diverse sexual orientations—not only from the point of view of surgeons, but also trainees, nurses and patients.

Guest editorialist Bhagwan Satiani, MD, kicks off the discussion with a personal reflection on overcoming prejudice. This is followed by three personal stories dealing with sexuality and a report on ways to promote women into leadership roles in our specialty. As we mark Pride Month, our DEI journey continues.

See pages 4–10

VASCULAR SURGEONS AT the University of Massachusetts became the first in the United States to carry out procedures using the breakthrough imaging technology Fiber Optic RealShape (FORS) last month, reporting a 75% decrease in fluoroscopy use after one of their earliest experiences of the system—a fenestrated endovascular aneurysm repair (FEVAR) of a thoracoabdominal aortic aneurysm (TAAA).

Andres Schanzer, MD, professor and chief of vascular surgery at the University of Massachusetts Medical School in Worcester, whose team is at the vanguard of the technology’s debut Stateside, describes the platform as representing “a transformative change” in how surgeons navigate vascular anatomy.

FORS, developed by Philips, is currently available at a limited number of centers in Europe and the U.S. as it continues to undergo clinical study. The technology has CE mark approval in Europe and is Food and Drug Administration (FDA) 510(k) cleared.

The platform, which enables real-time 3D visualization of the Continued on page 11

See page 9

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GUEST EDITORIAL

Overcoming prejudice and uniting our diverse but vulnerable specialty

BY BHAGWAN SATIANI, MD

THE UNITED STATES HAS BEEN LIVING THROUGH some charged times recently. Our profession is not immune to these conflagrations. In recent times, minority members of the diverse specialty of vascular surgery have seen people who look like them come under attack. And there are politicians and other actors who make it their mission to try to divide us. Against this backdrop, I will relate a personal journey of confronting discrimination and, ultimately, of hope and acceptance.

Confusion, frustration, depression, anger and, finally, determination: These emotions represent stages of a personal journey, reflecting just a few of my early professional experiences in the United States.

There are many practical examples.

There was the time when I did not make the “cut” three times during my pyramid general surgery residency. Only eight residents out of 13 were selected to finish the fiveyear program. As destiny would have it, I sneaked in after three consecutive residents picked ahead of me chose to drop out.

Or there was the time when my three-month scheduled rotation as chief resident at an elite university hospital was suddenly switched by the chair to another institution the week before. I presume it was because I might not “fit in” among the almost all-white team there. When I complained, I was taken to the woodshed by the powerful chair, who warned me about destroying my career.

Or the time when, after finishing my final year (apparently as the first resident of color), I was not selected for the vascular surgery fellowship at the same university hospital. In recent years, for instance, any resident from the same general surgery program who applied was selected.

Among my many experiences here, these incidences ran counter to my impression of the United States. I gained

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

4 | Vascular Specialist

perspective when, as a junior resident working a busy surgical emergency room, I walked across to the medical side. There, I could see the remnants of a sign fixed over the water fountain. Barely legible, yet still discernible after being scrubbed, it read: “For whites only.” My anger subsided and was replaced by a determination to show “them” that I was more than capable of succeeding.

This process of acculturation is experienced by most immigrants in one form or another. Immigrants tend to work much harder to prove themselves, and, if they so choose, blend into the American melting pot. Personally, I did not have a backup option to which I could return.

Support On the other hand, my reaction may also have been muted due to my having grown up in a place where religious bigotry was acceptable. The false accusation of blasphemy hung over minorities like a sword. I survived because of half a dozen wonderful friends from the majority religion, two of whom are members of our society. That perspective alone helped me see the difference. In the U.S., most people I have met have been accepting, supportive and borne goodwill toward immigrants.

As Shelby Steele once said in reference to racism: “It was not an outrage, but an impersonal and immutable feature of the world, like snow in the winter or rain in the spring.”

Or, I had simply exchanged a far worse life-threatening environment for one that, to a large degree, I could overcome. Ultimately, the U.S. has shown me the true spirit of this nation. Despite some of my early experiences, there were other examples of great kindness. And elsewhere along the way, I have seen that many hearts would change.

Starting with the white security guard at my destination airport, who, at midnight, offered to take me—an

Bhagwan Satiani

unknown, disheveled foreigner—in his yellow Volkswagen and drop me off at the downtown hospital where I was going to work. There was the white senior nurse who took my wife and I under her tutelage, and later became a Godmother to our two children. There was also the elderly white physician-owner of the (same?) hospital who tore up the large medical bill for my father’s bypass surgery, saying, “You are one of us.”

Another senior faculty at the same university hospital where I completed my residency hired me as a trauma fellow for a year because I did not get an offer from one of the few vascular surgery programs in existence. He allowed me to spend one month on the vascular surgery service that rejected me, just so I could demonstrate my capabilities. That vascular surgery program director would later tell me he made a mistake in not selecting me. The chair who sidelined me in my final year—an individual considered a giant in American surgery—would later praise me in writing as one of the finest residents to complete the program. He would also call the fellowship director with whom I ended up the following year, advising that I be selected, and offered a money-back guarantee if said director was not happy with my performance.

As I saw this acceptance, my faith in the American people continued on page 6

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

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June 2021

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continued from page 4

grew and I never doubted that the system could work.

Immigrants are eager to make contributions. Like all Americans, we want our children to do better than we did. We may start on the bottom rung, but, given an opportunity, we do not stay down there for very long.

Indeed, I saw the real U.S. through thousands of my elderly patients, who were respectful, and placed their trust both in God and a brown-skinned immigrant surgeon for more than 40 years.

Hope and refuge Again, my story is probably not that different from many immigrants. One of the most memorable moments of my life was the day I took the citizenship oath after going through the prescribed legal process. The First Amendment to the U.S. Constitution, which protects the right to freedom of speech, religion and the press remains my favorite from that founding document.

Of course, we still have some way to go as a nation. I fully agree that we should push back against crimes related

to hatred against minorities, just as I do for any serious criminal offence. But, the question remains: Is it fair to hurl accusations of racism at a whole class of people of any race? Over the long haul, ordinary citizens of all races will vastly outnumber the few racists in our midst.

To the second or even third-generation immigrants, ask your parents or grandparents some questions. First, are they happy that they came to America? Besides the recent turmoil, from a racial perspective, are things better here than they were when they arrived? The answer, I would proffer, will be yes. Despite all of its warts, the U.S. gives hope and refuge to oppressed people from all over the

The chair who sidelined me in my final year—an individual considered a giant in American surgery— would later praise me in writing as one of the finest residents to complete the residency program

Does this loofah make me look gay?

world. The French political theorist Alexis de Tocqueville aptly remarked that Americans “take pride in the glory of their nation.” We immigrants and our children are proud to be a part of this great nation. We should guide it closer to its founding ideals and help America shine even brighter.

I ask each one of us to look past the politicians and others who try to divide us to be united in our small, increasingly diverse yet vulnerable specialty. Please be kind to each other. We have enough external challenges ahead. If you or your parents have been afraid to speak up in the places from which you came, you will understand how crucial that right to freedom of speech is. We should respect those on the other side of arguments. We should also continue to listen to one another. Let me be clear: I have not forgotten any of the affronts. I simply choose to move forward. Because dwelling on the negative experiences is a losing proposition. You are free to disagree.

BHAGWAN SATIANI is professor emeritus in the division of vascular diseases and surgery in the College of Medicine at The Ohio State University. He is an associate medical editor of Vascular Specialist.

is because I work in nursing and medicine where my peers have more education and therefore more tolerance, but over the years and, after building a network of gay officer friends who work in other areas outside of medicine, by and large their

BY JOSEPH BIDDIX, BS experiences have been positive.

After spending several years as a medI doubt many people remember a specific time they watched surg nurse and then an outpatient clinic manager, I made the career choice to C-SPAN, let alone the exact date. But on Dec. 18, 2010, there I switch to perioperative nursing. The Navy was, in my Durham, North Carolina, apartment, watching the U.S. offers a hefty bonus to operating room Senate vote on the Don’t Ask, Don’t Tell Repeal Act of 2010. Up (OR) nurses, and I knew I wanted it. I am until 1993, the military forbade openly gay people from serving, not ashamed to admit that—it’s called even though it was common knowledge that gay men and women a retention bonus after all. That said, during my time shadowing in the OR in have served this country in every war. preparation for the Navy’s hen Congress passed graduated. The Navy has a perioperative nurse training “Don’t Ask, Don’t Tell” program for nursing students program, I thoroughly enjoyed in December 1993, it where they provide you with the team atmosphere that was intended to be a a signing bonus and monthly exists in the OR. Everyone compromise between those who wanted to stipend during school in has their role, and each role end the military’s ban on LGB individuals return for active duty time is essential and valued. I saw from serving and those who wanted to after graduation. After the bill how surgeons relied on their keep the ban in place. The idea was that passed the Senate, President seasoned surgical techs and LGB people could serve as long as they Barack Obama signed it on circulating nurses to ensure did not reveal their sexual orientation, and Dec. 22. I called my recruiter a case went well. I marveled military leaders were not supposed to ask. on Dec. 23.

Joseph Biddix at the skills the young Navy However, it did not stop the discharging of You could say the rest is corpsmen surgical techs It was the chief demonstrated during complex LGB service members who were “outed,” history, but that would be whether voluntarily or not. During a disservice to the past 11 surgeries when I was just of vascular Congressional hearings on the proposed years. When I left for Officer trying to learn the names of surgery who repeal, then-Chairman of the Joint Chiefs Development School, I was the instruments. asked me if Admiral Mike Mullen stated, “…allowing so nervous about what my After spending three gays and lesbians to serve openly would be experience would be as a months in perioperative I would be the right thing to do. No matter how I look gay man in the military. I training, I transferred to interested in at the issue, I cannot escape being troubled carefully packed my suitcase, my next assignment as a sharing my by the fact that we have in place a policy making sure not to pack perioperative nurse. At the which forces young men and women to lie anything too colorful or too story. The days time of my arrival, I quickly about who they are in order to defend their tight. I distinctly remember learned that the service nurse of choosing fellow citizens. For me, personally, it comes choosing a washcloth instead for peripheral vascular surgery washcloths down to integrity—theirs as individuals and of a loofah because loofahs was due to leave around ours as an institution. I also believe that were clearly gay. Who was I the time I would complete over loofahs the great young men and women of our kidding? Anyone who talked orientation. The thought are long gone of running a service after military can and would accommodate such to me for five minutes would a change.” have a pretty good idea of just completing orientation I had already been accepted to nursing where I fell on the Kinsey at my first duty station was school at the University of North Carolina Scale. Yet, all of that fear and anxiety daunting. Not only that, we are talking at Chapel Hill when the repeal was signed ended up being for nothing. I have had about vascular surgery. into law, but I knew that I wanted to be literally zero personal attacks on me for my The reality was, I did not really have a U.S. Navy Nurse Corps officer after I sexuality since joining the Navy. Perhaps it a choice. We have a term in the military

W

6 | Vascular Specialist

called “volun-told.” It goes something like this: “Hey, nice work getting that vascular surgery position. Did you volunteer for it?”

“No, I was volun-told.” “Oh…well, good luck! I’m sure you’ll do great…”

Luckily for me, I happened to be placed with an amazing team of surgeons who are supportive and epitomize teamwork. They frequently assist each other in cases by scrubbing in or just being in the room to offer their input. I could see scenarios when a surgeon would not necessarily want the input of another surgeon during a case, but this team embraces it and encourages it. There is a genuine sense that everyone can learn something, and everyone brings something unique to the table. I have watched them mentor and train our young surgical techs, and they have taught me so much as well. During all of this, not once has my sexual orientation ever been an issue, nor have I felt the need to mask who I am. It was the chief of vascular surgery who asked me if I would be interested in sharing my story. The days of choosing washcloths over loofahs are long gone.

My hope is that if there is ever someone in our OR who has not yet made that choice to express their truth or emerge from the closet that they see the genuine fun our team has in the OR. I hope they see the mutual respect the team members share for each other. I will not go so far as to say that we have achieved a post-sexual identity era in the military or in America.

The issue of open transgender service has been volleyed back and forth for the last six years. That said, I am proud to be out amongst my colleagues and appreciate the professional friendships we have forged together in our vascular surgery corner of the OR. *Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect the official policy of the Department of Defense or the U.S. Government.

LT. JOSEPH BIDDIX is based at Walter Reed National Military Medical Center in Bethesda, Maryland.

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Being queer without proximal or distal control

BY ERIC PILLADO, MD

“What do you mean your partner? Does that mean a man?” These were among the questions one of my mentors asked me when we were discussing my list of pros and cons regarding the vascular surgery residency training programs to which I would apply. “Yes, my partner is a man.” The expected “oh…” was a reply I heard going to research meetings and throughout the residency interview trail.

Unclear was whether this “oh” was one of disappointment, a nervous response, or concern if I would “fit” in vascular surgery.

This “oh” haunts me because, in one short utterance, all of my accomplishments can be easily stripped away.

B

ut I am tired of hiding my queer identity. The further I progressed through my medical education, the harder it became to compartmentalize my professional and personal environments. My stuttering and avoidance of discussing anything outside of medicine with surgeons became more difficult. So, I have decided to embrace myself fully and let my two worlds collide. I was mesmerized by vascular surgery in medical school. It combined the unique, broad surgical opportunities from complex open surgery to innovative endovascular techniques, along with the continuity of care from an outpatient perspective, where one is actively engaging in patients’ healthcare. I wanted the opportunity to build connections with my patients and aid in intimate, life-changing procedures. At the same time, I knew I was entering a field that historically did not accept me as an equal human being, let alone as a surgical colleague. Somehow, I convinced myself it was alright as long as I separated my personal life from work. As society continues to become more accepting and inclusive, medicine continues to lag. Further, surgery is at the final frontier of acceptance and inclusivity.

While I agree being queer is only one aspect of my identity, it is a significant one that has affected my personal and professional life. I intentionally brought up my partner during my residency interviews with a significant amount of “ohs” that typically led to no follow-up questions or the occasional conversation one would expect in a heterosexual situation.

Wellbeing Up to 30% of surgical physicians have been surveyed to have homophobic attitudes.1 Within medical students, almost half expressed some explicit bias against lesbian, gay,

8 | Vascular Specialist

Eric Pillado

bisexual, transgender, queer and intersex (LGBTQI+) people, and 82% expressed at least some implicit bias.2 Further, three out of 10 non-LGBTQI+ Americans would feel “very” or “somewhat” uncomfortable if they found out their doctor was gay.3 This translates to discrimination in the workplace that can affect the wellbeing of a physician.

In surgery, we have been taught professionalism is key to fostering a good work environment and upholding the values physicians agreed upon when saying the Hippocratic oath. Unprofessional behavior encompassed discussing political views or personal life events at work.

However, this view on professionalism is inherently built to protect the comfort of heterosexual, cisgender white men.

Within operating rooms (ORs), there is always time where surgeons will quickly talk about their wife and kids. There are moments where you’re proud of life events outside of work that it is human nature to share them with the people you see the most. For the gay resident who still deals with homophobia within their family, this conversation can be a landmine.

Having political discussions dismissed regarding my fiancé and the ongoing debates on whether we have the right to have children in every state becomes isolating.

The political debates on the need to re-evaluate whether or not marriage equality and its subsequent human rights for the LGBTQI+ community are valid remain silenced out of fear of causing debate or unprofessional behavior.

However, these are problems that affect my wellbeing.

Battles Surgical residency is hard enough. Adding additional stress from fear and isolation that affects a queer person piles on another layer of resiliency that one hopes to obtain. It was not until midway through my time in medical school in 2015 that the United States of America legalized same sex marriage, which is not too far away from the present. Prior to this, I was not afforded the same right to marry my partner as my heterosexual counterparts. You learn to choose your battles with regards to correcting people who think you’re married to a woman. I’m tired of correcting the outside-hospitaltransfer patient who is actively listening to why queer people shouldn’t get married or adopt children on the television. I’m an exhausted resident who knows nothing good can come out of arguing with a patient who is here for their health needs. I bottle up the “ohs” and the multiple times I’ve wanted to correct someone, but it only eats away at me. Going into vascular surgery, I knew my masculinity would be questioned because I can have flamboyant tendencies. Yet, I embrace my masculinity as more than just the heteronormative use of the word.

At the same time, I hope diversity

You learn to choose your battles with regards to correcting people who think you’re married to a woman continues to push the boundaries of vascular surgery and becomes a model of redefining professionalism. My request of vascular

surgery is for the specialty to be more proactive about embracing diversity. When leadership stays silent about ongoing issues, it leads to us feel isolated. We need proactive allies. It’s not enough to “accept” or “tolerate,” but rather embrace and protect through allyship. During my medical education, I have seen hate crimes where gay people have been murdered, assaulted and discriminated against just because of whom they love. Nothing stops those people from being me. My white coat and degrees do not protect me from being verbally abused while walking down the street with my partner.

Inclusion I’m not asking for the divisions and departments of vascular surgery to go to every pride march (though I know we would all have a good time). I am asking for simple inquiries about my life and the injustices that affect me. In order to create a more inclusive and supportive environment, I believe the field of vascular surgery needs to include the following: n Allyship with the LGBTQI+ community that goes from passive activism to proactive activism. The Society of Vascular Surgery (SVS) needs to standardize what is true allyship, have concrete ways of reporting discrimination against the LGBTQI+ community and have zero tolerance for negative behavior n Reevaluating and normalizing personal life discussions at work and within meetings. While diversity brings in different people from within the society, inclusion starts with integration and acceptance of minorities.

Normalizing personal life discussions fosters more productive and candid discussions to truly appreciate and respect our differences n Plans from leadership on addressing the divisions and departments of vascular surgery whenever there is an event in the news that can be triggering to minorities.

I don’t want to be isolated when these tragic events happen. I don’t want there to be silence at work because it is uncomfortable. I need help. I need support because most likely I’m not okay It’s alright if having these conversations makes you uncomfortable. Trust me, I’ve been out of my comfort zone since the minute I entered medical school. I intentionally chose my residency program because, not only did it support my career interests, but it also understood the importance of my queer identity.

I cannot thank the vascular team at Northwestern University enough for talking and truly engaging about my personal life, normalizing it for the first time. Yes, I enjoy talking about sports, but I also love talking about fashion and pop cultural references. Yes, my OR will one day play Lady Gaga during an aorto-bifemoral bypass.

Most importantly, these are all interests also seen in a vascular surgeon. In the end, the respect I hold for my mentors and patients is the same that I hope to receive— regardless of my identity.

References 1. B urke B.P., White J.C. Wellbeing of gay, lesbian, and bisexual doctors. BMJ. 2001;322(7283):422–425.

2. Burke S.E., Dovidio J.F., Przedworski J.M., Hardeman R.R., Perry S.P., Phelan S.M., et al. Do contact and empathy mitigate bias against gay and lesbian people among heterosexual first-year medical students? A report from the Medical Student CHANGE Study. Acad Med. 2015;90(5):645–51.

3. The Harris Poll. GLAAD Harris Poll Accelerating Acceptance 2018: A Survey of American Acceptance and Attitudes Towards LGBTQ Americans. 2018.

ERIC PILLADO is an integrated vascular surgery resident at McGaw Medical Center of Northwestern University in Chicago.

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Patient: ‘Whole body wellness includes the mind and body’

and correct pronouns was the surgeon and his assistant.

Kathryn Bowser, MD, a member of the Society for Vascular Surgery (SVS) Diversity, Equity and Inclusion (DEI) Committee, talks to Justin Michel, 29, who identifies as a non-binary trans masculine person, about the patient experience navigating medical care as an individual of minority sexual identity.

Q: Can you explain your story, what your identity and acceptance of your identity by others mean to you?

How does your identity, if at all, come up in clinical encounters?

A: I started socially transitioning 10 years ago and started my medical transition a little over five years ago. At the beginning of my transition, I simply identified as a trans man, but in the last year or so I found myself not fully batting for either team, though I prefer to have male pronouns. Acceptance has always been something I fight for, but it’s a complicated battle on many different fronts.

I just want to be seen as who I am, and not what’s in my pants or how people perceive me.

Q: Have you been targeted or marginalized in any way by physicians or healthcare providers for your identity, and how so?

A: I don’t believe that I have been directly targeted, though I feel like a lack of knowledge knocked them off kilter.

Whenever I would see a doctor, they always Justin Michel assumed that whatever ailment I had was because of my hormone replacement injections [HRT], even though I had been stable on my meds for more than three years. Another way that left a bad flavor in my mouth was when I was having my gender confirming surgery. Everyone at the hospital kept referring to me

“Whenever I would see a doctor, they always assumed that whatever ailment I had was because of my HRT” — Justin Michel by my birth name and legal pronouns. Plus, whenever they saw I was having a double mastectomy, their first assumption was that I was a cancer patient. The only people at the hospital who called me by my chosen name

Elevating women in vascular surgery

BY BRYAN KAY

Over a one-year period, Association of American Medical Colleges data showed that 25% of women in surgery reported experiencing disrespect based on their gender, Melina R. Kibbe, MD, chair of the department of surgery at the University of North CarolinaChapel Hill, told a Frank J. Veith International Society webinar that sought to address how to promote women in vascular surgery.

“W

e have a problem, and we have an issue,” Kibbe told a group of four fellow women vascular surgeon presenters and another five male colleagues invited as discussants.

In a talk that looked at barriers and strategies to becoming a chair of surgery, Kibbe identified key areas standing in the way of women, based on her own lived experience.

“For one, I will tell you that implicit bias against women is definitely still prevalent and exists in surgery,” she said.

“I think, speaking here as a female leader, expectations of female leaders are different than those of male leaders. I think that female leaders are under the microscope much more than male leaders for their decision-making processes.

“I think that decisions that female leaders make are questioned and challenged more often than male leaders. I think that people try to manipulate female leaders more often than male leaders.

Female leaders receive less overall support 10 | Vascular Specialist

and encouragement, and support for female leaders I don’t think is as strong when going against the status quo.

“Female leaders are often not as recognized as their male counterparts.

And I would also say female leaders are still subject to the stereotypical descriptors, for example, of being ‘difficult’ instead of ‘decisive and ‘authoritative.’ Or being ‘indecisive’ instead of ‘thoughtful.’”

She underscored how “significantly” underrepresented women are in positions of leadership in surgery.

“But, plenty of qualified women are there,” Kibbe added. “I do think women leaders face unique challenges, so we must become more aware of our implicit biases. As all of the other speakers have commented, we must actively think of and promote women into these positions of leadership to overcome these barriers.”

Following an introduction from Enrico Ascher, MD, executive director of the society, a robust session of five talks and associated discussion took place with moderation by Keith D. Calligaro, MD,

Q: What does it mean to be a LGBTQIA+ friendly physician in your eyes?

A: An LGBTQIA+ friendly physician is someone who takes into account what your body is doing but still respects how you wish to be seen. When I see a doctor about my uterus, I don’t want to be smothered in she/her and femme language. I’m still a man and I wish to be respected as such.

Q: How important is it for you to see a doctor who is LGBTQIA+ friendly?

A: At this point in my life, I no longer will go to a practice that is not LGBTQIA+ friendly. I no longer want to have to tiptoe around who I am. If their office doesn’t say anything about LGBT on their website, I’m not interested.

Q: How important is it for you to be comfortable with your doctor, and what is one message you would want our readership to know?

A: It’s literally life and death when it comes to medical treatment, so I want to be comfortable enough to speak plainly. If my doctor is to take care of me they need to know all aspects of me. Whole body wellness includes the mind and body, so all things must work together. If the patient is uncomfortable and disrespected, then the mind isn’t well and you are doing your patient a disservice.

chief of vascular surgery and endovascular education at the University of Houston, therapy at Pennsylvania Hospital in took viewers on a journey through Philadelphia, and Amy B. Reed, MD, the barriers and strategies to being an professor and chief of vascular and academic editor. endovascular surgery at the University of Julie A. Freischlag, MD, the CEO of Minnesota in Minneapolis.

Wake Forest Baptist Health in WinstonVenita Chandra, MD, program director Salem, North Carolina, discussed lessons of the vascular surgery residency and she learned on the way to becoming the fellowship programs first—and, to-date, at Stanford only—president University in of the Society for California, spoke Vascular Surgery on ways to (SVS). Meanwhile, improve diversity Edith Tzeng, MD, at the conference professor of surgery podium. at the University of “Clearly, a Pittsburgh Medical more diverse Center and chief of podium will vascular surgery for result in improved the VA Pittsburgh discussion, an Healthcare System, increased number explored how to of perspectives develop and retain and opinions, and women as vascular “I think that decisions increased innovation that female leaders make surgeon-scientists. and research ideas,” The discussants are questioned and she said. were Ali AbuRahma, “But there are challenged more often MD, president-elect other benefits as of the SVS; Peter F. than male leaders” — well. We all know Lawrence, MD, chief that the people of vascular surgery Melina R. Kibbe going into medicine at the University today are changing. of California, Los There’s an increasing amount of diversity Angeles (UCLA); Richard Powell, MD, in our medical students, and particularly an chief of vascular surgery at Dartmouthincreasing number of women going into Hitchcock Medical Center in Lebanon, residencies in medical schools. Increasing New Hampshire; Anton Sidawy, MD, chair diversity on the podium allows these young in the department of surgery at George people to look up to the podium and see Washington University in Washington, people who look like themselves.”

D.C.; and Frank J. Veith, MD, professor of Among the other presenters, Ruth L. surgery at both New York University and Bush, MD, associate dean for medical the Cleveland Clinic College of Medicine.

June 2021

IMAGING

Fiber Optic RealShape used in US for first time continued from page 1

full shape of devices inside the body without the need for stepping on the fluoroscopy pedal, sends pulses of light through hair-thin optical fibers within minimally invasive devices.

Schanzer illustrates how a busy complex aortic practice at his institution currently depends on X-ray imaging for the entirety of procedures.

“What FORS has enabled us to do is to really get away from using X-ray for all of the steps of the procedure,” he tells Vascular Specialist in an interview shortly after undertaking his third procedure with the platform. “[This is achieved with] fiber optic wires and catheters to decrease our reliance on X-ray.”

In addition to the decreased radiation and lowered procedure time FORS allows, Schanzer continues, another notable advantage includes an ability to work with completely new angles than those to which vascular surgeons are accustomed with

June 2021

X-ray. “There’s no limitation on having to move a C-arm gantry around a patient,” he says. “You can be looking at several different angles like a biplane view at the same time.

“I think it’s going to change the way we look at all vascular interventions.”

Quantifying the exact radiation reduction is going to take time and data to determine, Schanzer says. But by his third case, the four-vessel type II TAAA FEVAR, his team was able to decrease radiation use compared to their mean for that extent of repair from an average of 88 minutes down to just 22 minutes, or 75%.

“We are at the very start of our learning curve,” Schanzer says, reporting that by the end of May he and colleagues should have completed six cases with FORS. “We’re really trying to see exactly where it fits in and how to maximize its use, and maximize the benefits to patients.”

FORS is expected to be rolled out to a total of five U.S. centers as part of clinical trials, in addition to the same number in Europe.

Shortly before FORS’ debut in the U.S.,

“What FORS has enabled us to do is to really get away from using X-ray for all of the steps of the procedure” ­— Andres Schanzer

The University of Massachusetts team cannulated the celiac, superior mesenteric, right renal and left renal arteries of a type II TAAA patient using FORS

during the Charing Cross (CX) 2021 Digital Edition Gustavo S. Oderich, MD, professor and chief of vascular and endovascular Surgery at the University of Texas’ McGovern Medical School in Houston, emphasized its potential, suggesting that “radiation will be a thing of the past” thanks to this new technology.

“I’ve always had a really strong interest in imaging,” Schanzer comments. “I believe the imaging side of what we do is just as important as the device side. This is certainly the biggest leap forward that I have seen in my career with regards to the imaging.”

Ultimately, the technology is at the start of its journey, he adds. “Currently, we’ve only used it in complex aortic procedures but I very much see us broadening the applicability in all types of vascular cases.

“This is a first-generation technology, and I think there is still room for improvement as we expand the devices, the catheters and the wires that are enabled with this technology. I think that’s going to happen very quickly. This proof of concept we’ve already seen in a few cases that have been done around the world really shows the enormous value that this technology holds.”

vascularspecialistonline.com | 11

VAM

Back in the room: Registration now open for Vascular Annual Meeting

BY BETH BALES

Registration for the live, in-person 2021 Vascular Annual Meeting (VAM) has begun—and organizers promise you won’t want to miss the meeting.

V

AM will be Aug. 18 to 21 in beautiful San Diego, California.

Educational programming will be presented across all four days of the conference. The Exhibit Hall will be open Aug. 19 and 20.

The registration and housing kick-off is especially welcome, say Society for Vascular Surgery (SVS) leaders, after the COVID-19 pandemic forced cancellation of VAM 2020 and also prompted SVS to move this year’s VAM from June to the August dates.

That move turned out to be a prescient one, as VAM becomes one of the first meetings to be held in nearly 18 months at the San Diego Convention Center.

“We’ve all missed being together in person and we look forward to welcoming you, live and in person, back to VAM,” said President Ronald L. Dalman, MD. He called this year’s meeting “a homecoming for friends of vascular surgery everywhere.”

At this year’s meeting, SVS also will begin the party for the Society's 75th anniversary (culminating in Boston at VAM 2022) and, importantly, enjoying the camaraderie and company of colleagues and friends.

SVS Program Co-Chair Andres Schanzer, MD, reiterated the plea for attendees to take note of the changed structure and programming instituted this year.

“We’ve changed the schedule significantly, moving several ‘traditional’ Thursday events to Wednesday,” he said.

These include: n The Opening Ceremony, 7:30 a.m. n The first plenaries, including the William J. von Liebig Forum at 8 a.m. n The E. Stanley Crawford Critical Issues Forum, 10:45 a.m. This year’s Crawford Forum will focus on multispecialty collaboration, “The role of multispecialty practice in vascular/ endovascular surgery: Can we work together?”

In addition, in direct response to feedback, planners scheduled all morning sessions to be conflict-free (except for breakfast sessions) and limited overlapping sessions in the afternoon to three.

Instead of having all postgraduate 12 | Vascular Specialist

courses on Wednesday, this year’s three courses are held on three separate days.

“Please remember that if you want to take full advantage of everything we’re offering, make your travel arrangements to be here Tuesday night and leave after 5 p.m. Saturday, following the final concurrent session and the Championship Round of the Poster Competition,” said Schanzer.

Of course, attendees’ health and safety remain the top priority, and SVS has instituted protocols to safeguard them as authorities continue to overcome the pandemic. At this writing, attendees will need to provide either COVID vaccine verification OR a negative COVID test within 72 hours of travel. These protocols will undoubtedly change, said Dalman, so members should check the VAM Protocols webpage often. (See www. vascular.org/VAMProtocols.)

“And, as a California resident, I can’t wait to show off my state,” said Dalman.

“The June gloom will be history; August promises some of California’s nicest weather. Bring the family and extend your stay to take advantage of beaches, baseball at Petco Park, San Diego Bay and the incredible number of tourist attractions San Diego has to offer.”

(The San Diego Padres are playing at home Aug. 20-22, against the Phillies, and from Aug. 24-26, for those staying later, against the Dodgers.)

For all things VAM-related, visit the VAM website, at vascular.org/VAM.

Exhibitors ready to welcome SVS It’s not only members who are eager to attend the VAM this August. Industry representatives are enthusiastic to see everyone as well.

More than 60 exhibitors are already booked for the Exhibit Hall, 10 weeks before Opening Day. The slots for industry presentations, including the popular Vascular Live presentations, symposia and industry breakfasts, likewise, are almost full.

The Exhibit Hall is an integral part of VAM. All members of the vascular team, as well as other attendees, will be able to see a wide-ranging array of products of

“We’ve changed the schedule significantly, moving several ‘traditional’ Thursday events to Wednesday” — Andres Schanzer interest to vascular surgeons and their teams from dozens of vendors.

Participants also can take advantage of non-CME learning opportunities, giveaways, training opportunities and networking potential.

Industry-Supported Evening Satellite Symposia will be held from 6:30 to 8 p.m.

Wednesday and Thursday. Wednesday’s session is sponsored by Gore; Thursday’s is sponsored by Medtronic.

Industry Breakfast Symposia will be held from 6:30 to 8 a.m. Thursday. n B1: “Why clinical trial participants need to look like us and how we can improve care for the underserved population living with peripheral arterial disease (PAD),” sponsored by Abbott n B2: “Paclitaxel safety: A view from multiple perspectives,” co-sponsored by Boston Scientific and Medtronic n B3: “Clinical insights in chronic coronary artery disease (CAD)/ PAD: Reducing the risk of major

cardiovascular events,” sponsored by Janssen Pharmaceuticals Industry-sponsored symposia are not eligible for CME credit.

Vascular Live includes six innovative sessions about the latest products and developments related to vascular surgery, in a theater-in-the-round setting during Thursday and Friday’s coffee breaks and lunch hours.

These sessions are frequently standingroom only, so be sure to arrive early in order to secure a good seat. Device makers Abbott, BD and Gore are sponsoring two sessions each.

Remember that industry participation in the VAM exhibits underwrites a significant portion of VAM, thereby allowing us to keep registration fees at a much lower rate than other industry meetings.

Please support our industry partners. A complete list of exhibitors and their booth locations will be available as the dates of VAM draw closer.

Meanwhile, the SVS will again host a Scavenger Hunt during Thursday’s opening reception.

The first-place prize is two roundtrip airline tickets to anywhere in the continental United States.

More than 60 exhibitors are already booked for VAM 2021's Exhibit Hall 10 weeks out from the event

June 2021

VRIC comes to VAM This year, the two major meetings of the Society for Vascular Surgery (SVS) that involve the presentation of scientific research are being housed in one tent.

THE VASCULAR RESEARCH Initiatives Conference (VRIC), typically held in May and geared to translational research, will be held over two sessions Thursday and Friday at the 2021 Vascular Annual Meeting (VAM).

More than 25 abstracts will be presented in four sessions covering arterial remodeling and discovery science for venous disease; vascular regeneration, stem cells and wound

Thank you to VAM 2021 supporters (as of: 5/6/21)

Educational grants: Medtronic

VAM sponsorships: 3M Health Care BD Gore Medtronic Philips

Useful links VAM website:

Vascular.org/VAM Registration:

vascular.org/RegisterVAM21 Hotel reservations:

Vascular.org/VAMHousing Health and Safety Protocols:

vascular.org/VAMProtocols Schedule at-a-Glance:

vascular.org/VAMSked

San Diego attractions:

Vascular.org/VisitSanDiego

June 2021

Selected content to be live-streamed at VAM

BY BETH BALES

Organizers stress that the best way to experience the 2021 Vascular Annual Meeting (VAM) is in-person, surrounded by friends and colleagues, participating in small-group sessions and seeing all the devices and information available in the Exhibit Hall.

“BUT WE KNOW NOT EVERYONE – particularly our international members – can travel just yet,” said SVS Program Committee Co-chair Andres Schanzer, MD. “To accommodate these individuals and other situations, we have carefully chosen selected content to be live-streamed. We hope offering streaming will let us reach our goal to provide all vascular surgeons worldwide access to our live meeting.”

All the abstract-based plenary sessions will be live-streamed, as will four international events, specialty lectures and the two presidential addresses. A total of 15 Continuing Medical Education (CME) credits can be earned from among the streamed sessions.

Additionally, most VAM sessions will be recorded and available in the new SVS OnDemand six to eight weeks following the live event.

Schanzer urged those who cannot participate in person to consider registering for the streaming option. Visit vascular.org/ RegisterVAM21 to register today.

healing; atherosclerosis and the role of the immune system; and aortopathies and novel vascular devices.

The four recipients of the VRIC Travel Award—participating in vascular research in labs across the country—also will be recognized.

Thursday’s session includes abstracts in the first two categories followed by a short discussion and summary session.

Friday’s session will be preceded by a networking lunch from 12 to 12:55 p.m.; the afternoon’s program will be from 12:55 to 3 p.m. Philip S. Tsao, PhD, of Stanford University, will present the Alexander W. Clowes Distinguished Lecture, “Molecular and genetic approaches to understanding abdominal aortic aneurysm disease,” beginning at 1:30 p.m. Friday. Tsao also is associate chief of staff for precision medicine at the Department of Veteran Affairs Palo Alto Health Care System and director of the VA Palo Alto Epidemiology Research and Live-streaming sessions (all times are Pacific Time) are:

WEDNESDAY nP lenary Session 1/ William J. von Liebig Forum, 8 to 9:30 a.m. nP lenary Session 2, 9:45 to10:45 a.m.

Ronald L. Dalman nC rawford Forum, “The role of multispecialty practice in vascular/ endovascular surgery: Can we work together?”, 10:45 to 12:15 p.m. n I nternational Forum, 1 to 3 p.m. n International Fast Talk, 3 to 4 p.m.

THURSDAY nP lenary Session 3, 8 to 9:30 a.m.

Kim n Awards Ceremony, 9:30 Hodgson to 9:45 a.m. n Roy Greenberg Distinguished Lecture, presented by Elsie Gyang Ross, MD, 9:45 to 10:15 a.m. nP residential Introduction and Address, (address by Immediate Past President Kim Hodgson, MD), 10:45 a.m. to 12 p.m. n International Chapter Forum, 1:30 to 3 p.m.

FRIDAY nP lenary Session 4, 8 to 9:30 a.m. n Diversity, equity and inclusion invited speaker, Lee Kirksey, MD, 10 to 10:20 a.m. nD EI Scientific Session (abstracts presentation), 10:20 to 11 a.m. n Presidential Introduction and Address (address by President Ronald L. Dalman, MD), 11 a.m. to 12:15 p.m. n International Young Surgeons Competition, 1:30 to 3 p.m.

SATURDAY nP lenary Session 5, 8 to 9:30 a.m.

Information Center for Genomics. VAM registrants may attend VRIC@VAM as part of their registration fee.

Those who want to attend only VRIC may do so. Cost is $100 for an SVS member, $75 for a candidate member and $50 for residents and fellows (both SVS member and non-member); $200 for a non-member physician; $75 for allied health professionals; and $25 for medical students (both member and non-member).

To register, visit vascular.org/ RegisterVAM21.

“It’s definitely not our ‘regular’ VRIC this year,” said Luke Brewster, MD, chair of the SVS Research Council. “But we are excited to be presenting our translational research—many of it from vascular surgeon-scientists relatively early in their careers—to the wider VAM audience. It’s important for these researchers to have this forum, and it’s important for our SVS members to be presented with their exciting work.”—Beth Bales n J ohn Homans Lecture, presented

by Jim Stanley, MD, 9:30 to 10 a.m. nP lenary Session 6, 10:30 a.m. to 12 p.m.

Meeting at large The lineup of educational programming includes a total of six plenaries, six "Ask the Experts" small-group sessions , six concurrent and six breakfast sessions, three postgraduate courses and a number of other special sessions.

The special sessions include a COVID-based program, collaborative sessions with the American Venous Forum (AVF) and the Society for Vascular Ultrasound, a session for members in community practice, programming for physician assistants, content on diversity, equity and inclusion issues, and the Aortic Summit, presented jointly by the SVS with The Society of Thoracic Surgeons.

Hodgson, the SVS' immediate past president, will be delivering his 2020 presidential address, which he was unable to deliver last year after VAM was canceled and replaced by SVS ONLINE. President Dalman will introduce Hodgson at 10:45 a.m. Thursday, followed by Hodgson’s speech at 11 a.m.

On Friday, President-elect Ali AbuRahma, MD, will introduce Dalman at 11 a.m., with the latter taking the microphone at 11:15 a.m. And the mood is sure to be festive in 2021, as the SVS begins a year-long celebration of the 75th anniversary of its founding.

For the complete schedule, see the Schedule At-a-Glance at vascular.org/VAMSked. vascularspecialistonline.com | 13

YOUR SVS

New SVS vice president, revised bylaws set to be unveiled at June 16 Annual Business Meeting

BY BETH BALES AND BRYAN KAY

Members, be sure to register for the June 16 Virtual Annual Business Meeting, the first of two business meetings for 2021.

REGISTRATION IS REQUIRED TO ASSURE A quorum. Register at vascular.org/ABM1Register. The second meeting will be held Saturday, Aug. 21, during the Vascular Annual Meeting (VAM).

The Wednesday, June 16, meeting will be from 6 to 7 p.m. Central Daylight Time. Members will hear reports from President Ronald L. Dalman, MD, Secretary Amy Reed, MD, and Treasurer Keith Calligaro, MD. Nominating Committee Chair R. Clement Darling III,

MD, will present his report, announce the results of the election for SVS vice president and on bylaws revisions, and introduce the 2021–22 Officers.

Active and Senior members voted in May, selecting between the Texas-based duo of William Shutze, MD, and Joseph Mills, MD, as the new vice president.

Shutze first entered private practice in Dallas in 1991, and in 1997 joined the Dallas- and Plano-based Texas Vascular Associates, where he remains as a partner. Operating from a community setting, he is credited with authorship or co-authorship of nearly William Shutze 80 peer-reviewed publications. Among the numerous SVS positions he has held, Shutze currently serves as the chair of the Clinical Practice Council.

He listed his favorite accomplishments thus far as developing the SVS Mentor Match program as well as the Society’s Community Practice Section. “I am humbled and honored for this nomination and I am grateful for the opportunities given me to serve my colleagues, friends, peers and patients,” Shutze told the SVS. Mills is currently chief in the division of vascular surgery and endovascular therapy at Baylor College of Medicine in Houston, counting extensive clinical experience in multiple practice settings, including military,

Progress made during year like no other

BY BETH BALES

While the COVID-19 pandemic and its effects dominated 2020–21 fiscal year—including the cancellation of the live 2020 Vascular Annual Meeting (VAM)—it did not deter progress on many important initiatives.

“WHEN COVID HIT, IT INTENSIFIED our focus on what was truly important: our members, their patients and the SVS as their Society,” said Executive Director Kenneth M. Slaw, PhD. “That focus was sustained the past 15 months and it has led to innovation and an unprecedented volume of member value programs.”

He outlined important highlights from the fiscal year that ended March 31—just more than a year after the pandemic was declared—and the vital initiatives that continue to move forward.

“The SVS Executive Board led by President Ronald L. Dalman, MD, was phenomenal, as was the staff leadership, as SVS developed and implemented plans to adjust, plan forward, evolve and weather the storm,” said Slaw.

Priority one was converting the canceled in-person VAM to SVS ONLINE, with sessions held virtually throughout a twoweek period. It was essential to continue the Society’s mission of advancing vascular surgery through research and discovery, and continuing education, said Slaw.

Priority two was opening up communication pathways to members.

In the pandemic’s early days, with members’ professional lives impacted

14 | Vascular Specialist

profoundly, then-President Kim S. Hodgson, MD, instituted a series of Town Halls, focusing on topics of great importance to members. The first covered vascular surgeons’ early experiences with COVID, while subsequent town halls addressed COVID’s impact on education, training and wellness; financial assistance programs; telemedicine; restarting clinical practices and more. The SVS website houses the Town Hall recordings and related handouts and practice tools.

To keep members informed, the biweekly Pulse electronic newsletter began publishing weekly (it has since returned to biweekly dissemination). This led the SVS Executive Board to create a new Communications Committee, with three subcommittees: the existing Public and Professional Outreach Committee, a Website Committee and a Social Media Committee. SVS then acquired and integrated “Audible Bleeding,” making the popular podcast an official SVS publication.

Priority three was to keep members engaged and offer more opportunities for members to become involved.

The SVS Appointments Committee expanded to increase diversity and made the entire application and selection

Veterans Administration (VA), county, university and private hospitals.

He has authored more than 300 peer-reviewed journal articles and book chapters and is co-founder of the Southern Arizona Limb Salvage Alliance (SALSA). A past-president of the Association of Program Directors in Vascular Surgery (APDVS), Mills has served the SVS as treasurer and chair of the Distinguished Fellows Council.

Most recently, he has led the Public and Professional Outreach (PPO) Committee, helping spearhead the Joseph Mills SVS branding campaign.

Meanwhile, participants also will witness the transition of leadership from Dalman to Ali AbuRahma, MD, as SVS president, see the entire SVS officer and Strategic Board lineup and hear AbuRahma preview the Aug. 21 Second Annual Business Meeting.

Attending the Annual Business Meetings is an essential civic responsibility of all members. Mark your calendars today for both meetings.

Registration for the August meeting will be included as part of VAM registration, though attendees must obtain a ticket (available at the registration site, vascular.org/ ABM1register) or onsite at the annual meeting. Only SVS members may attend the Annual Business Meeting.

process more transparent and inclusive.

Several key priorities in the SVS Strategic Plan also became top priorities, including branding. A branding toolkit was designed to help members communicate their roles in comprehensive vascular care.

On the quality front, six new clinical practice guidelines were published in 2020, with four more to come in 2021.

The Appropriateness Committee will complete the first-ever SVS Appropriate Use Criteria, on claudication, expected to be published shortly after VAM in August.

The SVS Vascular Center Verification Quality Improvement Program to certify vascular programs across the country is now nearing completion with fieldtesting, with a launch targeted for late August. And the SVS Executive Board created a new Quality Improvement Committee.

In education, the groundbreaking SVS Leadership Development Program graduated its first cohort in December 2020 and the second cohort started its work in early 2021. The fifth edition of the Vascular Educational and SelfAssessment Program debuted in July, and the new Learning Management System

“When COVID hit, it intensified our focus on what was truly important: our members, their patients and the SVS as their Society. That focus was sustained the past 15 months” — Kenneth M. Slaw

and video library launched in January.

In Advocacy, the SVS joined the Surgical Care Coalition with 11 other surgical specialties, helping secure an 11th-hour temporary reprieve from Congress on reimbursement cuts to vascular surgery.

The SVS Research Council began the process of completing an environmental scan and establishing top priorities for vascular surgery research, updating its 2010–2020 Published Research Priorities for 2020–30. A white paper is expected shortly after VAM 2021.

The Society, working with hospital data consulting firm Sg2, completed its vascular valuation study, assessing the importance and financial impact of vascular services to health systems. The SVS Supervised Exercise Therapy (SET) app trial launched to great success and is progressing. SVS established a new Population Task Force to begin focus on vascular surgery delivery models in valuebased, population-based care systems.

In addition, the Community Practice Committee transitioned to a Community Practice Section. Finally the SVS continued its intense focus on wellness and burnout, launching a peer-to-peer Vascular Surgery Coaching Program with the Academy for Surgical Coaching.

“No medical society has ever undertaken something like this,” said Slaw.

In a year that brought racial unrest and diversity issues into full visibility, the SVS Diversity, Equity and Inclusion Task Force completed its work and was formed into a new standing Diversity Committee.

“With great challenges come great opportunities” noted Slaw. And there’s more to come in the years ahead, he promised. “Many of these initiatives are ongoing and we have ambitious plans for what we will do next year.

June 2021

‘Disproportionate decrease’: Vascular surgeons see buying power fall, study finds

BY BRYAN KAY

Inflation-adjusted Medicare reimbursement rates for the 20 most common vascular surgical procedures decreased by more than 20% in the last decade, a new analysis found.

T

he study, which looked the buying power of change to mean adjusted reimbursement over the 10vascular surgeons, uncovered data showing year study period across the five surgical specialties was an unadjusted average fall in payments to found to be statistically significant (p<0.001). vascular physicians of 7.2% over the 2011–21 “A sub-analysis comparing average change in adjusted time period. reimbursement across procedure type demonstrates A research team that included first-named author Jack that venous procedures experienced the largest average M. Haglin, BS, of Mayo Clinic School of Medicine in decrease in adjusted reimbursement at -42.4%,” the Scottsdale, Arizona, and corresponding author Andrew researchers stated.

J. Meltzer, MD, the chair of vascular surgery at Mayo They further reported that endovascular procedures Clinic Arizona in Phoenix, discovered the great decrease experienced the next largest decrease in average adjusted was among venous procedures. The findings were reimbursement at -20.1%. Open procedures decreased published recently in the Annals of Vascular Surgery. the least at -13.9%. This difference across procedure The investigators set out to establish a comprehensive types was also statistically significant (p<0.001), Haglin understanding of Medicare reimbursement trends over et al wrote. the 10-year period probed in order to inform evolving The authors concluded: “Medicare reimbursement for payment policy. common surgical procedures has declined over the last “Currently, Medicare covers the majority of such decade. While absolute reimbursement has remained services, acting as the primary payer for approximately relatively stable for several procedures, accounting for a 70% of all vascular surgery care in the United States,” decade of inflation demonstrates the true diminution of the authors reasoned. buying power for equivalent work.

They used the Centers for Medicare & Medicaid “The most alarming observation is that vascular Services (CMS) physician/supplier surgeons have faced a disproportionate procedure summary file to identify decrease in inflation-adjusted “When all the 20 procedures most commonly reimbursement in comparison to other reimbursement data surgical specialists. performed by vascular surgeons from 2011–2021. A similar analysis was was corrected to 2021 Awareness of these trends is a crucial performed for urology, orthopedic, step towards improved advocacy dollars to adjust for first general and neurological surgeons. and efforts to ensure the ‘value’ of inflation, the mean vascular surgery does not continue to The authors found that the mean unadjusted reimbursement rate for erode.” reimbursement all included procedures decreased for all 20 vascular by 7.2%. “When all reimbursement Cuts averted procedures included Steep cuts to Medicare that had been data was corrected to 2021 dollars to adjust for inflation, the mean set to go into effect this year were in this analysis reimbursement for all 20 vascular averted by Congress late in the decreased by an procedures included in this analysis day. average of 20.1% — decreased by an average of 20.1% Thousands of hours of from 2011 to 2021,” they wrote. effort

by Society for Vascular Jack M. Haglin et al During the same time period, Surgery (SVS) committees they continued, the adjusted and members were put in to reimbursement rate for all included help halt the expected 7% procedures decreased by an average of 2% per decrease in payments for the services year, experiencing an average compound vascular surgeons provide that was annual growth rate of -2.3%. This indicated set to ensue. “a steady annual decline in reimbursement Nearly 800 members engaged when adjusted for inflation,” the authors in grassroots efforts to write added. to their lawmakers and urge When they compared this trend analysis support for stopping the cuts. across other surgical specialties, they In four separate efforts to discovered that the mean 20.1% decrease engage with Congress, members observed within vascular surgery was a sent 2,627 messages to their greater decrease than that observed in lawmakers. One campaign, urology (-17.4%), orthopedic urging Congress to surgery (-15.1%), general act on bills directed surgery (-12.0%) and at stopping the cuts, neurosurgery (-8.3%). garnered 925 calls The difference in percent Andrew J. Meltzer to action.

June 2021

2011–2021 Reimbursement rates

REIMBURSEMENT

Mean unadjusted

Adjusted for inflation

-7.2% -20.1%

vascularspecialistonline.com | 15

VASCULAR PRACTICE

VOYAGER PAD shows rivaroxaban ‘significantly’ reduced total ischemic events in PAD patients

The randomized, double-blind VOYAGER PAD trial enrolled 6,564 patients in 34 countries who had PAD and had undergone lower-extremity revascularization. The patients’ median age was 67 years and 74% were men.

Patients were randomly assigned to receive either rivaroxaban or a placebo in addition to daily aspirin. The trial’s primary endpoint was timed to the first event of a composite of acute limb ischemia, major amputation of vascular etiology, myocardial infarction (MI), ischemic

BY WILL DATE stroke or cardiovascular death. Another prespecified Rivaroxaban combined with low-dose aspirin led to a significant reduction in the endpoint was the total number of vascular events, including recurrent primary endpoint events as well as occurrence of total ischemic events in patients with symptomatic peripheral arterial other vascular events. The median follow-up time disease (PAD) who underwent lower-extremity revascularization, according to was 28 months after revascularization. researchers conducting the VOYAGER PAD trial.

The research team reported in a latebreaking clinical trial presented at THE FINDINGS WERE revascularization, there is a ACC.20/World Congress of presented during a late-breaking four-fold risk of acute limb Cardiology that VOYAGER fewer adverse events session at the 70th Annual Scientific ischemia, Bauersachs told PAD met its primary endpoint, in the rivaroxaban Session of the American College of ACC.21 attendees, adding with a 15% statistically group than in the Cardiology (ACC.21), held May 15–17 that this is associated with significant reduction in the placebo group virtually, and simultaneously published a high incidence of limbrisk of a first major adverse online in the Journal of the American related complications. limb or cardiovascular event College of Cardiology (JACC).

“There is a need for seen in patients who received Rupert Bauersachs, MD, director of Rupert Bauersachs greater awareness that rivaroxaban compared with —an vascular medicine at the Darmstadt PAD is a distinct disease those who received the placebo. absolute Clinic in Darmstadt, Germany, and lead author of the state and that patients The current study reports on reduction in study, told ACC.21 attendees that the use of rivaroxaban with PAD have a high risk the total number of vascular significantly reduced the occurrence of total severe events for cardiovascular adverse events with more than 4,700 risk of of the heart, limb or brain and issues related to other events, and are generally occurring in the 6,564 patients vascular complications in patients with symptomatic PAD a very vulnerable population, randomized over three years. who underwent lower-extremity revascularization. The especially in the post-revascularization “There were 342 fewer adverse events findings underscore the broad benefits of this strategy in setting,” Bauersachs said. “Care for these in the rivaroxaban group than in the placebo this high-risk patient population, researchers said. patients is often fragmented because the surgeon group, which translates to an absolute reduction in “To our knowledge, this is the first time that the or interventionalist who performs the revascularization risk of 12.5%,” Bauersachs said. “In a high-risk population, addition of low-dose rivaroxaban to aspirin has been may not follow them for complications or recurrences. that is a big gain in avoiding the need for patients to come clearly shown to reduce the occurrence of both first They deserve to receive optimal treatment to reduce the back with vascular complications.” and total adverse events in patients with PAD who have risk of recurrences.”

The 6,564 study participants experienced a total of 4,714 undergone lower-extremity revascularization but remain vascular events during the study period with 2,301—or at high risk for a heart attack, stroke or recurrent arterial about one-third—experiencing at least one vascular event, “The benefits we saw in the blockage in a limb,” Bauersachs said. “The benefits we saw Bauersachs said. trial for total events were in the trial for total events were statistically significant and VOYAGER PAD was funded by pharmaceutical entirely consistent with those for first events. Rivaroxaban companies Bayer and Janssen, which, in a press release, statistically significant and entirely 2.5mg twice daily with aspirin should be considered as reported that the analysis showed a very high burden of consistent with those for first adjunctive therapy after revascularization to reduce first subsequent events and a consistent 14% reduction in both events” — Rupert Bauersachs and subsequent adverse outcomes.” primary endpoint events and total vascular events over Recent data have shown that, after lower-extremity a median of 2.5 years.

342

12.5%

Boston Scientific and BD initiate venous stent recalls

BY JOCELYN HUDSON

Boston Scientific and BD have both initiated recalls of venous stents. According to a Food and Drug Administration (FDA) medical device recall notice posted May 21, Boston Scientific has recalled its Vici venous stent system (Vici SDS) and Vici RDS venous stent system. In a recall notification dated May 12, BD announced that the company has expanded a safety notice issued earlier this year for the Venovo venous stent system.

THE FDA ANNOUNCEMENT regarding the Vici stent reads that Boston Scientific initiated the recall on April 12 “after reports indicate that the stents may migrate or move from where they are initially implanted.” The FDA has labeled this a Class I recall.

Outlining the risks associated with stent migration, the statement reads:

16 | Vascular Specialist

“A migrated stent may require another surgery or catheter procedure to retrieve it, which increases risks to the patient, including possible damage to the blood vessel, heart walls, or other organs. If the stent migrated to the heart, it could cause life-threatening injury.”

There have been 17 complaints and reported injuries related to this issue, the

notice states, which adds associated with it.” that no deaths have been According to reported.

BD, potential BD has expanded the scope harm includes the of the urgent medical device The Vici following: “prolonging and safety notice issued on Jan. 13 for the procedure, damaging Venovo the Venovo venous stent system or deformity of the stent, venous to include all sizes and lots within potential vascular injury stents expiry date. and/or hemodynamic “BD received reports on the disruption affecting the Venovo venous stent system blood flow and/or a indicating that the proximal end thrombotic event.” In cases of the stent does not immediately expand where the stent self-expanded, the notice upon deployment but remains connected adds, there is no incremental risk to the stent cushion on the delivery of harm. system,” the May 12 statement reads.

While this issue was initially observed It details the potential consequences: on the 14mm diameter product offering, “If the proximal end of the stent does not there have been reported complaints immediately expand upon deployment, across other sizes of the product over-manipulation or forcing the catheter offering since the initial safety notice delivery system, as well as use of other was published. To date, BD has intravascular devices or techniques received approximately 250 reported to assist the stent’s expansion, could complaints across various sizes of the potentially have a varying degree of harm product offering.

June 2021

NEWS BRIEFS

Medicare E&M coding changes and EHR physician burnout

BY ANAHITA DUA, MD, AND PATRICK RYAN, MD

A recent article published in Vascular Specialist summarized data regarding the undeniable relationship between electronic health records (EHRs) and burnout amongst physicians. There is ample irony in the fact that a graph depicting the increased focus on “physician well-being” in 2021 is effectively the inverse plot of a graph showing increased utilization of the EHR. Logic would dictate that if physician burnout were a true priority of the system, the first stop on the journey to increasing wellness would be developing an EHR that is usable for physicians and designed primarily for patient care rather than billing.

T

he EHR was sold to physicians as a tool to optimize workflow when in actuality it is a tool for billing. As a tool for billing, EHRs generally perform well—and therein lies the real problem. Billing is an inefficient and arduous process, requiring clinically irrelevant and superfluous documentation by insurance companies and governmental agencies, and based on clinically irrelevant guidelines. This results in direct patient care being consumed by computer work, causing reduced physician job satisfaction and increased burnout.

Work-life balance is destroyed when weekends, holidays and nights are devoted to catching up on notes and answering menial, but billable, clinical documentation queries.

Regardless of career stage, EHRs impact physicians equally: Junior residents are now spending up to 5.6 hours in front of the computer daily while attendings spend up to 49% of their workday staring at the computer. Even more disconcerting is that U.S. clinicians have a greater EHR burden than any other developed country, something lawmakers and the health system should be considering while simultaneously advocating physician wellness.

Now that the relationship between EHR and burnout has been so clearly established, the next step in taking care of physician wellness should stem from making government-level changes to billing to allow the EHR burden to decrease. It should take fewer clicks than it currently does to prove a doctor did what he or she claimed to have done for a patient.

One such change has been revising the codes for office evaluation and management (E/M) visits.

The 2021 office E/M visit codes (99202–99205 and 99211–99215) underwent their first substantial revision since being implemented in 1992. The reasons and goals for the changes are multifold, but

5.6

Junior resident screen time: hours daily

June 2021

focused on reducing the administrative burden of hollow documentation. In addition, payments were revised to be resource-based and achieve payment parity amongst specialties (i.e., shift payments from physicians who perform procedures to physicians who perform E/M services).

The primary revision was the elimination of specific history and physical exam (H&P) requirements to requiring "medically necessary" H&P. The new guidelines now allow providers to select the level of code based on Medical Decision Making (MDM) or time. MDM elements have not changed, but the definitions have been widely revised. The level one new-patient office visit code has been deleted. Coding based on time requires detailed documentation of the face-to-face and nonface-to-face time related to patient care only on the day of service.

Unfortunately, your local Medicare Administrative Contractor (MAC) may or may not be following the guidelines as published by CPT and accepted by CMS. Private payors are not obligated to follow the new CPT guidelines at all.

While all other E/M codes (e.g., inpatient visits, discharge management) are unchanged for 2021, these codes are currently going through similar review.

Doctors and other healthcare practitioners are burning out at an increasing rate and we know why. It behooves us to do something concrete to decrease rates of burnout by attacking the absurdity of the demands of EHRs and poor usability full-force. The SVS is committed to working, through its Government Relations, Political Action and Coding committees and all its advocacy efforts, to ensure that our voices are heard on the national stage.

ANAHITA DUA and PATRICK RYAN are members of the SVS Government Relations Committee.

Attendings:

49%

of workday

Why donate to the SVS PAC?

BY PETER ROSSI, MD

A few years ago, in his presidential address to the Midwestern Vascular Surgical Society, Mark Mattos, MD, spoke eloquently about the need to “protect our specialty.” A large part of this, he argued, is protecting our patients; no other specialty in medicine can provide the type of comprehensive vascular care that we offer.

THE DAILY REALITY WE ALL FACE IS THE POTENTIAL FOR declining Medicare reimbursement for our services. As a member of the Surgical Coalition, the Society for Vascular Surgery (SVS) is always dealing with Medicare payments being under pressure from the Centers for Medicare & Medicaid Services (CMS) antiinflationary payment policies. While physician services represent a very modest portion of the overall growth in Medicare spending, these services are perennial targets for cuts when policymakers seek to tackle spending.

Although Congress repeatedly intervened to prevent reimbursement cuts to surgeons, Medicare physician payments have remained constrained by a budget-neutral financing system.

Moreover, updates to the conversion factor (CF) have failed to keep up with inflation. The result is that the CF today is only about 50% of what it would have been if it had simply been indexed to general inflation starting in 1998. For calendar year 2022 payments, the SVS will again need its members’ help to address potential reductions in Medicare payments.

This is your Society, and your Political Action Committee (PAC) is here to be the conduit from those of us on the frontlines of vascular disease management to our legislators. Every month the members of the PAC committee write letters, attend online events with legislators and work to make sure that our specialty and our patients are represented.

On average, about 7–10% of our members donate to the PAC annually. Our PAC has been fighting for us for years. And it has had a positive impact in fighting off reduced surgical reimbursement from CMS for our services as recently as last year.

If our Society is going to be able to continue to positively impact legislation, such as the potential CY 2022 Medicare payment cuts, we need your help.

PETER ROSSI is an SVS PAC Committee member.

In Memoriam David Rosenthal, MD, 76, of Marietta, Georgia. A co-founder of the Atlanta Vascular Society and later president of both the Southern Association for Vascular Society (SAVS) and the Georgia Vascular Society, and mentor to many, he passed away on May 18.—Beth Bales

While registering for VAM, donate to SVS Foundation

Members and others registering for the Vascular Annual Meeting (VAM) have the opportunity to contribute to the Society for Vascular Surgery (SVS) Foundation’s continued research, and prevention and awareness efforts.

Registrants will see a box to fill in to make their contribution. Donations fund awards and other important programs to improve vascular care. Visit vascular.org/RegisterVAM21.

Spotlight American College of Surgeons (ACS) Presidentelect Julie A. Freischlag, MD, CEO of Wake Forest Baptist Health and a past president of the Society for Vascular Surgery (SVS), has been named the Triad Business Journal 2021 recipient of the Outstanding Women in Business Special Achievement Award.

Seattle Magazine has named its 2021 top doctors in vascular surgery in the regional area, with eight of the nine selected SVS members. They are Renee Minjarez, MD, Benjamin W. Starnes, MD, Nam Tran, MD, Brian Ferris, MD, Kathleen Gibson, MD, Swee Lian Tan, MD, Matthew Sweet, MD, and Derek Nathan, MD.— Beth Bales

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COMMENTARY

Corner Stitch

This month: Tackling first year Welcome to another installment of Corner Stitch, the home of medical students, vascular surgery residents and fellows looking to tackle the issues that matter most to them, their training and their careers. To contribute, send ideas for the attention of Malachi Sheahan III, MD, the Vascular Specialist medical editor, to bryan@ bibamedical.com. This month, the trials and tribulations of the intern year are under the microscope.

Pearls of wisdom for interns

BY CHRISTOPHER AUDU, MD

It’s June and, in less than a month, a swarm of new faces, and freshly minted MDs and DOs will descend upon most academic teaching hospitals.

MANY WILL JUST BE GETTING used to being called “Dr.” They may look around when first addressed by that title.

They may feel giddy (or terrified) when they place their first order and someone acts on it. Overall, however, they will be…

Eager. Diligent. Cautious. Respectful.

Ready.

These interns are ready to take on the responsibilities of internship, and to handle a suddenly never-quiet pager.

Because surgical internship presents

helplessness or despair. Listening can be therapeutic—sometimes even more so than the scalpel.

As many know, patients with vascular pathologies are some of the sickest in the hospital, and those who have had “routine” procedures require the same amount of vigilance (if not more) as those who have had big operations.

Who are these patients? The fresh amputations, the dialysis access patient with end-stage renal disease (ESRD), the endovascularly-treated peripheral

a mixed bag of emotions and a hidden curriculum, I want to share some aphorisms that helped me through this phase in the hope that it helps some, inspires most, and allays fears.

arterial disease (PAD) patient. These are the patients who can turn on a dime quickly, and, before you know it, a code is being called. Remember that the most significant postoperative complication from vascular interventions is myocardial infarction. Be vigilant.

‘Put the patient first and you’ll rarely go wrong’ If given the choice between checking on that worrisome patient one more time, and calling it a night, go check on the patient. Don’t be afraid to alert your immediate senior to your concerns about a patient. Don’t be afraid to advocate for your patient—even if you don’t know all the answers. Ask for help if you feel overwhelmed. You are rarely alone in the hospital. Surgery is a team effort.

Listen to your patient. Listen with your ears. Listen with your heart. Take note of the little things. Ask about the patient’s dog or cat. Talk to the difficult patient. Often, you’ll find their difficulty to be a facade for fear, loss of control, 18 | Vascular Specialist

‘In the race to average, enthusiasm will set you apart’ With every gain in medicine, you become more of the average. The top college student becomes the average medical student. The top medical student finds that they are now an average intern among other stellar interns. Remember that you are enough. I repeat you are enough.

Being enthusiastic does not mean being insufferably Pollyanna-ish, but it does mean that you show up. Be punctual. Be reliable. Be honest. Be humble. Own your mistakes. Read. The more people can rely on you, the more responsibility you’ll

gain, the more you’ll learn and the more goodwill you’ll build. Which leads me to my next point…

‘Your reputation is built in the first 3–6 months of residency… and it will follow you until graduation’ First impressions count in surgery. Work diligently and with humility with the allied health professionals, operating room (OR) and nursing staff. Most will want to help you succeed. Questions posed with the intention of gaining knowledge are always welcome… and honestly, most people want to teach you about their job. Build a solid reputation now, and like a bank deposit, it will offer you the trust you will need from your attendings and senior residents in the future.

‘Work on your craft’ You will suck at first in the OR—and that’s normal. Especially that first time when the senior resident looks up at the

Work diligently and with humility with the allied health professionals, operating room (OR) and nursing staff. Most will want to help you succeed end of a case, mumbles “You got this?” and de-scrubs, leaving you with a 12cm wound to close. It’s OK to suck at first.

The key is to keep improving.

Grab supplies and practice at home.

Practice knot tying and throwing knots— one-handed, two-handed, nondominant handed. Practice with Castro Viejos.

Repeated exposure and practice is the key to surgical training.

‘To thy known self, be true’ Wellness efforts are rampant these days and sometimes it’s reduced to a

buzzword. Take care of you. Surgical residency is a marathon, and not a sprint.

Know your limits, ask for help, take that vacation, go see that family. Residency is hard enough. Make friends and don’t go it alone, if you can help it. Don’t forgo family. Save money if you can. Get a low-maintenance pet. Be forthright with your PD if you need time off for personal reasons.

‘Pay it forward’ All of a sudden, with a medical degree behind your name, you’ll find that, in the presence of a student, you won’t be the first person called to answer a question in the OR anymore. The great thing about having gotten this far, is that you’ve likely observed some great teachers and some lousy ones.

Now it’s your turn. Most students are not looking for you to solve all of surgery.

Most are happy if you include them in patient workup and/or tasks. It’s not difficult to impart what you do know to your juniors. Take them aside when you

have a down moment and do mock oral sessions helping them prepare for their exam. Point out ‘shelf-worthy’ pearls pertinent to vascular and/or general surgery. If you are able to, pay for the med student’s lunch or dinner when they’re with you on call. It’s the little things that count.

In the end, surgical residency will always demand more and more of you.

July will have its learning curve. You must protect the greatest asset that you cannot get back: time.

With this, I hope you’ll be encouraged on your first call shift in July knowing that you’re not alone and many of us (even those of us not at your institution) are just an email or phone call away, and are willing to help.

CHRISTOPHER AUDU is an integrated vascular surgery resident at the University of Michigan in Ann Arbor, Michigan.

June 2021

TCAR

TCAR vs CEA: Research shows fewer myocardial infarctions after TCAR with use of general anesthesia

BY BRYAN KAY

A Vascular Quality Initiative (VQI) analysis uncovered a reduction in the risk of myocardial infarction after transcarotid artery revascularization (TCAR) compared to carotid endarterectomy (CEA) when general anesthesia is used—an observation mainly found in patients with symptomatic carotid artery stenosis.

THE FINDINGS, RECENTLY published in the Journal of Vascular Surgery, suggest that general anesthesia use would most likely benefit patients with symptomatic carotid artery stenosis due to the decreased risk of myocardial infarction if they are treated with TCAR instead of CEA, the study authors conclude.

The investigators behind the research include first-named author Rebecca A. Marmor, MD, and Mahmoud Malas, MD, who are, respectively, fellow and chief in the division of vascular and endovascular surgery at the University of California San Diego in La Jolla. Marmor, Malas—the site principal investigator (PI) for the ROADSTER 1 and ROADSTER 2 multicenter trials of TCAR—and colleagues set out to understand the impact of anesthetic choice on perioperative

June 2021

outcomes among patients treated with TCAR and CEA. Though most carotid revascularization procedures are performed under general anesthesia, “prior authors have hypothesized that increasing numbers of TCAR procedures will be performed under local/regional anesthesia as surgeons’ comfort-level with the procedure increases,” they stated.

The researchers obtained all consecutive patients undergoing TCAR with the ENROUTE Transcarotid Neuroprotection System and CEA between 2016 and 2019 from the VQI TCAR Surveillance Project trial. A total of 8,132 TCAR and 57,205 CEA cases were identified, including both symptomatic and asymptomatic patients. Some 93% of CEA procedures were performed under general anesthesia, compared to 81% of TCARs. No significant

association was observed in the risk of stroke or death after TCAR and CEA and the choice of anesthesia, the authors found.

However, compared with CEA under general anesthesia, equivalent patients undergoing TCAR had a 50% decreased risk of myocardial infarction (0.5% vs. 1.0%; relative risk [RR], 0.50; 95% confidence interval [CI] 0.32–0.80; p<0.01), “which was driven by risk reduction” among symptomatic patients only (0.4% vs. 1.2%; RR, 0.33; 95% CI, 0.15–0.75; p=0.01), they discovered.

The study also demonstrated there was no difference in risk of myocardial infarction among asymptomatic patients treated under general anesthesia (0.6% vs.

0.9%; RR, 0.64; 95% CI, 0.37–1.14; p=0.13).

“On the other hand, when performed

under local anesthesia, TCAR and CEA had similar risk of myocardial infarction independent of symptomatic status (0.3% vs. 0.4%; RR, 0.82; 95% CI, 0.18–3.7; p=0.80),” the researchers outlined in their findings.

“When carotid revascularization is performed under general anesthesia on an asymptomatic patient, TCAR and CEA appear to have equivalent risk of postoperative myocardial infarction,” they state. “However, when revascularization is performed under general anesthesia on a symptomatic patient, TCAR offers a decreased risk of postoperative myocardial infarction as compared with CEA, despite the fact that more patients in the TCAR group had coronary artery disease.”

SOURCE: DOI.ORG/10.1016/J. JVS.2021.03.037

Transcarotid artery revascularization (TCAR)

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