Vascular Specialist–November 2021 by BIBA Publishing

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Vol.17 No.11 NOVEMBER 2021 Official Publication

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DISINFORMATION The truth hurts but the lies are killing us

SURGICAL SKETCHES The power of art in communicating surgery

CMS CUTS Professional Measures Committee responds

OPEN REPAIR

IN GOOD HANDS? The twin issues of center volumes for open AAA repair as well as training implications came under the spotlight at two recent regional vascular conferences BY BRYAN KAY

THE VOLUME OF ELECTIVE open abdominal aortic aneurysm (AAA) repairs that medical centers perform directly correlates with the outcome measure “failure to rescue,” or in-hospital death after a patient experiences a complication—with a nearly 10% decreased risk evident for each additional five cases per year an institution performs, the New England Society for Vascular Surgery (NESVS) annual meeting (Oct. 15–17) in Cape Neddick, Maine heard. The findings were part of an analysis of all elective open AAA repair procedures included in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) between 2003 and 2020. Against a backdrop of debate over the annual center volumemortality relationship and varying minimum procedure volume recommendations, the researchers behind the VQI study identified failure to rescue as “an attractive alternative outcome measure” due to the fact it judges overall team and hospital system performance, and is a composite measure, therefore “is less sensitive to riskadjustment errors and may further improve discriminations for interhospital quality comparisons.” The work was led by senior author David H. Stone, MD, a

Julie A. Freischlag becomes American College of Surgeons president BY BRYAN KAY Newly installed American College of Surgeons (ACS) President Julie A. Freischlag, MD, called for her fellow surgeons to apply the principles that underpin enhanced recovery as medicine begins to emerge from the COVID-19 pandemic. The former Society for Vascular Surgery (SVS) president made the plea during her presidential address before the 2021 ACS Clinical Congress (Oct. 23–27), held virtually. “As leaders and as surgeons, COVID-19 has brought a storm of challenges we never could have imagined—from delays in elective procedures to redeployment of staff, financial strain and new safety practices,” said Freischlag. “There also have been silver linings where we have seen the most amazing acts of bravery and teams come together stronger than ever,” added the chief executive officer of Wake Forest Baptist Health, dean of Wake Forest School of Medicine, and

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FROM THE EDITOR

The truth hurts but the lies are killing us BY MALACHI SHEAHAN III

This is the first installment of a twopart editorial examining the role of fake news and science denial in the COVID-19 pandemic. IN MARCH 2019, THE FIRST WAVE OF THE COVID-19 pandemic hit an unprepared New Orleans hard. Hospitalizations and deaths soared unabated. But as the city had done so many times in the past, we came together. We took our medicine. Masks, social distancing, and shutdowns—bitter pills for a place where the economy is based on tourism and the culture is built on community. The city had survived worse. Fires and floods have destroyed the infrastructure here many times over. But like all great places, what makes New Orleans special isn’t the buildings—it’s the people. Resilience and rebirth are in their fabric. So the subsequent outbreaks of COVID-19 seemed self-limited. In Louisiana, we can teach our children the English alphabet from hurricane names and now the Greek alphabet from COVID-19 variants. The current fourth wave, though, seems different, darker. The numbers are even bigger. On Aug. 21, 2021, one in 1,500 Louisianans are hospitalized with COVID-19. The majority of these patients are unvaccinated. Children are getting sick at an alarming rate. Maybe this time we didn’t all come together. Some of us didn’t take our medicine. Everyone versus the virus started to seem like us versus them. The first wave forced us to come together. We buckled down. Physicians retrained to help in the overwhelmed emergency rooms and intensive care units.

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 Assistant Marketing & Social Media Manager Kristin Crowe

2 | Vascular Specialist

Some of us became line teams, putting an endless number of patients on dialysis. We reused our PPE, storing our trusty N-95 masks in paper bags for unclear scientific reasons. We took near chemical showers to prevent bringing the virus home to our families. Some of us even learned to recognize that look in our spouse’s eye that said, “I am homeschooling three boys, do not ATTEMPT to complain about your day.” As doctors, though, we did our job. We really did our job. Physicians need to delicately balance empathy and depersonalization to be effective. If the pendulum swings too far in one direction, our patients suffer, as will we along with them. What happens to our well of empathy when the disease we are facing is entirely preventable? Our actions—which felt heroic at the start of the pandemic—now seem futile. These new deaths were avoidable, so somehow even more tragic. Conspiracy theorists claim the original COVID-19 virus was manmade; well, the fourth-wave surge of the Delta variant certainly was. Science denial is nothing new. We have seen it from the tobacco industry, fossil fuel companies, and even electronic health record (EHR) vendors. Their stance is easy to understand. Create doubt and block consensus. When “the jury is still out,” profit follows. What about when science denial serves no apparent benefit? What about when it is harmful or even fatal? The spread of misinformation during the COVID-19 pandemic has been so widespread that the World Health Organization (WHO) labeled it an “infodemic.” To combat the disinformation, physicians need to lead. In the office, in the community, even on social media. First, we need to understand where the misinformation is coming from and why so many people believe it. And then perhaps the most significant test: How do we convince the doubters? Our society is overrun with pseudoscience. Chiropractors, holistic healers, and herbalists promote dubious benefits. Homeopathy claims efficacy through quantum physics (?!). Colonics provide a strikingly unpleasant example of the trust some will place in fake remedies. Think of the “male enhancement” industry, with regular national TV ads featuring celebrities and retired athletes. These ginkgo biloba delivery agents can’t actually promise any specific results, so they are given pornographic names like Malestrom, Lengthergize and others that can’t be mentioned in a family publication like

Vascular Specialist. At the start of the pandemic, much of this pseudoscience seemed quaint or silly, but now thousands are dead. As information gains new pathways, so does misinformation. Fake news is as old as the news itself. Thomas Jefferson once lamented: “Nothing can be believed which is seen in a newspaper. Truth itself becomes suspicious being put into that polluted vehicle.” Jefferson didn’t have to look too far for evidence. Co-Founding Father Benjamin Franklin would frequently write fabricated accounts of murderous Indians working with the British troops. Fake news has always been profitable. The New York Sun published a popular series about an alien civilization on the Moon in 1835. More recently, journalist Craig Silverman discovered that 140 popular fake news sites all emanated from a small city in Macedonia. Here, a bunch of teenagers were getting rich publishing stories with headlines like “Obama’s Ex-Boyfriend Reveals Shocking Truth That He Wants To Hide From America”. Traditional media coverage can be skewed even while factual. Think of the focus on anti-maskers and antivaxers, even though both healthcare measures have broad support among the population. While more than 3,600

Conspiracy theorists claim the original COVID-19 virus was manmade; well, the fourth-wave surge of the Delta variant certainly was continued on page 4

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November 2021

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MEDICAL

FROM THE EDITOR

The truth hurts but the lies are killing us

as a package deal. Indeed, once the pandemic became political, it seemed that we were doomed. Research from the University of Strathclyde in Glasgow, Scotland, by Stephanie Preston et al demonstrated that individuals are more likely to believe a fake news story if they have personal experience with the subject matter or if the report confirms one of their preconceived opinions. Stories that uncover a “hidden problem” or that use numeric graphs are particularly effective. The researchers also found that emotional intelligence was protective. This is a key finding because emotional intelligence can be learned. Next month, in part two of this editorial, we will discuss how fake news stories are constructed and methods for communicating with patients who embrace science denial.

continued from page 2

healthcare workers died of COVID-19 during the first year of the pandemic, the most shared story on Facebook from January to March 2021 concerned whether the vaccine had led to the death of a physician. The press seems especially interested where vaccines fail. Think about how often we learn precisely how ineffective the annual influenza vaccine is, versus how many lives it saves. Of course, fake news can’t spread without an audience. In 1620, Francis Bacon wrote that one of the main barriers to learning the truth was that humans are more likely to believe facts that fit our preconceived notions—a psychological phenomenon we now refer to as confirmation bias. As social groups form and need to feed their preconceived notions, an ecosystem develops to provide this material for profit. It is often said that humans are social animals. So much so that those who eschew community are labeled with a psychiatric diagnosis (Avoidant Personality Disorder, ICD9 301.82). But the need for a group can be pathologic as well. Humans fear social death more than actual death. Shame and embarrassment are two of the most powerful emotions. Suicide bombers, the tragedy at Jonestown, and the Japanese tradition of seppuku are just some examples of individuals choosing physical death over social. Our communal groups are defined more than ever by social media. Former Facebook manager Tim Kendall testified to Congress that his company “took a page from Big Tobacco’s playbook, working to make our offering addictive from the outset.” He stated that they used the term engagement as a euphemism for the addictive properties of the medium. “The social media services that I and others have built over the past 15 years have served to tear people apart with alarming speed and intensity.” While tearing some apart, social media can also build

References

Think about how often we learn precisely how ineffective the annual influenza vaccine is powerful social groups. So strong are these connections that their members would rather risk death than expulsion. For some groups, vaccine hesitancy is ingrained. In Native and African Americans, we reap the consequences of our historical sins. Other groups argue that mask and vaccine mandates are threats to “American Freedom”—a claim also used by the tobacco companies against government regulation of their product. So while Patrick Henry exclaimed, “Give me liberty, or give me death!” in 1775, in 2021, they apparently come

1. P reston S, Anderson A, Robertson DJ, Shephard MP, Huhe N. Detecting fake news on Facebook: The role of emotional intelligence. PLoS One. 2021 Mar 11;16(3):e0246757 2. Fleming N. Coronavirus misinformation, and how scientists can help to fight it. Nature. 2020 Jul;583(7814):155–156. 3. Caulfield T. Pseudoscience and COVID-19—we've had enough already. Nature. 2020 Apr 27. 4. https://www.niemanlab.org/2019/06/yes-itsworth-arguing-with-science-deniers-and-hereare-some-techniques-you-can-use/ 5. https://www.scientificamerican.com/article/to-understandhow-science-denial-works-look-to-history/ 6. https://www.nytimes.com/interactive/2021/05/20/ opinion/covid-19-vaccine-chatbot.html 7. https://www.theguardian.com/books/2019/nov/22/ factitious-taradiddle-dictionary-real-history-fake-news 8. https://www.bbc.com/news/blogs-trending-42724320 9. https://www.politico.com/magazine/story/2016/12/ fake-news-history-long-violent-214535/ 10. https://www.americanpurpose.com/ articles/a-short-history-of-fake-news/

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.

‘Do not blame the legal system for the present state of medical malpractice’

In last month's guest editorial, Andrew J. Meltzer took aim at medical liability in vascular practice

BY O. WILLIAM BROWN, MD

I read with both interest and disappointment Dr. Andrew J. Meltzer’s guest editorial regarding medical malpractice published in the October issue of Vascular Specialist. He unfortunately chose the often traveled, but dead-end road of blaming the legal system for the current state of the medical malpractice system. This approach neglects the basic tenets of medical malpractice law. TO FILE A MEDICAL MALPRACTICE lawsuit, an attorney must show that the defendant physician had a physician-patient relationship with the patient, violated the standard of care, that the violation was responsible for the damages, and that the plaintiff did, in fact, suffer damages. The critical component of these requirements, in almost all cases, is the testimony of an expert witness who establishes the violation of the standard of care. This testimony is provided by a physician, not an attorney. Yes, one of our “colleagues.” 4 | Vascular Specialist

explain why they are not filing the suit and suggest the client seek another legal opinion. He/ she cannot tell the client that there is no case. To do so would constitute legal malpractice. For many years, I have encouraged my colleagues to report marginal testimony to the appropriate authorities or societies. However, to my disappointment, this is rarely done. I have suggested that deposition testimony be presented as part of the program of the national society meetings but have been told that to “shame” these doctors would be inappropriate. I disagree. A physician

O. William Brown

If there is no expert, as a matter of law, the case must fail. Do you really believe attorneys can determine whether the standard of care has been violated? They rely on physicians. It is true that attorneys may shop around for a physician who will support their case, but, like it or not, that is their job. An attorney who has an injured client, and is informed by an appropriately credentialed physician that the injury was the result of negligence by the treating physician, must either file a lawsuit or

should be willing to defend his/her testimony to their colleagues, or perhaps should not testify. Do not blame the legal system for the present state of medical malpractice. Physicians need only look in the mirror to find the real source of the problem. Unfortunately, Dr Meltzer, you have no case. O. WILLIAM BROWN is a professor of surgery at Oakland University/William Beaumont School of Medicine, Auburn Hills, Michigan, and an adjunct professor of law at Michigan State University College of Laws, East Lansing, Michigan. November 2021

OPEN REPAIR

COVER STORY

IN GOOD HANDS? continued from page 1

exponential, with a 24-fold relative risk increase being present.” In terms of specific types of complications and the predicted risk of failure to rescue, Scali and colleagues found that renal complications had the lowest predicted rate. By comparison, a postoperative cardiac complication had a nearly three-fold higher risk, while a return trip to the operating room (OR) for bleeding was associated with a nearly 12-fold increased risk compared to a renal complication. “Center volume does appear to be an effective proxy for quality given its strong association with failure to rescue,” Scali concluded. “A majority of centers fail to meet SVS-endorsed volume thresholds, which may have implications for outcome reporting and inter-hospital comparisons. Crude volume-based comparisons alone may be suboptimal in discerning high-quality AAA care among centers nationally.”

resources in these low-volume hospitals need to be focused.”

Future of open aortic education At the Western Vascular Society (WVS) annual meeting (Oct. 16–19) in Jackson Hole, Wyoming, meanwhile, a research team from Stanford University, California, presented data on the future of open aortic education, finding that with the incidence of open AAA repair decreasing nationally, practice shifting toward teaching hospitals, and opportunities for training declining amid the continuing adoption of endovascular aneurysm repair (EVAR), “open aortic Elizabeth reconstruction for aortoiliac occlusive George disease is rising among trainees.” Delivering the results, Stanford vascular surgery chief resident Elizabeth George, MD, told WVS attendees: “Just from our back-of-the-envelope calculations and looking at national volumes, these aortic volumes, at least from those at teaching hospitals, are adequate to meet graduation requirements. However, strategies to maintain and maximize the education as well as the experience from these cases should be top priority for vascular surgery program directors.” George and colleagues set out to explore how evolving endovascular technology has transformed open aortic surgical education. To do so, they probed the National Inpatient Sample (NIS) for open AAA repair as well as aortoiliac occlusive disease estimates between 2006 and 2017. They also looked at Accreditation Council for Graduate Medical Education (ACGME) case volumes for the same procedures among vascular surgery residents and fellows graduating during the same time period. In the NIS, George and colleagues found significant decreases in volume for both total open aortic repair volume and open AAA, with open repair for aortoiliac reconstruction seeing a far less steep decline. Meanwhile, the ACGME data showed that in 2006, graduating fellows could claim an average of 19 open AAA repairs, George reported. However, this figure had dropped to 11 by 2017. On the other hand, the equivalent statistic for aortoiliac occlusive disease increased over the same time span, she said. Data derived for those in integrated vascular surgery residency told a similar story, she added.

professor of surgery and program director at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and Salvatore Scali, MD, a professor of surgery and program director at the University of Florida in Gainesville, Florida, who delivered the findings before the NESVS meeting. Context of failure to rescue The team set out to measure the impact In an interview with Vascular Specialist, Scali said of failure to rescue on elective open AAA the varying open repair volume thresholds posed repair outcomes and its association with for optimal care begged the question: “Is there a center volume, as well as to determine the better way?” Regionalization of aortic care, while factors associated with failure to rescue. The David Stone worthy, works in small countries with single-payor analysis was performed on data from 218 VQI systems and “relatively monochromatic societies,” hospitals. Some 9,700 open repairs were retrieved, with but less so in continental-sized countries and markets in 32% found to have at least one postoperative in-hospital the form of the U.S., he said. complication recorded. Among the 3,176 patients Furthermore, there are low-volume centers “that experiencing a complication, 10% died in hospital— perform well, that don’t meet the thresholds” but on representing the failure-to-rescue cohort, Scali explained. average can deliver quality care, Scali continued. “How “We determined that older patients, and women, as do you align so that when you go to a lower-volume well as subjects with higher comorbidity burden, larger hospital, you know you are going to get high-quality AAA diameters, and any history of prior aortic surgery care? How do you make the lower-volume centers look were all significantly more likely to be present among like the higher-volume centers?” the failure-to-rescue cohort,” Scali told those gathered. That’s where failure to rescue comes in, Scali said. Technical differences were also noted between the two “There are so many ancillary services required, and, most groups, he added. Recommended adjuncts including importantly, that postoperative care—the surveillance decreased epidural use occurred in the failure-to-rescue that occurs both in-hospital and out-of-hospital—and cohort, while variables associated with greater operative having robust processes of care are probably the biggest complexity and greater blood loss were more common determinants of the outcome.” Surgeon-level factors, among the same group. too are important, “but if you really want to align these Unadjusted analysis showed center volume was lower-volume hospitals with higher-volume hospitals you inversely associated with failure-to-rescue rates: There have to target metrics that measure team performance.” was a 9% decrease in risk for each additional five procedures per year a center performed, “Crude volume-based Scali said. Some 73% of VQI centers performed less than 10 open repairs ‘Refreshing’ data comparisons alone may be per year—the current SVS-endorsed Designated discussant Benjamin W. Starnes, MD, the suboptimal in discerning highvolume threshold. Yet, Scali pointed vascular surgery chief at the University of Washington out, they accounted for around a third in Seattle, called the data presented by George and quality AAA care among centers of all open AAA repairs nationally. colleagues a “refreshing” interlude amid previous nationally” – Salvatore Scali “When adjusting for demographics, forecasts spelling out “doom and gloom” in light of Salvatore Scali comorbidities and procedure-related vascular trainees not gaining enough open surgical factors, patients undergoing elective open AAA repair at experience in order to achieve competency. “Facing an centers performing more than 10 AAA repairs per year These new results help characterize patterns of increase in vascular disease, an aging population and the had a 50% reduction in the likelihood of experiencing complications—particularly those deemed high silver tsunami, better cancer therapies and patients failure to rescue,” he continued. risk, Scali added. “Where [our study] sheds new surviving longer to develop vascular disease, and When exploring the association between the number light—yes, the volume-outcome relationship more minimally invasive methods to treat these of postoperative complications and subsequent is known—is that failure to rescue further patients, we’ve now grown at the University of probability of failure to rescue, “significant differences” validates this based on our dataset. But, more Washington from six to 16 vascular surgeons were detected. For example, if a patient experienced importantly, if low-volume centers are going to in just 15 years,” he said. “Our open experience two postoperative complications, they had a more than continue to do this work, they might want to Benjamin W. has only increased for our trainees rather than three-fold likelihood of experiencing failure to rescue develop processes of care that target very highdecreased.” Starnes compared to a patient suffering a single complication, the impact complications, for one. Starnes placed this into context with data from researchers found. “As we’ve shown in our work, things like a return his institution for the last year: He found that 38% of “This difference is further amplified when looking to the OR for bleeding, or patients who have a the aortic cases with which he was personally involved at patients experiencing two vs. three or more postoperative pulmonary complication, to name a couple were open repairs, and went on to ask George how other complications,” Scali said. “Specifically, a seven-fold of high-profile complications;those are key patients that, types of exposures should be counted toward open aortic increase in predicted risk of failure to rescue occurred when those complications occur, are at the highest risk surgery for the ACGME. in patients experiencing three or more complications of having a downstream event that leads to failure to “Since vascular surgery itself has evolved over the when compared to those cataloged as having two rescue and in-hospital death. So, you would want to do past 20 or 30 years, I think the metrics with which we complications. Finally, the difference between a single everything you can to reduce the risk of those events. measure our trainees should also change in kind,” complication and three or more complications was And if those events did occur, those are where the she said. 6 | Vascular Specialist

November 2021

AORTA

Community practice surgeons report improved rAAA survival after adoption of EVARfirst approach Overall survival improved from 71% to 80% after a group of community practice surgeons started using an endovascularfirst approach to ruptured abdominal aortic aneurysm (rAAA) repair.

cott S. Berman, MD, a vascular surgeon at Pima Heart & Vascular in Tucson, Arizona, revealed the finding during a rapid-fire presentation offering a look at his practice’s experience with rAAAs in the private community setting during the Western Vascular Society (WVS) annual meeting in Jackson Hole, Wyoming (Oct. 16–19). Berman and colleagues carried out a retrospective review of their prospectively collected Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) data, pointing out the unusual nature of the community practice-setting metric. Against a backdrop of rAAA mortality rates running as high as 50%, Berman said his research team looked at

Julie A. Freischlag becomes president of American College of Surgeons continued from page 1

chief academic officer of Atrium Health Enterprise in Winston-Salem, North Carolina. Titling her address “#SurgeonsSowingHope,” she said she planned to encourage fellow ACS leaders to create either a one-minute podcast, video or social media post using the hashtag in order to share enhanced recovery thoughts as “we go forward beyond the pandemic” during the year of her presidency. “Hope for improved health is a driver behind enhanced recovery after surgery— enhanced in its various forms means to improve the quality of, or strength of, to make better, and to educate and enlighten,” she told ACS Clinical Congress attendees. “Its very essence is captured by this care approach, which aims to medically optimize the health and safety of patients before surgery on day one and throughout the continuum of care. ”Enhanced recovery after surgery has proven benefits,” Freischlag continued. ”It is associated with improved patient outcomes and safety, reduced hospital stays and readmissions, shorter recovery times, and lower costs. November 2021

their practice during two distinct two] with pretty good survival as periods: from January 2011 to well. Despite a lot of positive December 2015 (group one) trends with our survival rate, prior to the adoption of an the only variable that was endovascular aneurysm repair statistically significant was (EVAR)-first approach to rAAA, ICU [intensive care unit] stay and from January 2016 to greater than three days, which December 2020 (group two), was much higher with open after the move to adopt an repair (p<0.05). We had some EVAR-first protocol. trends: The probability of The researchers analyzed death was higher with open open repairs and EVARs repair; time to extubation was carried out over the two periods, higher with open repair; and any scrutinizing data elements common post-op complication was higher to both and undertaking comparisons with open repair.” with univariate and multivariate Berman concluded: “Our analyses. outcomes with an endovascular-first The data showed 10% of the approach are certainly superior to “You need a 24/7 456 aneurysm repairs his practice historically quoted outcomes for vascular call team. undertook were rAAAs—equating to rAAA. The real challenge is defining You either need to have an appropriate center of excellence 41 overall, Berman reported. With 21 repairs completed in group one and for management of ruptured an array of devices 20 in group two, the results showed a is certainly on hand, or you have aneurysms—this survival rate of 67% vs. 88% for EVAR evolving. We think it’s pretty simple: to have reps available You need a 24/7 vascular call team. and 73% vs. 33% for open repair over the two time periods. Furthermore, You either need to have an array who can provide overall survival was 71% vs. 80% devices on hand, or you have emergency devices” of between groups one and two, Berman to have reps available who can — Scott S. Berman told WVS attendees. provide emergency devices. And it’s “You can see there is definitely an really not dependent on the title of improvement in survival with the academic vs. community practice. endovascular approach,” Berman Hopefully, the combined project commented. “In group two, we did 17 vs. three open between the SVS and the American College of Surgeons compared to group one [which saw 15 open vs. six [ACS] in defining vascular center certification will help EVAR]. We had decent long-term follow-up at 12 months objectively define appropriate levels of care for [76% overall; and 82% in group one vs. 75% in group each center.”

Through a combination of evidence-based guidelines based on patient education and engagement, multidisciplinary teamwork, screening tools, nurse navigation and patient champions, the whole patient is supported throughout the surgery journey and beyond through recovery.” Freischlag pointed to two recent studies published in the Journal of Vascular Surgery as examples of the benefits that can come from enhanced recovery applications. Among lower-extremity bypass patients in an enhanced recovery program, there was a decreased length of stay of 8.32 vs. 11.14 days and reduced variable costs of $13,208 vs. $18,777 compared to those who were not. And in a study of patients undergoing abdominal aortic aneurysm (AAA) repair, enhanced recovery protocol was associated with a reduced time to discharge of five days, compared to 8.4 days among patients undergoing standard open surgery. “Both of these studies have what I consider the most important element of enhanced care: a multidisciplinary team at the core,” said Freischlag. “Enhanced recovery is a thing we can apply on an even larger scale as we begin to emerge from the pandemic. Many of the same principles that underlie this approach to optimization—collaboration, compassion, inclusion, engagement and innovation—can guide us as we heal, recover and lean forward.” Freischlag then asked: What has COVID-19 done for us? The list is not long, she conceded, but silver linings include enhanced communication capabilities,

telehealth advances and improved work flexibility. During the pandemic period, the medical profession has seen reports of 52% of surgeons suffering burnout, 41% of adults delaying or avoiding medical care, and 34% of COVID-19 deaths among African-American patients, Freischlag noted. She contended the key to recovery might lie in the values that underpin enhanced recovery—like compassion, inclusion and innovation. “The pandemic created a paradigm shift, pushing us to innovate quickly,” she said. “Telehealth

“When we open opportunity and empower others, our teams become stronger, and together we go further” — Julie A. Freischlag

emerged as a safe, convenient and lowercost alternative to in-person visits, while still allowing us to engage with and include patients in their care.” Freischlag shared how a racial equity task force was started at her hospital during the pandemic, bringing together leaders, staff, students and community members focused on “positive change.” At the heart of enhanced caring is compassion, she said, with studies pointing toward many associated benefits, including improved patient outcomes, reduced costs, time savings, and lower levels of physician burnout. Research shows that more than half of physicians believe they don’t have time for compassion, Freischlag continued. Yet, the same findings show that “it takes only 40 seconds to create a meaningful connection with a patient,” she said. “This made me think, ‘What can I do in just 40 seconds to make a compassionate connection and difference?’ For me, it’s treating patients how I would want my own family treated, and asking, ‘How do you feel?’ and ‘What are you hoping for?’” Enhanced care and recovery necessitate “true teamwork based on communication, trust, transparency and opportunity,” Freischlag concluded. “When we open opportunity and empower others, our teams become stronger, and together we go further.” She also encouraged self-care. “Surgery is a rewarding but demanding profession, and, as a recent New York Times article shared, we need to find ways to flourish.” vascularspecialistonline.com | 7

NEW ENGLAND

Reemerging from the pandemic: ‘What truly motivates us?’ BY BRYAN KAY

How to find “flow” and motivation through goal setting and reacquainting with “intrinsic priorities” on the other side of the COVID-19 pandemic formed the basis of the presidential address delivered by Alan Dardik, MD, at the New England Society for Vascular Surgery (NESVS) annual meeting in Cape Neddick, Maine (Oct. 15–17). DARDIK SPOKE OF HOW THE VIRUS HAD highlighted the necessity of humility and actually harbored two pandemics: one of SARS-CoV-2 itself, the other “ignorance, stupidity and denial.” Yet, as the pandemic rumbles on into the distant future, the Yale School of Medicine, New Haven, Connecticut, professor of vascular surgery posed the question of how to restart? “How do we carry on?” Dardik asked the NESVS gathering. “How do we establish our new normal? Indeed, what is normal now? How do we get back to our lives? Do we want to go back to our previous lives? How do we determine what are our new lives and habits? How do we restart?” Quoting the book Drive by Daniel Pink, Dardik pondered its practical lessons for life in a post-COVID-19

world. “We must set our own goals and remember our own intrinsic priorities,” he said. “For us, New England vascular surgeons, I believe this is relatively straight forward: Be the best surgeon you can be. Do not focus on your compensation, but remember why you entered this noble, revered, sacred profession: to help others and advance the art and science of healing for patients with vascular disease. In these paths, nothing has changed during the pandemic; we need to continue to focus on our goals and direct our own lives; this is autonomy. We need to extend and expand our capabilities, mastery. And we need to live a life of purpose.” Dardik turned to the concept of “flow,” describing it as a state of being “totally invested” in an experience without consciousness of time—such that “if you have lost track of the time during this address, then you are in flow right now,” he told those gathered. “As surgeons we all feel flow when the operation goes, and seven hours pass without a thought or an attention to the phone ringing or even an urge to eat or pee; it is why we are all terrible judges of the time we spend in the case,” Dardik explained. “It is what we all hope to feel, and what my father told me is the best part of the day. I also tell my students that operating is truly an escape from the outside world and a sincere pleasure. My wife can tell from the look on my face when I come home what I was doing that day; being a surgeon in the operating room, in flow, helping another person through their vascular issues, saving limb and life. This is why we all do this.” To the question of restarting then? He offers not an answer but a suggestion: Get into the operating room and get lost in flow. “If you do not spend much time in the

“Do not focus on your compensation, but remember why you entered this noble, revered, sacred profession” — Alan Dardik

Ontario carotid endarterectomy registry risk model provides reliable predictions of stroke and death following surgery BY SARAH CROFT

The Ontario carotid endarterectomy registry (OCER) model was found to be the most reliable predictor of stroke or death after carotid endarterectomy (CEA) among 17 models assessed. This was the primary finding of a systematic review published in Stroke by Michiel Poorthuis, MD, of the department of neurology at University Medical Center Utrecht, The Netherlands, and colleagues. THE RISK OF PROCEDURAL DEATH or stroke determines the net benefit of CEA. Current guidelines recommend CEA if 30-day risks are <6% and >3% for symptomatic stenosis and asymptomatic stenosis in patients. The systematic review by Poorthuis and team—whose senior

8 | Vascular Specialist

authorship included Marc Schermerhorn, MD, chief of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston—aimed to identify and externally validate prediction models for procedural death or stroke, in a registry of patients from the U.S.

Alan Dardik

operating room or with patients, as some career directions sometimes evolve, then find your activities that give you flow,” Dardik said. “Identify when you are naturally in your flow state. Learn how to get into it by working backwards. Understanding the benefits of flow can reinforce the habit. And start trying to shift into your flow state on purpose. Time is our most precious commodity. We cannot invent more of it. We can make more money, exercise to gain strength, even make or adopt or marry into more family members. We can buy another home and certainly fill it with more ‘stuff.’ We can learn a new skill. But we cannot make more time.” The quest to continually reinvent vascular surgery to provide empathetic, patient-oriented, and personalized care to patients carries on regardless, Dardik added. “We can restart our lives not after the pandemic, but right now, as the pandemic continues. We can achieve flow and all else will follow.”

A total of 788 reports were screened, Out of the 26,293 patients, 702 (2.7%) with 15 studies consisting of 17 prediction developed a stroke or died within 30 days. models of procedural outcomes after The range of C statistics varied across CEA included within the systematic all patients (0.52–0.64). Symptomatic review, through MEDLINE and EMBASE. patients’ C statistics were between The models were validated with patient 0.51–0.59 and 0.49–0.58 in asymptomatic data from those who received CEA from patients. The OCER model, consisting 2011–2017 in the American College of symptomatic status, diabetes, heart of Surgeons National Surgical Quality failure, and contralateral occlusion as Improvement Program. Using C statistics predictors, had C statistic of 0.64, with the and calibration graphically, discrimination strongest concordance between predicted was assessed. Additionally, the and observed risks. Furthermore, number of patients with the findings displayed the predicted risks that exceeded OCER model identified 4.5% OCER recommended thresholds of of symptomatic and 2.1% model procedural risks to perform of asymptomatic patients reliability CEA were determined. with procedural risks that Out of the 17 prediction exceeded recommended models, nine were developed thresholds. In conclusion, in populations including out of the externally both asymptomatic and validated prediction symptomatic patients, models (n=17), two in symptomatic and the OCER model five in asymptomatic enabled the most populations. A total of reliable predictions 26,293 patients who Asymptomatic of death and stroke Symptomatic underwent CEA were in patients following included within the external validation CEA. The model can also inform patients cohort. Of the patients studied, 11,035 about the procedural hazards of CEA, and experienced symptomatic carotid stenosis, help create focus towards patients who with 14,772 asymptomatic patients. would benefit greatly, the authors add.

4.5%

2.1%

November 2021

WESTERN VASCULAR

Rise in cardiovascular disease, vascular surgeon burnout presents a public health crisis, Western Vascular Society hears BY SARAH CROFT

Cases of cardiovascular disease are rising across the U.S., with large disparities seen in ethnic groups and poorer geographical areas. In combination with increased burnout in the vascular workforce, this has led to a public health crisis that requires immediate action. These were among the main takeaways from a presidential address delivered by Michael S. Conte, MD, at the Western Vascular Society (WVS) sixth annual meeting in Jackson Hole, Wyoming (Oct. 16–19).

nsuring the vascular health of patients is crucial to ensure freedom from pain, disability, physical limitations, emotional stress, and limb loss, to name a few, Conte explained. It is vital patients experience freedom from both mortality due to vascular issues, and escape the treatment burden, to manage quality of life, the outgoing WVS president said. Time away from the hospital is vital to facilitate this; however, vascular health harbors many different perspectives, including patient preference, the primary healthcare provider, the government, and public health agencies, he continued. It is important to consider that the social determinants of health contribute greatly to vascular health. Determinants include patient income status, education, food security, and social environment. Although this is widely known by healthcare professionals and the general public, there is a lack of information regarding vascular health in circulation, Conte communicated. The number of cases of heart disease and stroke across the U.S. is rising. In 2010, the American Heart Association (AHA) developed Life’s Simple Seven (LS7), as a measure of cardiovascular health. The seven indicators are smoking, diet, physical activity, body mass index (BMI), blood pressure, total cholesterol, and fasting glucose. Conte presented data relating to these indicators in the U.S. population. The U.S. performed well with smoking, with numbers at an ideal rate. In contrast, the majority of the population performed extremely poorly compared to those performing ideal or intermediate, explaining that “BMI and physical activity were poorer in adults, significantly impacting cardiovascular health.”

Healthcare disparities “It is apparent physical activity that BMI, diabetes, and smoking rates are all increasing, according to past trends, with smoking rates presenting the highest in the U.S., compared to all indicators. This rise in indicators will therefore hold impacts November 2021

on future health and requires attention,” explained Conte. Peripheral vascular disease affects one in 18 adults (25+ years) worldwide, and 8.5 million Americans. One-third of diabetic Americans over 50 years old also have peripheral arterial disease (PAD), with up to half not displaying symptoms. Of these individuals, one in three will die within five years following diagnosis, with one in three admitted to hospital for myocardial infarction (MI) or stroke, with low anklebrachial index (ABI). There are large vascular health disparities among ethnic groups, with African Americans and Native Americans particularly affected. “Amputation in Black Americans sits at two-to-three times higher than the national average,” stated Conte. Patients with PAD are also commonly overlooked, he said. It is indicated that in comparison to MI or stroke, in patients with PAD, following the event (30 days) fewer patients received statins and less aggressive medical care, despite ongoing research. Not only does this impact ethnic groups, but females and the older population (80+ years) are also highly affected, Conte said. In May last year, Lizzie Presser of ProPublica shed light on the present amputation epidemic faced by Black Americans in the realm of the mainstream press, Conte noted. Presser detailed a finding that “Hispanic and Black patients experience a greater disease severity at clinical presentation (n=834),” with one in four experiencing amputation following hospitalization from PAD, compared to one in seven in non-Hispanic white patients (n>140,000). Across all Americans, the rate of diabetes is increasing, with around 10% diagnosed. Conte further pointed out that lower-extremity amputation rates reduced in the 2000s, increasing in 2010, with 60,000 patients receiving toe amputation in 2015. When analyzing amputation patterns across geographical locations, in California, there is a positive relationship between lower-extremity amputation rates and poorer areas, he said. Conte pointed out that in areas “with increased poverty levels,

Michael S. Conte

amputation rates are higher.” Additionally, in areas of the U.S. where more Black individuals reside, amputation rates are higher, indicating a clear health inequality. Research also found that Black Americans with vascular disease are less likely to receive revascularization, with white Americans receiving treatment at a higher rate. In this light, Conte concluded there is a positive “strong relationship between Black individuals, lower-income and increased amputation risk.”

“Amputation in Black Americans sits at two-tothree times higher than the national average” — Michael S. Conte ‘Lend a hand, save a leg’ To tackle this disparity, the Society for Vascular Surgery (SVS) launched the Vascular Volunteers in Service to All (VISTA) initiative, with the catchphrase, “lend a hand, save a leg,” Conte continued. VISTA launched pilot programs across underserved areas of the country like the

state of Oklahoma in an attempt to drill into the underlying issues. There have been several initiatives that aim to work with these vascular health disparities. The WVS Diversity, Equity and Inclusion Committee launched a program in 2021, based on “healthcare disparities in vascular surgery: identifying inequalities and improving outcomes,” Conte said. The Society for Vascular Surgery (SVS) has also taken steps to tackle this issue, with member numbers currently increasing. However, only half of these members are practicing vascular surgeons in the U.S. Conte reported a public health crisis of physician burnout: It is predicted that until 2040, the U.S. will face a shortage of surgeons, leading to increased cases of burnout, he said—echoing a theme reported at other recent regional meetings. More than 50% of U.S. physicians selfreported burnout, highlighting the extent of the problem. With the increasing prevalence of cardiovascular disease, burnout in vascular surgeons presents a growing public health concern, due to the impact on the adequacy of the vascular surgery workforce, he added.

WVS names new president-elect BY BRYAN KAY University of Southern California (USC) vascular chief Vincent Rowe, MD, took over as the new president of the Western Vascular Society (WVS)—with University of Arizona chief of vascular surgery Wei Zhou, MD, named the new president-elect—during the organization’s 2021 annual meeting in Jackson Hole, Wyoming, held Oct. 16–19. Rowe succeeds Michael S. Conte, MD, the co-director of the University of California, San Francisco (UCSF) Heart & Vascular Center and chief of the UCSF division of vascular and endovascular surgery. Conte ended his WVS presidency with a presidential address that was formally introduced by Rowe and his three children. “Dr. Conte transferred out here from New England but has been a staunch contributor to the society and to science in general, especially for PAD [peripheral arterial disease],” Rowe, professor of surgery at the USC Keck School of Medicine in Los Angeles, told attendees. Zhou a professor of surgery at the University of Arizona College of Medicine-Tucson, Arizona, was also recently named the second Society for Vascular Surgery (SVS) representative to the the World Federation of Vascular Societies (WFVS) council of officers.

vascularspecialistonline.com | 15

INTERVIEW

The value and utility of surgical sketches BY BRYAN KAY

W. Michael Park, MD, was first turned onto the utility and wonder of anatomical sketching during medical school. Back then, he developed an affinity for the visual-learning benefits afforded by his own hand and for how much better it allowed him to absorb complexity over the alternative of staring endlessly at the drawings of others. SINCE THAT TIME, PARK HAS developed an intricate hand for surgical and anatomical sketching, lately sharing instructive examples via social media, alongside notes on the particular procedures they illustrate. Many of his colleagues will engage in the practice of tracing out their procedures visually, at least on some rudimentary level, Park muses in a interview with Vascular Specialist. But his recent experience as chief of vascular surgery for the Cleveland Clinic Abu Dhabi underscored just how valuable his skill for graphical surgical sketches could be. “The pictures were very important because of the language barrier,” Park recalls. “People understand pictures. Especially for complex procedures, there’s no question the pictures helped bringing across complex concepts. “Outside our small coterie of vascular surgeons, these are the dark arts. It’s mysterious: people may have been exposed to vascular surgery during a medical clerkship, medical school clerkship, or may

have seen a video here and there, but the fact is 99% of doctors have very little idea of what vascular surgery is about. That’s one of the key points that have come up in society presidential talks is disseminating what we do and what we offer. I’m doing my little part.” Patients, families and referring doctors in particular benefit greatly from sketches— typified by a recent example he shared of an in-situ bypass operation, Park explains: “Saying in-situ bypass to someone and them nodding their head... it’s very unlikely the patient understands exactly what is going to happen to them.” A sketch can preclude

Three-year VIVO results back ‘continued safety and effectiveness’ of Zilver Vena venous stent BY BRYAN KAY

Three-year results of the VIVO clinical study support the continued safety and effectiveness of the Zilver Vena venous stent (Cook Medical) in the treatment of symptomatic iliofemoral venous outflow obstruction, attendees at the Vascular Interventional Advances (VIVA) 2021 (Oct. 5–7) in Las Vegas. PAUL GAGNE, MD, A VASCULAR SURGEON AND an associate clinical professor of surgery at New York University’s School of Medicine, presented the new data during a late-breaking session. “There are high rates of freedom from clinically driven reintervention, high rates of patency out to three years [by ultrasound], sustained clinical improvement in the patients’ response as scored by VCSS [Venous Clinical Severity Score], VDS [vascular duplex scan], CIVIQ [Chronic Venous Insufficiency Questionnaire] and change in CEAP [Clinical, etiology, anatomy, pathophysiology] ‘C,'” he told the gathering. 16 | Vascular Specialist

W. Michael Park. Above: An example of his sketches

a patient waking up and wondering why they have incisions on their leg when they understood they were to undergo work to increase blood flow in their lower extremity. The economy of a picture might bear even more dividends among referring doctors, continues Park, who recently returned to Cleveland, Ohio, from the Middle East. “If you can post this picture into your electronic medical record [EMR], it speaks volumes— much more than an op note. An op note can go on for pages, can be exquisitely detailed, lyrical even. It won't capture a part of the information that's conveyed in a picture.” Park uses his imagery in many different ways. He deploys them for 3D reconstructions, planning for open surgery, and, with the increasing sophistication of technology, can have a completed sketch in a patient's inbox within a few taps of a digital device. “It’s

“In spite of a significant number of patients in this study who had extension under the inguinal ligament, no stent fractures have been identified by core lab evaluation.” Patients with symptomatic obstruction of one iliofemoral venous segment were enrolled—those with a CEAP clinical classification ≥3 or VCSS pain score ≥2. Follow-up through three years included measures of patency, reintervention, clinical outcomes (measured by VCSS, VDS, CEAP “C,” and CIVIQ), and device integrity measures of fracture and migration. The VIVO study enrolled 243 patients (70% female; mean age, 53±15 years; 67.5% with current or past deep vein thrombosis). The 30-day primary safety endpoint and 12-month primary effectiveness endpoint were met, exceeding the corresponding performance goals (p<0.0001), and improvement in clinical outcome measures was demonstrated at 12 months (p<0.0001). Follow-up through three years is complete, Gagne told VIVA attendees, reporting that results observed at 12 months were maintained. Specifically, three-year outcomes include high rates of patency by ultrasound (90.3±2.2%), freedom from clinically-driven reinterventions (92.6± 2%),

“In spite of significant number of patients in this study who had extension under the inguinal ligament, no stent fractures have been identified by core lab evaluation” — Paul Gagne

been a tremendous advantage to have that skill—I was lucky to come upon in medical school.” Even simple sketches can be of asymmetrical benefit against voluminous wordage, he argues. “If you think about the economy of information that's needed to convey an idea: It’s possible to describe something with very few graphical points. It’s sort of like being able to pass information digitally with very few bits; a symphony recording requires very few sample points; an idea for a bypass is really just connecting two dots.” Park says he is coming across more and more of his colleagues who are artistically inclined. “The simple fact of the matter is that drawing something out is much more simple and less verbose than chattering on about something. You see people get lost in the details, in anatomical terms. The technical terms of surgery are challenging to teach in a short moment, but a picture will illustrate something very quickly.” Tablet devices and phones now come armed with pens, making the ability to learn or refine the art of surgical sketches all the more accessible, Park notes. “It’s simple enough to learn and to have a docket of information to graphically show a procedure that you are going to do.” Ultimately, the tool of communicating through pictures goes back to the earliest days of the human species, he ponders. “Cro magnon man was doing it 40,000 years ago, and he was doing it before written words. It’s a tool that is available to all of us, and requires very little practice— just lines, circles and dots. If you want to be fancy, use the air brush tool for shading, and all of a sudden the picture pops.”

and freedom from reinterventions (82.9±2.6%). Clinical improvement, as measured by VCSS, VDS, CEAP “C”, and CIVIQ, was sustained through three years (p<0.0001). There were no core lab-reported stent fractures, and only one core lab-reported migration (adjudicated as technique-related due to device undersizing) through three years. Session moderator Niten Singh, MD, associate chief of vascular surgery at UW Medicine in Seattle, commented: “It’s nice to see a venous stent with some longer-term outcomes being successful.”

Zilver Vena venous stent

November 2021

RADIATION SAFETY

Study detects higher incidence of chromosome aberrations in endovascular operators BY JOCELYN HUDSON

Researchers have observed an increased frequency of chromosomal aberrations in endovascular operators that is likely to be related to occupational radiation.

peaking in the Prize Session at this year’s radiation damage. Dicentric chromosomes are also European Society for Vascular Surgery (ESVS) associated with malignancy, Abdelhalim added. annual meeting (Sept. 28–29) held in Rotterdam, The team’s research also considered translocations, The Netherlands and online, presenter Mohamed which, the presenter clarified, are exchanges of genetic Abdelhalim, MBBS—a doctoral research fellow supervised material between two or more chromosomes, some by Bijan Modarai, MBBS, at King’s College London of which are transmissible and therefore have a in London, England—conveyed his hope that, malignant potential. The final area of research with more research, biodosimetry will be was aneuploidy, which is when a chromosome used as an adjunct to physical dosimetry in is lost entirely from a cell, Abdelhalim noted, the future. causing genomic instability and thus having Modarai and colleagues have previously the potential for malignant transformation. shown a rise in acute markers of DNA The researchers hypothesized that damage in endovascular operators. chronic occupational radiation exposure According to the research team, however, from endovascular procedures increases the there has been no analysis of biological markers frequency of chromosome aberrations and so of chronic DNA change to date. Mohamed aimed to determine the incidence of chromosome Abdelhalim The present research focused in part on aberrations in high-volume endovascular dicentric chromosomes, the presenter relayed, operations. noting that these are the “gold standard” for biodosimetry. Abdelhalim summarized the team’s research, which Such chromosomes are a rare occurrence in the they conducted in collaboration with experts in radiation lymphocytes in the normal population, whereas their biology both from Public Health England and Brunel frequency rises proportionately with radiation exposure, University in London. The team isolated lymphocytes he explained, making them a “very good marker” for from peripheral blood samples, stimulated mitosis in

these lymphocytes, arrested mitosis exactly at the point of metaphase, and then fixed the samples to microscope slides, before separating the samples into two groups: a dicentric assay and a sample analyzed with mFISH. “Both of these techniques are incredibly time consuming and labor intensive,” the presenter remarked. Despite this, he conveyed that the team were able to analyze 54,000 cells with the dicentric assay and 2,000 cells with mFISH, which he described as a “completely manual process.” The team recruited a total of 18 operators for the study, 12 of whom were exposed endovascular operators, with the remaining six being radiation-naïve colorectal surgeons, used as controls. Abdelhalim noted that there were no significant differences between potential confounders between the groups, such as age, years of consultant practice or smoking status. All of the operators

“The frequency of dicentric chromosomes is significantly higher in endovascular operators compared with colorectal surgeons” — Mohamed Abdelhalim in the exposed group did high volumes of endovascular procedures, the speaker added. “The frequency of dicentric chromosomes is significantly higher in endovascular operators compared with colorectal surgeons,” Abdelhalim revealed. Other key findings were that reciprocal translocation was more common in endovascular operators compared to controls, complex chromosomal arrangements were twice as common, and there was a significantly higher frequency of aneuploidy in the endovascular cohort.

Take advantage of SVS diabetes resources BY BETH BALES

November is National Diabetes Month. The Society for Vascular Surgery (SVS) has many resources to help its members educate their patients and families and reach out to referring podiatrists and other providers. Members can customize many of the resources with their own contact and practice information, photos, and logos. MATERIALS INCLUDE SVS Foundation patient fliers on diabetes, peripheral arterial disease (PAD), carotid artery disease and overall vascular disease. These are available in both English and Spanish and can be downloaded instantly to hand out to patients. The SVS Diabetes and Vascular Disease page at vsweb.org/YourDiabetes offers several resources for patients, families and physicians. Materials from the SVS Branding Toolkit, exclusively available to members, can also be put to use. “The incidence of diabetes has grown exponentially in recent years, affecting more than 382 million people worldwide. It is one of the leading causes of chronic disease and limb loss,

November 2021

and many of our members frequently care for patients with diabetes,” said Benjamin Pearce, MD, chair of the Public and Professional Outreach Committee, which leads the SVS branding initiative. “Let’s educate our patients and prospective patients. Let’s let our referring physicians and other providers know we can be valuable additions to patients’ care teams.” The Branding Toolkit was created specifically for members’ use and benefit, he added. “Use the toolkit—and all our SVS resources—to help your patients and your practices.” Visit vsweb.org/branding for more information on branding resources. Visit vsweb.org/VascularFliers for the SVS Foundation patient education fliers.

Call for Abstracts

Call for abstract and video submissions Nov. 17, 2021, to Jan. 12, 2022

Learn more: vascular.org/vam

vascularspecialistonline.com | 17

YOUR SVS

SVS Foundation asks members to give in ‘Giving November’

go to research, public education, awareness and the other funds of the SVS Foundation.” Contributors to the challenge will be listed weekly in Pulse, the SVS’ electronic weekly newsletter. Lawrence wants every SVS member to donate to the Foundation to support its work. “My goal is 100% participation. No amount is too small,” he said. For the entire month, all contributions—which are tax-deductible— will be matched, dollar for dollar, up to $20,000. In 2020, four SVS members sponsored a similar campaign. They BY BETH BALES brought in more than $10,000 from new donors, and those who had not contributed over the previous five years. Inside the SVS, a With generous matching funds pledged by Society staff campaign brought in nearly $1,100, which Executive Director for Vascular Surgery (SVS) leaders for a monthKenneth M. Slaw, PhD, matched. A concurrent staff campaign will long Matching Gift Challenge, the SVS Foundation also take place this year. “Not only did we raise additional dollars in this year is turning “Giving Tuesday” into “Giving 2020 over 2018 and 2019, but we also raised critical awareness of the November.” work we do,” said Lawrence. “In addition, more members donated in a short period of time than ever before. And we hope to build on that success this year.” he SVS Executive Board of Directors, the SVS Foundation The SVS Foundation’s core mission is Board of Directors and the “to optimize the vascular health and wellchairs of the SVS Foundation being of patients and the public through Development Committee have GIVING NOVEMBER support of research that leads to discovery banded together to match up to $20,000 of knowledge and innovative strategies, as for donations given in the month of DONATION well as education and programs, to prevent November. Their hope is to turn $20,000 MATCHING and treat circulatory disease.” into $40,000. That takes several forms, including The month will culminate in Giving Gifts to the SVS Foundation grants and awards, some for research and Tuesday, Nov. 30, the global day of made in November will be matched by SVS Leadership! others for various aspects of vascular care; giving held annually on the Tuesday community awareness and prevention following Thanksgiving to kick off Double the donation, double the good. projects, such as health initiatives and the year-end charitable giving season. patient education fliers; and the new Charities around the world participate. VISTA—Vascular Volunteers In Service “Turning Giving Tuesday into a to All initiative—to address the significant month-long event accelerates the power “My goal is 100% participation. disparities in access to vascular healthcare of giving,” said Peter Lawrence, MD, across the U.S. chair of the SVS Foundation. No amount is too small” “With a dollar-for-dollar match, $50 — Peter Lawrence Visit vascular.org/SVSFoundation to becomes $100, $100 becomes $200, and donate today. $500 becomes $1,000. And every dollar will

Members: Come together to fight cuts to Medicare

THE SVS PAC IS IN THE biggest fight of its life to prevent huge Medicare cuts facing all vascular surgeons. The 11% in proposed cuts affect academic and private practice vascular surgeons alike. In private practice, we experience the cuts immediately—usually BY ADAM KEEFER, MD in the next month’s profitand-loss statement. However, Vascular Surgeons have always used the Vascular academic physicians also stand to lose considerable amounts Annual Meeting (VAM) as a time to break from when yearly budgets aren’t the rigors of daily clinical practice to learn and balanced and larger procedures discuss current ideas and opinions with fellow become margin-losers. This colleagues. This year, VAM afforded us this results in salary reductions and opportunity and was a success, though following less time devoted to clinical research. When these universal the VAM there developed some dissent in cuts occur, does it matter what SVSConnect between a few academic side you’re on? surgeons and a few private practice The SVS PAC needs surgeons, on the ownership and use donations from all its members of office-based labs (OBLs) to provide immediately. Only 10% of all patient care. As a private-practice members donate, and even fewer than that are politically vascular surgeon, member of the SVS, active. As a PAC member, member of the SVS Political we are in constant Action Steering Committee contact with (PAC) and owner of my own legislators advocating OBL, I believe this discord is for fair treatment of Adam vascular surgeons. senseless. Keefer I tell them that

18 | Vascular Specialist

much of my limb salvage work is done in the outpatient center and patient access to care is unparalleled. Hospital admissions are down, and cost savings are up. However, I also spend equal time telling them that inpatient procedures and vascular labs are vital to saving lives and limbs. I strongly disagree with anyone that says the SVS PAC is anti-private practice and antiOBL. Some 40% of our PAC members are in private practice, with many of them owning OBLs. We support all vascular surgeons, whatever type of practice with which they are primarily associated. The Centers for Medicare & Medicaid Services (CMS) and Medicare want to divide us, so we fight each other—and not the spending cuts. Please support us and come together as one so we can fight these harmful cuts. A few individual opinions do not reflect the SVS PAC mission. ADAM KEEFER is a member of the SVS PAC Steering Committee.

Review the year in Foundation annual report In a year prominently defined once more by COVID-19, the SVS Foundation nonetheless took some big steps forward, with new initiatives and a big increase in the number of donors (28%) as well as the percentage of Society for Vascular Surgery (SVS) Active members who contributed (26%). The Foundation is, as the title of its annual report proclaims, “Opening Doors to New Horizons.” Read the report for: n Financial highlights n The major impact—a 9.5fold return—of a major SVS Foundation research award program n How mentorship influences the profession’s future n A donor’s story of why he gives n The SVS Foundation’s “honor roll” of donors n How to give to the SVS Foundation Please contribute to the SVS Foundation's annual appeal today to help it continue to impact patient care and to continue to open doors to new tomorrows in healthcare. In appreciation, contributors’ names will be included in an “honor roll” of donors on the Foundation website, on the SVS Foundation recognition board at the 2022 Vascular Annual Meeting (VAM) and in the FY22 SVS Foundation annual report.—Beth Bales

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Read the report at vascular.org/ FoundationAnnualReport21. November 2021

Learn by doing at February SVS PAD workshop The Society for Vascular Surgery (SVS) Peripheral Arterial Disease (PAD) Workshop in February will feature four hours of hands-on surgical skills training, on 10 different facets of PAD treatment. “WE ARE OFFERING THE CHANCE for surgeons to be trained by surgeons, by people accomplished in the appropriate surgical techniques and well versed in possible complications and their management,” said Vikram Kashyap, MD. He is directing the workshop with Patrick Geraghty, MD, with assistance from Daniel McDevitt, MD, chair of the SVS Community Practice Section Executive Committee. Registration opened in early November for the course, which is limited to 75 participants to assure each attendee receives plenty of individual attention.

The course will be Feb. 11 and 12, 2022, in Rosemont, Illinois, minutes from Chicago’s O’Hare International Airport. This hands-on educational workshop represents the start of a new era for the Society, said Kashyap. “Our members have long sought—and SVS leadership has wanted to provide—this kind of handson skills training. This is definitely not a standard workshop or conference.” The 1.5-day workshop features overviews, guidelines, standards of care and case discussions, as well as the skills training. It is geared primarily at younger surgeons who want to learn or practice

PAD techniques and procedures. Topics include national trends in open and endovascular therapies, the team approach for limb salvage, imaging, device access, therapies, working in an office-based lab (OBL) versus an ambulatory surgery center and more. (See the full course lineup at vascular.org/PADagenda.) Attendees will practice and perfect hands-on skills in simulations, some using cadavers and some using models, taught by expert faculty. Hands-on training topics include ergonomics and radiation safety, access of pedal vessels (cadaver vs. simulator), closure devices, endovascular embolectomy/thrombectomy, PTA and stent choices, endovascular deep venous arterialization, atherectomy choices and

“Our members have long sought this kind of hands-on skills training” — Vikram Kashyap

axial imaging. In groups of five, attendees will spend 20 minutes on each topic in two, two-hour sessions. The faculty will also present information on gaps in outcomes data for chronic limbthreatening ischemia and how to generate viable research steps to address these gaps. For more information and to register visit vascular.org/PADCourse22. Course organizers call the assembled faculty “world-class and representing a broad cross-section of SVS members,” said Kashyap. “These surgeons are excited to be involved in this first-of-its-kind workshop and to teach what they know to our members,” he said. Faculty members include Danielle Bajakian, MD, Venita Chandra, MD, Dan Clair, MD, Brian DeRubertis, MD, Bryan Fisher, MD, Elizabeth Genovese, MD, Steve Henao, MD, Vipul Khetarpaul, MD, Norm Kumins, MD, Miguel Montero-Baker, MD, Pat Muck, MD, Inkyong Parrack, MD, Darren Schneider, MD, Peter Schneider, MD, and Eric Scott, MD.—Beth Bales

SVS PMC responds to proposed CMS payment changes Dear colleagues, Many changes in Medicare payment policy have been proposed. In response, the Society for Vascular Surgery Performance Measures Committee (SVS PMC) has been working diligently defending our professional standards and securing a fair compensation plan for the complex procedures we perform and our value as specialists in every healthcare system where we are employed. This past month the SVS PMC has composed a response letter to the proposed Centers for Medicare & Medicaid Services (CMS) program. With regards to the Merit-based Incentive Payment System (MIPS) and value pathways (MVPs), the Society urges CMS to include more measures under each MVP to allow physicians of various practice patterns to report an MVP. We encourage the CMS to design a formal process of soliciting feedback on a structured and timely manner that will allow transparency and coordination in the early development of an MVP. Particularly, CMS should publish quarterly a list of MVPs to alert medical societies in order to build out their specific MVPs in collaboration with CMS. Moreover, CMS should require that all MVPs submitted should be subjected to a 60-day comment period to allow developers to effectively revise their proposals as needed. The SVS wants CMS to provide for a more gradual implementation of the MVP, proposing the program would first become an option in 2024, with 2023 being used by CMS as a “pilot year.” Furthermore, the SVS does not support CMS’ proposal to make MVP participation mandatory; the Society urges CMS to include an option for voluntary MVP participation for physicians in the traditional MIPS pathway. In terms of MVP reporting and scoring, the

November 2021

SVS urges CMS to work with the specialty societies and develop quality and cost measures based on clinical pathways. In our opinion, MVPs need to be activities that, when performed, will increase the quality of patient care and reduce overall cost. SVS does not support the CMS quality performance proposal to remove bonus points on additional outcome measures. To promote the infrastructure needed to allow a subgroup to report an MVP, CMS needs to continue to award bonus points for end-to-end reporting. CMS proposes to increase the weight of the Cost Performance Category from 20–30% of the final MIPS score in 2022 and beyond. Following three years of unprecedented disruptions to the health care system and MIPS due to the COVID-19 pandemic, we urge CMS to reweight the Cost Performance Category to its weight—15%—prior to the Public Health Emergency in 2019. At a minimum, CMS should maintain the weight of the Cost Performance Category at 20%. Lastly, the SVS supports the CMS proposal to take additional actions to identify changes that may occur in Alternative Payment Models (APM) participants’ organization affiliations so their incentive payments may be paid correctly. The SVS supports the clarifications CMS is making for the APM Incentive Payments to Qualified Participants. Sincerely,

Nikolaos Zacharias, MD SVS Performance Measures Committee member and Massachusetts General Hospital, Boston, vascular surgeon

Nikolaos Zacharias

SVS: Medicare Physician Fee Schedule final rule maintains threat to patient care The Medicare Physician Fee Schedule (MPFS) final rule released Nov. 2 by the Centers for Medicare & Medicaid Services (CMS) doubles down on the 3.75% cut to surgeons and surgical practices that will harm patient access to care, the Society for Vascular Surgery (SVS) said in a press release. An early analysis shows the cut—combined with automatic Medicare cuts—will slash Medicare payments to vascular surgery by 12.75%, the SVS release pointed out. “Five percent of the cuts, related to changes in payment for clinical labor, will be phased in over four years, but 9% are slated to be put into effect on Jan. 1, 2022,” the Society stated. “As COVID-19 cases and hospitalizations have already caused Americans to delay needed care, these cuts will only further exacerbate the strain on health care systems nationwide.” The Society urged vascular surgeons to remain united in urging Congress to take action. “As vascular surgeons, we provide comprehensive care to a predominantly elderly, sick, and vulnerable population,” said Ali AbuRahma, MD, SVS president. “These cuts will further strain a healthcare system already on the brink of breaking, and will place the neediest patients in the greatest jeopardy for losing access to medically necessary services.”—Bryan Kay

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GENDER DISPARITIES

‘Female sex predicts reintervention after elective EVAR for AAA’ BY BRYAN KAY

Females were found to be at greater risk of reintervention following elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) at both the one- and five-year mark following their initial procedure, researchers in New Jersey discovered. THE RETROSPECTIVE CHART review conducted by first-named author Taylor Corsi, BS, a medical student at Rutgers Robert Wood Johnson Medical School in New Brunswick, senior author William Beckerman, MD, a vascular surgeon at Robert Wood Johnson University Hospital, and colleagues showed freedom from reintervention rates of 86% for females vs. 96% for males at one year (p=0.02) and 69% (female) vs. 86% (male) at five years (p=0.03). Delivering the data at the recent Eastern Vascular Society (EVS) annual meeting (Sept. 23–26; Charleston, South Carolina), Beckerman told attendees the findings “support recent conclusions that, despite similar one- and five-year mortality, females do have a higher rate of early and longterm postoperative morbidity such as reintervention.

“This refutes the suggestion that comparable outcomes using a single device and trial inclusion criteria can be applied broadly.” The Rutgers data, from 2011 to 2016, include 185 patients—75% of them men, with 25% women. The research team looked at primary outcomes of survival along with freedom from reintervention at one and five years. Secondary outcomes analyzed were postoperative intensive care unit (ICU) stay and 30-day readmission. The researchers found no statistically significant difference in postoperative ICU stay or 30-day readmission rates between the sexes but a trend toward significance in terms of more females requiring an ICU stay after their initial operation. Similarly, they did not detect a statistically significant difference in one- and five-year survival rates.“Looking at reintervention, we did

see a difference at both one and five years in terms of freedom from reintervention between males and females, with females having a greater risk of reintervention at both of these time points,” Beckerman explained. “With the reinterventions, there was a little bit of a drop right from the beginning, which was associated with more access site complications in Freedom from females, whether reintervention that was in the iliac at one year: artery in terms of dissections, thrombosis or from the At five years: common femoral access, whether percutaneous or open. As time went on, it mostly trended toward an endoleak intervention as a cause for reintervention in these patients.” On William multivariate analysis, Beckerman female sex alone predicted increased five-year risk of reintervention (p=0.02), Beckerman added. He concluded: “Female sex was independently associated with one- and fiveyear reintervention and not survival. We did find that there were sex-specific factors that contributed to greater surgical morbidity after elective EVAR. This is one of the

only studies to our knowledge that utilizes the full depth of institution-specific data with five-year follow-up. And it provides real-world evidence in support of a need to study devices in a more heterogenous population, especially getting more women enrolled in trials for these devices.” Beckerman conceded limitations, including the fact the data were drawn from a few hundred patients at a single tertiary v care center. He said the research female male team intends to (p=0.02) study more recent patients to account for the development v of smaller devices and also plans to female male collaborate with (p=0.03) non-tertiary care centers “to better evaluate representative outcomes.” Speaking from the audience, Incoming EVS President Robert Y. Rhee, MD, pointed out the preponderance of men in investigational device exemption (IDE) trials, which, depending on the subset, can consist of 80–90% men, he said. Beckerman added: “No one is expecting a 50-50 split just because there is not a 50-50 split in terms of aneurysms being treated in women vs. men but it would be nice to see, at the very least, a study population that is equivalent to the population that is being treated.”

86% 96% 69% 86%

PAD Skills Course The hands-on opportunity you've been asking for is finally here! February 11-12, 2022 The OLC @ SVS Headquarters, Rosemont, IL

November 2021

NEWS BRIEFS

Let’s get the party started

Peer reviewed JVS CASES, INNOVATIONS AND TECHNIQUES evaluates a new metric, the bicycle exercise ABI (ankle-brachial index) recovery time, or BART, to provide an additional measure of postoperative hemodynamic improvement. This new exercise hemodynamic metric can be used to further characterize pre- and post-treatment lowerextremity hemodynamics in limbs undergoing surgical correction of external iliac artery endofibrosis, which affects up to 10–20% of highperformance cyclists. In “Resolving the biological paradox of aneurysm formation in children with tuberous sclerosis complex (TSC),” JVS-Vascular Science presents a case report of an abdominal aortic aneurysm in a two-year-old with TSC. Authors said the study offers a way to “speculate how these findings may support translation into clinical practice.” The Editors’ Message in the December Journal of Vascular Surgery highlights the state of the JVS publications—“stronger than at any time in the history of our journals.” The message, from Peter Gloviczki, MD, and Peter Lawrence, MD, includes information on the

impact factors of both JVS and JVS: Venous and Lymphatic Disorders; updates on the other two publications, the Journal of Vascular Surgery Cases, Innovations and Techniques and JVS– Vascular Science; and the effects of the second year of the pandemic. “The progress JVS journals made was due to the outstanding manuscripts our authors submitted from around the world, and we are grateful for these contributions. Success, however, would not have been achieved without the hard work and expertise of an exceptional JVS team,” they wrote. “We greatly appreciate the contributions of our associate editors, Thomas L. Forbes, MD, Fred A. Weaver, MD, Ulka Sachdev-Ost, MD, and Alan Dardik, MD, and of our assistant editors, Keith D. Calligaro, MD, Paul DiMuzio, MD, Audra Duncan, MD, and Daniel K. Han, MD. We also express our deepest gratitude to the dedicated members of our editorial board and our many reviewers.”— Beth Bales

The message will be available by Nov. 19 at vsweb. org/JVSeditors21.

VAM 2022 abstract submissions to open MEMBERS’ RESEARCH FOR THE 2022 VASCULAR Annual Meeting (VAM) on vascular disease-related topics is wanted on topics ranging from “left subclavian to right carotid artery retropharyngeal bypass,” to trauma in civilians and follow-up intervals following endovascular aneurysm repair (EVAR) after marked aneurysm sac regression. The Society for Vascular Surgery (SVS) will open the VAM abstract submission site on Wednesday, Nov. 17. Abstract submissions will be accepted until 3 p.m. Central Standard Time on Wednesday, Jan. 12, 2022. “The SVS VAM meeting is the scientific highlight of the year for vascular surgeons around the globe,” said Andres Schanzer, MD, SVS Program Committee chair, which plans much of the meeting’s educational content. “Send in your best work that addresses key knowledge gaps so that we can continue to move our exciting field forward.” Submission categories and guidelines are available at vsweb.org/Guidelines22. Learn more about VAM at vsweb.org/VAM22. The 2022 meeting will be June 15–18, 2022, in Boston. Educational programming will be held across all four days and exhibits will be open June 16–17, 2022. The SVS Foundation Gala, celebrating the Society’s 75th anniversary, will be June 17, 2022. Registration and housing will open in early to mid-March.—Beth Bales

November 2021

GILBERT R. UPCHURCH JR., MD, chair of the University of Florida department of surgery, has been named to the National Academy of Medicine for his “seminal contributions to the understanding of the development of vascular disease and contributing greatly to the advancement of all aspects of vascular and surgical care.” Journal of Vascular Surgery Editorin-Chief PETER GLOVICZKI, MD, received Semmelweis University’s prestigious Semmelweis Budapest award in a recent ceremony celebrating the start of 2021/2022 academic year. This annual award recognizes scientists who have made significant advancements in biomedical research over the course of their career. GIUSEPPE PAPIA, MD, has been elected secretary of the Canadian Society for Vascular Surgery (CSVS).— Beth Bales

Spotlight

The party planners—a past president among them—are in place and they are starting to organize the festivities for SVS’ grand 75th anniversary celebration next June. The SVS Foundation Gala will be held the evening of Friday, June 17, 2022, during the 2022 Vascular Annual Meeting (VAM) in Boston. As befits an occasion so momentous as marking 75 years of excellence in caring for those with vascular disease, SVS kicked off the commemoration at the 2021 VAM. Members will celebrate all the way to June ’22. Immediate Past President Ronald Dalman, MD, chairs the Gala Committee with Co-chairs Matthew Eagleton, MD, and Venita Chandra, MD. All Gala proceeds will benefit the SVS Foundation. One of the first orders of business, said Dalman, is encouraging all celebrants to donate to the live and silent auctions, a big part of the celebration. He urged members to be creative. In 2019, then-SVS President R. Clement Darling, MD, combined philanthropy with his love of whiskey by offering the “Darling Magical Whiskery Tour,” Dalman pointed out. The evening included top-tier whiskey-tasting in a mutually agreed-upon city, complete with Darling’s own personal reflections and experience on the nuances of fine bourbon and other whiskeys. “Innovation is one of our driving forces,” said Dalman. “How else would vascular surgery continue to advance and evolve? I challenge all of us to channel our creative sides on behalf of the SVS Foundation to find or put together auction items that will draw tremendous interest.” For questions about auction items, email SVSFoundation@ vascularsociety.org.—Beth Bales

Calling all medical students: Audible Bleeding introduces ‘Holding Pressure’ series In memoriam Senior member Jess Young, MD, 93, of Cleveland Heights, Ohio, Aug. 13. Young was a founder and first president of the Society for Vascular Medicine; the Jess R. Young Outstanding Vascular Medicine Educator Award is given annually “in recognition of his ground-breaking work in the field of vascular medicine, his pre-eminence as an educator and his vision for multi-specialty programs.”

Picture this! Members can now download VAM 2021 photographs. The snaps are organized by days, from Aug. 17–21, and by events. Visit vascular.org/ VAM21Photos.

SINCE ITS INCEPTION, THE AUDIBLE Bleeding vascular surgery podcast and its growing team have continued to develop engaging educational resources for earlycareer vascular specialists. With this goal in mind, the Audible Bleeding team has added a new series, “Holding Pressure,” geared towards medical students who have an interest in the vascular surgery specialty. The first episode was recently released. In the first episode, a group of medical students who are leaders or founders of Vascular Surgery Interest Groups (VSIGs) at their respective medical schools share their experiences and provide an inside look at the vascular surgery field. VSIGs aim to promote vascular-related research and service activities to students early in their medical careers, provide early exposure to surgery and assist them as they seek career mentorship. Medical students are encouraged to follow the series and submit questions for an upcoming mailbag episode. Listeners can ask the Audible Bleeding team any question related to vascular surgery, and have it answered directly on the podcast. Submitters should include their name, school and year (“anonymous” is allowed as well), and who should answer the question (resident, fellow, attending or someone specific on the team). Questions may be submitted in writing or in voicerecorded format. Email questions to HoldingPressure.AudibleBleeding@gmail. com along with any ideas, suggestions or comments.—Anna Vecchio vascularspecialistonline.com | 21

COMMENTARY

Corner Stitch

Sparking interest in vascular surgery

VSIGs increase early exposure to vascular surgery in med school BY AKUL ARORA, BS

This month, we are focusing on medical student recruitment into vascular surgery. In many medical schools, students do not get any exposure to the field of vascular surgery (or to vascular surgeons) during the preclinical years, and even during the clinical years, vascular surgery can sometimes be a late find. The introduction of Vascular Surgery Interest Groups (VSIGs) aims to change this “initial exposure” problem. HERE’S MY STORY. I am currently a third-year medical student at the University of Michigan, an executive board member of the vascular surgery interest group (VSIG) on campus, with aims to apply to vascular surgery residency programs.

My involvement in VSIG was quite coincidental. As I mention above, vascular surgery isn’t highlighted in pre-medical training in undergraduate study and only sparsely mentioned in medical school compared to other fields. I came into medical school thinking I wanted

Trainee wellness: ‘No one really prepared me for the failures’ BY BRYAN KAY

Communication and an awareness of how often vascular surgery fails emerged as key talking points during a Vascular Surgery Interest Group (VSIG) Lunch Symposium panel discussion aimed at providing trainees and medical students with career guidance during the Western Vascular Society (WVS) annual meeting in Jackson Hole, Wyoming (Oct. 16-19). FACULTY AND RESIDENTS PROVIDED TIPS ON maintaining wellness, avoiding burnout, and preparing for the unanticipated challenges of vascular surgery during training. The link between surgeon wellness and the sometimes-grim realities of vascular surgery outcomes was captured by Leigh Ann O'Banion, MD, assistant professor of surgery at University of California San Francisco Fresno (UCSF-Fresno) in Fresno, California. “You’ve watched all of these [WVS annual meeting] talks, and you’ve watched the statistics—they’re not

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to go into a procedural field and work with the circulatory system—which I have always found fascinating. My plan therefore, was to explore fields related to those two criteria. I had no idea that there was an entire field solely devoted to surgery and the circulatory system. Well, I quickly came across interventional radiology, cardiology and cardiothoracic surgery. One day, a friend from my class reached out inviting me (and other M1s) to join the VSIG executive board. That email started a chain of events leading to my exploration of vascular surgery and eventually becoming an active member of the club. VSIG-UMich helped me learn what vascular surgery really was during my first and second years, when I had limited exposure to vascular surgeons. I remember attending a technology day that was hosted during my MS1 year where company representatives brought stents and simulators, and walked us through their use, indications and

“VSIG-UMich helped me learn what vascular surgery really was during my first and second years, when I had limited exposure to vascular surgeons”

deployment. Events like these, as well as panel events, career day presentations, and case walkthroughs were integral for my exposure to the field. VSIG also allowed me to interact with vascular residents, fellows and faculty, and solidify my career choice. I was lucky to have a VSIG and an engaged section of vascular surgery at my medical school. However, if someone wanted to establish a VSIG in their medical school, there are two key components that I can envision being extremely helpful. The first is a faculty mentor to sponsor the club, and the second is reaching out to an established club at another institution. The faculty mentor can provide resources and input from the department, and the outside club can provide event ideas and a framework to build off. Once the club is started, reach out to the vascular residents! They are closest to medical students in training and often have invaluable advice and contacts to help further your club along. The great thing about vascular surgery is that the faculty and residents are often very personable and willing to help. VSIGs increase the early exposure to vascular surgery in medical school and if you need assistance starting one, please reach out. AKUL ARORA is a medical student at the University of Michigan Medical School in Ann Arbor, Michigan.

great. It’s true: Our resident at Stanford patients are sick, and if University Medical a pedal bypass works Center in Stanford, 50% of the time and California. “If you’re gets healing, I’m faking it until you make ecstatic,” she told those it in this respect, it’s gathered for the VSIG really not a tenable session, which also solution. Just make covered different types sure you’re honest with of vascular practice, yourself. Communicate match applications, with your partners, your research during training faculty and other trainees and preparing for the too.” The WVS VSIG Lunch Symposium panel discusses Board exams. “But no Humphries, an wellness, burnout and the unexpected one really prepared me for the associate professor of surgery failures. And we fail a lot in vascular surgery. That can at University of California Davis Medical Center in be mentally daunting sometimes.” Sacramento, California, reiterated the importance of O’Banion relayed to the students and residents reporting problems so that they can be fixed. about the times she would call fellow panelist Misty “If you don’t tell me there’s a problem, I can’t fix it,” Humphries, MD, “crushed” because a patient had died, she said. “I tell this to the residents all the time. Please or an arduous bypass had failed. report your work hours accurately. Please tell me “We’re going to fail more times than we’re going to there’s a problem.” actually succeed, so I think that’s where the wellness Niten Singh, MD, the associate chief of vascular comes in,” O’Banion told them. surgery at the University of Washington Medical The panel spoke to the importance of speaking Center in Seattle, described measures taken at his up—to mentors, faculty and even family members— institution to foster wellness. “In our program, we’ve when burnout rears its head. “As residents, a lot of instituted a policy over the last couple of years now, the variables are not in our control by any means, where if somebody has been on call, has been up all either financially or from a schedule standpoint,” said night, they just go home the next day,” he said. “All the Elizabeth George, MD, an integrated vascular surgery faculty have been supportive of it.”

November 2021

VASCULAR PRACTICE

Coaches can help with more than surgery BY BETH BALES

Surgical coaches can help surgeons handle problems as diverse as ergonomic issues in the operating room, to difficult patients, negotiating a raise and even creative ways to carve out some downtime. COACHES PROBABLY EVEN HAVE suggestions for using that downtime. With the Academy for Surgical Coaching, the Society for Vascular Surgery’s Physician Wellness Committee has launched the SVS Surgical Coaching Program. It pairs a trained coach with an SVS surgeon to meet virtually four times over three months, working to achieve the surgeon’s goals, improve his or her wellness and solve problems. All conversations are confidential. “We know there’s a stigma attached to surgeons

November 2021

asking for help,” said Dawn Coleman, MD, committee co-chair. “But this is truly an opportunity to extend your training beyond the traditional and into the uncharted territory of your unique situation. “Many surgeons are struggling to manage worklife balance, navigate career difficulties and create life-changing goals. This is a wonderful opportunity to do one or all of those things.” The SVS Wellness Committee created the program to help improve members’ wellness via: n Having conversations with a colleague who can listen and ask good questions n Building a sense of control n Working through technical and clinical concerns n Helping the member step back, slow down and be more thoughtful n Assisting in personal and professional growth The coaches will help their surgeons with: n Taking on problems

“We know there's a stigma attached to surgeons asking for help”

causing frustration and delay in the operating room n Providing expert, personalized feedback on the surgeon’s technique n Brainstorming on implementing new ways of performing procedures or tackling intraoperative challenges n Helping in difficult professional situations n Holding their members accountable to making change Think of it, said Coleman, as a way to step up your career and achieve wellness at the same time. Coaches are Shipra Arya, MD, Carlos Bechara, MD, Jean Bismuth, MD, Coleman, Laura Marie Drudi, MD, Matt Eagleton, MD, John Eidt, MD, Mark Mattos, MD, Daniel McDevitt, MD, Erica Mitchell, MD, Elina Quiroga, MD, Amy Reed, MD, Vincent Rowe, MD, Russell Samson, MD, Jessica Simons, MD, Ravi Veeraswamy, MD, Gabriela Velazquez, MD, and Max Wohlauer, MD. Connect with a surgical coach at vascular.org/GetaCoach. Participants are eligible for up to 4 CMEs for program participation. Dawn Coleman

Canadian Vascular: Spin in RCTs A large proportion of statistically nonsignificant randomized controlled trials (RCTs) yielded interpretations that were inconsistent with their results, according to an analysis of 31 manuscripts covering research comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS) for carotid stenosis and endovascular aneurysm repair (EVAR) to open repair for abdominal aortic aneurysms (AAAs). That was the main finding presented by Allen Li, a medical student at the University of Ottawa, Canada, during the Canadian Society for Vascular Surgery 2021 annual meeting (Sept. 24–25), held virtually. Li et al probed all phase-three RCTs with nonsignificant primary outcomes comparing open repair to EVAR or CEA to CAS. Spin was identified in nine abstracts and 13 main texts among 18 AAA articles, and seven abstracts and 10 main texts across 13 carotid stenosis studies. For both, “spin was most likely to be found in the manuscript discussion section,” the authors found, and increasing journal impact factor was associated with a statistically significant lower likelihood of grade A spin, or spin in the title or abstract conclusions. No significant association could be found with funding source, they added.—Bryan Kay

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