46 minute read
Guest editorial
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 HansHenning 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
Christopher Audu, MD
Executive Director SVS
Kenneth M. Slaw, PhD
Director of Marketing &
Communications Bill Maloney Managing Editor SVS Beth Bales
Marketing & Social Media Manager
Kristin Crowe
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Vascular Specialist is the official newspaper of the Society for Vascular Surgery and provides the vascular specialist with timely and relevant news and commentary about clinical developments and about the impact of healthcare policy. Content for Vascular Specialist is provided by BIBA Publishing. Content for the News From SVS is provided by the Society for Vascular Surgery. | The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher. The Society for Vascular Surgery and BIBA Publishing will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services, or the quality or endorsement of advertised products or services, mentioned herein. | The Society for Vascular Surgery headquarters is located at 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018. | POSTMASTER: Send changes of address (with old mailing label) to Vascular Specialist, Subscription Services, 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018. | RECIPIENT: To change your address, e-mail subscriptions@bibamedical.com | For missing issue claims, e-mail subscriptions@bibamedical. com. | Vascular Specialist (ISSN 1558-0148) is published monthly for the Society for Vascular Surgery by BIBA Publishing. | Printed by Vomela Commercial Group | ©Copyright 2022 by the Society for Vascular Surgery
Adam Tanious, MD, discusses how he dealt with “end-stage vascular disease” during patient and family consultations and conversations for the first time as an attending vascular surgeon.
Like any good presentation I feel obligated to start with my disclosures: 1) I am married to a woman who decided to pursue a separate fellowship in bioethics, even after a fellowship in pediatric anesthesia. This means that every time I come home and start to discuss a patient’s tough clinical situation, I am invariably met with the question, “Did you discuss all their options with them?” And, 2) I just celebrated my one-year anniversary of being an attending, and, while my confidence slowly grows with each day, I am still always a bit apprehensive when it comes to any major vascular case, from a carotid endarterectomy to a complex bypass—and particularly open aortic surgery.
Allow me to present Patient X, a 70-year-old male who was transferred to our hospital while I was on call. He presented to an outside hospital with obstipation of several days’ duration with associated abdominal pain. His history was notable for an aortic endograft placed for aneurysm four years prior which was explanted and replaced with a rifampin-soaked interposition graft for infection in the last two years. The outside physicians were concerned mostly about his bowel obstruction but thought something was “off” about how the bowel was associated with the graft. Like most centers, we accepted the patient to get them to our hospital and figured we would get the necessary teams involved upon arrival. Upon his arrival to our hospital, we got our gastrointestinal surgery colleagues involved and began working through his history and current status. His initial labs showed a severe leukocytosis and within 24 hours his blood cultures were growing pseudomonas. Additionally, within 24 hours of presenting to our hospital, he began to show signs and symptoms of a colovesicular fistula. A nuclear medicine study was done showing definitive uptake at the site of his aortobifemoral bypass.
To summarize, we have a 70-year-old man with a prior infected endovascular aneurysm repair (EVAR) that was explanted and repaired with a rifampin-soaked Dacron graft which was now also infected and causing a bowel obstruction, leading to sepsis, in addition to a colovesicular fistula.
At this point I’d like to introduce the term “end-stage vascular disease” and, with the readers’ permission, apply it to Patient X. I do not make this statement lightly, nor mean anything offensive by it. My wife and I were discussing patients one evening and she made a comment that really stuck with me. She equated vascular surgery to medical oncology in the sense that in the world of medicine, medical oncology patients often have very tough pathology to treat, “wins” are hard to come by, and any intervention, more often than not, alters the future quality of life for the patient in addition to duration. Furthermore, there are patients that present with terminal disease who despite all the best efforts and current medicine/technology available, intervention is unlikely to alter the inevitable outcome.
I consider myself more than fortunate to have trained at some of the best institutions in the country where the above story is only all too common. These patients present to our hospitals as we are usually the only facility in the state/region with the appropriate recourses and supporting personnel capable of handling such complex pathologies. Their understanding of their pathology is understandably limited, and they appreciate the gravity of the situation only as it applies to need for their transfer. As a trainee, I’d get fairly excited about this pathology and the opportunity to undertake a major vascular surgery to cure the patient of their infection that could (and most likely would) result in death in the not-too-distant future. When consenting them and their families for their procedure, we were trained to be as accurate as accountants when it came to risks associated with the specific procedure each patient would need while still being human—talking them through the potential outcomes and try to paint a picture of what life would look like should the patient make it through their procedure.
The next few weeks would proceed in a fairly standard fashion including a complex and lengthy surgery with major blood loss; some form of a post-operative complication; prolonged hospital stay; and a transition to inpatient rehabilitation. While the life of a trainee meant that I was usually on a different service/rotation by the time these patients came back for follow-up, my particular interest in these patients infected aortic pathology made me track their outcomes and, not surprisingly, only about 50% of these patients ever made it back for their follow-up once discharged, with about 25% never making it out of the hospital.
So, 13 months into practice, I am presented with Patient X and it is my job to discuss with him our options on how to proceed, knowing that regardless of his decision, I am about to affect the course of not just his life, but the life of all his friends and family. If I’m being honest, I was torn. Here I am talking to a man who just retired and had grand plans to finally enjoy his well-earned retirement with his wife by traveling and experiencing the world. If I steered him towards surgery, we all know what his life would look like for the next year as well as the associated numbers as stated above. But what was my alternative suggestion? What would my peers and partners think? Would they think I was simply scared to tackle this type of procedure? This would be the biggest case I could have done as junior faculty and I know it is the only “life-sustaining” option? We are taught to offer surgery when the benefits outweigh the risks. The risk of not operating in patients with end-stage vascular disease is most often death. This could be an imminent death, a death within a certain amount of time, or eventual death—but death is the conclusion.
I kept thinking about what Patient X’s life would look like and how he would remember his final days should we proceed with surgery. Then I discussed the case with my wife. Physicians,
specifically surgeons, often fall victim to the following sentiment “[doctors] will do everything they can to prolong someone’s life… many medical practitioners are not trained to handle conversations that focus on quality of life or relief of pain and suffering, and instead lean toward recommending their own treatments.” This is a quote from Jeffrey Schnipper, MD, research director for the Division of General Internal Medicine and Primary Care at
Brigham and Women’s Hospital, taken from an article about physicians’ lack of understanding regarding end-of-life care. In a study titled “Surgeons’ perceived barriers to
DIVERSITY NEW DEI PILLAR SIGNALS ADDITIONAL PRIORITY FOR SVS FOUNDATION
By Beth Bales
The SVS Foundation has been guided by the three long-term pillars of research and innovation, community vascular care and patient education, and disease prevention. Recently, the Foundation added a fourth pillar—for diversity, equity and inclusion (DEI) initiatives. It will emphasize, among other projects, research into healthcare disparities and care delivery solutions, scholarships and career advancement for under-represented minority vascular surgeons, and workforce development.
“DEI is an important cornerstone of the Society for Vascular Surgery itself and we applaud adding diversity, equity and inclusion as a bedrock pillar for the Foundation as well,” said Vincent Rowe, MD, chair of the SVS DEI Committee.
“This helps us support our community of vascular surgeons,” said Palma Shaw, MD, co-found-
Vincent Rowe
er of the SVS Women’s Membership Section. “We are investing into the future of vascular health with programs for our diverse communities and helping the Society more closely resemble the patient population. People want a surgeon who looks like them.”
SVS Foundation Chair Peter Lawrence, MD, said: “The new pillar reaffirms the Society’s commitment to DEI and enables the SVS Foundation to serve as the portal for initiatives of SVS’ many regional societies, such as diversity scholarships or attendance at training courses.”
Early plans for DEI initiatives include targeted scholarships, awards and research grants for diversity candidates, research projects focused on healthcare disparities or bringing programs to under-served areas.
The new pillar highlights, among other tenets, research into healthcare disparities—one of the updated SVS research priorities.
The new pillar reaffirms the Society’s objectives, supported by the DEI Task Force which now has become an ongoing committee as well as a summer DEI summit, with outcomes to be announced soon ahead of a second summit planned for January 2023. In addition, the Society’s new research priorities added healthcare disparities as one of seven important topic areas. The focus in that area is evaluating “interventions aimed at improving vascular health in all socioeconomic, racial and ethnic populations.”
Both Rowe and Shaw pointed to how commemorative months—Black History Month, Women’s History Month, Pride Month and Hispanic Heritage Month, among them—celebrate the diversity of modern life. “We mark these months and others, to celebrate the diverse voices of the vascular community,” said Shaw.
“We will be funding the future of vascular health through a lot of these initiatives,” said Rowe. “We want to grow and nurture these initiatives, while we grow and cultivate our increasingly diverse vascular workforce.”
Palma Shaw
PALMA SHAW
DISPARITIES Diversifying clinical trials: ‘There needs to be some kind of cultural competency’
By Bryan Kay
THE COVID-19 PANDEMIC EXPOSED LINGERING MISTRUST IN
the U.S. healthcare system among patients from minority communities as physicians continue to confront the conundrum of healthcare disparities in terms of outcomes alongside a lack of diversity in clinical trials, a roundtable discussion at Vascular Interventional Advances (VIVA) 2022 in Las Vegas (Oct. 31–Nov. 3) heard.
Vincent Rowe, MD, chair of the SVS diversity, equity and inclusion committee, told the gathering, entitled, “How to be a trialist,” that despite a National Institutes of Health (NIH) intervention nearly 30 years ago aimed at recruiting more minorities into clinical research, “we haven’t seen much change.”
“We’ve talked a lot about clinical trials, their importance and how they have to be applicable to the full population of patients that we deal with,” he said. “Unfortunately, there are still a lot of disparities in our outcomes, so we’re going to need a diverse cohort to be able to understand the differences.”
Rowe pointed to a study that looked at patients eligible for cardiometabolic trials. The problems that emerged, mostly from the patient side, included lack of awareness, lack of information, mistrust, and a lack of comfort with the process. He highlighted how historical experiences with the healthcare system have led to low levels of trust, especially among the Black community. “And if you think that it is all over and things have gotten better, I think the COVID pandemic was a perfect microcosm of this mistrust that happened,” he said.
Rowe said combating these problems is multifactorial but suggested greater diversity among site investigators and cultural competency as among potential remedies. “You need people in your trials to be applicable to all the patients that you’re seeing,” Rowe said, demonstrating how enrollment for the BEST-CLI trial at his institution among the Hispanic community was bolstered by the involvement of a colleague fluent in both the culture and language. “There needs to be some kind of cultural competency,” but that does not require race concordance, he added. “There just needs to be someone talking to them that’s technically competent and understands the culture.”
The role of referring physicians, too, is key, in order that they receive the support required “to send us patients from a culturally diverse environment,” Rowe told the VIVA gathering. “We’re going to need to increase these patients in clinical trials,” he said. “It may be difficult based on the times we are in. People say they are so entrenched in their views, but I think it is possible—and it can only help to improve the care for all of our patients.”
GUEST EDITORIAL VASCULAR SURGEONS: THE ‘ONCOLOGISTS’ OF THE SURGICAL ARENA continued from page 2
➽palliative and end-of-life care” in the Journal of Palliative Care Medicine from 2018, 76% of surgeon responders cited no formal training or education in palliative care, while more than one-third cited lack of training in how to forgo life-sustaining measures and communication regarding these matters.
What if Patient X’s final days involved a few extra medications to treat symptoms but also family dinners and a trip to an exotic destination he had always wanted? He would ultimately succumb to his infective process, but did that mean not enjoying the time between then and now? Could we offer a picture that focused on enjoying the time he had instead of “fighting” through the proposed surgical course?
I sat down and had a family meeting with Patient X, his wife, his brother and sister-in-law. I drew pictures, explained the proposed procedure(s), potential complications, and expected hospital and post-operative course. I laid out a timeline. I was blunt. I was not callous, but I was direct. I then offered some alternatives (after discussing with our infectious disease, gastrointestinal surgery, and urology colleagues). I offered Patient X the option of antibiotic therapy and pain medication to treat his symptoms. I painted a picture of what his life would look like through this option’s lenses. I then told everyone in the room that Patient X had my support no matter his decision and that we would do everything in our power to ensure the best outcome regardless of his choice. Then I sat there silently.
What felt like an eternity passed. Patient X broke the silence. He started by thanking me. All parties asked several questions to understand the details that were pertinent to them. They asked me what I would do. The question I feared but prepared for. I told them that the answer to that question depends on what each individual values. I couldn’t decide for Patient X what values were most important to him. All I could do is paint as realistic picture as possible and hope that one option would resonate with them. I told them that I know individuals who would happily select either path based on their values and that there is no wrong answer. They thanked me again and asked for some time to decide.
I felt drained. What had I just done? Was I being a coward? My goal is not to talk all of my complex patients out of their complex surgeries. I do feel strongly that we as a society, and surgical community, need to focus more on these types of conversations and goals when interacting with our patients and our trainees. Quality of life is a metric more recently making into the literature, but why is it not a course that all medical students are taught or a rotation that interventional trainees must spend one month to counsel patients appropriately about all their options?
I was paged not too long after the conversation… Patient X wanted to go home on antibiotics and take a trip to a city he and his wife had been looking forward to visiting for many years.
ADAM TANIOUS is an associate program director for the vascular surgery residency program at the Medical University of South Carolina (MUSC) in Charleston.
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†Compared to surgical arteriovenous fistulas.
SVS ELECTIONS SVS asking members to expand diversity in Nominating Committee
By Beth Bales
THE SOCIETY FOR VASCULAR SURGERY (SVS) WILL
ask voting-eligible members to consider three revisions to article X of the SVS bylaws that would take a step toward change on the SVS Nominating Committee.
In the past several years, the membership of the committee, which selects candidates for officer consideration, has expanded from the three most recent past presidents to include four more members: a member of the Strategic Board of Directors, an at-large member elected from among the membership, the vice chair of the Community Practice Committee and the chair of what formerly was called the Leadership and Diversity Committee. There also has been an ex-officio, non-voting representative of the Young Surgeons Committee (now Section).
The referendum changes would keep the Nominating Committee membership at seven, while expanding diversity of perspective. The SVS Executive Board has proposed—and the Strategic Board of Directors has approved—putting the following three changes to the membership for a vote: ◆ Reducing the number of past presidents on the Nomi-
nating Committee from three to two; the most current past president, who serves on the Executive Board, will join the Nominating Committee one-year removed from this service ◆ Adding the SVS Diversity, Equity and
Inclusion (DEI) Committee chair, or vice chair if the chair is unavailable, as a voting member of the Nominating
Committee, replacing the chair of the
Leadership Committee. The Leadership Committee chair was added when the committee’s name was the Leadership and Diversity Committee, but diversity has since been migrated to the DEI Committee ◆ Adding the chair of the Young Surgeons Section, or the vice chair if the
MICHAEL C. DALSING
COMPLETE SVS SURVEY BY NOV. 22
To help the Society for Vascular Surgery chart a path into the future, members— and non-members alike— are asked to complete an ongoing survey by Nov. 22.
The survey is to help SVS better understand members’ and non-members’ perception of top priorities and professional needs and challenges, as well as their experiences with SVS. This feedback is critical to ensure SVS can best support members over the next three-to-five years.
This survey is intended for both current members and non-members eligible for SVS membership. It should take about 20 minutes to complete. Respondents can enter a drawing to win one of three $100 Amazon gift cards.
Avenue M. Group LLC, an independent market research firm and SVS’ partner for the survey, emailed participation invitations in early November. For information, contact Joanna Bronson at JBronson@ vascularsociety .org. Michael C.
Dalsing
chair is unavailable, as a voting member of the Nominating Committee. The Young Surgeons Section chair has been serving as a non-voting ex-officio member
These changes have been proposed and approved to further increase the diversity of perspective and voice in the Nominating Committee process. Because the process for nominating SVS officers for 2022–23 begins in January 2023, this special referendum is being called to ensure changes are implemented in time for the 2023 nominating process and elections.
“We feel it is imperative to broaden the perspective of the group that selects our candidates, to hear from the wide range of voices among our members,” said SVS President Michael C. Dalsing, MD.
“The Strategic Board of Directors feels making this change before our next election cycle is so important, in fact, that we’re taking the unusual step of holding an off-cycle referendum election.”
Online voting on the questions will begin in early December. Only Active and Senior members in good standing are eligible to vote.
Read the proposed changes at vascular.
org/2023NomComm
BylawsChange.
References 1Hull JE, Jennings WC, Cooper RI, Waheed U, Schaefer ME, Narayan R. The pivotal multicenter trial of ultrasound-guided percutaneous arteriovenous fistula creation for hemodialysis access. J Vasc Interv Radiol. February 2018;29(2):149-158.e5. 2Shahverdyan R, Beathard G, Mushtaq N, et al. Comparison of Ellipsys percutaneous and proximal forearm gracz-type surgical arteriovenous fistulas. Am J Kidney Dis. October 2021;78(4):520-529.e1. 3Hull JE, Jennings WC, Cooper RI, Narayan R, Mawla N, Decker MD. Long-term results from the pivotal multicenter trial of ultrasound-guided percutaneous arteriovenous fistula creation for hemodialysis access. J Vasc Interv Radiol. Published online June 2, 2022. 4Franco G, Mallios A, Bourquelot P, Jennings W, Boura B. Ultrasound evaluation of percutaneously created arteriovenous fistulae between radial artery and perforating vein at the elbow. J Vasc Access. September 2020;21(5):694-700. 5Mallios A, Bourquelot P, Franco G, et al. Midterm results of percutaneous arteriovenous fistula creation with the Ellipsys vascular access system, technical recommendations, and an algorithm for maintenance. J Vasc Surg. December 2020;72(6):2097-2106.
Brief Statement Indications The Ellipsys™ system is indicated for the creation of a proximal radial artery to perforating vein anastomosis via a retrograde venous access approach in patients with a minimum vessel diameter of 2.0 mm and less than 1.5 mm of separation between the artery and vein at the fistula creation site who have chronic kidney disease requiring dialysis.
Contraindications The Ellipsys™ system is contraindicated for use in patients with target vessels that are < 2 mm in diameter. The Ellipsys™ System is contraindicated for use in patients who have a distance between the target artery and vein > 1.5 mm.
Warnings • The Ellipsys™ system has only been studied for the creation of an AV fistula using the proximal radial artery and the adjacent perforating vein. It has not been studied in subjects who are candidates for surgical fistula creation at other locations, including sites distal to this location. • The Ellipsys™ system is not intended to treat patients with significant vascular disease or calcification in the target vessels. • The Ellipsys™ system has only been studied in subjects who had a patent palmar arch and no evidence of ulnar artery insufficiency. • Use only with the Ellipsys™ Power Controller, Model No. AMI-1001. • The Ellipsys™ Catheter has been designed to be used with the 6 F Terumo Glidesheath Slender™*.
If using a different sheath, verify the catheter can be advanced through the sheath without resistance prior to use. • Use ultrasound imaging to ensure proper placement of the catheter tip in the artery before retracting the sheath, since once the distal tip of the catheter has been advanced into the artery, it cannot be easily removed without creation of the anastomosis. If the distal tip is advanced into the artery at an improper location, complete the procedure and remove the catheter as indicated in the directions for use. It is recommended that a follow-up evaluation of the patient is performed using appropriate clinical standards of care for surgical fistulae to determine if any clinically significant flow develops that require further clinical action. Precautions • This product is sterilized by ethylene oxide gas. • Additional procedures are expected to be required to increase and direct blood flow into the AVF target outflow vein and to maintain patency of the AVF. Care should be taken to proactively plan for any fistula maturation procedures when using the device. • In the Ellipsys™ study, 99% of subjects required balloon dilatation (PTA) to increase flow to the optimal access vessel and 62% of subjects required embolization coil placement in competing veins to direct blood flow to the optimal access vessel. Prior to the procedure, care should be taken to assess the optimal access vessel for maturation, the additional procedures that may be required to successfully achieve maturation, and appropriate patient follow-up. Please refer to the “Arteriovenous Fistula (AVF) Maturation” section of the labeling for guidance about fistula flow, embolization coil placement, and other procedures to assist fistula maturation and maintenance. • The Ellipsys™ System is intended to only be used by physicians trained in ultrasound guided percutaneous endovascular interventional techniques using appropriate clinical standards for care for fistula maintenance and maturation including balloon dilatation and coil embolization. • Precautions to prevent or reduce acute or longer-term clotting potential should be considered. Physician experience and discretion will determine the appropriate anticoagulant/antiplatelet therapy for each patient using appropriate clinical standards of care.
Potential Adverse Events • Potential complications that may be associated with creation and maintenance of an arteriovenous fistula include, but may not be limited to, the following: • Total occlusion, partial occlusion or stenosis of the anastomosis or adjacent outflow vein • Stenosis of the central AVF outflow requiring treatment per the treatment center’s standard of care • Failure to achieve fistula maturation • Incomplete vessel ligation when using embolization coil to direct flow • Steal Syndrome • Hematoma • Infection or other complications • Need for vessel superficialization or other maturation assistance procedures.
CAUTION: Federal (USA) law restricts this device to sale by or on the order of a physician. Important Information: Indications, contraindications, warnings, and instructions for use can be found in the product labelling supplied with each device.
medtronic.com/ellipsys UC202301636 EN ©2022 Medtronic. Medtronic, Medtronic logo, and Engineering the extraordinary are trademarks of Medtronic. All other brands are trademarks of a Medtronic company. 09/2022
WOUND HEALING DECADE OF WORK LEADS TO LANDMARK PUBLICATION IN NASCENT FIELD: ‘THIS IS A NOVEL PATHWAY THAT IS IMPLICATED IN MULTIPLE MALIGNANCIES BUT HAS NEVER BEEN DIRECTLY LINKED TO WOUND HEALING BEFORE’
cularized tissue, application of a topical (or other formulation) with a JMJD3 inhibitor could lead to improved diabetic wound healing—thus adding to the armamentarium of therapeutics for this population of patients whom we care for as vascular surgeons.
VS: Your research team worked tirelessly to get this work published— what is next for the team?
CA: Yes, it’s been a lot of work to get to this point, especially since most of the work was done during the height of COVID-19 pandemic restrictions. The next items for the team are really developing that last point: bringing this to the clinic. Right now, our wound healing Christopher Audu, MD, and colleagues at the University of Michigan lab in Ann Arbor examples are in mice. While we have a firm mechanistic grip on this, we’d like to take this back to the bedside to— led by Katherine Gallagher, MD, recently saw the latest paper on their tireless work on hopefully—start helping patients in a meaningful way. Also macrophage-specific inhibition of the histone demethylase JMJD3 published in a recent issue of Cellular & Molecular Immunology. The vascular surgery resident—and Vascular on the docket is understanding the immunologic interplay of various other cell types in the diabetic wound milieu so that we identify other targets for therapeutic development. Specialist editor in charge of trainee issues—tells Bryan Kay about how the research team Personally, therapeutic development and design in various reached this juncture. vascular pathologies is exactly the kind of work I intend to do as an independent surgeon-scientist.
Christopher Audu
VS: Your team has been prolific in this area of research in vascular science. Can you give us some background on this latest publication?
CA: You’re right. This work builds on a decade of work in the Gallagher lab where we have been studying macrophage immunology to figure out why the diabetic wound environment allows for sustained inflammation. What we have found, over the years, is that inflammation is the first step to wound healing, as we all know. However, in diabetes, key enzymes necessary for stopping inflammation and moving into the next phase of wound repair are not made. Our group has been trying to answer why this is by looking at the production of DNA gene regulators that, incidentally, are affected by the diabetic environment, i.e., simply having diabetes changes the gene expression of these critical enzymes. This field of study, epigenetics, applied to wound healing is a nascent field.
VS: What are the key takeaway messages from your findings and their implications for future research work and clinical practice?
CA: In this recent paper, we report the dichotomous nature of a gene regulator called JMJD3, which is overproduced in diabetes. Our takeaways are: ◆ JMJD3 regulates inflammation in both diabetic and non-diabetic wound healing ◆ In diabetic wound macrophages, JMJD3 gets turned on late and stays on ◆ Persistent JMJD3 expression leads to persistent inflammation in diabetes via key inflammation pathways such as the Stimulator for Interferon Genes (STING) cascade. This is a novel pathway that is implicated in multiple malignancies but has never been directly linked to wound healing before ◆ Inhibiting JMJD3 in diabetic wound macrophages by using nanoparticles leads to significant wound healing improvement by limiting multiple inflammatory cascades ◆ The clinical implications of this work are that it provides a new avenue of therapeutic development for wound healing. So, for instance, should we be able to improve in-line arterial flow and debride diabetic wounds to vas-
CHRISTOPHER AUDU
VS: You recently completed your research fellowship and returned to clinical work. How is the transition going?
CA: Coming back has been refreshing. I missed operating and caring for patients! It’s also been challenging as I had to dust the “rust” off and continue learning. Overall, I would say that I’ve come back from the research fellowship energized about how I can contribute to the field as a scientist, and ready to continue learning all that I can so that I can be a competent, confident, and compassionate surgeon. Merging the surgeon-scientist model requires different skillsets and right now, my primary goal is to hone my surgical skillset in my final years of training.
Latest work from the Gallagher lab is published in Cellular & Molecular Immunology
VASCULAR LEADERS COHORT FOUR OF LEADERSHIP DEVELOPMENT PROGRAM SELECTED
TWENTY-NINE PEOPLE HAVE BEEN
selected for development as future leaders of the profession and the Society for Vascular Surgery (SVS).
They represent cohort four of the Leadership Development Program (LDP), ninemonth-long interactive program designed to help them reach their full potential as leaders and positively impact their workplaces, communities, the vascular surgery specialty and other important areas of their lives.
Content includes the functional day-to-day behaviors and skills that drive success in leadership, how and where physicians can lead most effectively in complex health delivery systems, the science and physics of leadership, personality styles and emotional intelligence, strategies to strengthen resilience and avoid leader burnout, as well as conflict resolution and negotiation strategies.
“I think more about switching gears between how I interact with colleagues in the operating room compared to clinic, the office, etc.,” said Max Wohlauer, MD, a cohort three member. “It was a very positive experience.” Fellow participant Mark Wheatcroft, MD, said the experience “taught me the importance of spending time gathering as much information as possible from the right people before acting, and to think deeply about strategy development. “I also find the LDP toolkit very helpful with analysis.”
The program also provides four $3,000 Mastery Grants to LDP graduates, permitting them to continue leadership education.
Selected for 2022–23 are: Clayton Brinster, MD, of Ochsner Health, New Orleans; Joseph Hart, MD, of Medical College of Wisconsin, Milwaukee, Wisconsin; Sharon Kiang, MD, from VA Loma Linda Healthcare System, Loma Linda, California; and Elisa Greco, of the University of Toronto, Toronto, Ontario, Canada. It is co-sponsored by the Society for Clinical Vascular Surgery (SCVS) and the Vascular and Endovascular Surgery Society (VESS).
REGIONAL ROUND-UP NESVS 2022 Presidential Address: ‘We can create a bold new future for vascular surgery: It’s go time’
3D mapping during an aortic procedure
Surgical augmented intelligence: New evidence of radiation reduction benefit emerges
SURGICAL AUGMENTED
intelligence in the form of 3D mapping during complex aortic procedures can decrease radiation exposure, fluoroscopy time and contrast use when combined with real-time fluoroscopic images, a new analysis has established
The results were presented during the 2022 Western Vascular Society (WVS) annual meeting in Victoria, Canada (Sept. 17–20) by Rohini Patel, MD, from the University of California San Diego. The researchers aimed to flesh out whether surgical augmented intelligence can be used to decrease radiation exposure in the operating room.
The retrospective chart review, from 2015–2021, looked at 116 patients who underwent a complex aortic repair— with 76 receiving a procedure using augmented intelligence. The majority underwent physician-modified endograft (PMEG) repair.
“Our group that was treated with augmented intelligence had almost half the amount of radiation exposure, with 1,955mGy compared to 3,755mGy in the non-augmented intelligence group,” Patel told WVS.
The former also saw a decrease in fluoroscopy time of around 56 minutes compared to 87 minutes in the latter group of patients, with contrast use significantly decreased to 122cc from 199cc, she added.
Adjusted analysis showed these significant reductions remained, Patel explained.
“Overall, we believe that surgical augmented intelligence is a way to decrease radiation exposure for the entire team and should be further investigated,” she said.—Bryan Kay
“COLLABORATE, INNOVATE, MENTOR, CHAMPION DEI [DIVERSITY,
equity, and inclusion] and relish the opportunity to form deep connections with our amazing patients.” This was the key take-home message delivered by Andres Schanzer, MD, chief of vascular surgery at the UMass Memorial Medical Center in Worcester, Massachusetts, during his Presidential Address at the New England Society for Vascular Surgery (NESVS) 49th Annual Meeting in Newport, Rhode Island (Oct. 14–16).
The topic of Schanzer’s address was “creating a bold new future for vascular surgery,” and one of the keys to this—according to the president—is to focus on the patients. “They are the ones who inspire us to get up each morning, and deal with the challenges that we all encounter every single day.” He expressed his belief that the “rich, long-term relationships” with patients that are “unique to vascular surgery” is what will keep the field “thriving.” He added that, while the cure for burnout is “different for everyone,” for him it is rounding on his patients once in the morning and once before he heads home in the evening. “That is what keeps me going.” Schanzer also placed a spotlight on DEI as another crucial point of focus. “As providers, we need to build a workforce that looks more like our patients,” he stressed. “This is not about committees and statements and tweets, it is about hiring, promoting, paying, and acknowledging the indisputable fact that diversity makes us better. If you are not bringing underrepresented groups to the table in whatever leadership capacity you have, then you are the problem.” The president also remarked on the wider importance of championing DEI: “We need to do this not for ourselves, but for our patients, for our trainees, and for our society.” Schanzer had a specific message for the trainees and young faculty who are the future of the vascular surgical specialty and will “undoubtedly face challenges” in the years to come. “Remember this,” he said: “Try to take yourself a little less seriously. I know that I need to do this often.” In closing, Schanzer summarized: “It is not about any one person or any one career, it is certainly not about mine. It is about our field and advancing it by sticking to and leverageing these key anchor values that makes vascular surgery so special. We can create a bold new future for vascular surgery: it’s go time.”—Jocelyn Hudson
Andres Schanzer delivers the NESVS 2022 Presidential Address
New study shows ‘encouraging increase in academic footprint of female-driven research’
HOW DOES VASCULAR SURGERY
compare to other specialties in the growth of gender diversity in published research? “Are we leaders in the field, or are we trailing?” Those were questions posed by Monica Majumdar, MD, a general surgery resident at Tufts Medical Center in Boston, during the Eastern Vascular Society (EVS) annual meeting in Philadelphia (Sept. 29–Oct. 1) as she presented new data on the topic. “In the Journal of Vascular Surgery there was a statistically evident linear increase in female-first authorship over time at only 5.3% in 2010 compared to 20% in 2020. And while there appeared to be some gains in the percentage of last authorship and overall proportion of female authors, these trends were not linear or significant over the 10-year study period,” she said. When compared to ophthalmology and neurosurgery, the trend showing “an encouraging increase in the academic footprint of femaledriven research” in vascular surgery “is significantly greater.”—Bryan Kay
Weaving magic in academic vascular surgery at JVS
PAST JOURNAL OF VASCULAR
Surgery (JVS) group editor-in-chief Peter Gloviczki, MD, invoked his hobby of magic to help illustrate what it requires to take the reins of an illustrious peer-riewed publication like JVS during the Eastern Vascular Society (EVS) annual meeting in Philadelphia (Sept. 29–Oct. 1).
Role models and mentors, commitment, the pursuit of competence, compassion and family support are some of the keys to success, he told EVS 2022 attendees in a keynote lecture.
“A journal editor is competent if she or he has an established record of academic excellence and scientific integrity, is a prolific author ... and has leadership qualities since editing a journal is teamwork,” Gloviczki said.
“My life from being a young Hungarian magician to become editor of JVS has been exciting, sometimes difficult, but ultimately joyful and most satisfying.”—Bryan Kay
Peter Gloviczki delivers EVS keynote
Study finds no link between frailty score and surgical site infection
A VASCULAR SURGERY-SPECIFIC
composite frailty score was not associated with with risk of surgical site infection in patients undergoing lower-extremity revascularization in a review carried out by Andrew Edsall, MD, a general surgery resident in the Gundersen Health System in La Crosse, Wisconsin, and colleagues.
The research team sought to assess an adapted version of the Risk Analysis Index using the Vascular Quality Initiative (VQI), or the VQI-RAI.
Some 1,130 patients treated between 2007 and 2019 were retrospectively analyzed, with an overall rate of observed surgical site infection of 8.05% noted, most of them superficial, Edsall revealed as he delivered the results at the 2022 Midwestern Vascular Surgical Society (MVSS) annual meeting in Grand Rapids, Michigan (Sept. 15–17).—Bryan Kay
CYCLICAL TOPICAL WOUND OXYGEN THERAPY: A NEW GENERATION OF WOUND HEALING DEVICE SHOWING SUSTAINED RESULTS
In the beginning, it took a little convincing for Anil Hingorani, MD, to come around to the idea that cyclical Topical Wound Oxygen Therapy (TWO2) could be the sort of device he would add to his armamentarium with some degree of confidence. But then he saw the results in some of his most intractable patients, and he started to see value in the multi-modal approach to wound healing. “Remarkable,” was how the clinical professor of vascular surgery in the Department of Surgery at NYU Grossman School of Medicine in New York described the progress in some of the wounds he treated with TWO 2 .
“We tried hyperbaric oxygen for a while and found that to be helpful in certain patients, but hyperbaric oxygen was expensive,” explains Hingorani, also describing issues around insurance company authorization difficulties, transportation convenience and potential systemic complications. Home oxygen therapy, on the other hand, “circumvented a lot of those problems,” he said.
“We started using TWO2 on our patients who were some of the most difficult—the nonhealing on whom we’d tried everything,” Hingorani continues, describing how the technology was put to use among a demographic of his patients in south Brooklyn who are challenging both economically and in terms of their level of basic medical education.
“Finally, we said, ‘Let’s try this new product.’ We didn’t know if it was going to work, but we had some patients who had had ulcers for years, and other practitioners had tried to take care of these patients. Then we had some positive results. And we started to notice a consistent pattern. That’s why we started using this TWO2 device. Based upon the fact we had some experience with arterial patients, now we’re using this new product with both arterial and venous patients—on diabetic foot ulcers [DFUs]—and we’ve had some very good responses.”
TWO 2 combines supplemental oxygen with non-contact cyclical compression and humidification through a single-use extremity chamber system, which is accompanied by a controller and oxygen source.
“For me, what really drives TWO2 is that the machine itself is a little bit different from prior generations in that it not only applies some relatively low oxygen, but also the pressure it puts on is fairly low,” observed Hingorani. The extremity chamber, or boot, extends up to and above the knee, he says, and can be placed over all but occlusive dressings.”
A multinational randomized, double-blinded, placebo-controlled trial to evaluate the efficacy of TWO2 in the treatment of chronic DFUs (known as the TWO2 Study), led by podiatric surgeon Robert G. Frykberg, DPM, and colleagues, showed that the system was six times as likely to heal a DFU wound at 12 weeks compared to optimal standard of care alone after adjusting for ulcer severity (p=0.004). The data, published in the peer-reviewed journal Diabetes Care, demonstrated that TWO 2 therapy was “safe, without complications, and provided more durable healing for those who had wound closure compared to optimal standard care alone,” the trial investigators concluded. Additionally, they reported, TWO2 can be “administered by the patient at home without the expense and difficulties of daily travel to a specialized center” and can be combined with other advanced wound care modalities.
Hingorani believes such data—allied to upcoming randomized prospective data being collected for publication in the vascular surgery literature—might help to trigger more widespread uptake of the device.
“TWO 2 has shown not only positive wound healing at 12 weeks for DFUs, but also sustained wound healing, especially in patients with DFUs,” he says. “The retrospective data from Ireland for venous stasis ulcers has also shown benefit at 12 weeks for those patients using the product.”
The system “is not meant to replace what you are already doing,” emphasizes Hingorani. Rather, the cyclical pressure—applied twice per minute with oxygen—”makes a big difference in some of our patients” owing to how that component helps combat edema in the wound, which is, “I think, an underappreciated cause for some of our wounds not to heal,” he adds.
Richard Neville, MD, chairman in the Department of Surgery and associate director of Inova Heart and Vascular Institute in Falls Church, Virginia, recently sat in on a presentation on TWO 2, leaving with a resolve
Clockwise from top left: Anil Hingorani, Richard Neville and Frank J. Veith
to dig deeper on the positive impression the technology made on him. “I was impressed by this particular technology more than some of the other ones I’ve heard, and I’m hoping that we can investigate it and that it has a role in our system,” he says.
A wound care expert colleague, Vickie R. Driver, DPM, is keen to pursue research on its efficacy, Neville explains. “The right people think highly of it, so we’re going to look to either investigate—or start to use—the technology, and then hopefully we’ll be able to make some presentations in the vascular space.”
While his hospital system has four hyperbaric oxygen chambers, Neville adds, “this seems different. This is more of a focused raising of oxygen tension in the tissue, which theoretically leads to some advantages that the hyperbaric chamber may not.
Meanwhile, vascular surgery luminary Frank J. Veith, MD, a limb salvage pioneer for more than half a century, says preliminary data behind TWO2 suggest it may hold some promise. He highlighted the device’s advantage of oxygen application in combination with compression and moisture versus hyperbaric oxygen therapy, describing the early findings on the tri-modality approach as a potential indicator that it could prove to be an important adjunct to revascularization. “The data that I’ve seen, although not conclusive indicates that TWO 2 could prove to be an adjunct to help save limbs that might not otherwise be saved,” says the New York University and Cleveland Clinic professor of surgery, and former Society for Vascular Surgery (SVS) president. “The technology is not going to replace revascularization, but every little bit helps.”
For Hingorani, one other component stands out: the people behind the equipment at Advanced Oxygen Therapy Incorporated (AOTI). “In south Brooklyn, our patients can be quite challenging,” he says. “A lot of them have problems with not only education in general but medical education is very, very poor, and getting the patients to actually comply with a lot of their wound care, diabetes care, venous stasis care, coming into the office even—basic stuff you would think would be fairly standard—can be very challenging.
“Having the people behind it, the company behind it, the personnel behind it, who are willing to work with some patients who
ANIL HINGORANI
may not have all of the resources that other patients may have in our neighborhood, makes the biggest difference. We have been very fortunate to have some people behind the product who are willing to go the extra mile with some of our challenging patients to really work with them to get them the products they need, some of the wound care and some of the basic education about how to take care of their wound.
“So, it’s not just the machine, not just the product, not just the oxygen; it’s also the people behind it who matter a lot.”
VETERANS AFFAIRS A call to surveillance
By Paul W. White, MD, Erin K. Greenleaf, MD, and Alexis Lauria, MD
FOR MANY OF THOSE INJURED IN COMBAT, THE
transition in care from the Military Health System (MHS) to the Veterans Health Administration (VHA) can be a daunting one, fraught with logistical and clerical challenges. The deluge of administrative tasks as one shifts from active military service to civilian life can drown even capable and medically sophisticated individuals. Certainly, great strides have been made over the past two decades. The Department of Defense and Department of Veterans Affairs have made it a priority to ensure that veterans have access to healthcare. But there currently exists a cohort of patients with vein bypass grafts who are not receiving adequate surveillance.
These patients are well-known to the federal healthcare system, the MHS and the VHA, but for some, injury-specific healthcare has not been provided. When we reviewed nearly 100 veterans who had undergone vein bypasses for combat-related arterial injuries during Operation Iraqi Freedom and Operation Enduring Freedom, we found only 13% had had an imaging study appropriate for bypass surveillance in the last two years. Even fewer had been seen by a vascular specialist. Among these veterans, 88% had a documented visit with a healthcare provider within the previous two years, including 81% who had seen a primary care provider. Similarly, Haney et al, reporting on data from the VA Vascular Injury Study (VAVIS), could only find imaging studies to confirm patency in 30% of a similar cohort of injured patients.
Few would argue that the best care for patients with a vein bypass includes regular surveillance by a vascular specialist, including imaging of their vein grafts. The specialized care necessary to treat an individual’s unique injuries, which may be complex, may be overlooked when one gets referred to the VHA, as may be the case for those veterans who have suffered vascular injuries over the last two decades. The scope of the current problem is neither small and inconsequential, nor grand and insurmountable. And it’s something we’ve faced before. During and after the Vietnam War, long-term patient follow-up was conducted almost single-handedly by Norman Rich, MD, with the Vietnam Vascular Registry.
Still, the present need for a solution is urgent, as the consequences of missed care could be catastrophic. Approximately 52,000 United States services members were wounded in action in Iraq and Afghanistan. In those casualties, the rate of vascular injury was 12–17%. Approximately 80% of these injuries occurred in the extremities and 50% underwent repair, of which interposition or bypass graft with vein were the most common methods. A conservative estimate would suggest that between 700 and 1,500 veterans underwent a vein graft repair for vascular injury. To have nearly 90% of these veterans miss adequate surveillance and vascular care is a true misfortune, even taking into account that a percentage might have received care outside of the VHA or MHS.
The call to action is before us. We suggest a three-pronged approach to recapturing those veterans who have undergone service-related vein bypasses in the past 20 years. First, the MHS and VHA should attempt to identify as many veterans with vein graft repairs as possible. Second, efforts should be made to contact these veterans either directly or through Veterans Service Organizations (VSOs). Lastly, we must educate primary care and other first line non-vascular providers on the need for ongoing surveillance for vascular injuries.
Certainly, these initiatives will face many fiscal, logistical, administrative and psychological challenges. By aligning veterans who have undergone arterial repair in the past with current vascular surveillance, we can optimize the vascular care of one of our most deserving patient populations.
References 1. Unpublished Data. Walter Reed National Military Medical Center
IRB #927445. Lauria AL, Kersey AJ, White JM, Rsamussen TE,
White PW. 2. Haney LJ, Bae E, Pugh MJV, Copeland LA, Wang CP, MacCarthy
DJ, Amuan ME, Shireman PK. Patency of arterial repairs from wartime extremity vascular injuries. Trauma Surg Acute Care Open. 2020 Dec 24;5(1):e000616. doi: 10.1136/tsaco-2020-000616.
PMID: 33409373; 3. Shireman PK, Rasmussen TE, Jaramillo CA, Pugh MJ. VA
Vascular Injury Study (VAVIS): VA-DoD extremity injury outcomes collaboration. BMC Surg. 2015 Feb 3;15(1):13. PMID: 25644593; 4. Zierler RE, Jordan WD, Lal BK, Mussa F, Leers S, Fulton J, Pevec
W, Hill A, Murad MH. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J
Vasc Surg. 2018 Jul;68(1):256–284 PMID: 29937033. 5. Rich NM, Elster EA, Rasmussen TE. The Vietnam Vascular Registry at 50 years: An historical perspective and continuing legacy. J
Trauma Acute Care Surg. 2017 Jul;83(1 Suppl 1):S4-S8. doi: 10.1097/
TA.0000000000001545. PMID: 28452900. 6. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne
LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011 Jun;253(6):1184-9
PMID: 21217514. 7. Patel JA, White JM, White PW, Rich NM, Rasmussen TE. A contemporary, 7-year analysis of vascular injury from the war in Afghanistan. J Vasc Surg. 2018 Dec;68(6):1872–1879.
PMID: 29945835 8. Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser
AN, Jenkins DH, Smith DL, Rich NM. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll
Surg. 2007 Apr;204(4):625-32. PMID: 17382222.
PAUL W. WHITE and ERIN K. GREENLEAF are members of the SVS VA Vascular Surgeons Committee; ALEXIS LAURIA is an SVS surgical resident member, stationed at Walter Reed National Military Medical Center.
Driving Change. TOGETHER.
Every 3 minutes in the US a person with diabetes has a limb amputated. 85% of these amputations are preventable. AOTI has teamed up with the American Diabetes Association to raise awareness about unnecessary diabetic amputations which disproportionately affect rural residents, low income and minority individuals.
The only wound therapy proven to reduce amputations by 71%. Combining oxygen, cyclical compression and humidification, this seamless addition to your care plan can be used in any clinical setting or self-administered by the patient at home, improving compliance and access to care for all.
6X 6X
Delivering Exceptional Outcomes
MORE LIKELY TO HEAL DFUs in 12 weeks LOWER RECURRENCE rate at 12 months
88% 71%
REDUCTION in Hospitalizations at 12 months
REDUCTION in Amputations at 12 months
REFERENCES: - https://diabetes.org/get-involved/advocacy/amputation-prevention-alliance - A Multinational, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Trial to Evaluate the Efficacy of Cyclical Topical Wound Oxygen (TWO2) Therapy in the Treatment of Chronic Diabetic Foot Ulcers; Robert G. Frykberg, Peter J. Franks, et al. The TWO2 Study; Diabetes Care 2020;43:616-624 | https://doi.org/10.2337/dc19-0476. - Reduced Hospitalizations and Amputations in Patients with Diabetic Foot Ulcers Treated with Cyclical Pressurized Topical Wound Oxygen Therapy: Real-World Outcomes. Yellin JI, Gaebler JA, et al. Adv Wound Care. 2022 Dec;11(12):657-665. doi: 10.1089/wound.2021.0118.
