New VAM lecture

INTERVIEW Limb salvage in focus: New VAM lectureship, born of a pioneering spirit, thrills honoree

By Bryan Kay

It all started around the late 1970s, early 1980s. Back then, recalls Frank J. Veith, MD, the notion of aggressively pursuing limb salvage in a gangrenous foot or toe went against the grain of current thinking. What Veith and his colleagues were undertaking represented “very distal bypasses,” and, at the time, what he was doing seemed to amount to virtual heresy, he muses. No one else seemed to accept the legitimacy of the surgeries. Yet they worked, says the vascular surgery luminary, former Society for Vascular Surgery (SVS) president, and current chairman of the internationally renowned VEITHsymposium.

“Everybody thought, if you had a gangrenous foot, toe or any kind of ischemic lesion of the foot that was due to atherosclerosis below the groin, that the right treatment was an amputation,” Veith tells Vascular Specialist. “We were amongst the first to start advocating aggressive limb salvage. We were able to save, I guess, more than 90% of the patients that presented with limb-threatening ischemia, to save their leg.”

Veith was speaking shortly after the occasion of a new Vascular Annual Meeting (VAM) named lectureship being announced by the SVS—in his honor—that will focus on peripheral arterial disease (PAD) and, in particular, limb salvage. Coined the Frank J. Veith Lecture, the maiden talk is set to take place next year at VAM 2023 in National Harbor, Maryland (June 14–17).

The focus of the lecture, Veith says, bears particular importance for the SVS amid the currently crowded field of physicians from other specialties involved in the treatment of PAD. It was vascular surgeons who originated the treatment for limb salvage,

he continues, and so it is vascular surgeons who should lead the limb salvage charge going forward. “Now, of course [limb salvage] surgery has been accepted around the world, and, even more importantly, we were among the first to do percutaneous angioplasties in association sometimes with a bypass,” Veith elaborates. “But now the treatment has largely become interventional—I’d say 75–80% of limb salvage procedures are done endovascularly—and the field has exploded. Now the other interventional specialists, like interventional cardiology and interventional radiology, are becoming strong advocates of limb salvage.” Despite being progenitors of the procedure, Veith says, in many communities vascular surgery is gradually losing out to these other specialties. “I think the SVS putting emphasis on these procedures, some of which are going to require open vascular surgery, many of which will be done interventionally by vascular surgeons, I think is going to go a long way to maintaining vascular surgery’s leadership in this area.” Placing a focus on limb salvage might also help attract up-andcoming vascular trainees and surgeons to a largely unglamorous area of the specialty, Veith adds. “We think that this lectureship will promote progress by vascular surgeons in the sometimes-unpopular field of lower-extremity revascularization. Right now, everybody is interested in fenestrated and branched endografts and treating big, complex aneurysms. That is an important field, and the advances are really quite dramatic. But the less glamorous field of treating patients with limb-threatening ischemia, I think, is extremely important for vascular surgery to maintain a leadership position in.” For medical students, trainees and emerging surgeons who might be viewing the broad swathe Frank J. Veith of vascular surgery with a curious eye, Veith has a succinct message. “Sometimes it’s best, if you want to achieve leadership in a specialty, to go into a field that is not primarily popular,” he says. “In other words, don’t try and replace all of the extremely skillful vascular surgeons doing these complex aneurysm repairs endovascularly—go into a field that is maybe a little less glamorous and sub-specialize in it, and you may achieve prominence more quickly than you might if you went with the crowd.”

SVS ADDRESSES PAIR OF CRITICAL PAYMENT-RELATED PROPOSED RULES

In July, the Centers for Medicare and Medicaid Services (CMS) released two critical paymentrelated proposed rules for CY2023—the highly anticipated Medicare Physician Fee Schedule (MPFS) Proposed Rule followed by the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule.

Of note, in the MPFS, CMS is proposing to cut the Medicare conversion factor—the basic starting point for calculating Medicare payments—by approximately 4.5% for CY2023. In addition, payment reductions for many vascular surgeons are compounded by the second year of CMS’ phasedin implementation of its clinical labor pricing update, which was finalized in the CY2022 MPFS Final Rule.

“This year’s proposed rule is yet another example of how the current payment system fails to support physicians and the patients they serve,” said Matthew J. Sideman, MD, chair of the Society for Vascular Surgery (SVS) Advocacy Council. “These significant year-over-year payment cuts will most certainly jeopardize patient access to critical vascular healthcare. Congress must begin work in earnest to avert these cuts and establish a new payment system that will provide stability for both physicians and patients.”

In the OPPS rule, CMS is proposing to update payment rates by 2.7% for hospitals that meet applicable quality reporting requirements. This update is based on the projected hospital market basket percentage increase of 3.1%, reduced by a 0.4 percentage point for the productivity adjustment.

The SVS is analyzing both rules and will submit extensive comments to CMS. SVS members should be prepared to engage in these ongoing advocacy efforts through the remainder of the year, said Sideman.—Megan Marcinko

FROM THE COVER:

‘STEPTEMBER’ ASKS SURGEONS TO WALK THE WALK continued from page 1

➽a major initiative aimed squarely at promoting the health benefits of walking. The STEPtember Vascular Health Challenge takes place during September, National Peripheral Arterial Disease (PAD) Awareness Month.

During STEPtember, vascular surgeons will not only talk the talk but walk the walk, competing in teams whose members each pledge to walk at least 60 miles during the month. The 60 miles represent the 60,000 miles of blood vessels in the human body.

STEPtember is not just a fundraiser but an opportunity for vascular surgeons across the country and the world to engage with their communities and spread the word about the importance of vascular health.

STEPtember also will raise awareness about vascular disease, and what a vascular surgeon is and what they do. The SVS Public and Professional Outreach SubCommittee is spearheading the project. “As vascular surgeons, we put patient health and outcomes above everything else, and ‘STEPtember’ is a tangible way to demonstrate that commitment,” said Benjamin Pearce, MD, committee chair.

After all, vascular surgeons focus a great deal of time to mitigate the effects and causes of vascular disease without surgery, said committee member Alan Dietzek, MD. “There’s no more beautiful message than surgeons doing their best to keep their patients out of surgery,” agreed Pearce. “It all links back to our motto, ‘Surgery is only part of our story.’” Pearce himself is a big advocate of walking, eschewing golf carts while partaking in a favorite activity. “I’ve been an adamant walker for years on the golf course,” he said. He estimates a golfer can log nearly 2,000 more steps in nine holes when walking versus riding in a cart. Dietzek said the No. 1 complaint his older patients give, when asked how aging affects their lives, is “I can’t walk the golf course anymore.”

Pearce, Dietzek and the other committee members want to link the SVS and walking. “When you think of smoking cessation, you think of the American Lung Association,” said Pearce. “I want people to automatically think of SVS when they think about walking for health.”

Walking affects many aspects of cardiovascular health, from PAD to hypertension to slowing the growth of abdominal aortic aneurysms (AAAs). The SVS has created lists of factoids on the benefits of walking that SVS members can download and give to patients. One such infographic is the “Steps for Vascular Health” poster, tying the health benefits of various numbers of steps.

PPO Committee members will be among

“It all links back to our motto, ‘Surgery is only part of our story’”

BENJAMIN PEARCE

the first to form their “STEPtember” walking teams. The idea is straightforward. Individuals sign up on the Charity Footprints website, at vascular.com/ STEPtember, and pair their personal fitness devices, such as a Fitbit or Apple Watch, to the site, download the Charity Footprints application on smartphones, or log in manually on the website. SVS members will join their respective regional team, and community participants can start their own team or join an existing one. Then, between Sept. 1 and 30, participants get walking, logging the steps, and transferring them to the website. Walkers can seek donors for an overall amount or a per-step contribution. All proceeds will go to the SVS Foundation, which will use the monies generated to assist vascular patients with exercise therapy. In addition, proceeds will help create additional public education materials about vascular health and support further development of the SVS Supervised Exercise Therapy (SET) app.

Committee members also are thinking creatively about how to undertake the challenge. Pearce is hoping to walk with his team on a Grand Prix racetrack in his home state of Alabama. Dietzek wants to involve the world of professional golf. “Think of an area in your community that would provide an inspiring way to finish the challenge,” urged Pearce. “It could be the track around the high school football stadium, or a riverwalk, or a well-known park.”