COMMENT& ANALYSIS CORNER STITCH What I wish I had known in vascular training

By J. Aaron Barnes, MD

WELCOME NEWLY MATCHED vascular surgery residents into the fold! I am just over six months into my first attending position after completing my residency training at Dartmouth. While nothing reminds you of how much you don’t know or haven’t seen like being an early career attending, I suppose I am now in a position to reflect back on what I wish I knew or did differently in training. This is certainly not an exhaustive list, but I write this in the hopes that current trainees and those who just matched into vascular surgery are able to find something that resonates with them.

You are a product of your environment

“Gentle, gentle!” This was a phrase that had been said to me—and at me—countless times and at many different volumes throughout my training by a specific attending. I did not fully appreciate the extent to which this phrase was burned into my psyche until I noticed I was often muttering it to myself alone while operating as a new attending in Alaska. This is just one small example of how we become products of the environment in which we train.

From quirky idioms to highly specific operative techniques, we are shaped by those who train us. Some of the things we learn are obvious—techniques are taught, knowledge is conferred through didactics—while others are subtle. How an attending explains long-term stroke risk in clinic, establishes and maintains a relationship with a referring provider, or speaks with a family after a poor outcome, are not taught but rather observed. I wish I had paid more attention to how my attendings practiced and navigated these crucial yet less obvious aspects of being a vascular surgeon as a trainee.

The things that are ‘mindless’ can be anything but

The night before I performed my first lower-extremity bypass as an attending, I pored over the patient’s chart and history, reviewed the diagnostic studies and pre-operative imaging, studied the anatomy, confirmed we had all necessary equipment available, and made contingency plans in case things went awry. I arrived the morning of surgery feeling ready. This confidence all came crashing down when the circulator asked me what drapes I wanted to use. It took longer than I want to admit to recall the default drape configuration from residency. Fortunately, I was able to pull the information from the recesses of my mind, and the case was soon underway. This instance, plus a few others that can be described as less than glamorous, made me wish I had paid closer attention to the seemingly mundane things like draping and room setup as a trainee.

Go back to go forward

As in many training programs, I had my pick of cases as a chief resident. My weeks were filled with open aortic cases, complex endovascular aortic aneurysm repairs (EVARs), carotid endarterectomies, transcarotid artery revascularizations, and a smattering of lower-extremity bypasses. Towards the end of my training, though, I was given the opportunity to perform various less complex procedures such as venous ablations, arteriovenous fistula creations, and straightforward peripheral bypasses without the assistance of an attending scrubbed in. These experiences were invaluable. Those “intern-level” cases are part of my current practice and I needed to freshen up on them. I needed to learn to operate alone, as I do many of my cases without an assistant today. While I am thankful for the experiences I did have, I wish I would have made more of an effort to seek out those autonomous experiences with simple cases earlier and more frequently in my training.

Varicose Veins

Dexter reported that 12-month follow-up among 176 patients was completed, with 20% presenting with a PTS Villalta score of greater than 4—and 17 limbs, or 10.5%, with a score greater than 9 (moderate or severe).

There is a method to the madness

The transition from trainee to attending is a little bizarre. Seemingly overnight your role in the surgical hierarchy flips, and you suddenly have more say over your schedule, your cases, and your patients’ care. Now that I am a bit more removed from training, I can look back and see the gradual transition from trainee to attending. I can now appreciate so many aspects of my training program. Case conference forced me to come up with case plans, defend their indications, and have backup plans. Sizing and ordering devices for EVARs in residency prepared me to do so confidently in the middle of the night as an attending for a rupture. Morbidity and mortality conferences taught me to critically examine my complications and identify areas to target to improve outcomes. In the moment and taken individually, these and many other aspects of training, can be seen as mundane. When taken as a whole, these tasks shape us into vascular surgeons. I am not sure it is possible to truly appreciate the entirety of training when you are in the midst of it, but I wish I had known as a trainee that I would eventually understand the method to the madness.

Results from first US trial of Sonovein delivered

THE 2023 ANNUAL MEETING OF THE AMERICAN VENOUS FORUM (AVF) heard the final results from the first U.S. trial of emerging varicose vein treatment, Sonovein echotherapy, with data showing 100% technical feasibility at three months—the principal study objective.

INTERIM ONE-YEAR OUTCOMES from the multicenter, prospective, single-arm CLOUT registry investigating use of the ClotTriever thrombectomy system in all-comer patients with deep vein thrombosis (DVT) demonstrated that 93.5% of limbs had flow present, 97.1% were compressible and 10.5% of patients presented with moderate or severe post-thrombotic syndrome (PTS).

The results were presented by David Dexter, MD, an assistant professor of surgery at Eastern Virginia Medical School in Norfolk, Virginia, at the 2023 annual meeting of the American Venous Forum (AVF) in San Antonio, Texas (Feb. 22–25).

The primary effectiveness endpoint— complete or near-complete (≥75%) clot removal, assessed by an independent core laboratory—was achieved in 91.2% of patients. Nearly two-thirds of patients saw complete thrombus removal. “Patients reported immediate symptom relief and demonstrated sustained improvements in one-year clinical and quality-of-life outcomes,” Dexter told AVF 2023. Rates of PTS “remained low” at the one-year mark, he added.

Dexter concluded: “This one-year interim analysis from the real-world CLOUT registry indicates that the ClotTriever system can effectively remove thrombi with significant and sustained long-term clinical improvements, including PTS, pain, and quality of life. Follow-up with the complete dataset to two years is ongoing.”— Bryan

Kay

Antonis Gasparis, MD, director of the Center for Vein Care at Stony Brook University in Stony Brook, New York, told the AVF gathering in San Antonio, Texas (Feb. 22–25), that the Food and Drug Administration (FDA)-approved trial saw 20 great saphenous veins (GSVs) in 18 patients receive treatment using the high-intensity focused ultrasound (HIFU) procedure. Gasparis said no anesthesia was used during the cases and that there was no post-procedure compression.

The study results further revealed that ablation of venous reflux was achieved in 95% of the cases, or 19 of the 20; ablation to flow was recorded at 65%; no complications were reported; and venous clinical severity score (VCSS) improved from 6.9 pre-procedure to 1.1 at three months. Gasparis said the next step is for the HIFU technology to be evaluated in a multicenter trial after FDA approval. “It’s here to stay,” he added.

Meanwhile, separately, Ferdinand Steinbacher, MD, from the Karl Landsteiner Institute for Functional Phlebosurgery in Melk, Austria, delivered the latest data from Europe on the Sonovein S+ and Sonovein HD iterations of the technology.

From the end of November 2021 through mid-December 2022, 40 GSVs and anterior accessory saphenous veins were treated, he revealed. Overall efficacy was 88%, Steinbacher said, with the first period of treatment (Nov. 30, 2021, to March 9, 2022) yielding a 71% occlusion rate (12 of 17) when only the Sonovein S+ was used.

During the second period (April 26, 2022, to Dec. 14, 2022), during which both the Sonovein S+ and HD version were utilized, a 100% occlusion rate was achieved among the 23 veins ablated—10 with the S+ and 13 with the HD.—

Bryan Kay