From rural America to the vanguard of a revolutionary surgical specialty

The Friday morning of VAM 2023 saw Michael C. Dalsing, MD, deliver what is an annual hallmark of the VAM program— the SVS Presidential Address.

By Jocelyn Hudson and Marni Davimes

DALSING CHARTED HIS PERSONAL journey from “small-town boy with some big dreams” to president of the SVS, as well as the history of the Society and that of the vascular surgery specialty in general, all the while delivering the salient message that “the annual meeting is only part of our story.”

Rural America was the opening scene for Dalsing’s address. This is where he grew up, with parents who were “deeply affected by World War II and the Depression,” with his mother— who, Dalsing said, would have traveled widely given the chance—“convinced that education would open doors to the world.”

“I remember insensitive people making remarks about our lack of material worth –they didn’t understand a family’s true value,” Dalsing remarked. “What you ‘have’ does not define you.”

Dalsing took this set of values to heart, refusing to let his humble upbringing prevent him from achieving his goals, especially when it came time to consider higher education. “Not wanting to spend [his] life farming,” Dalsing was quick to accept the opportunity to attend college on a full-ride scholarship when given the chance.

Against this backdrop, Dalsing moved away to attend a small college, majoring in biology and expecting to be a scientist, before making “potentially one of the most consequential decisions of [his] life” and taking the Medical College Admissions Test (MCAT), thus launching a long and celebrated career in vascular surgery.

“Destiny, maybe, but they say you make your own,” he teased.

Before delving into his introduction to the world of vascular surgery, Dalsing took the opportunity to touch on the impact his personal life has had on his professional success, not hesitating to declare that “the most important event in [his] life was meeting and marrying [his] wife, Rosa, just before [his] surgical internship.” He credited Rosa as the “emotional strength” in his life and “a pillar of acceptance, joy, and safety.”

Vascular influences

Jumpstarting his journey into vascular surgery was achieved by observing Victor Bernhardt, MD, and Jonathan Towne, MD, during his time at Marquette. But, Dalsing observed, his interest in vascular surgery was really awoken by Russell Dilley, MD, and John Glover, MD.

Completing a one-year fellowship at Northwestern, where he was greatly influenced by John Bergan, MD, James Yao, MD, and Bill Flynn, MD, Dalsing admitted that this time in his life was a “blur of hard work and long hours, convincing [him] that no one is ‘entitled to anything,’ but hard work can win the day if given the opportunity.”

Alongside his personal and professional journey to SVS president, Dalsing delivered a sweeping history of vascular surgery and outlined how the twists and turns of certain decades were pivotal in defining it as the distinct specialty that it is today, as well as some ship by establishing criteria for endovascular credentials nationwide.” As “established vascular surgeons gained endovascular experience,” he continued, sometimes spending months undergoing further training, by 2009, upwards of 80% of endovascular resident training was being provided by vascular surgeons.—an experience that would foreshadow a “complex and, in some cases, contentious” relationship with those who would “encroach on our discipline.”

Despite describing vascular pathology as an “unrelenting foe requiring special attention to proper timing and intensity of care,” Dalsing went on to note that “we are the only specialty who can correct the interventional misadventures of others, or enable others to provide complete trauma, orthopedic, or cancer care. This central role highlights our position as champions for quality vascular care.”

The president, who is professor emeritus in the Division of Vascular Surgery at Indiana University School of Medicine in Indianapolis, reflected on his current position within the vascular surgery field, paying stated, with its role extending far beyond the calendar highlight that is VAM. “SVS is literally reinventing itself as it evolves and moves forward to integrate dozens of new innovative ideas currently under consideration for implementation. This process happens year over year. We are coming of age as a mature organization,” he told attendees.

SVS: Vascular surgery’s advocate

And who but the SVS will advocate for the interests of vascular surgeons? Dalsing asked. “No one!” He stressed that the SVS is a small group that “must speak with a strong and unified voice to be heard,” all in the interest of vascular patients, as well as members’ well-being.

of the challenges that it presently faces.

In the 1940s, he said, vascular surgery was “coming of age.” In the 1970s and early 80s, training, certification, and defining the specialty took “center stage.” And the endovascular revolution of the 1990s and 2000s, he continued, saw a vascular surgery field that was “changing fast.”

Alongside mounting changes, the space was also being confronted by new challenges on the horizon. As “radiologists and cardiologists were embracing endovascular interventions” due to the access they had to appropriate imaging facilities, vascular surgeons didn’t get the same privilege.

A ‘unique’ specialty

“Vascular surgeons were pushing the envelope in the endovascular treatment of aortic aneurysms,” Dalsing said. “Some were trying to incorporate an endovascular suite in the operating room with some success. But we would have to catch up—take ownership—or be left behind. We righted our honorable mention to a “long list” of individuals who have influenced his career over the years. He also described the “immense joy” at seeing the next generation of vascular surgery residents and fellows serve their communities as “compassionate and skilled vascular surgeons,” in addition to being “exceptional people.”

Dalsing’s talk argued that vascular surgery is “unique” as a specialty, in that it involves the care of a patient from initial contact to the end of their life. As a result, specialists “must master several dissimilar skillsets requiring years of training.”

The specialty is, however, a “hidden gem,” Dalsing said, which he highlighted as a problem. “In general, people do not know what we do,” meaning the specialty risks being “overlooked as a needed partner in discussions about our patients’ care.”

And this is all in the context of an aging population and its “increasing demands,” being served by a “finite” number of providers.

This is where the SVS comes in, Dalsing

“We are the champions of quality vascular care. We must embrace this role and encourage those who want to be on the vascular team,” Dalsing said. He expressed his belief in the need to market to the general population—a seemingly “unattainable” goal, but one he feels is the “endgame” if there is a desire to be recognized as the “undisputed champions of quality vascular care.”

He defined the scope, the added value the specialty brings, and a general impression of the players involved. The next steps? According to Dalsing, they are “defining the rules of engagement and tactics to be used for success,” with education a “centerpiece” of this effort.

As his “musings [came] to an end,” Dalsing expressed thanks to everyone who gave a once “small-town boy with some big dreams” the chance to represent the SVS as president. It has been, he said, a “distinct privilege and honor” to serve in the role—one he described as “unexpected but dearly cherished.”

“Our society is you, a collection of diverse individuals reflective of our general population, but one in dedication and purpose for our patients,” Dalsing concluded. “I admire what you do daily, I am proud to be a vascular surgeon, and will miss the personal interactions I have had with many as I filled this role. Good luck and the best to us all as we face the world together.”

By Marni Davimes and Bryan Kay

THE SAFE MANAGEMENT OF AORTOiliac graft infections has proven possible by utilizing either cryopreserved arterial allografts (CAA) or rifampin-soaked Dacron (RSD) for select in-situ reconstruction based on the findings of a recent study conducted by the Mayo Clinic and Karolinska Institutet.

While it was found that reinfection rates among the RSD group were lower compared to the CAA group, it was not statistically significant, making both interventions viable options for infected patients.

Armin Tabiei, MS, a vascular surgery research trainee and medical student at the Mayo Clinic in Rochester, Minnesota, and Karolinska Institutet in Stockholm, Sweden, shared these findings at VAM 2023 in National Harbor, Maryland.

Although a single-center retrospective cohort study, said Tabiei, results showed “comparable early and long-term morbidity and mortality between the groups.”

While rates were higher in the CAA group and there was a trend toward higher reinfection rates in the RSD group, Ta- biei expressed confidence in both as viable options for in-situ reconstruction patients and conveyed that they “need to be customized for each patient’s characteristics.”

Tabiei et al’s objective was to compare the safety and effectiveness of CAA and RSD as options for in-situ reconstruction in aorto-iliac graft-infected patients.

Data collected from aortic and iliac graft-infected patients undergoing in-situ reconstruction with either CAA or RSD from January 2002 through August 2022 were analyzed retrospectively to assess overall survival rates as well as secondary outcomes such as graft-related intervention, reinfection, perioperative mortality, and major morbidity, The study included 149 subjects, 80 of which received RSD intervention and 60 who underwent CAA, with a mean age of 68.9 and 69.1, respectively. Moreover, endovascular stent grafts were infected in 60 patients, 41 of which were in the CAA group, with the remaining 19 patients in the RSD group.

With respect to graft-enteric fistulas, they were significantly more common in the RSD group, and management included complete resection of the infected graft. Aortic reconstructions were covered in omentum in 57 CAA patients and 63 patients in the RSD group.

There was a median follow-up of 20.5 months in the CAA group and 21.5 months in the RSD group, with