2 Guest editorial Beyond private equity: A new sheriff in town
8 WFVS Twin global burdens of growing PAD prevalence and vascular workforce shortfall demand action
11 Photo gallery VAM 2024 revisited: Through the lens
15 Complex aortic New data on TAMBE outcomes in complex aortic aneurysms emerge
A calling seeded
childhood:
vascular surgery for the betterment of patient care
By Bryan Kay
www.vascularspecialistonline.com
By Bryan Kay
HUGE OPPORTUNITIES abound for vascular surgeons to take a leadership role on the frontlines of a developing peripheral arterial disease (PAD) treatment crisis in the U.S., says Michael Conte, MD, who gave the second annual Frank J. Veith Distinguished Lecture at VAM 2024.
Conte, speaking on “The State of PAD Care in the U.S.,” called on vascular surgeons to take a leadership role amid great unmet need among a population who face a significant public problem during the talk in Chicago.
“There are a lot of exciting developments, and vascular surgery really needs to seize the day to lead in the science, lead in the challenges; it’s core to what we do, it’s core to our patient population,” the professor and chief of vascular and endovascular surgery at the University of California San Francisco (UCSF) told Vascular Specialist on the VAM 2024 sidelines.
“I think it’s a really great time for vascular surgeons to get
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Many attending the 2024 Vascular Annual Meeting (VAM; June 19–22) might have been unaware of the early life of 2023–24 Society for Vascular Surgery (SVS) President Joseph Mills, MD. Amongst an intrepid childhood following his father’s career as a dentist, incoming SVS President Matthew Eagleton, MD, noted as he introduced Mills to give the 2024 Presidential Address in Chicago, Mills had spent a portion of his formative years growing up on the Navajo reservation in Arizona. There, an elementary-school-aged Mills was one of only two non-Native American children in his class.
That period of the Baylor School of Medicine in Houston professor and chief of vascular surgery planted a lifelong respect
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By Marlén Gomez
The Society for Vascular Surgery (SVS) has announced Linda Harris, MD, as its next vice president, meaning that she enters the presidential line and will become SVS leader in 2026.
The announcement was made during the SVS Annual Business Meeting, held on June 22 in Chicago as part of VAM 2024.
The vice-presidential election process took place online,
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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 | 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
Saranya Sundaram, MD
Executive Director SVS
Kenneth M. Slaw, PhD
Senior Director for Public Affairs and Advocacy
Megan Marcinko, MPS
Manager of Marketing
Kristin Spencer Communications Specialist
Marlén Gomez
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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 News. 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 News 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 News. | Printed by Ironmark | ©Copyright 2024 by the Society for Vascular Surgery
The well-written recent editorial from Mal Sheahan, Vascular Specialist medical editor, explained the case against private equity in medicine, and what is at stake for physicians and patients.
I published a review of private equity about three years ago, hoping that surgeons would exercise caution before they jump into a ”deal.”1 It concluded that, “Fatigued by numerous stressors, physician practices and ASCs [ambulatory surgery centers] are increasingly choosing financial security through partnership with private equity investors as an alternative to hospitals or large group employment. However, careful consideration is needed in partnering with ‘for-profit’ and majority investor-owned private equity firms.”
My opinion about private equity in healthcare has changed from being slightly negative to truly negative. However, as we pointed out, the model may work for a small group of physicians planning to retire within a few years. Other than cardiology, the number of private equity acquisitions dropped in 2023. I suspect this is because most physicians are hearing about the downsides from colleagues, and the Department of Justice (DOJ) is hot on the trail over allegations of poor business practices against private equity.
A much larger, and darker, cloud has appeared over our healthcare system, as I warned on these pages. “Over time, some of us may feel they are faced with thralldom and are looking for options,” I wrote. And: “Novel options may include staying in practice but considering non-traditional and even provocative paths.”2 I mentioned private equity and the new sheriff in town that has taken up residence: the publicly-traded insurance companies. This happened quietly and quickly.
honchos back then that they knew how to make the system more efficient, bring down costs and, of course, improve the quality of care.
Let me remind younger members of the Society for Vascular Surgery (SVS) of the origin of the behemoth UnitedHealth Group insurance company. Physicians and others founded the firm in 1974 and incorporated it as Charter Med Incorporated, later morphing into United HealthCare Corporation (UHC). I was too busy with patient care, naïve and cash-poor then and missed the boat on buying shares in the company. In 1992, UHC acquired Columbus, Ohiobased HMO Physicians Health Plan of Ohio for $84 million. An older orthopedic surgeon friend bought shares. Do not ask me what those shares are worth today. The company kept buying up smaller health plans, and now you know the rest of the story, as the late Paul Harvey would say.
United Health Group, the parent group of insurance subsidiary UnitedHealthcare with $372 billion in revenue last year, is the largest insurer and covers about 53 million people. Its Optum subsidiary is now the largest employer of physicians in the U.S., with more than 90,000 employed or affiliated physicians, 40,000 advanced practice clinicians, pharmacy benefit managers, and technology and data analytics. Humana, Aetna, CVS Health and Anthem followed quickly.
This entire wave of acquisitions reminds me and many others to remember the halcyon days, when hospitals went full throttle in the 1980s to hire thousands of primary care physicians
When hospitals—which have integrated horizontally, vertically and every which way to consolidate and hire thousands of physicians— complain about the insurance companies buying physician practices, we better pay attention. Insurers like UnitedHealth Group now employ not only more physicians than the health systems, but they also own data analytic centers, accountable care organizations, office-based labs (OBLs), pharmacy benefit managers, urgent care centers, nursing homes, behavioral and mental health centers, and nursing schools. A recent example is the large acquisition of Wisconsin-based ProHealth Care, armed with 800 employees to manage the revenue cycle, information technology and data analytics. The strategy is to build out the back office to support the workers. Amazon-like, isn’t it? A particular concern with insurerowned physician practices that are dominant in certain markets is their poor record related to passing on any savings to employers and ultimately patients.
You might say that is a corporate takeover? Right. Isn’t it prohibited by law in some states? Right again. They do this because state legislators have looked the other way. The Affordable Care Act (ACA) probably did nothing to discourage corporatization either. In fact, the law may have encouraged it. Insurers told the ACA head
Not to be left out, retailers including Walgreens, Walmart and Amazon are joining the physician buyout wave. Amazon purchased primary care company One Medical, which has 815,000 members, for $3.9 billion. Walmart acquired a health technology and a telehealth company, and expanded its Walmart Health centers. In this environment, why should retailers of home appliances such as Best Buy be left behind? TVs are part of healthcare, right? Sick people watch TV too. Fear not. They acquired GreatCall, a home health company, and offered technical support to Atrium Health (hospital at home program).
The latest sector of great concern to surgeons is ASCs. Optum snatched Surgical Care Affiliates (SCA), an owner of ASCs, for a mere $2.3 billion in 2017 to add to their portfolio of more than 300 ASCs and surgical facilities. Another big player in ASCs is Tenet, which, after acquiring/ partnering with established United Surgical Partners, has grown to 500 ASCs and “surgical” hospitals.3 I would not be surprised if they or others are already planning to approach surgeons who currently own about 35% of OBLs.
The American Hospital Association (AHA), representing powerful but alarmed members, has pointed out that from 2019–2023, most physicians were acquired by private equity (65%), physician groups (14%), payors (11%), health systems (8%) and others (4%). This trend has accelerated since then, compelling the AHA to argue against the
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beginning in early June, and garnered some 867 eligible SVS members in good standing who cast a ballot during the voting period.
Harris, a professor of surgery and the program director for the vascular surgery fellowship and residency programs at the University at Buffalo in Buffalo, New York, began her tenure as SVS vice president immediately following the announcement, and will serve in the role through VAM 2025 taking place in New Orleans, where she will become president-elect.
“I’m honored to have been elected as vice president with the chance to eventually become president of this amazing Society,” said Harris, a former president of the Eastern Vascular Society (EVS), after she was unveiled as the new vice president.
“We have so much that we can really do if we work together; the threats that we face are primarily outside threats, and that’s why we need to come together.
“If we are fractured, we won’t succeed. We have so many bright minds and capable people. I want to engage everyone who would like to be involved.
“Anyone who has ideas, please feel free to reach out. We want to hear what you have to say because you’re part of us and we all have to work together.”
for—and interest in—Native American culture. It also led him down a path of service, following in the footsteps of his father before him, who had landed on the Navajo reservation as part of a public service commitment.
It cast a compelling backdrop to the core message behind Mills’ address in Chicago.
Mills issued a rallying call steeped in classical history and decades of collected vascular surgery wisdom with a singular aim: to overcome “unrest” and to drive forward vascular care with a broad approach to diversity.
Mills variously tackled the consolidation of medicine into ever-larger for-profit enterprises, the stresses inherent within a body of people such as the SVS, and the strong political position taken by the Society over appropriate care during his term of office.
He cast some of the conundrums facing the specialty thus: “Tension is an everyday consideration in life,” said Mills. “Tension and shear stress in arteries modulate wall thickness and vessel diameter. Tension is a fundamental aspect in each of our lives as well as in society at large.”
Examples include tension between physicians and payors, Mills continued, “tensions between physicians and the healthcare system, and tensions between alternative techniques, societies and specialties and even within societies.”
He invoked the democratic ideals of the ancient Greeks and how these principles drive collected interests in societies. “The poet and pre-Socratic philosopher Xenophanes stated that justice is a form of ‘tension-in-action,’” he said. “So how do we mitigate tension, particularly within the Society for Vascular Surgery, as we are simply a microcosm of society at large?”
Mills homed in on the necessity of a more diverse SVS Executive Board (EB). The EB, he explained, has expanded to include officers who are either self-nominated or nominated by others and then selected by the Nominating Committee and the 37-member Strategic Board of Directors to add diversity of perspective and additional competencies.
But by greater diversity, said Mills, he means more than the obvious markers such as gender and skin color. Diversity is multifactorial and must include diversity of perspective and cog-
FROM THE COVER GRASPING THE NETTLE: THE NEED TO TACKLE PAD PROBLEM HEAD ON
involved, whether that’s in the clinical research, the disparities and access to care issues, amputation prevention programs, or multidisciplinary care.
“There’s a lot there for young vascular surgeons to embrace,” Conte continued. “The service part as well as the research part are significant. So, if you look at what’s happening at the SVS with the VISTA [Vascular Volunteers In Service To All] program [now known as Vascular Care for the Underserved], all the way through to promoting clinical trials in PAD, this is the time—it’s a generational thing.”
With carotid disease now “pretty stable,” as Conte described it, and with the strides made in aortic disease treatment meaning “we’ve solved a lot of stuff” in that domain,
he said many roads now lead to PAD, which he labeled “huge” and in need of “a lot of help.”
First comes the opportunity, Conte declared, then the nature of the growing, countrywide public health problem— advancing age, diabetes not abating.
“We need to embrace and promote science-guided, evidence-based practice,” he says. “To do that, we have to continue to try to execute on designing and executing clinical trials using our registries to address important issues of quality of care, and continue to write and update meaningful practice guidelines. It’s a multispecialty space and we should embrace that, not shy away from it. We should just lead.”
During the Veith Lecture, Conte outlined the breadth of the challenges and opportunities at play in PAD treatment. He demonstrated the public health magnitude, the disparities in access to care and health outcomes, and the need to improve available therapies owing to persistent gaps in outcomes.
“What I really want you to take home from this is that in this tremendous field full of opportunities for vascular surgeons at every level, and particularly young vascular surgeons, to embrace and lead,” he implored the VAM 2024 audience.
Conte emphasized the need in the U.S.: “While we were doing really well with cardiovascular mortality, going from the
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nitive diversity, he continued. “Alternate perspectives and points of view must be included for a society or group to make the best decisions. As my long-time friend and vascular brother Spence Taylor used to say, if you go to see the brown shoe salesman, you are going to get a pair of brown shoes. Or, to paraphrase Atticus Finch in To Kill a Mockingbird, you never really understand a person until you consider it from their point of view and walk in their shoes.”
Mills started his vascular surgery career at Wilford Hall USAF Medical Center in San Antonio, Texas, there beginning the service-minded approach instilled by his father.
Later in his career, Mills returned to the scene of those early experiences in Arizona, where he helped lead efforts to establish a respected multidisciplinary limb salvage group known as SALSA, or the Southern Arizona Limb Salvage Alliance—a toe and flow model that paved a path for cross-specialty collaboration.
“I would propose that the broad disparities in vascular research and training that have been widely written about are fundamentally due to lack of inclusion and diversity among practitioners and investigators, whether one looks at disparities related to gender, people of different skin colors, or people living in rural environments. In fact, nearly all vascular diseases that have been studied, as well as the majority of device trials, have failed to sufficiently include all members of our society,” he said.
In tandem with the diversity message came a tone pointing toward the necessity of collaboration. “In line with building coalitions in a crisis, major efforts are being made to engage other organizations when they are in alignment with our goals and objectives to promote our specialty for improving the care of patients with vascular disease,” Mills related.
“We are a small group, far too small to be splintered or fragmented,” he said, finishing with a favorite maxim: “If you want to go fast, go alone. If you want to go far go together.”
He added: “It is unquestionable that giant leaps have been made in our field by many individual pioneers and innovators, but the way we reach the goal of optimizing our clinical effectiveness and improving care for all people with vascular disease, is to work together. All major individual accomplishments need to be translated into work that we can all do to provide better care for our patients.”
1980s to the early part of this decade, since 2010 things are going backwards. Cardiovascular mortality rates for both men and women have been back on the rise for the last 10 years, and there is a geographic distribution to this as well.”
After some decades of improvement in overall amputation numbers, those too are rebounding, Conte pointed out. Many are minor “but reflect the growth of diabetic foot disease overlaying with PAD. Those two things in concert have really taken over our practices. We are seeing many, many patients with neuroischemic wounds and diabetes, and a rise in the need for limb amputations.”
Conte turned to disparities in outcomes and the severity of disease, which “is certainly not equally felt by people of all races, colors and creeds.”
He said, “We have a lot of work to do to address the unbalanced proportion of Black and Hispanic patients who are presenting at late stages of disease and are at higher risk for amputation than their White counterparts.”
Economic disparity overlays with racial
disparity, he continued. Similar overlays can be demonstrated with food and housing insecurity, Conte said, “highlighting the fact that some of the racial and ethnic disparities are tied into social determinants of health. And until we tackle all of that together, we’re probably not going to be able to make a dent in some of this disparity.”
He pointed to a number of advances in medical therapy for PAD, referencing a change in the approach of the pharmaceutical industry to approach the disease process as an entity in its own right, separate from coronary disease. “Overall, this is a huge change in opportunity but it requires a lot more education and public awareness to transfer this to effective outcomes for patients,” Conte said.
He also addressed access, appropriateness and value issues in vascular care. “It’s difficult to say where we are,” Conte reflected. “Too little care or not enough care?”The issues within this conundrum must be tackled “head on,” he implored.
In sum, Conte emphasized vascular surgery’s lead role in PAD care delivery, science and innovation—”but multidisciplinary collaboration is fundamental to success.” The SVS should lead by fostering clinical excellence, education, science and building community across all PAD stakeholders, he added.
therapy in diabetic foot and venous leg ulcers: ‘A new, different functionality that penetrates the wound’
Until about a decade and a half ago, vascular surgeon Alisha Oropallo, MD, could be counted among the skeptics. Back then, she says, topical wound oxygen therapy for nonhealing vascular wounds did not have much traction in the vascular surgery community. Skepticism was widespread. There was little data behind the technology of the time, and questions lingered over its effectiveness.
Then along came a new mechanism of oxygen delivery to the wound bed. Data followed, including results from a randomized controlled trial (RCT) showing durable healing in chronic diabetic foot ulcer (DFU) wounds.
The key difference maker, says Oropallo, who is professor of surgery at Zucker School of Medicine at Hofstra University/ Northwell and director of the Comprehensive Wound Healing Center at Northwell Health in New Hyde Park, New York, is the cyclical pressurized oxygen applied directly to sites of wounds by Topical Wound Oxygen (TWO2) therapy.
“It wasn’t cyclical before, there wasn’t 100% oxygen, there wasn’t proof that it was actually penetrating the tissues—I think they were just blowing in oxygen from the outside and there wasn’t really a pump mechanism for the most part,” she explains. “It’s new and different multi-modality func-
tionality in how it penetrates the wound with oxygen.”
For Oropallo, TWO2 use is now routine. With DFU patients who qualify, she starts topical oxygen therapy almost immediately. For patients who she sees with radiation injuries, she almost always refers them for TWO2. And then there are those patients with venous leg ulcers (VLUs), and particularly recurrent VLUs.
A real-world outcomes study, conducted on a very co-morbid diabetic population—similar to the population that Oropallo treats—showed that even in the face of dysvascular function, and in many cases dialysis, this technology can help this particular population achieve successful outcomes and expedite healing of these hard-to-heal wounds. As the data in the study—carried out by Jessica Izhakoff Yellin and colleagues, and published in Advances in Wound Care in 2021—demonstrates, the significance of being able to decrease hospitalizations that prevent amputations in this group of patients with diabetic foot ulcers is life changing for them, Oropallo points out. It also showed that it was economically beneficial for all concerned when this TWO2 therapy can be implemented, she adds.
Oropallo cites a recent VLU case involving a 64-year-old man with a history of multiple deep vein thromboses (DVTs) and Factor V
Leiden deficiency. Prior, he had undergone left iliac vein stenting and radiofrequency ablation. The patient had residual deep venous reflux of the femoral vein and recurrent leg ulcerations, despite compliance with compression therapy, says Oropallo. “He received adjunctive therapy, such as skin substitutes,” she explains. “TWO2 was applied with subsequent improvement from baseline [image 1] and over four months duration to closure [2 and 3].”
Oropallo says she deploys TWO2 whenever feasible. “I use it throughout the treatment too,” she continues. “Because a lot of times the patients are only given a few weeks of hyperbaric oxygen therapy through insurance and that’s just not enough. So, I use it adjunctively and concomitantly. I don’t find that they’re mutually exclusive. I think that they can both help to enhance the wound healing, at least from a continuous basis.”
evidence behind the therapy. Known as the TWO2 Study, led by Robert G. Frykberg, DPM, it demonstrated that at 12 weeks and 12 months, adjunctive cyclical pressurized TWO 2 therapy was superior in healing chronic DFUs compared with optimal standard of care alone. Oropallo believes a similar study carried out in the setting of VLUs and published in the vascular literature might eventually lead to topical wound oxygen therapy forming part of the guidelines.
“The TWO2 Study is one of the strongest manuscripts in the literature regarding Wagner grade 1 and 2 DFUs,” she says. “So, I think that pans out really well for vascular surgery in general. If a DFU is a 3 or a 4, then it is more challenging, but the application may still be there—especially concomitantly with an adjunctive therapy.
Alisha Oropallo
“Some do very well with TWO2,” she adds. “It also depends upon the mental status of the patient too, because if the patient is cognitively impaired, that can change the role of how we use TWO2, because they have to administer it themselves.”
Oropallo says the RCT that evaluated the efficacy of TWO2 in the setting of DFUs represented a gamechanger in the level of
“ The TWO2 Study is one of the strongest manuscripts in the literature regarding Wagner grade 1 and 2 DFUs”
ALISHA OROPALLO
“Probably the bulk of vascular surgeons’ work is in the field of foot ulcers, because that’s where they do a lot of the revascularization. Most of those patients are admitted in the hospital; they’re going to be under the vascular surgery service line; they’re not going to be under podiatry. The podiatrist might be seeing them ancillary, but the vascular surgeon is really making all the decisions and seeing the patients every day.”
Oropallo contrasts how vascular surgeons face DFU patients with the current VLU treatment landscape.
“Unfortunately, not many patients with venous leg ulcers get admitted too often at the hospital anymore, but they are routinely seen about 80% of the time,” explains Oropallo. “There’s not a lot of good literature out there on topical oxygen in VLUs. But for patients with hard-to-heal wounds who have been recurrently coming back to the office, I wrap the wounds and apply TWO2 on those patients who really have some challenging wounds that are difficult to heal.”
market power of Optum to the DOJ, and requesting an antitrust investigation. The DOJ has obliged.
Like with the pursuit of private companies, the DOJ has now started looking into massive ownership interests and the conflicts between Optum-owned physicians and competing physicians.
The last time the DOJ questioned the UnitedHealth Group about its acquisition of Change Healthcare (recent target of a cyber attack), it took a pass.
This entire wave of acquisitions reminds me and many others to remember the halcyon days, when hospitals went full throttle in the 1980s to hire thousands of primary care physicians. The hospitals lost their shirts. I suspect the loser in the end will be the stockholders of many—but not all—of these public companies that are going outside of their core businesses to catch the wave. What, then, happens to their employed physicians?
There appear to be several objectives to the employment of thousands of physicians: starting with “value-based
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care” and fixed payments for every service. We are already seeing some of this with physicians sharing profits with insurance companies for Medicare Advantage patients, by taking some financial risk in the care of these patients.
Beside profits, their focus is to aggressively push into the large healthcare markets with a focus on “meeting patients where they are, and utilizing technology and established retail locations to make healthcare as convenient as possible.”4
The impetus comes from the desire to project a “one-stop shopping” façade.
While I agree with almost all of Dr. Sheahan’s commentary in his recent editorial, shifting the blame onto judges— conservative or liberal—is missing the point.
The blame rests, as it often does, with Congress, which finds it convenient to ignore its own responsibilities in providing the federal bureaucracy with ambiguous directions. It is easy to blame a faceless and politicized bureaucracy.
So, what is ahead? It is possible we may have three or four vertically
By Andrew Kenney
Stakeholder organizations such as the Society for Vascular Surgery (SVS) play a crucial role in shaping healthcare policies and ensuring that the voices of medical professionals are heard in the legislative and administrative processes. These organizations utilize several key methods to interact with Congress and the Administration, including Requests for Information (RFIs), comment letters and letters of support.
RFIs are formal tools Congress and federal agencies use to gather input on specific issues from stakeholders, including professional organizations, industry experts and the public. When an RFI is issued, it signals that lawmakers or regulators seek detailed information or opinions.
For an organization like the SVS, responding to RFIs is an opportunity to influence policy by providing evidence-based insights and recommendations. These responses typically include data from clinical research, expert opinions and practical insights from medical practice. The SVS can help shape policies that impact vascular surgery and broader healthcare practices by submitting comprehensive and well-supported responses.
The SVS has recently submitted comments to an RFI regarding consolidation in healthcare markets.
and horizontally integrated for-profit juggernauts serving the entire healthcare supply chain or a single payor system. Erstwhile foes like hospitals and insurers, now gaining the upper hand, may just join hands. Can you imagine the lobbying cash available?
It is like the Wild West and Dodge City right now. Is it possible for physicians to “get outta Dodge” and escape from this scenario? Is it possible that we will see a repeat of the hospital acquisitions of the 1980s and the accompanying financial disaster? CVS Health just purchased Oak Street Health, which employs 600 primary care physicians in 21 states. So far, that deal has been a huge money loser.
Not only that, the DOJ is reportedly investigating CVS for giving out “gift cards, swag and goody bags”!5 An Oregon-based Optum group recently lost 32 physicians within two years. Walgreens lost over $5 billion getting rid of its primary care chain.
We cannot discount that probability. We know there will be versions 3.0 or 4.0 of this familiar tale—and we as physicians
Highlighting its negative impact on independent practices and patients, the SVS noted that mergers can worsen geographic, logistical and cost barriers, reducing access to vital services for vulnerable populations.
The SVS urged the Administration to consider these concerns in policy and enforcement decisions. For more information, visit vascular.org/RFI_Response
Comment letters are another vital mechanism through which the SVS can influence federal policy, distinct from RFIs in both purpose and timing. RFIs are typically issued at the early stages of policy development to gather broad input and ideas from stakeholders. In contrast, comment letters are solicited during the rulemaking process after a proposed regulation has been drafted. This timing allows organizations like the SVS to respond to specific regulatory proposals with focused feedback.
The SVS leverages its expertise to submit comment letters that critique, support, or suggest modifications to these proposed rules. By focusing on the regulations’ practical implications, the SVS can highlight potential impacts on patient care, medical practice and healthcare costs. These letters provide detailed analysis, often supported by clinical data and professional experience, to substantiate the organization’s position. Participating in this process allows the SVS to ensure that the concerns and perspectives of vascular surgeons are directly considered before final regulations are enacted.
The SVS recently joined a coalition of medical organizations in submitting a formal response to the U.S. Preventive Services Task Force (USPSTF) regarding its draft research plan on Enhanced Risk Assessment for Cardiovascular Disease. The response emphasizes
will watch from the sidelines as always.
References
1. Satiani B, Zigrang TA and Bailey-Wheaton JL. Should surgeons consider partnering with private equity investors? The American Journal of Surgery. https://doi. org/10.1016/j.amjsurg.2020.12.028
2. Satiani B. The choice between autonomy, true partnership, or the slow drift to thralldom. Vascular Specialist. Feb. 2023
3. Newitt P. https://www.beckersasc.com/asctransactions-and-valuation-issues/tenetenters-new-era-driven-by-uspi-growth.html
4. Bailey-Wheaton JB. Zigrang TA. Health Capital Topics. Available at https://www. healthcapital.com/hcc/newsletter/03_23/ HTML/CORP/convert_corporate_moves_ in_hc_topics.php
5. Abelson R. Corporate Giants Buy Up Primary Care Practices at Rapid Pace. New York Times. Available at https://www. doximity.com/articles/365f4e62-b782-4420b3d8-0a231d61a056
BHAGWAN SATIANI is an associate editor for Vascular Specialist
the need for a balanced approach in evaluating both the benefits and potential risks and calls for a research framework that integrates comprehensive data from recent and historical studies to mitigate health disparities and enhance early diagnosis and treatment of cardiovascular diseases. For more information, visit vascular.org/Comment_Letter
In contrast, letters of support are proactive endorsements of legislative initiatives or regulatory actions. Letters of support are used to endorse specific pieces of legislation, regulatory actions or other governmental initiatives. When a bill that aligns with the SVS’s goals is introduced in Congress, organizations may issue a letter of support to circulate to Congress. These letters articulate why the proposed legislation benefits patient care, public health and the medical community. Letters of support often highlight the legislation’s practical implications, provide patient testimonials and cite relevant research to bolster the case. By lending its voice, the SVS can help build momentum for legislative initiatives that align with its mission and advocate for policies that improve vascular health.
The SVS joined over 60 other medical organizations in advocating for continued education, training and mental health resources for healthcare professionals by sending a letter of support to the reauthorization of the Dr. Lorna Breen Health Care Provider Protection Act.
For more information, visit vascular.org/Support_ Letter
ANDREW KENNEY is a member of the SVS advocacy staff, representing the Society in Washington, D.C.
By Christina Cui,
MD
While I certainly received my fair share of offhand comments and physical struggles, these mental hurdles proved to be the most taxing experience. With family on the opposite coast and close friends scattered throughout the country, my primary goal was to simply get through my pregnancy. And, I somehow only did because the community in the hospital reached out in ways I could never have dreamed of.
AS A VASCULAR SURGERY RESIDENT, OUR training emphasizes anticipating and planning for complications. This mindset is undoubtably critical clinically but can be less beneficial in settings outside of hospital confines. It certainly was my first reaction to the positive pregnancy test halfway through my second year of clinical training.
To be clear, the timing didn’t help. I had just started my pediatric surgery rotation, where my waking hours were spent with babies crashing onto extracorporeal membrane oxygenation (ECMO), undergoing exploratory laparotomies in the neonatal intensive care unit (ICU), or screeching through during trauma activations. My subsequent months in the surgical ICU presented a fresh set of challenges. I was inundated with a wave of post-partum patients that demonstrated all the ways childbirth would try to kill you. I was thoroughly convinced that one of these worst-case scenarios would become my reality, and I carried out my daily life with a simmering sense of unease.
Operating room staff would sneak stools behind me for all cases and refused to let me move patients. Our advanced practice providers would stock their mini-fridge with ginger ale and regularly allowed me to raid their personal snack stash. My attendings were willing to cover call shifts when the morning sickness extended far past the morning and felt much stronger than just “sickness.”
My co-residents threw the most incredible, well-fed baby shower, complete with themes, a balloon arch, charcuterie and a custom cake. They all pitched in to buy me a stroller, the first thing I let my husband assemble. I am especially grateful for the food and designer adult diapers they brought to the hospital.
This generosity extended far beyond just the pregnancy period. I came home from the hospital to flowers, food delivered personally to my home, and even had people come over to cook food within my home. I received bags of clothes, extra bassinets and baby swings, all ma-
terializing through a support network I previously did not fully appreciate. Even as I reflect on the experience, I am struck by just how invested and kind every individual was. I made it through the nine months in large part because of every single person who took time and energy out of their busy schedule to care for me.
While my narrative is one of gratitude and community support, I am acutely aware that not all share this experience. As a cisgender, heterosexual, Asian female who did not face significant medical complications or the challenges of alternative paths to parenthood, my experience was in many ways very straightforward. I was fortunate to spend the latter part of my pregnancy in my research year, which provided a degree of flexibility many do not have.
“My attendings were willing to cover call shifts when the morning sickness extended far past the morning and felt much stronger than just ‘sickness’”
There remains a multitude of reasons that better cultural, structural and institutional support is needed for family-building alongside surgical careers. There has been an incredible influx of literature discussing pregnancy complications, leave policies, post-partum support, discrimination, among other topics. These discussions are crucial as they pave the way for a more inclusive and supportive environment for those who come after us.
By Bryan Kay
A GROWING PREVALENCE OF peripheral arterial disease (PAD) across the world parallels a deteriorating PAD landscape in the U.S., underscoring a need for more vascular surgeons and risk-factor reduction globally, according to a leading expert in the field.
Vincent Rowe, MD, chief of vascular surgery at the University of California, Los Angeles (UCLA), was speaking during the VAM 2024 World Federation of Vascular Societies (WFVS) Educational Session on, June 19, telling the audience, “It is pretty apparent, that in both the U.S. and globally, we are heading down this dark road to the complications that occur with PAD: if we don’t do something soon it could be an issue, not only for the United States, but also globally.”
Risk factors in the U.S. include tobacco use and glucose and blood pressure control, Rowe explained. Across the world, it is a similar picture, he said, adding low physical activity and diet to the list.
He raised the twin specter of diabetes, with “a tsunami” expected across the U.S. in the next 20 to 30 years, especially among some minority patients, running alongside the global PAD burden. “If we look at diabetes globally, you can see it is increasing, both in terms of prevalence and in terms of incidence, and also deaths.”
Rowe referenced a recent publication that laid out the scope: a 72% increase in global prevalence of PAD, with mortality also continuing to rise.
“The authors stated that this pattern represents a major public health challenge that warrants a coordinated and targeted response from governmental and private medical institutions to try to combat this disease, and especially slow the progression medically,” he said.
The global picture of increasing PAD and associated risk factors—body mass index and food consumption levels among them—plays out across gender and among
children, Rowe pointed out.
The bottom line is, according to Rowe, “in the U.S., with all these increases in risk factors, that we predict we’re going to need more vascular surgeons.
“The current estimate is a 31% shortfall in the next couple of years, he noted, “and unfortu nately we’re not very well dis tributed across the country.”
Currently, some 2,600 coun ties in the U.S. have no vascular surgery representation, Rowe said.
And they’re not all rural: “Almost half of them are considered urban counties,” he added. “If we look at the world, we can see that the population is going to continue to increase, and our distribution of vascular surgeons across the world in certain countries is not very good at all.”
Rowe offered some potential remedies aimed at starting to tackle the increasing disease burden and workforce shortfall. “We can try to increase the number of vascular surgeons, but that is going to be a tall order. But we’re going to really need to, especially globally,” he said.
He also raised the idea of international rotations. “Perhaps if we were allowed to take our fellows and residents internationally, that would increase their interest in going back and serving in those countries,” he elaborated, also suggesting paid service programs as another possible avenue.
“Also, maybe loan forgiveness: we for-
Paper exploring stroke rates in arch TEVAR emerges as winner of VAM Poster Competition
By Marlén Gomez
VAM 2024 IN CHICAGO SHOWCASED EMERGING talent in vascular surgery through a moderated Poster Competition held over two days of the conference. his event provided a platform for research and recognized excellence among the next generation of vascular surgeons.
Hassan Chamseddine, MD, a research fellow from Henry Ford Hospital in Detroit, Michigan, secured first place for his poster titled “Comparative analysis of stroke rates in arch TEVAR [thoracic endovascular aortic repair]: Total endovascular repair plagued by high stroke rates.” Chamseddine expressed his gratitude to the organizing committee for the award.
“It feels tremendous to be recognized for the research we’ve been doing at Henry Ford Hospital. We hope this project helps move endovascular stent grafting of the aortic arch forward in the future,” he said.
The competition, organized by the SVS Program Committee, involved a two-round judging process. In the first round, accepted abstracts were divided into topic groups for poster presentations. The 11 winners selected from each group advanced to the final round and presented their posters in a championship round on the final day of VAM.
Jason
give loans for people who go and practice in underserved areas—maybe they should forgive them if someone goes and practices for two to three years internationally as well.”
Rowe added one more remedy from his own circle. “One of my friends is from Nigeria, and he does global grand rounds—not to educate the vascular surgeons but to educate all the other practitioners about vascular disease to help them take care of these patients medically.”
“One of my friends is from Nigeria, and he does global grand rounds—not to educate the vascular surgeons but to educate all the other practitioners about vascular disease to help them take care of these patients medically”
VINCENT ROWE
competition moderators, emphasized the importance of the event, commenting how “the Poster Competition has always been one of the favorite opportunities for people to quickly showcase their research projects.”
He continued, “Being able to deliver a message in three minutes is a skill that we want researchers to learn, and providing immediate feedback through a quick questionand-answer session makes it very educational.”
Lee will head the VAM Program Committee for VAM 2025 in New Orleans.
The competition final on June 2022 was moderated by Edith Tzeng, MD, professor of vascular surgery from the University of Pittsburgh Medical Center; Matthew Eagleton, MD, the current SVS president and chief of the Division of Vascular and Endovascular Surgery at Massachusetts General Hospital-Harvard Medical School; Joseph Mills, MD, the immediate past-president of the SVS; and Michael Stoner, MD, professor in the Department of Surgery at the University of Rochester Medical Center.
Lee outlined the competition’s benefits for both presenters and attendees.
The combined 180 minutes of presentations allowed attendees to view numerous research projects from future leaders in the field, he said. Lee pointed out that top
posters often become highly competitive abstracts for publication.
“For many of the people who have won the poster competition, that was often the first paper they had published, and it’s exciting. It’s often been the younger part of our attendees and trainees, and that allows them to have that experience of seeing a project all the way from inception to presentation to publication,” Lee added. Third and second places were awarded to Chloé Powell, MD, a vascular surgery resident at Michigan Medicine in Ann Arbor, and Arash Fereydooni, MD, a vascular surgery resident at Stanford Health Care, California, respectively. Powell was recognized for her work titled “Duplex screening for renal artery stenosis plus selective second trimester angioplasty to reduce maternal morbidity and improve pregnancy outcomes among women with hypertensive disorders of pregnancy.” Fereydooni was recognized for his research, “A standardized, scalable and automated open-source CT [computed tomography] AAA [abdominal aortic aneurysm] diameter measurement tool using deep learning.”
“The SVS Poster Competition and championship highlights the innovative research being conducted in vascular surgery and provides a valuable learning experience for participants. Each topic’s best poster is seen up on the podium, allowing researchers to gain exposure and recognition for their hard work,” said Lee.
Fracture medial arterial calcium while debulking intimal morphologies
Proven success in below-the-knee arteries, where calcium tends to be more prevalent2
Safety at the forefront. Treat with confidence by minimizing the risk of embolization and dissection3
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The Auryon Atherectomy System and Auryon Atherectomy Catheters with aspiration are indicated for use as atherectomy devices for arterial stenoses, including in-stent restenosis (ISR), and to aspirate thrombus adjacent to stenoses in native and stented infra-inguinal arteries.
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1. Rundback et al. Treatment effect of medial arterial calcification in below-knee after Auryon laser atherectomy using micro-CT and histologic evaluation, Cardiovascular Revascularization Medicine, 2023,ISSN 15538389, https://doi.org/10.1016/j.carrev.2023.06.027.
2. Paul D. Bishop, Lindsay E. Feiten, Kenneth Ouriel, Sean P. Nassoiy, Mircea L. Pavkov, Daniel G. Clair, Vikram S. Kashyap, Arterial Calcification Increases in Distal Arteries in Patients with Peripheral Arterial Disease, Annals of Vascular Surgery, Volume 22, Issue 6, 2008, Pages 799-805, ISSN 0890-5096, https://doi.org/10.1016/j.avsg.2008.04.008.
3. Rundback J, Chandra P, Brodmann M, et al. Novel laser-based catheter for peripheral atherectomy: 6-month results from the Eximo Medical B-LaserTM IDE study. Catheter Cardiovasc Interv. 2019;94(7):1010-1017.
care is a ‘team sport’ founded on infrastructure, personnel and standards
By Jamie Bell
THE E. STANLEY CRAWFORD CRITICAL ISSUES
Forum at VAM 2024 in Chicago—which featured the tagline ‘Quality Care Everywhere’—underscored the importance of standards, infrastructure, personnel and verification programs in vascular surgery.
Multiple speakers throughout the session described vascular care as a “team sport,” alluding to the need for collaboration within individual centers. In addition, presenting experiences from one of the first inpatient centers to have utilized the SVS and American College of Surgeons’ (ACS) Vascular Verification Program, R. Clement Darling III, MD, said the program “allows you to feel proud of what we do as vascular surgeons.”
Following an introduction from then SVS President-elect,
TARGET’
By Jamie Bell
NEW DATA PRESENTED AT VAM 2024 have revealed poor overall rates of medical therapy adherence in moderate asymptomatic carotid stenosis patients— with smoking cessation representing a “ripe target” for improvement moving forward.
“The objectives of this study were to examine adherence to three common tenets of medical therapy among a cohort of patients treated with medical therapy alone, and then to identify shortfalls in therapy to serve as opportunities for improvement,” said Randall Bloch, a research fellow at St Elizabeth’s Medical Center in Boston, presenting these data on behalf of senior author Mark Conrad, MD, chief of vascular surgery at St Elizabeth’s, and colleagues.
The single-center, retrospective study involved reviewing consecutive carotid duplex ultrasound scans from 2019–2020.
now President Matthew Eagleton, MD, the session also saw Clifford Ko, MD, discuss ACS quality initiatives and campaigns; Anton N. Sidawy, MD, outline the Vascular Verification Program (Vascular-VP) itself; and William P. Shutze Sr, MD, home in on how the program can be of help to outpatient centers.
Sidawy spoke of the need for vascular surgery to take charge of ensuring standards and handling its own verification processes, noting that “if we do not define it, someone else will define it for us.”
A salient message delivered by Ko was that centers with the correct standards and personnel—in short, those who “have it all set up”—tend to perform better. However, Sidawy later alluded to the fact that these criteria are not always met, hinting at disparities between vascular surgery and other specialties.
“Just go to your hospitals and look at two things,” he said. “Look at transplant and trauma, and see how much support they have. We would dream, as vascular surgery programs, of such support. And the reason they have this support is because, in order to be verified, that’s what they need to have—and this is one part of why we really wanted to embark on this verification program.”
Ko, speaking as the director of the ACS’ Division of Research and Optimal Patient Care, added: “We often are finding, in all of our care—cancer as well—that, in order to provide the level of care that we want to provide, we need to have those resources, those people there, in order to do the processes and in order to get the outcomes.
“This partnership together with the SVS and the vascular experts is really trying to identify those things to move us forward.”
Patients with moderate (50–69%) asymptomatic carotid stenosis—based on SVS guidelines—were included in the study, while those who underwent upfront surgery “for any reason” were excluded, as were those without follow-up data.
Patients were assessed for their adherence to optimal medical therapy at the time of the index duplex scan, the first follow-up visit, and at each subsequent follow-up visit until the end of the study, ultimately leading to a median follow-up period of 2.7 years.
In the study, optimal medical therapy was defined via three key tenets: abstinence from smoking; use of aspirin or other antiplatelets; and use of statins or other lipid-lowering therapies.
The study, now also published in the Journal of Vascular Surgery, identified a total of 323 duplex ultrasound examinations with moderate asymptomatic carotid stenosis across 255 patients. Bloch reported that 56.1% of these patients were already on all three of the aforementioned aspects of medical therapy at the time of the index duplex, with this rate improving to 68.6% by the end of the follow-up period.
“However,” Bloch said, “when looking specifically at the 112 patients that were not already on medical therapy, 38.4% were able to achieve adherence to all three tenets of medical therapy by the end of follow-up—and abstinence from smoking was the aspect of medical therapy that was least commonly achieved.”
The presenter went on to highlight the
“Just go to your hospitals and look at two things. Look at transplant and trauma, and see how much support they have. We would dream, as vascular surgery programs, of such support”
ANTON N. SIDAWY
fact that patients with hypertension and those who were not smoking at the outset of the study demonstrated the highest rates of medical therapy adherence.
According to Bloch, non-smokers achieving generally better adherence rates was able to be attributed to a rapid, initial uptake in adherence, likely due to “the relative ease of adding additional medications to the regimen, as opposed to the relative difficulty of smoking cessation.”
In addition, multivariable analysis revealed that smoking at the time of the index duplex was associated with lower odds of achieving optimal medical therapy adherence.
“In conclusion, adherence to best medical therapy is suboptimal—less than 40% of patients who were not previously on therapy were able to achieve adherence to best medical therapy by the end of follow-up,” Bloch stated. “And, so—despite rapidly evolving medical therapies for cardiovascular risk reduction—smoking cessation remains a ripe target for interventions aimed at adherence to medical therapy.”
Discussions subsequent to Bloch’s presentation saw Kakra Hughes, MD, chief of vascular surgery at Howard University in Washington D.C., note that these data lead him to a slightly different conclusion.
“I don’t quite agree with your conclusion that best medical therapy is not good [in this study], because it’s 80% adherence when you take away smoking
cessation—and we all know that smoking cessation is very difficult,” Hughes said. “I’d consider that the adherence to best medical therapy is about 80%, and I’d conclude that it is pretty good.”
Bloch agreed with Hughes to some degree, echoing his point that medication adherence alone was “pretty good,” but went on to assert that smoking cessation was part of the prespecified regimen in the study and is also recommended by the SVS as well as multiple other societal guidelines.
“So, I think it’s important to continuously look at how we’re doing in terms of providing comprehensive care for these patients,” the presenter added.
Another comment came from session moderator Wei Zhou, MD, chief of vascular surgery at the University of Arizona in Tucson, Arizona, who described this as a “really important study”, and suggested that it may have wider implications in other medical areas beyond carotid disease where medication adherence is also poor.
Speaking to Vascular Specialist, Bloch provided further context regarding his discussion with Hughes, stating: “Given that smoking cessation is such an integral aspect of best medical therapy, my concern is that separating it from the medication regimen may lead to a false sense of success when it comes to stroke and cardiovascular risk reduction. As such, smoking cessation should be a leading priority in the care of these patients.”
VAM 2024 has been hailed as another highly successful iteration of the SVS community’s annual gathering. Considered the premier educational and scientific meeting on the vascular surgery conference circuit, the event’s four days of programming saw eight plenary sessions stacked with new science, a multitude of focus sessions covering every aspect of the vasculature, as well as long-standing meeting staples such as the Crawford Forum and the Homans Lecture alongside the second annual Veith Lecture.
the
outgoing President Joseph Mills with his grandkids after his address; the 2024 Gala yields more photo opportunities; the SVS Foundation’s award-winning Voices of Vascular initiative plays center stage nearby SVS Central; Palma Shaw, WFVS secretary-general, joins the many attendees scrutinizing new science; and Yale’s Cassius Iyad Ochoa Chaar presents from the podium
“We are a small group, far too small to be splintered or fragmented”
JOSEPH MILLS
By Kristin Spencer
“Life over limb”—that was one of the key messages to emerge from the VAM 2024 SVS Women’s Section session that placed a lens over vascular trauma treatment. Misty Humphries, MD, associate professor of surgery at University of California Davis in Sacramento, California, who was covering mangled extremities and providing tips from the frontlines of a level-1 trauma center, underscored the point that maintaining life was always paramount.
“I don’t really implement treatment the way a vascular surgeon would—a lot of times I’ll do things as a trauma surgeon would,” she said. Humphries walked through the definition of a true mangled extremity, with severe damage being caused to at least three of the four: bone, vessels, nerves and/ or soft tissue. Humphries shared her salvage vs. amputation decision tree and discussed the multidisciplinary evaluation that needs to take place before a decision is made. Humphries covered different orthopedic cases and studies that aided in
her trauma training and decision-making on whether to amputate an extremity over time. She wrapped up her time at the podium by sharing practices she had adapted over time to help with extremity trauma.
The session, entitled Vascular Trauma: What I Need to Know in the Middle of the Night, was the brainchild of co-moderator Erica L. Mitchell, MD, professor and chief of vascular and endovascular surgery at the University of Tennessee Health Science Center in Memphis, Tennessee. “The idea was inspired by the paucity of vascular trauma literature as well as the rising interest of vascular trauma in the medical field,” she explained. “There needs to be vascular surgical engagement in the care of these vascular trauma patients, so I wanted to host a session that could make vascular surgeons more confident in providing that engagement.”
The session brought together a number of leaders in the vascular surgery arena who have extensive experience with vascular trauma cases. Manuel Garcia-Toca, MD, a vascular surgeon at Emory University in Atlanta, Georgia, discussed managing trauma to the head and neck vessels. “The neck has so many vital structures in a really confined space,” he said. “It is challenging when you get a phone call in the middle of the night when there’s a patient with a neck injury. You don’t know if the patient will have to go to the OR [operating room], and that is a tough call to make from the phone.”
A vast majority of the calls will be from blunt injuries to cervical vessels—injuries that, according to Garcia-Toca, received a lot of awareness in the 90s because people were having strokes as a result. “So, you need to review the CAT scan from home to make the call,” he said, stressing
By Marlén Gomez
THE SOCIETY FOR VASCULAR
Surgery (SVS) convened its Annual Business Meeting at the Vascular Annual Meeting (VAM) on June 22 in Chicago.
A highlight of the event was the announcement of the 2023–2024 award recipients by the outgoing Foundation Chair Michael C. Dalsing, MD.
The full list of recipients who received accolades during the gathering are as follows:
James S. T. Yao Resident Research Award
Kevin D. Mangum, MD, PhD
Vascular surgery integrated resident University of Michigan, Ann Arbor
Title: “The STAT3-SETDB2 axis dictates NFKB-mediated inflammation in macrophages during wound repair”
Vascular Research Initiatives Conference Trainee Awards
Shaunak Adkar, MD, PhD
Integrated vascular surgery resident Stanford University, Stanford, California
Title: “Soluble guanylate cyclase activators as potential novel PAD therapeutics”
Jack Bontekoe, MD
Integrated vascular surgery resident
University of Wisconsin Hospital and Clinics, Madison
Title: “Reduction of abdominal aortic aneurysm rupture by modulating smooth muscle cell phenotype switching”
Nathaniel Parchment, MD
Integrated thoracic surgery resident
University of Michigan, Ann Arbor
Title: “Endothelial mixed lineage leukemia 1 (kmt2a/MLL1) as a central mediator of immunothrombosis during SARS-CoV-2 infection”
Lucas Reckard-Mota, MD
General surgery resident
Beth Israel Deaconess Medical Center/ Harvard Medical School, Boston
Title: “Deciphering prosthetic bypass graft-to-artery anastomosis dynamics at the molecular level: A single-nuclei and spatial transcriptomics analysis”
Student Research Fellowship Awards
Daniel Zikri Aziz
University of Virginia, Charlottesville
Sponsor: Melina R. Kibbe, MD
Title: “Advancements in early detection of
the importance of acting within the first 72 hours to prevent a stroke. Garcia-Toca underlined the importance of establishing vascular trauma protocols at institutions and offered “pearls in the middle of the night”: that most blunt cerebrovascular injury injuries should be managed by antithrombotic therapy, encouraging the use of computed tomography angiography (CTA) to guide therapy unless there are hard signs of a vascular injury.
Elsewhere, Luc Dubois, MD, associate professor in the Division of Vascular Surgery at University of Western Ontario in London, Ontario, Canada, explored abdominal vascular trauma, highlighting endovascular vs. open procedures for abdominal aortic injuries. Sadia Ilyas, MD, a vascular surgeon at MedStar Heart and Vascular Institute in Washington, D.C., covered thoracic vascular injuries, discussing how she categorizes traumas into blunt or penetrating traumas, and shared the grading scale from the 2011 SVS Clinical Practice Guidelines. Ilyas also walked through how to manage patients with blunt aortic trauma and how to conduct surveillance. Andrea Lubitz, MD, assistant professor of surgery in the Division of Vascular and Endovascular Surgery at the Lewis Katz School of Medicine at Temple University Hospital in Philadelphia, spoke on a “rare but complex problem”: IV drug use-associated pseudoaneurysms. She described the nature of IV drug use (IVDU), its management and gave an overview of the current literature.
The session wrapped with a talk from Pedro Teixeira, MD, associate professor of vascular surgery at the University of Texas at Austin Dell Medical School, who discussed the rarity of vascular surgeons seeing trauma patients for follow-ups.
abdominal aortic aneurysms via nanomaterialconjugated contrast agents”
Warren Carter
Yale School of Medicine, New Haven, Connecticut
Title: “Carotid revascularization outcomes of premature carotid atherosclerosis among patients in neighborhoods of differing social disadvantage”
Caryn Dooner
University of Toronto, Toronto, Canada
Title: “Assessing and addressing health literacy in vascular surgery patients”
Alasdair Fletcher
VA Boston Healthcare, Boston
Title: “Comparing indications for and rates of atherectomy for PAD in single-payer VA healthcare system with national trends”
Alejandra Silva Hernandez
University of Washington, Seattle
Title: “A sustainable real vessel-on-a-chip as an observable disease model of intima hyperplasia”
Stuthi Iyer
University of Pittsburgh School of Medicine, Pittsburgh
Title: “The association between frailty and major adverse limb events is mediated by depression after revascularization for chronic limb-threatening ischemia”
Amin Ali Mirzaie
University of Florida, Gainesville
Title: “Assessing prognostic expectations
in patients with chronic limb-threatening ischemia”
Vikki Rueda
Northwell Health, New Hyde Park, New York
Title: “The impact of social determinants of health on genetic profiles in diabetic foot ulcers between responders and nonresponders to standard of care”
Andrew William Schwartz
Yale School of Medicine
Title: “The role of Sox6 expression in venous remodeling after arteriovenous fistula creation”
Hana Soraya Shafique
Duke University School of Medicine
Title: “The role of Spp1+ macrophages in peripheral arterial disease”
Garrett Blane Sweatt
Southern Illinois University School of Medicine, Springfield
Title: “Chronic total occlusion length on long-term femoropopliteal segment patency in chronic limb-threatening ischemia: Are the currently accepted cutoffs supported by clinical data?”
Ashley Xu
University of California, San Francisco
Title: “Underlying mechanisms of vascular calcification in peripheral artery disease (PAD)”
To learn more about the awards and the work of the SVS Foundation, visit vascular.org/ FoundationAwards.
‘WELL, HERE WE ARE—BUT RIGHT NOW I WISH I WASN’T”: EARLY-CAREER ERRORS
By Kristin Spencer
ON FRIDAY, JUNE 21, THE SOCIETY for Vascular Surgery (SVS) Young Surgeons Section (YSS) held their session at the 2024 Vascular Annual Meeting (VAM). The session began with Chelsea Dorsey, MD, highlighting the YSS’ achievements from the last year including a publication in the Journal of Vascular Surgery-Vascular Insights, and the announcement of a new traveling professorship program.
“I am really excited about the things that we have done, but also for the future,” said Dorsey. Dorsey served as the section’s chair from its inception in 2021 until recently when she rotated off the Steering Committee; Edward Gifford, MD, will now serve as the chair.
Once the opening remarks were made, the education portion of the section kicked off and shifted focus to early-career errors. The session had six speakers who covered their personal errors, three being clinical and the other three being professional scenarios that the speakers encountered.
Megan Parrott, MD, served as the first speaker in the session and went into details on a patient’s case, with her talk on, “What to do when even our best-laid plans go sideways.”
Ravi Ambani, MD, followed Parrott in the
speaking order and told the audience about the things he missed while considering his first job post-training, the missteps taken when moving on to his next role, and gave words of wisdom for building a network of trustworthy people to lean on when making those types of career decisions.
Kyongjune Lee, MD, took the podium next to discuss a patient case where something was missed on imaging, but pointed out by an outside surgeon before an operation took place. Lee shared his insight into the importance of listening to outside opinions and always giving them consideration, as well as soliciting feedback on treatment plans to ensure every piece of the puzzle is considered before moving forward. Lee also focused on the significance of having transparency with patients to help build trust.
“I loved how both the speakers and audience members were open to having a real conversation about some difficult clinical and career scenarios that many of us have or will face as practicing vascular surgeons,” said Dorsey. “It felt like folks latched onto the ‘brave space’ phenomenon described during VAM’s inaugural keynote address. It was fun to be a part of it and I hope we can continue that trend in years to come.”
Elizabeth George, MD, continued the ses-
sion by discussing managing pregnancy and returning to work early on in a vascular surgery career. George walked the audience through her three pregnancies and highlighted the stark differences that each one had when it came to her career and her personal life, ultimately stressing that being a surgeon and a great mother are not mutually exclusive. George brought forth the idea for the development of guidelines for surgeons who are expecting regarding radiation exposure.
Behzad S. Farivar, MD, came forward to discuss a time when he “zigged when he should have zagged” that focused on a patient case where an endovascular approach was originally taken. Postoperative imaging
“I loved how both the speakers and audience members were open to having a real conversation about some difficult clinical and career scenarios that many of us have or will face as practicing vascular surgeons”
CHELSEA DORSEY
showed three different issues, but the patient was okay. Farivar spent much of his time discussing treatment options with the audience and asking questions to make the audience critically consider next steps. His conclusion encouraged audience members to acknowledge that complications are a part of surgical practice, to learn from every experience, seek assistance and collaboration, understand the strengths and weaknesses of one’s institution and to always have a contingency plan. To reduce errors, Farivar encouraged adopting a holistic view, working toward continuous improvement while encouraging ongoing learning, and to adopt lean surgical procedures.
The final talk was given by Olamide Alabi, MD, and focused on the importance of finding the right mentor, and how to manage the relationship so it benefits the mentee. Alabi discussed the ideal mentor/mentee relationship, which consists of open dialogue that bring lead to critical thinking and planning, mutual participation and more. Alabi gave personal examples about mentor/mentee relationships that did not benefit her in the way that she needed, and how she managed the relationship to get more out of them.
YSS leadership designed the session with the intention of creating a space for young surgeons to feel comfortable discussing career mistakes. “We’ve gotten great feedback from attendees and presenters alike. The session seemed to strike the right note for where we want to see the section go in the future,” said Gifford.
Compiled by Marlén Gomez and Kristin Spencer
VAM 2024 recordings available now
ATTENDEES OF THE 2024 VASCULAR Annual Meeting (VAM) can now access recordings of the sessions, including poster presentations, lectureships and more. The recordings are available through the SVS mobile app or the online planner, providing a convenient way for participants to catch up on sessions they missed or review their favorite presentations.
To view the recordings, attendees should log in to the platform, click on “Full Schedule,” select the desired session, and click the pop-up. They can then look for the “Video Recording” button next to the moderator’s name. To access the recordings, visit vascular. org/OnlinePlanner.
THOSE LOOKING FOR A comprehensive review resource for vascular surgery are encouraged to check out the Society for Vascular Surgery’s (SVS) sixth edition of the Vascular Education and SelfAssessment Program (VESAP6).
This premier digital resource is designed to aid professionals in their examination preparation and ongoing education, with over 600 questions in more than 10 content areas.
Visit vascular.org/VESAP to purchase.
THE SOCIETY FOR VASCULAR SURGERY (SVS) Foundation has appointed new members to its Board of Directors. These individuals will continue the Foundation’s mission of driving advancements and impacting the field of vascular surgery. Peter Henke, MD (pictured), the new Research Council chair, replaces Raul Guzman, MD. Joseph Mills, MD, will assumes the role of Foundation chair, succeeding Michael Dalsing, MD, and Matthew Menard, MD, replaces Ulka Sachdev-Ost, MD.
Henke was the past chief of surgery at the Ann Arbor Veterans Affairs, co-director of the Blue Cross Blue Shield of Michigan Vascular Intervention Collaboration and a past president of the American Venous Forum. Mills currently serves as the Reid professor and chief of vascular surgery and endovascular therapy at Baylor College of Medicine in Houston. His extensive vascular surgery leadership and academic background have led him to hold the presidency in multiple vascular societies and contribute significantly to vascular surgery literature.
Menard is the vascular and endovascular fellowship program director at Brigham and Women’s Hospital in Boston.
“The SVS Foundation’s commitment to advancing vascular health is unwavering,” Mills said. “I am excited to lead this distinguished board in continuing to make impactful strides in our field. We will focus on driving research, fostering innovation, and improving patient care to meet the challenges of vascular disease.”
Keith Calligaro, MD, the SVS president-elect, will join the board as part of the presidential line. Calligaro is the chief of vascular surgery at Pennsylvania Hospital in Philadelphia.
For more information about the SVS Foundation and its Board of Directors, visit vascular. org/FoundationBoard.
REGISTRATION FOR THE Society for Vascular Surgery (SVS) Foundation’s 2024 Vascular Health Step Challenge is now open. The Foundation is hosting the third annual Step Challenge throughout the month of September in honor of Peripheral Arterial Disease (PAD) Awareness Month.
Throughout September, Step Challenge participants are encouraged to walk 60 miles to represent the 60,000 miles of blood vessels in the human body. Registration for the challenge costs $60 per participant. Once registered, participants can download the Charity Footprints mobile application and synch it to their smartphone or watch to monitor their daily step count. A leaderboard is accessible within the application so participants can monitor their progress and their competition.
Proceeds from the Vascular Health Step Challenge will benefit the SVS Foundationic.
Learn more and register at vascular. org/STEP2024
Compiled by Will Date and Bryan Kay
THE FOOD AND DRUG ADMINISTRATION (FDA)approved Gore Excluder Thoracoabdominal Branch Endoprosthesis (TAMBE) has been shown to be safe and effective at 30 days for the treatment of patients with complex aortic aneurysms involving the visceral aorta.
This is according to findings of the TAMBE trial, a prospective non-randomized multicenter study investigating the use of the TAMBE device in thoracoabdominal and pararenal aortic patients, enrolled in the U.S. and Europe. Findings of the trial were presented at VAM 2024 by Mark A. Farber, MD, from the University of North Carolina in Chapel Hill, North Carolina.
TAMBE is an implantable branched device designed for use in patients with thoracoabdominal aortic aneurysms (TAAA) and high-surgical risk patients with pararenal aortic aneurysms (PRAAs) of the aorta using an endovascular approach.
The device has four built-in pre-cannulated internal portals to facilitate placement of bridging stent grafts into the visceral arteries perfusing the internal organs within the abdomen.
The FDA granted approval for TAMBE to be used in the treatment of complex aneurysmal disease in January 2024, a move that was heralded by the device’s manufacturer Gore as
Acellular tissue-engineered vessel granted FDA Regenerative Medicine Advanced Therapy designation for advanced PAD
HUMACYTE RECENTLY ANNOUNCED IT has been granted Regenerative Medicine Advanced Therapy (RMAT) designation from the US Food and Drug Administration (FDA) for its investigational acellular tissueengineered vessel (ATEV), designed to treat patients with advanced peripheral arterial disease (PAD). This RMAT designation was granted at the same time as the FDA cleared a new Investigational New Drug (IND) application for the PAD indication for ATEV, formerly referred to as the human acellular vessel (HAV).
According to Humacyte, this is the third RMAT designation granted by the FDA for Humacyte’s ATEV, in addition to previous RMAT designations for vascular trauma repair and arteriovenous (AV) access in hemodialysis.
Gore announces first commercial implant of Gore Tag thoracic branch endoprosthesis in Canada
GORE HAS ANNOUNCED THE first commercial use of the Gore Tag thoracic branch endoprosthesis (TBE)
paving the way for the first off-the-shelf solution in the U.S.
Farber presented the first of two arms of the TAMBE trial, which targeted type IV TAAAs and PRAAs, including 102 patients in total. A secondary arm focused on Crawford type I-III aneurysms is continuing enrollment, having recruited 23 patients so far.
Patients enrolled in the primary arm of the trial had an average age of 73, were predominantly male (84%), and presented with significant cardiovascular risk factors including current smoking (42%) and hypertension (92%). Around 40% of patients were treated for PRAA, with around 60% treated for type IV TAAA, with 83% of the TAAA cohort and 72% of the pararenal group had an aneurysm diameter of >5.5cm.
Technical success of the procedure was achieved in all but one patient, Farber detailed, adding that there were no access failures, and 407 of the 408 target vessels were successfully stented. Non-TAMBE components were required to be placed in 19 patients.
Following their procedures, patients had a mean length of hospital stay of 4.9 days, with 89.2% of patients discharged to home. No lesion-related mortality or severe bowel ischemia were reported through 30 days.
Reinterventions were required in 9.4% of patients at 30 days, with one devicerelated death reported on post-operative day 39, which Farber commented was
in Canada. The news came as Canadian government health authority Health Canada approved the first-of-its-kind endovascular device, which is indicated to treat lesions of the descending thoracic aorta while maintaining flow into the left subclavian artery (LSA) in patients with appropriate anatomy.
Designed for thoracic endovascular aortic repair (TEVAR) procedures, the Gore Tag TBE provides a minimally invasive option in patients requiring aortic treatment into zone 2 across the left subclavian artery.
Boston Scientific announces agreement to acquire Silk Road Medical
BOSTON SCIENTIFIC HAS ANNOUNCED that it has entered into a definitive agreement to acquire Silk Road Medical, a medical device company involved in producing products to be deployed during transcarotid artery revascularization (TCAR).
The TCAR system gained Food and Drug Administration (FDA) approval in 2015 and is supported by several clinical studies demonstrating a reduced risk of stroke and other complications associated with traditional open surgery, a company press release reported as the acquisition was revealed.
The products sold by Silk Road Medical are the only devices commercially available for use during the TCAR procedure.
likely related to superior mesenteric artery (SMA) stent occlusion. Major adverse events occurred in 6.9% of patients, including two with respiratory failure, one disabling stroke, and two patients having developed new onset renal failure requiring dialysis. Two patients developed paraplegia. The success of the trial was measured against two composite primary endpoints, one including technical success and procedural safety, and the second reinterventions and lesion-related mortality.
“Overall, 92% of the subjects were free from procedural safety events, however, the uncomplicated technical safety performance goal, 80%, was not met in the study because of the number of unplanned non-TAMBE devices implanted,” Farber detailed.
“The TAMBE device has been shown to be safe and effective at 30 days at treating patients with complex aneurysms involving the visceral aorta”
MARK FARBER
Patient selection is likely to have had a significant impact on outcomes, and device applicability may not reflect real-world experience, Farber said, outlining some potential limitations of the study.
“The TAMBE device has been shown to be safe and effective at 30 days at treating patients with complex aneurysms involving the visceral aorta,” said Farber. “Outcomes demonstrate a high technical success rate, no 30-day mortality, and a low rate of safety events within 30 days of the index procedure.” He added, “Long term data will help determine where this treatment strategy will fit in the management of patients with TAAA and PRAA.”
GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis
Consult Instructions for Use eifu.goremedical.com
INDICATIONS FOR USE IN THE U.S.: The GORE® VIABAHN® VBX
Balloon Expandable Endoprosthesis is indicated for the treatment of de novo or restenotic lesions found in iliac arteries with reference vessel diameters ranging from 5 mm – 13 mm and lesion lengths up to 110 mm, including lesions at the aortic bifurcation.
CONTRAINDICATIONS: Do not use the GORE® VIABAHN® VBX
Balloon Expandable Endoprosthesis in patients with known hypersensitivity to heparin, including those patients who have had a previous incident of Heparin-Induced Thrombocytopenia (HIT) type II. Refer to Instructions for Use at eifu.goremedical.com for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available.
Products listed may not be available in all markets. GORE, VBX, VIABAHN and designs are trademarks of W. L. Gore & Associates. © 2021–2024 W. L. Gore & Associates, Inc. 241363902-EN JANUARY 2024
GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis (VBX Stent Graft)
With a 1 Fr profile reduction on most sizes, the VBX Stent Graft enables you to confidently address complex aortoiliac occlusive disease with greater versatility.
primary patency at 5 years per lesion1
89.5% of patients improved ≥ 1 Rutherford category from baseline at 5 years1 100%
freedom from target lesion revascularization (fTLR) at 5 years per subject1 89.1%
1. Holden A, Takele E, Hill A, et al. Long-term follow-up of subjects with iliac occlusive disease treated with the Viabahn VBX Balloon-Expandable Endoprosthesis. Journal of Endovascular Therapy. In press.
W. L. Gore & Associates, Inc. Flagstaff, Arizona 86004 goremedical.com
Please see accompanying prescribing information in this journal.
Products listed may not be available in all markets.
GORE, Together, improving life, VBX, VIABAHN and designs are trademarks of W. L. Gore & Associates.
© 2024 W. L. Gore & Associates, Inc. 241408302-EN MARCH 2024
