Vascular surgery oral boards text seeks to fill certifying void

A new reference textbook for trainees is proving a hit among those readying for the vascular surgery oral board exam, the authors tell Bryan Kay.

Think of it as the omega of the vascular surgical textbook literature, quips Andrew M. Wishy, DO. As a training resource, it fits neatly on the trainee bookshelf on one side— the end to a partner title, The Vascular Surgery Review Book, the alpha, or the beginning, on the other.

He is referring to Vascular Surgery Oral Board Review: Behind The Knife Premium, a textbook aimed at vascular surgery trainees taking the Vascular Surgery Board (VSB) Certifying Exam (CE), a work he helped craft and publish last year alongside colleagues Ravi N. Ambani, MD, and Kevin R. Kniery, MD, the latter known as a founder of popular surgical podcasts, Behind the Knife and Audible Bleeding

Like the author of The Vascular Surgery Review Book, Wishy, Ambani and Kniery produced their title to provide a training resource and help fill a void they identified as they made their way through their own training. The idea germinated as they studied together to take the VSB CE, realizing there was a lack of available material with which to prepare.

“Both Ravi and Kevin were general surgeons first and had

Carotid Disease

been through the oral board before in the general surgery realm,” explains Wishy, who, in contrast, completed his training under the integrated vascular surgery residency pathway. “We always practiced and tried to simulate these kinds of things for the integrated resident like me in our training institution: How is this really going to go? How is the back and forth going to be between the examiner and examinee? What kind of information are they going to want me to know? What’s too much? What’s not enough?”

As the CE preparation process was new to Wishy, that made him the perfect foil as the trio fine-tuned exactly what the textbook required. The ensuing text is comprehensive, he says.

“From cover to cover, you’re probably going to hit every high-yield topic there is [in vascular surgery], with every most-common procedure performed, and I would say the most common complications that I’ve ever ran into in practice, in the textbooks or heard from other people,” Wishy continues. “It’s not an all-inclusive resource by any means, but I think it’s a very good starting point, and covers the whole breadth of all the major and minor topics.”

The book has already proven a success among trainees since it was published last year, explains Ambani. “The three it was best to get the cases and material we used down on paper, and get it published,” he says. “After this last round of oral boards, a bunch of people messaged to say that this was the only thing they used, and that they were successful and passed.”

Ambani reckons the two reference titles— their Vascular Surgery Oral Board Review: Behind The Knife Premium and Creeden’s The Vascular Surgery Review Book—meet vascular surgery at a crucial juncture. “Vascular surgery as a group is growing,” he says. “It’s becoming one of the most competitive specialties to match into after general surgery and after medical school, so the volume of trainees keeps going up and the interest keeps peaking. We have our own boards, so it’s time for us to develop resources to help people study for those specialty boards. The resources that exist currently are aimed at general surgery as a whole.”

Top: of us were able to pass our boards on the first attempt, and once we had the proof of concept that we did well, and now that we’re all Board-certified vascular surgeons, we thought

SEX FOUND TO BE ‘IMPORTANT VARIABLE’ IN STUDY AND TREATMENT OF CAROTID ATHEROSCLEROSIS

A systematic review and meta-analysis have demonstrated “convincing evidence” that sex differences exist in carotid atherosclerosis, with all types of plaque features—including those relating to size, composition, and morphology—found to be either larger or more common in men than in women, reports Jamie Bell.

“OUR RESULTS HIGHLIGHT THAT sex is an important variable to include in both study design and clinical decision-making,” the authors, led by Dianne van Dam-Nolen, MD from the Department of Radiology and Nuclear Medicine at Erasmus University Medical Center, in Rotterdam, The Netherlands, write in the journal Stroke. “Further investigation of sex-specific stroke risks with regard to plaque composition is warranted.”

Over the past few decades, several individual studies on sex differences in carotid atherosclerosis have been performed, covering a wide range of plaque characteristics and including different populations, van

Dam-Nolen et al state. Their study began by systematically searching PubMed, Embase, Web of Science, Cochrane Central and Google Scholar for eligible studies, including both male and female participants, and reporting the prevalence of imaging characteristics of carotid atherosclerosis. The eligible studies were then meta-analyzed. Van Dam-Nolen et al prespecified which imaging modalities had to be used per plaque characteristic and excluded ultrasonography.

After identifying more than 1,000 unique citations, screening whittled this number down to 60 articles, with 42 being included in the final meta-analyses.

Six of these studies were included in a meta-analysis on the relationship between sex and atherosclerotic plaque size. All three of the characteristics used to measure plaque size—maximum wall thickness (1D size), wall area (2D size), and wall volume (3D size)—were more likely to be larger in men than in women, van Dam-Nolen et al report.

However, conversely, the normalized wall index, which accounts for the total vessel size, did not show a statistically significant difference between male and female participants, which the researchers describe as “surprising,” and possibly indicative of sex differences in plaque size being driven by contrasting vessel sizes.

In addition, analyzing three of the studies further regarding the degree of stenosis, the authors found no statistically significant sex difference for stenosis of 50–69%, although high-grade stenosis of 70–99% was more often seen in men than in women.

Meta-analyses relating to plaque composition examined the presence of calcifications, lipid-rich necrotic core (LRNC), and intraplaque hemorrhage (IPH), and found a higher prevalence in men versus women across all three components.

Expounding briefly on their calcification findings, van Dam-Nolen et al report statistically significant differences between men

The textbook tandem is “like a one-two punch,” Ambani adds. The Vascular Surgery Review Book plugs a hole for those the preparing for the Vascular Surgery In-Training Exam (VSITE) and the VSB Qualifying Exam, while Vascular Surgery Oral Board Review: Behind The Knife Premium slots into the oral boards, or CE, realm. “Together, they are synergistic. They both came out a couple of months apart. These both are super useful in different ways, and together relatively low-cost resources for trainees that get them through their entire training—and hopefully through their boards.” and women for the presence and amount of carotid calcifications, but not in terms of calcification percentage i.e. the amount of calcification relative to the total plaque volume.

“Furthermore, we found more pronounced sex differences for LRNC in symptomatic as opposed to asymptomatic participants,” they add.

Five studies were also included in the meta-analysis of the relationship between sex and plaque morphology, with the presence of ulceration and the presence of a thin-or-ruptured fibrous cap both being higher in men.

“The found sex differences in carotid atherosclerosis are of clinically significant importance, since the composition of plaque affects the risk of (recurrent) stroke,” van Dam-Nolen et al conclude.

“Previous studies have shown that especially IPH contributes to a higher stroke risk. Carotid LRNC, calcifications, total plaque size, and plaque ulceration, have also been reported as important risk factors. With regard to sex-specific risk prediction and treatment, it is essential to investigate the effect of these plaque characteristics per sex separately. We hypothesize that the stroke risk as a result of specific plaque compositions varies among men and women.”

Innovations and Exploration in Venous Interventions

April 27-29, 2023 | Miami Beach, FL

COURSE DIRECTORS