Vascular Specialist–May/June 2022 by BIBA Publishing

IN LUD INC GA

MAY/JUNE 2022 Volume 18 Number 05/06

THE OFFICIAL NEWSPAPER OF THE

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8-9 C omment & Analysis Surgeons on the frontlines: A tale of unspeakable horror and an unquenchable thirst for freedom

31 T he Alzheimer’s study A new pathway for preventing dementia?

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02 F rom the Editor A modest proposal: Let’s eat the trauma surgeons

33 Drug-coated technology IN.PACT AV DCB shows sustained and superior performance compared to PTA through three years www.vascularspecialistonline.com

OVERTREATMENT IN VENOUS DISEASE: FINANCIAL INCENTIVES ARE ‘THE ELEPHANT IN THE ROOM’

URBAN OR RURAL: ENSURING ACCESS TO QUALITY VASCULAR CARE ‘NO MATTER WHAT’ Michael Dalsing, MD, tells Vascular Specialist how his formative years growing up in rural Wisconsin, as well as experience of operating in inner-city Indianapolis, helped inform the topic he chose for this year’s Crawford Critical Issues Forum set to take place at VAM in Boston: ‘Quality Vascular Care for All—An Aspirational Goal of Merit’

To combat the “overtreatment problem” in the appropriate care of venous disease, “a concerted, complex, multimodal effort” is required from specialists across disparate parts of the world. That was the conclusion delivered by Manj Gohel, MD, from Cambridge University Hospitals, Cambridge, England, during the opening day Venous & Lymphatic Challenges session at the Charing Cross (CX) International Symposium in London (April 26–28). Gohel further told attendees: “But the elephant in the room is reimbursement. Until that is sorted,” he said, “we will not be able to get on top of this.” During his presentation, “How to curtail inappropriate care in venous disease interventions,” Gohel had stressed how the aim was to curb overtreatment but also not reduce innovation. “Probably the most inappropriate care in venous disease is actually undertreatment. We have masses of undiagnosed, and definitely undertreated, venous problems. Over-

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ven among many medical colleagues, the common misconception seems to go a little like this, says Michael Dalsing, MD, the Society for Vascular Surgery (SVS) president-elect: vascular surgeons may not have a lot of interest in preventing vascular disease before serious issues arise or, they’re “just focused on procedures.” Rather, says Dalsing, access to complete quality vascular care is a topic “all of us are interested in. I think it’s a universal mission, or goal, of every vascular surgeon. We want to make sure that everybody with vascular disorders is taken care of well, in the right time, in the right place, and by the right people.”

See page 11 (VAM preview section)

NEW VICE PRESIDENT, SECRETARY TO BE ANNOUNCED AT VAM IN JUNE Election results for the Society for Vascular Surgery (SVS) 2022–23 vice president and secretary will be announced at the

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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 Publishing. 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 Publishing 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 Publishing. | Printed by Vomela Commercial Group | ©Copyright 2022 by the Society for Vascular Surgery

Vascular Specialist | May/June 2022

FROM THE EDITOR A modest proposal: Let’s eat the trauma surgeons By Malachi Sheahan III, MD

ell folks, after more than two years of the pandemic, racial injustice, and medical misinformation, I have decided it is time to return to writing about what I truly love: fake feuds with other specialties. Remember the heady days of 2019 when surgeons took on the Association of periOperative Registered Nurses (AORN) in the Bouffant War? All it took was a global plague and international shortages of personal protective equipment (PPE) to prove that AORN’s 47 evidence-free recommendations for surgical attire might not be addressing the most pressing needs in modern medicine. Today, we are free to put on our skullcaps and bask in our victory, earlobes and napes of our necks exposed like the day our mamas made us. Now we are being pulled into a new, ridiculous feud. I think the millennials would describe it like this: No one: Absolutely no one: Trauma surgeons: Hey, I don’t think we need vascular surgeons anymore! The first salvo came in 2020 with the Annals of Surgery perspective article “Beyond the crossroads: Who will be the caretakers of vascular injury management?” The authors of this piece made several salient points detailing the lack of adequate training in vascular injuries for trauma and acute care surgeons. Our esteemed profession, however, endured several cheap shots in the process. “As vascular practitioners become more focused on elective endovascular procedures, they often develop ‘lesion vision,’ similar to ‘tunnel vision,’ focusing on obtaining gratifying before/after images, whereas failing to use the patient’s other injuries or physiology in the decision making of how the vascular injury should be managed.” Lesion vision? That’s not even catchy. I mean come on, “stenosis psychosis” is right there. Besides, who has lesion vision? Vascular surgeons, or the people calling us at 4 a.m. because they think they see a 5mm blush near the superficial femoral artery on an 18-year-old with palpable pulses? Elsewhere in the article, the authors declare without evidence that “Patients with injuries that may be best treated by open surgery receive endovascular care because that is what the local vascular surgeon knows.”

Other random grievances are aired. Vascular surgeons are apparently so afflicted with Lesion VisionTM that we fail “to fully prepare and drape the trunk and extremities to allow for rapid default for open proximal control or a later fasciotomy…” A remarkably specious accusation to cast at a specialty who routinely prep their endovascular aneurysm repairs (EVARs) from nipples to groins despite last performing an open conversion before the iPad was invented. I was fortunate to contribute to the response to this article organized by Drs. Brigitte Smith and Erica Mitchell. The resulting perspective was thoughtful and measured (despite my best efforts). The answer, we maintained, was collaboration between vascular surgeons and trauma surgeons. It certainly says something about our commitment to patients that we are so willing to battle over the management of vascular trauma. These cases live in that godless patch of night starting around 3 a.m., where you leave the comfort of your bed with the terrible knowledge that your day has now begun, and an Odyssean journey separates your return. Masochistically, I run the dispiriting math on the way to the hospital. Let’s see, I can finish this trauma by 7, get to my clinic at 8, grab a fast lunch, make war with the Trojans, three quick cath lab cases, then sail home to Penelope. Hopefully, there won’t be traffic on the Aegean. The back and forth in Annals of Surgery should have been the end of it, but, ladies and gentlemen, I regret to inform you that the trauma surgeons are back on their bullstuff. In the recently published study “Trauma surgeon-performed peripheral arterial repairs are associated with equivalent outcomes when compared with vascular surgeons,” the trauma surgeons from the Medical College of Wisconsin purport that their brachial and femoral artery repairs had the same shortterm outcomes as those performed by their institution’s vascular surgeons. In an unfortunate blow to the scientific validity of this conclusion, the femoral injuries treated by the vascular surgeons were significantly more complex and more likely to be associated with

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MALACHI SHEAHAN III is the Claude C. Craighead Jr. professor and chair in the division of vascular and endovascular surgery at Louisiana State University Health Sciences Center in New Orleans.

Welcome to your new-look SVS newspaper THIS MONTH, VASCULAR SPECIALIST, YOUR OFFICIAL monthly newspaper from the Society for Vascular Surgery (SVS), re-launches with a new look. Our masthead has been freshened up and the layout has undergone a revamp. We hope you enjoy this new, modern look. The edition is a double issue covering the months of May and June, and also includes a 20-page section devoted to the upcoming Vascular Annual Meeting (VAM) in Boston. Included in the regular pages of the newspaper are interviews with Vascular Surgery Board Chairman Thomas Huber, MD, a vascular surgeon-led commentary from the frontlines of the war in Ukraine, and a peek behind the curtain of the most recent issue of Seminars in Vascular Surgery with Editor-in-Chief Caitlin Hicks, MD, and Sherene Shalhub, MD, who was guest editor for a focused look at aortic dissection and the Aortic Dissection Collaborative. The VAM preview section—and the cover of this May/June special issue—features an interview with Michael Dalsing, MD, on the Crawford Forum he has put together, a

chat with Christopher Audu, MD, the winner of this year’s SVS Foundation Resident Research Award (also our own resident/fellow editor), along with reports on presentations from across various plenary, focused and special sessions. The preview section’s name, Vascular Specialist@ VAM, will also be the new name of the VAM daily newspaper starting this year, replacing Vascular Connections. Meanwhile, all of our regular features take up their usual spots in the paper, including Corner Stitch, our monthly column written by and for trainees and medical students. Thank you, as always, to our readership, and we look forward to more of your contributions to the rebooted Vascular Specialist in the months and years ahead. Yours,

Vascular Specialist | May/June 2022

FROM THE EDITOR

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other operative injuries. The brachial injuries treated by the vascular surgeons had a higher rate of gunshot mechanism, complete transection, and associated non-vascular injuries requiring surgery, although these factors did not achieve significance, likely due to the small sample size. The authors also cited a faster transition time to the operating room (OR) for the trauma surgeons, which they postulated may be due to the vascular surgeons ordering more imaging studies. While it is certainly possible that the generally more complicated cases being managed by vascular surgeons required a longer workup, a simpler explanation lies in the laws of physics. It is probably quicker to get to the OR from the emergency room than it is from your bed at home. Based on their data, the authors concluded they had “no difference in short-term clinical outcomes” compared to the work performed by their vascular surgeons. While that is one way to interpret the numbers, isn’t it also true that the vascular surgeons repaired more complex injuries with more associated orthopedic injuries without an increase in reinterventions, complications or mortality? I spoke with Dr. Peter Rossi, chief of vascular surgery at the Medical College of Wisconsin, regarding this paper from his trauma colleagues. He expressed disappointment and noted that “what should have been an opportunity for learning and collaboration” was instead conducted without their input. Accompanying this paper in the Journal of Trauma and Acute Care Surgery is a commentary written by Dr. Thomas Scalea, one of the co-authors of the original “Beyond the crossroads” piece. Titled “Caring for vascular injuries: Training more vascular surgeons may not be the answer,” the article provides no evidence to support its provocative title but does give Dr. Scalea a chance to roll out his Lesion VisionTM zinger once again. Dr. Scalea also provides anecdotal evidence of young trauma patients being treated in the community with stents, which he has had to subsequently remove. He also bemoans the lack of data supporting the increase in endovascular interventions. This is decidedly misleading. An analysis of matched patients in the National Trauma Data Bank found that those undergoing endovascular repair had nearly half the in-hospital mortality compared with the open surgery cohort. Some of the greatest advances in trauma care this century have been led by endovascular innovations. The benefits of stent grafting in aortic repair are obvious, but it also improves outcomes in other locations, such as axillosubclavian injuries where “…the morbidity of the operation is much less given that large complex incisions do not need to be made, there is much lower blood loss, and less operative time is needed.” Of

course, there is no need to remind Dr. Scalea of these facts as I pulled the quote directly from his recent article, “Endovascular management of axillosubclavian artery injuries.” Finally, Dr. Scalea notes, “The decisions, when to do definitive repair versus damage control and how to order the repair of vascular injuries in patients with multisystem trauma must remain the purview of the injury specialists, that is, the trauma surgeon.” Here we agree. Too often I have arrived at the hospital to find a patient with concomitant vascular and orthopedic injuries left in the ER for the respective specialists to battle it out. Early in my career, I was quick to repair these vessels only to find my bypass perplexingly thrombosed after the ensuing ortho procedure. After taking the time to actually witness an open reduction and internal fixation, let’s just say I am no longer perplexed!

Vascular surgeons may not be the heroes the trauma surgeons want, but we are the ones they need. The only sane pathway forward is collaboration While trauma surgeons may bemoan the ceding of vascular injury expertise to us, they have made little effort to correct the current status quo. Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowships in surgical critical care require no case minimums and can be essentially non-operative. The Acute Care Fellowship sponsored by the American Association for the Surgery of Trauma (AAST) mandates the management of only 10 vascular injuries: certainly not a pathway to competence. In

2021, general surgery graduates reported an average of 2.8 vascular trauma procedures over their five years of training—including 1.3 fasciotomies. Even experience does not automatically translate to aptitude and proficiency. Competence must be acquired from the competent. Vascular surgeons may not be the heroes the trauma surgeons want, but we are the ones they need. The only sane pathway forward is collaboration. Recognition of the importance of the vascular surgeons to a trauma center is key, and the trauma surgeons need to support our efforts here. In the United States, trauma centers are designated by regional governments and most rely on the standards set by the American College of Surgeons (ACS). The trauma center verification program was approved by the ACS Board of Regents in 1986, and the first Level I trauma center was verified in 1987. The most recent standards were published in March of this year in the Resources for Optimal Care of the Injured Patient manual. There is often confusion regarding the prerequisites for vascular surgery coverage in trauma centers. The ACS manual is partly to blame. On page 45, “Specialty Liaisons to the Trauma Service” are listed. Here orthopedics and neurosurgery are required but vascular is not mentioned. Flip to page 61, however, and expertise in vascular surgery is mandatory with continuous 24-7, 365-day availability for all Level I and Level II adult and pediatric trauma centers. This is a Type I standard, meaning verification is automatically withheld if it is not met. I know for a fact there are many trauma centers in the U.S. without continuous vascular coverage. Perhaps there is a perceived loophole in the “expertise” designation? The ACS guidelines require physicians with board certification or eligibility in general surgery, neurosurgery, orthopedic surgery, anesthesia, emergency medicine, and radiology, but it is not specified for vascular surgery. We need the ACS to hold those claiming vascular surgery “expertise” to the same standards. Stricter enforcement by the ACS will incentivize institutions to offer equitable call pay to vascular surgeons, as they do for our orthopedic and neurosurgery colleagues. The modern care of vascular injuries requires training and proficiency in both open surgical and endovascular techniques. In the U.S., completion of an ACGME-certified vascular training program, and subsequent Vascular Surgery Board (VSB) certification, is the sole pathway designed and proven to ensure these competencies. The “expertise” loophole is arbitrary, disingenuous, and a danger to the public. To safeguard the care of vascular trauma patients, we need to continue to grow the vascular surgeon workforce and take the steps needed to ensure their proper valuation by trauma centers.

FROM THE COVER: NEW VICE PRESIDENT, SECRETARY TO BE ANNOUNCED AT VAM IN JUNE continued from page 1

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SVS Annual Business Meeting on June 18 during the Vascular Annual Meeting (VAM) in Boston. Vice presidential candidates are Matt Eagleton, MD, and Amy Reed, MD. Candidates for secretary are Drs. Kellie Brown and William Shutze. All four have been active, involved SVS members. Get to know the candidates at vascular.org/22_23Candidates. Internet voting for officers and on proposed bylaws changes began May

23 and was set to close at 5 p.m. Central Daylight Time on Friday, June 3. Only Active and Senior members in good standing may vote; those whose dues are in arrears can pay any outstanding invoices and be able to vote immediately. The SVS Nominating Committee sought nominations for the two open positions in February and March, and then selected two candidates each. In 2020, members approved bylaws changes that permitted multiple candi-

dates to be selected for member voting, and also instituted online voting, said Michel S. Makaroun, MD, Nominating Committee chair. “We also moved to online voting, which permits all of our members in good standing to be part of the officer selection process, not just those who are in attendance at VAM and the Annual Business Meeting,” Makaroun explained. “Our members have fully embraced this change.” In addition to the vice president

Matthew Eagleton and Amy Reed

and secretary nominees, the following slate of officers will be presented at the Annual Business Meeting: President Michael Dalsing, MD; President-Elect Joe Mills, MD; Treasurer Keith Calligaro, MD (year three of three); and Immediate Past President Ali AbuRahma, MD. The Annual Business Meeting is set to take place from 12 noon—1:30 p.m. (EST) in Ballroom C.—Beth Bales

Vascular Specialist | May/June 2022

FROM THE COVER OVERTREATMENT IN VENOUS DISEASE: FINANCIAL INCENTIVES ARE ‘THE ELEPHANT IN THE ROOM’ continued from page 1

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treatment is however an enormous problem.” Why? Education plays a part, he said, along with such elements as patients’ desire for intervention and an evidence gap in some areas of care that “allows variations in practice.” Yet, the biggest is financial gain, Gohel outlined. “Reimbursement systems around the world are poorly incentivized,” he said. Earlier in the session, Steve Elias, MD, director of the Center for Vein Disease in Englewood, New Jersey, spoke on the extent of overtreatment in superficial venous disease care, stating how evidence demonstrated such overtreatment clearly represented inappropriate care—“people treating the wrong patients, or doing too many things on who we consider the right patients.” Responding to a question posed by Armando Mansilha, MD, from the University of Porto in Porto, Portugal, a session moderator, about how aspects of the overtreatment problem might be addressed, Elias offered one potential solution: “Stop paying people for doing the wrong thing by partnering with payors,” he said. Elias had referenced outliers in practice who may perform many more ablations per patient than the 1.8 shown in a Medicare data analysis from 2019. “Because the payors know what claims are being sent in. Let us start with those who were

two standard deviations away from the norm,” Elias added. These interventionists may be doing the right thing, or perhaps they are seeing patients with more advanced disease, but such a move to partner with payors would represent a move in the right direction, he explained. Kathleen Gibson, MD, from Lake Washington Vascular in Bellevue, Washington, turned the spotlight on deep venous disease, speaking on “managing the safe introduction of medical devices,” focused particularly on the developing area of dedicated venous stents. “When these were approved, it was kind of like taking people who were used to driving a stick shift [car],” Gibson said, making an analogy to heretofore use of the nondedicated Wallstent. “Now we have got a fleet of automatics.” Everyone could now drive easier, she said, except the dawn of dedicated venous stents “led to some disasters.” “Maybe we should curb our enthusiasm,” Gibson suggested. She pondered what venous disease specialists can do differently. “We need to make sure we have the right doctors doing the procedure with appropriate skills, judgement and ethics,” Gibson said.

That means “correct patient selection in terms of diagnosis and application of technology, and short- and long-term follow-up,” along with increased rigor of venous training, discouraging inappropriate use, and publishing complications. The value of recently published European Society for Vascular Surgery (ESVS) guidelines on chronic venous disease in the promotion of evidence-based care was highlighted by Marianne De Maeseneer, MD, from Erasmus Medical Centre in Rotterdam, The Netherlands, who is chair of the ESVS guideline-writing committee. “The new ESVS guidelines certainly help to promote evidence-based care for our patients with chronic venous disease,” she said. “A vast majority are class 1 and 2a recommendations, so they are clear guidance for the clinician. The level of evidence should still be improved in future research,” and gaps in the evidence should be filled by randomized controlled trials and real-world registries, De Maeseneer added. Gibson, meanwhile, offered perspective from the United States during the questions and answers following Gohel’s presenSteve Elias

tation on ways to curtail overtreatment. Venous disease is not well taught in fellowship or training Stateside, she said. Trainees receive lots of arterial training during the training years. Yet, a large portion of what they confront in practice is venous disease— and they are “not trained,” she said. Regulation, too, figures as an issue, Gibson added. While “hospitals can regulate who can put things in,” she said, “a lot of devices like iliac stents are put in in the office setting,” where there is no regulation, and where a dermatologist armed only with their state medical license can be performing venous procedures. Gohel was succinct as he added one further concluding statement. “If you have the right healthcare culture, humility, focus on patients, desire to audit and be transparent with your results, and amend your practice based on your results, that is the right approach,” he said.—Bryan Kay

“Reimbursement systems around the world are poorly incentivized” MANJ GOHEL

Vascular Specialist | May/June 2022

COMMENT&ANALYSIS A university building in Kharkiv lies in tatters

A TALE OF UNSPEAKABLE HORROR, UNPRECEDENTED UNITY AND UNQUENCHABLE THIRST FOR FREEDOM The war in Ukraine has exacted an enormous toll on the Eastern European country’s population, with public infrastructure, including medical facilities, deliberately targeted and many procedures postponed, write Andriy Nykonenko, MD, Maksym Karpusenko and Jean-Baptiste Ricco, MD

This editorial was written in the days leading up to April 2.

t about 4 a.m. (Kyiv time) on Feb. 24, Russian President Vladimir Putin announced the start of a military operation aiming to “demilitarize and denazify Ukraine.” A few minutes later, Russian troops crossed the Ukrainian border and started shelling. Russian ships approached the Ukrainian coasts from the Black and Azov seas and bombed Mariupol. Countless Ukrainians were awakened that day by heavy explosions. While nobody knows for certain where Putin was when his army attacked Ukraine, President Volodymyr Zelensky was at home with his wife and two children. It was they who woke him early on Feb. 24: “They told me there were loud explosions.” After a minute, he received the signal that a rocket attack was underway. The United States offered him a passage to safety. He chose to stay.

Kharkiv

As it turned out, Kharkiv, the hometown of one of us, Maksym Karpusenko (MK), became one of the fiercest battlefields. Since day one, and for more than a month, it

has been besieged from the northwest, the north and the east, and its outskirts have been shelled indiscriminately. According to Mayor Ihor Terekhov, 1,292 residential buildings have been destroyed, as well as 70 schools, 54 nurseries, 15 hospitals, and 239 administrative buildings, including the university. All but deafened by artillery shelling, anti-aircraft defense systems, machine guns and airplanes, people are forced to hide several times a day. From the very outset, Russians exalting “liberation from fascists and denazification” were shooting and killing. Kharkiv endured huge civilian casualties, including numerous dead and wounded children. As evidenced by video recordings and telephone conversations between Russian military personnel and their relatives in Russia, they were expressly targeting ambulances, private vehicles, residential facilities, orphanages, and hospitals. Located close to Russia, Kharkiv has been bombarded every day. MK hears the squealing of Russian planes overhead and the sound of explosions. He wakes up trying to determine whether his bedroom was a military target.

Since that day, the people of Kharkiv and other Ukrainian cities have spent most of their time in queues for food and drugs. Medicine is very scarce. Many old people have been stuck on high floors in buildings where the lifts are disabled. All the time they hear shells in the distance falling in waves; while MK never imagined that something like this could happen, he feels proud and inspired by the many Ukrainian friends and neighbors who have helped unstintingly. Despite superb work by local utility services, the city’s infrastructure has been severely damaged, leaving hundreds of blocks without gas or electricity. In some outlying areas, all food shops have been destroyed, which means that elderly and disabled people now rely on volunteers to bring food. One of the few landmarks of the residential district of Saltivka, “Rost” supermarket, was obliterated by a missile, with some Russian media claiming that it was a military warehouse. From the very first day, thousands of Kharkovites have sheltered in underground stations or cellars. Outside, everywhere, even in kindergartens, unexploded shells litter the ground. Evacuation has been organized by the Ukrainian railway and volunteers, carrying primarily women and children to towns in western Ukraine. Fantastic work is being done by charity foundations such as “Dobra Samarytyanka,” which delivers food and medicines, and evacuates residents. With most of its inhabitants more fluent in Russian than Ukrainian, Kharkiv appeared to the Russians to be a pro-Russian city, where they expected to be cheered. Instead, Kharkiv has become an unassailable citadel. When Putin ordered Russian troops into Ukraine, he was not alone in thinking victory would be swift. By the time the war was entering its sixth week, the side contemplating victory was not conquering Russia, but tearful Ukraine.

Mariupol

Kharkiv was far from the only town hit. In Mariupol, Russian bombardments have cut off the city’s water and power supply. Families have been huddling together for days, freezing in the dark. Dead bodies are reportedly strewn over the streets, with bombs falling. For weeks, hardly anyone was allowed to leave. In recent days, however, survivors have managed to flee, bringing first hand testimony according to which, every building has been hit. Missile casings litter the streets. People spend most of their time underground sitting in the dark, running up at times to rescue babies and the elderly from the ruins. Many have relatives in Russia, some of whom refuse to believe what has been happening. According to the Kremlin line, only neo-Nazis have been hit. Today, the city is practically ruined, the infrastructure is destroyed, as are hospitals, administrative buildings and factories. Civilian evacuation is blocked on the route to Zaporizhia by Russian checkpoints in Melitopol and Vasilievka.

Zaporizhzhia

In Zaporizhzhia, and elsewhere, the Russian leadership has expressly targeted factories, agricultural equipment, and medical and pharmaceutical plants. That is why Andriy Nykonenko (AN), another of us and a vascular surgeon, had difficulty finding drugs and sterile linen to care for the wounded. Plants in or around Kyiv have been destroyed or were under constant rocket fire and inaccessible. In times of dire emergency, a decisive role has been assumed by volunteer organizations, which in the nick of time appeared in every city. Most consisted of young people with their own vehicles organizing collection of drugs and food. Their heroism was of critical importance in the first month of the war, when healthcare systems were in a state of shock. With the active help of European colleagues, Ukrainian volunteers

www.vascularspecialistonline.com

developed a network to ensure supply of medicines and medical devices. The third of us, Jean-Baptiste Ricco ( JBR), was present at the border. The goods collected by volunteers throughout Europe were being transported by train or truck. The entire continent was mobilized in support of the Ukrainians’ fierce and unyielding resistance. Under catastrophic circumstances, organization was the key. In Zaporizhzhia, one of us, AN, organized vascular surgery procedures in active warfare zones. The first week of the war had caught everyone unaware. As many patients as possible were discharged from his vascular unit, but some could not go home as there was no transport available or because their towns were occupied by the Russian military. Since wounded persons were expected and the hospital was in danger of being bombed, scheduled operations were postponed. Moreover, supply chains from Kyiv and other centers had been disrupted, and no one had previously experienced such an emergency. That said, what the Russians did not expect was the unprecedented unity of the Ukrainian people, which prevented them from capturing large Ukrainian cities and destroying the country’s economy.

A nationwide healthcare network

Against his will, AN left Zaporizhzhia with his family for the relative safety of Uzhgorod. The journey to Uzhgorod was a four-day ordeal, with air raid sirens and rockets in cities along the way. When arriving in Uzhgorod, near the Slovakian border, AN discovered a city sheltering more than 600,000 refugees. With the support of a few of us, AN and his colleagues created a nationwide network designed to provide

hospitals with much-needed medical supplies. During the first weeks, many had received humanitarian aid—but, in most cases, it was not logistically coordinated and failed to meet their needs. Via the Viber and Telegram messaging services, AN and colleagues organized a first-aid package conveying selected medical supplies to war-zone hospitals for the treatment of all types of injuries, including vascular trauma. A few days later, a report was presented to the Executive Committee of the European Society for Vascular Surgery (ESVS), describing the organization, indicating its needs, and requesting accelerated aid that would circumvent bureaucratic European holdups. A few weeks later, organizationally-equipped to deal with immediate emergencies, AN and colleagues were performing more complex surgical procedures in safe medical centers. In parallel, they were dealing with chronic pathologies whose evolution required rapid treatment.

Why we believe Ukraine must win

While Ukraine has won the first phase of this war by surviving, more Western help is needed in a context where Presi-

Since wounded persons were expected and the hospital was in danger of being bombed, scheduled operations were postponed

dent Zelensky has stayed with his people, constantly evoking the sanctity of human life, the need for compassion, and the fight for freedom. The Kremlin initially planned to destroy the Ukrainian army, force the government to surrender, recognize the “people’s republics” and Crimea as Russian territory, change the Constitution and declare Ukraine’s neutrality. From the outset, Russian tactics involved high- and low-precision missile attacks, which caused massive infrastructure and residential destruction, killing servicemen and civilians alike. This war is a continuation of the conflict started by Russia in 2014 in Crimea and Donbas. The March 2, 2022, U.N. General Assembly resolution condemned the Russian invasion of Ukraine. Nobody knows how this conflict will evolve, and history is littered with wars meant to be short but which dragged on for years. To conclude, we have written this editorial to inform the readers of this publication of the war in Ukraine, the resources deployed to help the population, and the urgent need for European assistance. ANDRIY NYKONENKO of the vascular surgery and transplantation unit, is chief of the Department of Surgery, Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine. MAKSYM KARPUSENKO is a senior lecturer at the Karazin Kharkiv National University, Kharkiv, Ukraine. JEAN-BAPTISTE RICCO is professor emeritus at the University of Poitiers, France. This editorial was co-published with the European Journal of Vascular and Endovascular Surgery. The authors wish to thank all the Ukrainian volunteers who accompanied them in this struggle for freedom as well as Jeffrey Arsham, who helped in an emergency to translate and to edit the manuscript.

EMOTIONAL INTELLIGENCE

Cognitive dissonance, unhappy physicians and burnout

Bhagwan Satiani, MD, a Vascular Specialist associate medical editor, discusses an often overlooked facet of emotional intelligence: social regulation

EMOTIONAL INTELLIGENCE HAS been widely accepted as an important element of leadership. The seminal work of Daniel Goldman informs us that the education of leaders involves the four essentials of emotional and social intelligence (self-awareness, self-regulation, social awareness and social regulation). Grunberg and colleagues maintain that healthcare professionals must also gain these skills to lead others to counsel and treat patients, and assist with their physical and behavioral health.1 While the other three facets of emotional intelligence are often discussed, social regulation is often not mentioned in the literature. I have previously discussed self-imposed silence as one cause of burnout. Yet, of the four parts of social regulation, cognitive dissonance is of great importance for employed physicians dealing with burnout. Cognitive dissonance was coined by psychologist Leon Festinger, who saw it as an attempt to be internally consistent. When we are not, we are psychologically distressed and experience cognitive dissonance.2 As a non-mental health professional, cognitive dissonance seems to me like a struggle between our cognition and our behavior. When I have been conflicted, I have experienced anxiety, mental tension

and, occasionally, regret for having chosen a certain behavior. I have discovered that there were others like me who were self-aware but lacked understanding of the science behind the concept. “Cognitive dissonance is ever-present in both the smallest, simplest examples to the deepest layers of humanity that impact the way we interact with each other and view ourselves and the world,” according to Lawlor.3 Stress results when the dissonance occurs frequently, for long periods of time and “involve[s] difficult decisions and a commitment to action.”4 Now, to a couple of examples. One of my own personal life rules has been to avoid participating in fundraisers, and asking friends and colleagues for money. When I volunteered for an anti-domestic violence organization, and then became an officer, I was expected to raise money. The prospect of going “begging,” as I perceived it, was distasteful. Though many friends, relatives and colleagues obliged, the discomfort dogged me throughout. I have been a strong and sometimes partisan advocate for physicians throughout my career. When I was appointed to the board of a large healthcare system, I was advised that I had a “fiduciary” duty to represent the board rather than physicians. I sensed that physicians were

expected to mostly watch, listen and stay silent. In contrast, the medical staff expected me to represent their views. I did speak out at several critical junctures representing physicians’ views, but sadly not enough. In four years on the board, I felt bottled up inside. I tried to deal with this by “buttonholing” individual lay board members to better explain our perspective. Clinical practice also involves some degree of cognitive dissonance, even if we are following our internal ethical voice. An example often cited is that in evidence after research showed no benefit with arthroscopy for osteoarthritis of the knee. The surgeon is wrestling with the cognitive part related to the new research versus the firm belief hundreds of patients were helped (confirmatory bias). This is different from misrepresentation. We may overestimate the positive side of our decisions, justify sub-optimal outcomes, or be reluctant to admit that the benchmark outcomes reported are better. Physician-leaders can often have two different views of an issue—one for the outside world and one for themselves. As an example, some leaders may not act when they have publicly-stated support for a position, such as advocating for more resources. This duality may be appropriate at times,

or seen as hypocritical. Can a leader in this position preserve their integrity and resolve the dissonance? By recognizing the dissonance, we are provided with an opportunity to clarify our principles and beliefs, and then to decide on a course of action. Some may resolve the dissonance by distorting their cognition through self-justification.5 The leader can either change his or her belief system, or change the action to resolve the dissonance. When neither is possible, they may justify their action. The bottom line is that self-awareness is important in this regard. Batista advises that, first, we should expect cognitive dissonance with important executive or managerial roles.5 Festinger opines that we either avoid situations that create the dissonance, or recognize it, try to reduce dissonance, and attain consonance to feel more comfortable. Third, we should recognize the stress that the dissonance will create, and have mechanisms ready to deal with it. Finally, good leaders always have trusted advisers, a coach, or a small kitchen cabinet to help settle internal conflict. Self-awareness and understanding of cognitive dissonance also need to be taught in training programs. *The references for this commentary are available at vascularspecialistonline.com.

Vascular Specialist | May/June 2022

COMMENT&ANALYSIS CORNER STITCH

YOU’VE MATCHED INTO VASCULAR SURGERY FELLOWSHIP! NOW WHAT? To those who recently matched into a vascular surgery fellowship, congratulations! This accomplishment is the culmination of years of hard work, dedication, and perseverance. You will look back on this moment fondly. I know I do, writes Roberto G. Aru, MD SO, MOST OF YOU WHO HAVE RECENTLY MATCHED are in your fourth clinical year of general surgery residency. The final chapter of your general surgery training is an opportunity to continue to improve from a surgical, clinical and professional standpoint. I challenge you to critically re-evaluate yourself as a rising chief resident, identifying your strengths and weaknesses. These are my five tips to optimizing the remainder of your time as a general surgery resident.

1. Foster your leadership skills

Leadership is a critical skill that is commonly learned throughout the time of your residency. As a chief resident, you will be the face of your program, and you will have the privilege of mentoring all of those other residents who are part of your program. Leadership can be inherent, but we all must continue to develop our skills to be increasingly effective as our surgical careers progress. Always remember that leaders lead by example. There is an abundance of books to read on this skill, but The Way of the Shepherd is one of my personal favorites, highlighting a CEO’s seven secrets to successful leadership.

2. Strengthen your knowledge base

A surgical career is a continual learning process in and out of the operating room. In addition to the traditional surgical texts, expanding your knowledge base has become easier with the advent of high-quality surgical (both general and vascular surgery) podcasts, and Behind The Knife and Audible Bleeding are my personal favorites. Listen to the monthly virtual Society for Vascular Surgery (SVS) journal club. Studying for the American Board of Surgery In-Training Examination (ABSITE) is also an opportunity to jump-start your General Surgery Board preparation. The more you see, the more you know. Finally, wrap up any unfinished research projects.

attending surgeons beforehand. This preparedness demonstrates initiative, and it will serve you well with operative autonomy. Always have a plan A, B, and C for when operations do not go according to plan. Finally, you will translate surgical exposures from non-vascular rotations into your future vascular training. And of course, scrub into vascular cases as much as you can.

4. Expand your circle

The vascular surgery world is small, and while you met many vascular surgeons during your interview season, there are still so many people to meet. Academic conferences are not only an excellent opportunity to network but also to present your research and to learn. Since you went through virtual interviews, it is finally a chance to meet your friends from “The Trail” in person. While there are plenty of opportunities, the Society for Vascular Surgery’s Vascular Annual Meeting (VAM) and the Society for Clinical Vascular Surgery (SCVS) Annual Symposium (and its Rising Senior/Incoming Fellows Program) are two national conferences that I have attended and highly recommend.

5. Have fun

Last, but by no means least, enjoy yourself. For many of you, this will be the last time that you will do general surgery. One of my favorite things in this journey is to operate with my co-chiefs, and a close second is to take junior residents and interns through cases. They cherish this opportunity, and it reciprocally provides valuable experience for you as an educator and mentor to those around you who are rising in the field. Chief year is a beautiful time in your surgical training. Make the most of it. Once again, congratulations on this accomplishment. I hope to meet you down the line.

3. Refine your operative skills and decision-making Your chief year is the year to focus on surgical skills. This is an opportunity to take ownership of operations and perioperative care. When able, discuss your game plan for upcoming cases with

Roberto G. Aru

ROBERTO G. ARU is a general surgery chief resident at the University of Kentucky in Lexington, Kentucky. He is the rising vascular surgery fellow at Johns Hopkins Hospital in Baltimore, Maryland.

INTERVIEW

The ABS-VSB: Extolling the virtues of vascular surgery’s independent board THE EVOLUTIONARY PROCESS by which vascular surgery became a bona fide independent discipline has much to thank the American Board of Vascular Surgery (ABVS), but the specialty’s certification interests are now fully met by the American Board of Surgery Vascular Surgery Board (ABS-VSB), the annual meeting of the Florida Vascular Society (April 28–May 1) heard. The message came during the gathering’s Presidential Address, entitled “The Vascular Surgery Board of the American Board of Surgery: Our independent board,” delivered by Thomas Huber, MD, also the current chairman of the ABS-VSB. Huber took attendees on a history tour of the vascular surgical specialty’s development through the prism of evolving qualification and certification requirements; the evolution of the VSB inside the ABS as it morphed into the

entity it is today; and the emergence of the ABVS in 1996 as it sought a fully separate board for vascular surgery. The purpose of the talk, Huber told Vascular Specialist in an interview shortly after his address, was to place the ABS-VSB in historical context and to elucidate its independent role in the certification of vascular surgeons. “Vascular surgery as a discipline really has evolved since the mid-1950s, and perhaps more so since the mid-70s,” he explains. “By the early-80s, it had come to the point where it was perceived, at least by the providers, as a separate discipline. The American Board of Surgery recognized that with additional qualifications in vascular surgery that morphed into added qualifications. The discipline continued to evolve into the 80s and the 90s.” By the mid-90s, a feeling had developed among the vascular surgery leadership of the time that their profession had

evolved into “a truly separate discipline,” and that the ABS “was no longer meeting our needs,” Huber continues. It was a divisive time for many, he says. But by 2006, a primary certificate for vascular surgery had emerged under the then sub-board VSB: “Despite the controversy and concerns, we were morphing in the right direction,” Huber says. Meanwhile, the discipline itself was undergoing its “most dramatic change on top of all that” with the development of endovascular therapies, through the 90s and into the 2000s. “It was disruptive technology for vascular care, so that the only people doing vascular surgery now, in 2022, are truly vascular surgeons,” he adds. At this juncture, Huber says the ABS-VSB has met vascular surgery’s needs for board certification, its primary responsibility. There are, of course, ongoing matters concerning the likes

of predicted workforce shortages, appropriateness of care, and the training volume of open repairs, but the core purpose of the VSB is to certify candidates or maintain certification for practicing candidates, he points out. In that vein, a “Blueprint” redesign is currently underway in order to eventually update what the VSB defines as “vascular surgery” in the wake of the discipline’s evolution. The overarching message, Huber underscores, is that vascular surgery has evolved into a separate, independent discipline, “partly as a result of the leadership and effort of the ABVS,” he says. “For most vascular surgeons,” Huber reiterates, the issue of a separate board has “come and gone,” adding: “My message is to be conciliatory: For the people who have brought this forward: all their goals, desires and wants have been met. We have moved on in a very positive light.” —Bryan Kay

www.vascularspecialistonline.com

Welcome to your 20-page preview of the forthcoming 2022 Vascular Annual Meeting

RESIDENT RESEARCH AWARD Wound healing research earns SVS Foundation prize, place on VAM stage Resident Research Award recipient Christopher Audu, MD, speaks to Jocelyn Hudson about the science behind his winning paper

niversity of Michigan resident and Vascular Specialist resident/fellow editor Christopher Audu, MD, has been granted the SVS Foundation Resident Research Award for 2022. And, already, he is looking ahead to where the research might go next, and the wider importance of addressing his chosen research topic—wound healing—which he describes as a common and persistent problem in vascular surgery and beyond. The SVS Foundation Resident Research Award is given out to a resident in training who has engaged in basic science research, with the aim being to encourage scientific endeavours in the field of vascular surgery. Applicants must submit letters of recommendation and a summary of their research, as well as a manuscript that is in its preliminary stages. The award is given out annually, and the prize is an opportunity for the winner to present their work at the Vascular Annual

Meeting (VAM). Audu’s paper will kick off the William J. von Liebig Session, the first plenary, Wedenesday from 8–8:10 a.m. (Ballroom A/B). “This is the biggest stage that we have for vascular,” says Audu, describing the significance of the annual conference in the vascular surgery field. This year, Audu’s research into the proteins involved in diabetic wound healing stood out among the competition and, in doing so, earned a place on the agenda of this year’s meeting. Specifically, under the guidance of Katherine Gallagher, MD, Audu has been looking at one of several reasons why wounds do not heal—inflammation— and his work suggests there may be a “light switch” that controls various inflammatory pathways. Audu has been working on the prize-winning research for the past year and a half, he tells Vascular Specialist. At the University of Michigan, residents are allowed two years

in between their training for professional development. “I used those two years as my post-doctoral years in the laboratory to pursue this research,” Audu explains. Wound healing, he notes, is a common problem in vascular surgery that has “defied a lot of treatment options,” particularly when it comes to medications. “Usually, these patients have very poor circulation to the extremities—their fingertips and their toes are often the worst hit—and when they get wounds there, they just do not heal,” he explains. With his current research, Audu is “picking away” at

“Initially, you need some sort of inflammation when you get a bruise” CHRISTOPHER AUDU

one of the many reasons why wounds do not heal, which is ongoing inflammation. Audu details that the aim of his research was to understand what it is about macrophages in wounds that prevent them from healing. He considered a particular protein called JMJD3, which he discovered is involved in turning on cytokines that play a role in inflammation. “Initially, you need some sort of inflammation when you get a bruise, and then that should transition to a point where you are healing,” says Audu. “In the diabetic state, what we found was that that signal is on way longer than it needs to be, and that this particular enzyme, JMJD3, is partly responsible.” In addition, the team found that this enzyme turns on a number of other genes that are involved in inflammation. Audu and his colleagues in the Gallagher lab then tried to understand these

continued on page 12

FROM THE COVER: THE CRAWFORD FORUM URBAN OR RURAL: ENSURING ACCESS TO QUALITY VASCULAR CARE ‘NO MATTER WHAT’ continued from page 1

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“We’re concerned about the full spectrum of the disease. Certainly, if we could stop the disease early and have people not have issues, that would be great. If patients get to the point where something has to be done, then we have options for them.” That ability to reach people early forms a large part of the impetus behind why Dalsing selected matters concerning access to vascular care across the great hulking mass of the U.S.— urban and rural, insured and uninsured—for this year’s E. Stanley Crawford Critical Issues Forum, which takes place Wednesday from 10:45 a.m.–12:15 p.m. (Ballroom A/B). But the selection also drew inspiration from the incoming SVS president’s personal story. Dalsing grew up in rural Wisconsin and saw how remote communities could struggle for access to the expertise of a vascular surgeon, watching, for instance, how uncles who developed abdominal aortic aneurysms (AAAs) had to travel some distance to large cities in order to access appropriate treatment. His professional career, too, was instructive. The Indiana University School of Medicine professor emeritus has helped lead outreach efforts in inner-city Indianapolis and out into rural Indiana. Speakers will tackle such topics as the vascular surgery workforce shortages, as predicted over the next 20 years (Michael Go, MD, associate professor of surgery in the division of vascular diseases and surgery at The Ohio State University in Columbus, Ohio); how insurance affects access to quality vascular care (Mohammad Eslami, MD, chief of

vascular surgery at the University of Pittsburgh Medineed, such as among African Americans, Hispanics, cal Center [UPMC] Mercy in Pittsburgh); the probNative Americans and others who lack access due lems associated with access in rural communito low socioeconomic status. “VISTA looks at ties (Samantha Minc, MD, assistant professor of ways to address some of these shortages, it looks vascular surgery at West Virginia University in beyond what we are observing in the commuMorgantown, West Virginia); so-called “urban nity and into potential solutions,” says Dalsing. vascular care deserts” (Andrew Gonzalez, MD, In some cases, areas identified for improvement assistant professor of vascular surgery at Indiana might simply rest on education, he continues. “How Michael University School of Medicine); the potential role do people know they have a vascular issue? Some Dalsing of vascular population health initiatives on quality have no idea. They don’t know that the infection care for all (Leila Mureebe, MD, professor of vascular on their toe is due to the fact they don’t have enough surgery at Duke University in Durham, North Carolina); and blood supply.” how diversity and inclusion impact the kind of care patients Or it might involve providing local providers with a go-to receive (Vincent Rowe, MD, chief of the vascular surgery vascular surgeon to ask how best to take care of patients service at the University of Southern California in Los Ange- they think may have vascular problems, Dalsing says. “I les). Talks will be limited to seven minutes each to allow a think these early pilot projects might give us a real good maximum amount of time for discussion. idea about how we might extrapolate programs into bigger “The way I chose the speakers was based on either lead- populations, or other areas, or also what is most important ership roles in the SVS that dovetailed with the topic, or to provide up front, and then how you work from there.” they may have published on something that I thought The SVS has undertaken considerable work in trying would bring a different perspective to the discussion,” to get in front of U.S. legislators in an effort to create a explains Dalsing. level playing field for access to vascular care, adds Dalsing. The final presentation is being given by Jens Eldrup-Jor- Which gets back to the heart of his forum topic. “You gensen, MD, leader of the SVS Foundation Vascular Volun- shouldn’t have to come to Indianapolis to make sure you’re teers In Service To All (VISTA) program, an early-stage select going to be OK if you have a vascular problem,” he says. series of pilot projects aimed at enhancing vascular healthcare “You should be able to get care that is appropriate no in underserved communities—rural and urban—or areas of matter what.”

Vascular Specialist | May/June 2022

VAM OPENING DAY OFFERS WIDE VARIETY OF SCIENCE, EDUCATION

PRESIDENTIAL WELCOME

It’s the best time of the year We are almost to my favorite time of the year, the Vascular Annual Meeting. And with the completion of the year-long celebration of our 75th anniversary, this promises to be one to remember, says President Ali AbuRahma, MD

WITH A CANCELED VAM 2020 AND COVID-IMPACTED VAM 2021 in our recent past, I think VAM 2022 offers an even bigger emotional charge for us all. Between marking this momentous milestone, complete with our Gala on Friday evening, and the lineup our hard-working and incredible organizers have created, members and other attendees have a great experience in store. I’d like to point out some highlights.

LIVESTREAMING: With travel restrictions still in place for

some, we’ve expanded the livestreaming option this year. This permits those who would love to attend VAM in person but for any number of reasons cannot to still benefit from our research presentations and many other sessions. They also can receive educational credits and will have access to all of the recorded sessions afterwards.

MORE DISCUSSION: It may seem a minor change, but over-

whelming feedback from past meetings made it clear that attendees want to be able to talk more about the science that’s being presented. So, we’ve added discussion time to all plenary sessions – and by the way, we’ve added more scientific sessions, as well.

THE GALA, with a Silent Auction that anyone, anywhere, can

join. The SVS “Cheers to 75 Years” Gala takes place Friday evening, with a reception, dinner, entertainment, live and silent auctions and dancing. Tickets are sold out, but a waiting list has been created. The Silent Auction allows anyone with Internet connectivity to bid on an outstanding selection of auction items. Kudos to our chair, Dr. Ron Dalman, and co-chairs, Drs. Venita Chandra and Matt Eagleton, and their committee for all their hard work to make this an event to remember.

SPECIAL SESSIONS FOR OUR SECTIONS: Over the

past several years, we have added membership sections dedicated to certain subsections: physician assistants in vascular surgery, surgeons in the community setting, those with outpatient-based facilities, women and young surgeons. This year, each section has a special educational session, planned by and for them, on topics directly targeted to their needs.

OTHER SPECIAL SESSIONS: We have presentations devoted to

policy and advocacy. With all that’s been going on in Washington, D.C., related to reimbursement and other legislation that affects our work, these will be timely sessions.

SVN AND VQI: Once again both the Vascular Quality Initiative

and the Society for Vascular Nursing hold their respective annual meetings/conferences in tandem with our meeting.

EDUCATION CREDITS: Both livestreaming and in-person

attendees can take advantage of VAM to accumulate Continuing Medical Education and Self-Assessment CME credits. Our mobile app makes the process simple. If you haven’t already done so, register today at vascular.org/VAM. I look forward to welcoming all of you and celebrating what’s new and the incredible history of it our specialty that we continue to build on today. See you in Boston!

EDUCATIONAL OFFERINGS ON WEDNESDAY AT VAM 2022 start with the International Fast Talk at 6:30 a.m. and end 10 hours later, at the close of a session on endovascular innovation. In between are three other abstract-based sessions: the von Liebig Forum, Plenary Session 2 and the Vascular and Endovascular Surgery Society (VESS) Paper Session. Wednesday also will offer two of the popular 60-minute “Ask the Expert” (ATE) sessions and two 90-minute concurrent sessions. The first “Ask the Expert,” on proximal deep vein thrombosis (DVT), will be from 1–2 p.m. and the second, on cost-effectiveness in vascular surgery, will be from 3 to 4 p.m. Patrick Geraghty, MD, and Claudie Sheahan, MD, will facilitate the presentations on DVT. Faculty includes Patrick Muck, MD, on acute DVT, Erin Murphy, MD, on chronic DVT and Vipul Khetarpaul, MD, on chronic DVT with inferior vena cava filter thrombosis. Natalie Sridharan, MD, and Lauren Gordon, MD, will facilitate cost-effectiveness. The session will include an overview of concepts, research methods and behavioral economics, and will touch on some “particularly hot topics” of the subject. Also part of the presentation will be an explanation on why surgeons should understand costs; an international perspective; and three case presentations focused on a number of vascular procedures. William Robinson III, MD, chairs the Postgraduate Education Committee (PGEC) that oversees both “Ask the Expert” and concurrent sessions. “‘Ask the Experts’ has been a hit since we introduced it several years ago,” said Robinson. “As has happened several times in the past, we fully expect some of these sessions to be standing-room only.” Wednesday’s concurrent sessions include “Progressing and Sustaining our Vascular Surgery Workforce into the Future through Innovation in Surgical Education” and “Endovation: Endovascular Innovation for Urgent and Emergency Complex Aortic Disorders.” The workforce presentation will consider future and potentially alternative training paradigms that would ensure expansion of the vascular surgery workforce. Moderators are Dawn Coleman, MD, who chairs the SVS Physician Wellness Committee, and Jill Colglazier, MD. Rounding out Wednesday’s events are the first of two sessions on policy and advocacy, from 2 –2:30 p.m., the World Federation of Vascular Societies Reception (from 5–6 p.m.), the General Surgery Resident/Medical Student Reception (from 6:15–7:15 p.m.) and the Society for Vascular Nursing (SVN) Gala (from 7–9:30 p.m.), which celebrates the SVN’s 40th anniversary.—Beth Bales

RESIDENT RESEARCH AWARD WOUND HEALING RESEARCH EARNS SVS FOUNDATION PRIZE, PLACE ON VAM STAGE

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processes mechanistically, he continues, reporting that they were able to find a small molecule that could specifically inhibit macrophages in the wound and thereby improve wound healing in a diabetic mouse model. Audu notes that this research originated with Gallagher—the principal investigator of the study and an “expert” in epigenetics and in wound healing, according to Audu, as well as a vascular surgeon. When Gallagher pitched the research project to Audu, he recounts that he simultaneously pitched the idea of looking at a particular pathway called STING—an acronym for stimulator interferon genes. “So, we put our heads together and came up with a joint project that combined both of our interests,” Audu recalls.

“The work that we have done mechanistically shows that there is a way to target inflammation, and maybe even target a ‘light switch’ that controls several different inflammatory pathways—that’s the big picture idea,” he summarizes. A medicinal chemist by training, Audu is eager to “take a project from the beginning right through to finding something that could be a therapeutic angle.” Looking at what is next for the research, he states that the first step will be to get the paper published, but what he hopes for subsequently is that the team develop this “therapeutic angle” into something that can be applied directly to wounds. Wound healing in diabetic patients is “important to most vascular surgeons,” says Audu, pointing to a desire within

the specialty to find solutions for this patient population. But the problem is not confined to vascular surgery, and it is not only vascular surgeons who want to see changes in this area. Indeed, Audu points to the fact that specialists in various other areas, such as plastic surgery and podiatry to name just two, also encounter these patients on a regular basis. Elsewhere in the Gallagher lab, Audu details that he is involved in some other research into the multitude of different types of cells within wounds that could be contributing to poor wound healing and diabetes. Outlining this other research, he says that it revolves around the fact that certain cells are known to interact with a person’s T-cells, and that those T-cells are known to facilitate chronic

continued from page 11 inflammation in wounds, particularly if they overproduce inflammatory cytokines. “We have found that diabetic pDCs [plasmacytoid dendritic cells] are altered, and they are actually involved in turning these T-cells into inflammatory phenotype.” Details will be presented in a poster at VAM, he says. Further down the line, Audu is keen to bring his expertise in chemistry to vascular surgery and usher in drug development and design as a focus. “In the future, I hopes this is something I can advance in my own lab someday.” Aside from presenting his prize-winning science and some poster work, Audu is also looking forward to the in-person aspect of this year’s meeting. “I’m excited about meeting people in person who I have only even seen in Zoom meetings. That will be a highlight.”

Vascular Specialist | May/June 2022

CAROTID DISEASE

EARLY TCAR RESULTS IN HIGHER IPSILATERAL POSTOPERATIVE STROKE RATES WHEN COMPARED TO CAROTID ENDARTERECTOMY Adham Elmously, MD, a fellow at New York Presbyterian Hospital, New York, will present outcomes of early transcarotid artery revascularization (TCAR) vs. carotid endarterectomy (CEA) after acute neurologic events, reports Jocelyn Hudson

SPEAKING ON BEHALF OF SENIOR author Danielle Bajakian, MD, of Columbia University Medical Center, New York, and colleagues, Elmously will on Wednesday conclude that TCAR within 14 days of a neurologic event results in higher ipsilateral postoperative stroke rates when compared to CEA, especially when performed within 48 hours. Elmously and colleagues state that carotid revascularisation within 14 days of a neurologic event is recommended by society guidelines. They note that TCAR carries the lowest overall stroke rate for any carotid artery stenting technique, but stress that “outcomes of TCAR within 14 days of a neurologic event have not been studied or directly compared to CEA.” The research team compared in-hospital outcomes of symptomatic patients undergoing TCAR and CEA within 14 days of stroke or transient ischaemic attack (TIA) from January 2016 to February 2020 using the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) carotid artery stenting and CEA databases. They note that propensity score matching was used to adjust for patient risk factors, and that

the primary outcome was a composite of postoperative ipsilateral stroke, death, and myocardial infarction (MI). The researchers detail that 1,281 symptomatic patients underwent TCAR and that 13,429 patients underwent CEA within 14 days of a neurologic event. After 1:1 propensity matching, they add, 728 matched pairs were included for analysis. At VAM, Elmously will communicate that the primary composite outcome of stroke, death, or MI was more frequent in the TCAR group (4.7% vs. 2.6%, p=0.04). The presenter will inform delegates that this was driven by a higher rate of postoperative ipsilateral stroke in the TCAR group (3.8% vs. 1.8%, p=0.005). In addition, they will report that there was no difference between TCAR and CEA in terms of death (0.7% vs. 0.8%, p=0.8) or MI (0.8% vs. 1%; p=0.7). Although TCAR procedures were shorter (69 minutes, interquartile range 53–85 vs. 120 minutes, IQR 93–150, p<0.001) and postoperative length of stay was similar (two days, p=0.3) compared to CEA, TCAR patients were more likely to be discharged to a facility other than home (26% vs. 18.9%, p<0.01), Elmously will detail. He will also report

that performing TCAR within 48 hours of a stroke was an independent predictor of postoperative stroke or TIA (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.8–16). A numbers of the paper’s authors have previously been involved in published research on the topic of TCAR. Recently, co-author of the VAM paper Ambar Mehta, MD, a resident at New York Presbyterian-Columbia University Irving Medical Center, was lead author of the 2021 Journal of Vascular Surgery (JVS) paper “Transcarotid artery revascularization versus carotid endarterectomy and transfemoral stenting in octogenarians.” Bajakian, as well as co-authors of the VAM paper Priya B. Patel, MD, of NYP-Columbia University Medical Center in Fords, New Jersey, and Virendra I. Patel, chief of vascular surgery at NYP-Columbia University Medical Center, were also a part of the JVS paper study team. In this study, Mehta et al conclude that TCARs had similar outcomes relative to CEAs among octogenarians with respect to 30-day and one-year rates of stroke/death. They suggest that TCAR

“Outcomes of TCAR within 14 days of a neurologic event have not been studied or directly compared to CEA” ADHAM ELMOUSLY ET AL “may serve as a promising, less invasive treatment for carotid disease in older patients who are deemed high anatomic, surgical, or clinical risk for CEAs.” They begin the paper by noting that trans-

femoral carotid artery stenting (TFCAS) has higher combined stroke and death rates in elderly patients with carotid artery stenosis compared with CEA. However, they stress that TCAR may have similar outcomes to CEA. In the JVS study, therefore, the authors set out to compare outcomes after TCARs relative to those after CEAs and TFCAS, focusing on elderly patients. The researchers included all patients with carotid artery stenosis and no prior endarterectomy or stenting who underwent either a CEA, TFCAS, or TCAR in the VQI from September 2016 (when TCAR became commercially available) to December 2019. The team categorized patients into age decades: 60–69 years; 70–79 years; and 80–89 years. Writing in JVS, Mehta and colleagues report that they identified 33,115 patients who underwent either a CEA, TFCAS, or TCAR for carotid artery stenosis, where one-half were symptomatic. They reveal that the overall rate of 30-day stroke/death was 1.5% and of one-year stroke/death was 4.4%. Octogenarians had the highest 30-day and one-year stroke/death rates relative to their peers, the authors communicated, at 2.3% and 6.3%, respectively. Mehta et al add that, among all patients, the adjusted hazards of TCARs relative to CEAs was similar for 30-day stroke/death and slightly higher for one-year stroke/ death. Among octogenarians, however, they report that the adjusted hazards of TCARs relative to CEAs was similar for both 30-day stroke/death and one-year stroke/death. Finally, they communicate that TFCAS related to CEAs had higher hazards of both 30-day stroke/death and one-year stroke/ death in octogenarians. At VAM, Elmously will deliver the early TCAR outcomes presentation during the William J. von Liebig Forum (Ballroom A/B), from 8:23–8:34 a.m.

IMAGING

Silent coronary ischemia: FFRCT reduces cardiac death, myocardial infarction in carotid endarterectomy patients out to three years, study finds DIAGNOSIS OF SILENT, OR UNSUSPECTED, coronary ischemia in patients undergoing carotid endarterectomy (CEA) using fractional flow reservecomputed tomography (FFRCT), with selective postoperative coronary revascularization, significantly reduced cardiovascular death, cardiac death and myocardial infarction through three years of follow-up when compared to CEA patients receiving standard cardiac evaluation, researchers will report on Wednesday. Author Dainis Krievins, MD, a vascular surgeon at Stradins University Hospital in Riga, Latvia, will present results revealing that among a group of 100 patients who received FFRCT, researchers recorded extensive coronary calcification, with more than 50% stenosis in 46% of them. “FFRCT analysis revealed silent coronary ischemia in 57% of patients, with left main in 7% and multivessel ischemia in 28%. Severe coronary ischemia was present in 44% of patients,” he will tell VAM 2022 during Plenary Session 2 (9:45–9:56 a.m.; Ballroom A/B). The research compared the 100 elective CEA patients

receiving FFRCT—enrolled in a prospective institutional review board (IRB) study— to 100 concurrent matched controls who underwent standard pre-operative cardiac evaluation and no post-op coronary revascularization. In the first group, lesion-specific coronary ischemia was defined as FFRCT ≤0.80, with FFRCT ≤0.75 indicating severe ischemia, the research team will explain. The status of coronary ischemia was unknown in group two. After CEA, group one patients with silent ischemia were selected for coronary angiography one to three months post-surgery, with elective coronary revascularization carried out in 33, Krievins and colleagues will show. Group two patients had no coronary revascularization. At three years, the rates of myocardial infarction, cardiac death and cardiovascular death were significantly lower in group one compared to group two (p<0.05), with no significant differences in stroke or all-cause death, they will reveal. The researchers cite the need for prospective, controlled studies “to further evaluate the role of FFRCTguided coronary revascularization in CEA patients.”

Christopher Zarins, MD, senior author of the study and founder of HeartFlow, the company behind the FFRCT analysis used, told Vascular Specialist that the CEA patient study builds on the research group’s study of FFRCT use in critical limb ischemia patients. Christopher Zarins “The guideline-directed current standard of care for CEA patients is that if you do not have any cardiac symptoms or history, then you just go ahead and have your CEA, and afterwards you get treated with best medical therapy,” he said. “Everybody thinks and assumes that the way you treat cardiac risk is with medical therapy. In fact, medical therapy doesn’t really work if you’ve got left main disease, you have proximal LAD [left anterior descending] disease or severe coronary ischemia—you need to get your coronaries revascularized,” he added.—Bryan Kay

Vascular Specialist | May/June 2022

PERIPHERAL ARTERIAL DISEASE Open surgical bypass to distal targets at the ankle is viable infrapopliteal CLTI treatment Othman M. Abdul-Malak, MD, et al find that the open procedure continues to be a feasible option, with patency and amputation-free survival rates of an acceptable level

he Vascular and Endovascular Surgical Society (VESS) Paper Session on Wednesday will see Othman M. Abdul-Malak, MD, from the University of Pittsburgh Medical Center in Pittsburgh, deliver results from “Midterm outcomes and predictors of failure of lowerextremity bypass to paramalleolar and pedal targets.” Open surgical bypass to distal targets at the ankle remains a viable option for treating infrapopliteal chronic limb-threatening ischemia (CLTI), Abdul-Malak and colleagues conclude, with patency and amputationfree survival rates shown to be of an acceptable level. Abdul-Malak states his reasons for conducting the study: to determine whether or not the recent decrease in frequency of distal lower extremity bypass for infrapopliteal CLTI is warranted, based on poor paramalleolar and pedal target outcomes. The data on infrapopliteal CLTI patient lower-extremity bypass outcomes came from the Vascular Quality Initiative (VQI) infrainguinal database from 2003–2021. Primary outcomes were graft patency, major adverse limb events (MALE) and amputation-free survival at two years. Some 2,331 procedures (1,265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, and 283 tarsal/plantar) were included in the analysis. Abdul-Malak details how he was able to conclude that bypasses to distal targets have decreased from 13.37% of all procedures in 2003 to 3.51% in 2021 (p<0.001). Across the 18 years of data, the majority of cases

POSTGRADUATE

THREE CLASSES ADDRESS CRITICAL VASCULAR TOPICS

Beth Bales speaks to William Robinson III, MD, about what’s coming up during the postgraduate portion of this year’s program

Three postgraduate courses—spread across three days so attendees can hit all of them if they like—are scheduled for the 2022 VAM. All are designed to address situations vascular surgeons encounter frequently, offering new solutions and research. “These postgraduate courses, along with many other sessions this year, go to the heart of what our surgeons see every day,” said William Robinson III, MD, chair of the Postgraduate Education Committee, which oversees development of the courses. “Carotid disease, chronic limb-threatening ischemia and vascular trauma fit that bill. They’re some of the meat and potatoes of our practices. They are vital topics, critical to patients, and we feel participants will come away with important information that will help them make decisions in their practices.”

presented with Rutherford Class 5/6 ischemia (81.25%), with Class 4 representing 14.5% and Classes 1–3, 4.25%. Regarding postoperative complications, the study references the 8.9% incidence of major cardiac events, and that of surgical site infections, which occurred in 3.6% of cases. Abdul-Malak reports that major amputations occurred in 16.8% of patients at one-year follow-up, and postoperative mortality within the same timeframe was 10%. On unadjusted Kaplan-Meier survival analysis, primary patency was 50.56±3.6%, primary assisted patency was 58.79±4.03%, secondary patency was 60.48±4.12%, MALE was 63.49±3.27%, and amputation-free survival was 71.71±0.98%, with all data collected at two-year follow-up. With comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume all adjusted for, the paper presents that conduits other than the great saphenous vein (GSV) and prior ipsilateral vascular interventions (open/endovascular) were predictors of loss of primary patency and increased MALE. Conversely, high center volume at a rate of over 60 procedures per center over the total time period, was positively correlated with increased primary patency, as well as lower MALE at two-year follow-up, Abdul-Malak and colleagues find.

Vikram Kashyap, MD, Bruce Perler, MD, Hernan Bazan, MD, and Ross Milner, MD, will moderate the first course, “Updated Guidelines and Unresolved Controversies in Carotid Disease,” 1:30–4:30 p.m Thursday (Ballroom A/B). Topics will include: n ”Natural history outcomes after transient ischemic attack, amarousis fugax and stroke: The rationale for carotid intervention for >50% symptomatic stenosis,” Efthymios D. Avgerinos, MD n ”Are we missing neurocognitive changes in the setting of extracranial carotid stenosis? An unrecognized symptom,” Wei Zhou, MD n ”The optimal timing and patient selection for intervention after an acute stroke,” R. Clement Darling III, MD n ”The optimal sequence for intervention in patients with combined carotid and coronary artery disease,” Timur Sarac, MD n Debate: n ”Carotid endarterectomy provides the best outcomes in low-risk symptomatic patients,” Richard Powell, MD n ”Transfemoral or transcarotid approaches with flow-reversal are safer in acute stroke,” Mahmoud Malas, MD n ”The appropriate role for screening for carotid artery stenosis in asymptomatic patients: When is it indicated?” Caron Rockman, MD n ”Carotid plaque imaging: Are we closer to finding an embolic risk factor?” Brajesh K. Lal, MD

The data showed that increasing age, dialysis dependence, and recourse to conduits other than GSV during the procedure were all associated with a lower amputation-free survival rate at two years, he reveals. “Although it is now a lesser-used procedure, open surgical bypass to distal targets at the ankle is nonetheless a viable option for treatment of infrapopliteal CLTI, as demonstrated by data on patency amputationfree survival rates at two years,” Abdul-Malak said. “Furthermore, the conduit used, and whether or not the patient has undergone prior vascular interventions, are the key predictors of [lower-extremity bypass] failure.” To increase chances of procedural success, Abdul-Malak suggests that bypasses to distal targets be performed at high-volume centers. He will take to the podium in Ballroom A/B from 12:50 p.m.–1:03 p.m.—Clare Tierney

“The conduit used, and whether or not the patient has undergone prior vascular interventions, are the key predictors of [lowerextremity bypass] failure” OTHMAN M. ABDUL-MALAK

n Debate: n ”Maximum medical therapy is ideal for the asymptomatic patient,” Thomas Forbes, MD n ”Maximum medical therapy is rarely achieved: CEA provides the most durable benefit,” Robert W. Chang, MD n ”Not so fast: ACST 2 and TCAR data indicate stenting is as safe in the asymptomatic patient,” Marc L. Schermerhorn, MD Laura Marie Drudi, MD, Joseph Mills, MD, and Kwame Amankwah will co-moderate “Toe and Flow Rounds—Working Towards a Comprehensive Approach to the Management of Chronic Limb-Threatening Ischemia,” 1:30–4:30 p.m. Friday (Ballroom A/B). The course will include: n ”My story—What is living with CLTI like?” Anahita Dua, MD, on interviewing her patient with CLTI n ”Overview of the Global Vascular Guidelines for CLTI,” Ahmed Kayssi n ”Applying the Global Vascular Guidelines in clinical practice,” Michael Conte, MD n ”Advances in drug therapy for patients with diabetes and/or CLTI,” Aruna Das Pradhan, MD n ”Review of PAD trials: What do we know and where are we going?” Laura M. Drudi, MD n ”Amputations and next steps,” Philip P. Goodney, MD n ”Strategies to implement a successful multidisciplinary limb

salvage team and integration of podiatry,” David Armstrong, DPM n ”Sex disparities in prevention, treatment and outcomes in CLTI patients,” Kate McGinigle, MD n ”An overview of social determinants of health in patients with CLTI,” Bryan Fisher, MD n ” Implementation strategies to address disparities in limb salvage,” Tze Woei Tan, MD n ”Application of remote patient monitoring and telehealth for CLTI patients,” Judith Lin, MD n ”Community engagement to improve diabetic foot ulcers and CLTI care,” Lyssa Ochoa, MD Rishi Kundi, MD, and Todd Rasmussen, MD, will co-moderate the third and final postgrad course, “Management of Vascular Trauma: Exploring Consensus in the Who and Where Amidst Subspecialized Training and Practice,” 1:30–4:30 p.m. Saturday (Room 312). Among the topics are: n ”How best to train for vascular injury management: Residency and fellowship,” Meryl Logan, MD n ”Training and maintenance of skills in terms of wartime vascular injury,” led by Kevin Kniery, MD n A debate on whether the country needs national standards for treatment. Benjamin Starnes, MD, will argue for national consensus and standards. Leigh Ann O’Banion, MD, will argue they aren’t feasible and don’t impact care

Vascular Specialist | May/June 2022

QUALITY IN CARE

VQI returns for another @VAM appearance By Beth Bales

he Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) this year marks its sixth annual meeting— known as VQI@VAM—featuring special presentations on enhanced recovery, frailty and VQI’s new trainee program. The meeting begins the day before VAM, with sessions, on Tuesday, from 12 to 4:45 p.m. (a boxed lunch will be provided at the beginning of the conference for a working lunch), followed at 5 p.m. by the Poster Viewing and Networking Reception. VQI@VAM continues with a full day of sessions from 8 a.m. to 5 p.m. Wednesday (Room 312). All activities take place at the Hynes Convention Center in Boston. Conference registration is set for 10 a.m. to 6:30 p.m. Tuesday. A separate registration fee is required. The VQI collects, analyzes and shares data on pre-operative risk factors, intra-procedural variables, post-procedural outcomes and one-year follow-up data. The VQI uses these data to work to improve the quality, safety, effectiveness and cost of vascular healthcare. It has logged more than 900,000 procedures across 14 VQI registries. Tuesday’s registry panel discussions have been designed to foster an active dialogue with meeting participants, using questions from VQI members as a basis for the discussions. Discussants also will take questions from the live audience. “Please come prepared to ask your questions to these expert

panels,” said Jens Eldrup-Jorgensen, MD, VQI medical director. Wednesday sessions are designed for physicians, nurses, data managers, quality improvement professionals and administrators. Meeting organizers suggest that physicians with limited Jens Eldrup- time Wednesday attend from 1 to 5 p.m. Jorgensen “It’s somewhat astonishing to look back at our first meeting in 2016 and realize just how far we’ve come,” said Jorgensen. “Each year we take a look at suggestions from our participants and determine how we can make the following year a little better, a little more informative and useful for our attendees. “And each year it seems like we have plenty of really valuable information and initiatives – quality improvement tools and resources, how to apply VQI data, case studies, updates – to present.” The Poster Viewing and Networking Reception, added the second year, remains an important part of VQI@VAM. More than 20 posters, all on quality improvement based on VQI data, will be showcased, providing ideas to others for their own quality improvement initiatives. “It’s the one time where we’re all gathered together in a more casual atmosphere, visiting with each other and seeing the really fine quality

improvement work being done,” said Jorgensen. Appetizers and drinks will be available. Besides the reception, other highlights for 2022 include Enhanced Recovery After Surgery (ERAS) guidelines and Applications for VQI (presentation and panel discussion), from 8:30 to 9:15 a.m. Wednesday.

PATIENT REHABILITATION

Enhanced recovery, also known as “enhanced recovery protocols,” has been developed in other surgical areas, including colorectal surgery and oncology (also see story on next page). “The idea is to develop protocols and guidelines during and after surgery that help the patient rehabilitate,” said Jorgensen. “We are actively looking at ways to incorporate a few high-value reporting measures into the VQI registries, to track the efficacy of outcomes based on compliances with the SVS best practice recommendations.” The new VQI Fellowship in Training will also be showcased from 11:30 to 11:45 a.m. Wednesday. The program began in January and is for those completing medical residencies or fellowships in any vascular disease-focused specialty. Its aim is to foster an understanding of quality processes and metrics among trainees through mentorship in the VQI in collaboration with the Association of Program Directors in Vascular Surgery, American College of Cardiology and Society for Vascular Medicine. Meanwhile, the topic of “Tracking frailty in the VQI,” from 2:50–3:20 p.m. Wednesday, will be discussed. VQI does not actively track frailty, explained Jorgensen. “We want to look at some of the research on frailty and how it impacts patient care: patient selection, for example, and recovery, based on frailty.”

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ERAS COMMENT

ALTERNATIVE TECHNIQUES

By Katharine L. McGinigle, MD

By Will Date

ENHANCED RECOVERY AFTER SURGERY (ERAS) PATHWAYS HAVE BEEN beneficial for many surgical specialties and are now available to guide the perioperative care of patients undergoing open aortic operations. The VQI will discuss this important topic starting at 8:35 a.m. Wednesday, during the VQI@VAM annual meeting (Room 312). The Society for Vascular Surgery and the ERAS Society jointly endorsed the recent consensus statement, “Perioperative care in open aortic vascular surgery,” which was published in the Journal of Vascular Surgery in June. With the goal of delivering high-quality perioperative care and reducing the physiologic stress of surgery, this consensus statement is intended to help address the many perioperative challenges faced by vascular surgery patients, who are often older, frailer and with more comorbidities than the average surgical patient. The 36 graded recommendations emphasize the coordination and timing of care across disciplines to reduce unnecessary care variation and to give patients the best chances of quickly getting back to normal. Recommendations based on the universal ERAS elements include preadmission (screening, preoperative exercise therapy/prehabilitation, perioperative anti-platelet, anticoagulation plan); preoperative (fasting, carbohydrate loading, venous thromboembolism prophylaxis, pre-anesthetic sedative and analgesia medication, antimicrobials, nausea/vomiting prevention); intraoperative (anesthetic protocols, epidural analgesia, body temperature management, drainage of surgical site); and postoperative (multimodal analgesia and opioid reduction strategies, nasogastric drainage, oral feeding, fluid therapy, urinary drainage, glycemic control, early mobilization strategy, discharge education, audit of outcomes). Some of the recommendations are a clear departure from current routine care but should be carefully evaluated as there is high-level evidence that change is needed. For example, pre-operative fasting times should be dramatically reduced and the use of post-operative nasogastric tubes should be minimized. There are other recommendations based on more heterogenous and less rigorous data, particularly around pre-operative optimization and fitness for surgery. Numerous research gaps have been identified, and as ERAS programs are developed across the country there will be opportunities for multicenter research and VQI-supported quality improvement charters.

AMONG THE HIGHLIGHTS FROM THE “‘Endovation’—Endovascular Innovation for Urgent and Emergency Complex Aortic Disorders” session Wednesday is a presentation by Sukgu M. Han, MD, from the Keck Medical Center at University of Southern California, Los Angeles—“Guidelines from the front lines: Can we develop best practices or standardization for endovascular alternative techniques, and when should we use alternative techniques?” “I will be reviewing our own aortic center experience at the Keck Medical Center of University of Southern California, serving as a regional aortic center accepting more than 250 urgent aortic transfers annually,” Han tells Vascular Specialist, offering VAM 2022 attendees a glimpse of what they can expect. “Among the acute aortic pathologies, I will focus on urgent and emergent thoracoabdominal, suprarenal aortic aneurysms (TAAA/SRAAA),” he notes, adding that the presentation will include a brief overview of results from the Keck Medical Center, as well as those reported in literature on various off-label complex endovascular aneurysm repair (EVAR) techniques, which he details

DISCUSSING ENHANCED RECOVERY AFTER SURGERY

COMPLEX AORTA ‘Endovation’ highlights endovascular innovations Beth Bales talks to Jonathan Bath, MD, about a session showcasing new and creative ways devices are being used in the treatment of urgent complex aortic disorders

LEARN ABOUT NON-TRADITIONAL SURGICAL solutions in emergency situations during the non-traditional Endovation session at VAM (3–4:30 p.m. Wednesday, Room 210). Beyond lecture presentations, vascular trainees will discuss cases they submitted that used innovative surgical solutions, solving an aortic problem with endovascular means. The case discussion portion is called “Cases Under the Stars” and will occur in a reception-like setting and atmosphere with drinks included. Trainees have submitted case studies for possible use in the session. “This educational session aims to highlight options for treatment of complex aortic disorders using existing approved devices in innovative and creative ways,” said Jonathan Bath, MD, who is helping plan the Endovation line-up. “We hope that this session will provide an overview of

GUIDELINES FROM THE FRONT LINES

current solutions in contemporary practice to bridge the gap for patients with a need for complex aortic treatment.” The focus will be on solutions that can be applied in urgent or emergency situations, he said, encompassing: n Device modification (e.g., chimney, laser, back-table fenestration) n A device used in a non-traditional manner, such as OCTO fen, an innovative solution utilizing standard infrarenal devices associated with fenestrated graft to repair a thoracoabdominal aneurysm n Hybrid operations, such as a combination of an endovascular device with surgery, e.g., a bypass sewn to modified aortic device “Clearly for some patients in this era, an open operation may be neither tolerated nor warranted due to surgical risk,” said Bath. “Although there are an array of complex devices in clinical trials or within the auspices of an investigational device exemption, there are a limited number of physicians who have been granted access to these devices.” Most physicians who may encounter complex endovascular problems cannot rely upon these avenues, he said. In addition, patients in emergency or urgent situations may not be able to wait, or for whom access to a facility with such devices is simply not feasible. Grayson Pitcher, MD, and Sherene Shalhub, MD, will co-moderate this concurrent session. In addition to the case studies, presentations cover a broad array of complex aortic interventions.

will include parallel grafting, in-situ fenestration, and physician-modified endografting. Han continues: “Our own institutional algorithm for treatment of TAAA/SRAAA will be shared, while highlighting the fact that each individual algorithm may differ depending on access to technology, technical expertise, regulatory, and reimbursement challenges.” Finally, says Han, standardization in technique and clinical indication for these techniques is possible only when “we have robust data, which is currently lacking.” His presentation will end by summarizing some of the work currently ongoing for a multicenter, international PMEG registry. The Endovation session takes place from 3–4:30 p.m. in Room 210.

“Among the acute aortic pathologies, I will focus on urgent and emergent thoracoabdominal, suprarenal aortic aneurysms” SUKGU M. HAN

n “Chimney, snorkel and other parallel graft

techniques—patient selection, configuration and access are key to durability,” Ross Milner, MD n “In-situ laser fenestrated techniques for the visceral segment: Strategies for visceral perfusion, target cannulation and lessons learned,” Jonathan Bath, MD n “In-situ fenestrated techniques for the aortic arch: How to minimize cerebrovascular complications and ensure adequate seal,” Mathew D. Wooster, MD n “Navigating regulatory and reimbursement pathways: Experiences from the PMEG and IDE landscape,” Sara L. Zettervall, MD n “Guidelines from the front lines: Can we develop best practices or standardization for endovascular alternative techniques, and when should we use alternative techniques?” Sukgu M. Han, MD (detailed in the story above) n “Failure modes of endovascular therapy for complex aortic disorders: When is enough enough,” Eanas S. Yassa, MD

“Clearly for some patients in this era, an open operation may be neither tolerated nor warranted due to surgical risk” JONATHAN BATH

Vascular Specialist | May/June 2022

FLOORPLAN MAP HYNES CONVENTION CENTER 900 Boylston Street, Boston, Massachuestts 02115 t: 877-393-3393 f: 617-954-3326 w: signatureboston.com

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t | Boston, Massachusetts 02115 617.954.3326 | SignatureBoston.com

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OPENING DAY SCHEDULE AT-A-GLANCE Sheraton Boston Hotel Connection

Tuesday, June 14, 2022

Hilton Boston Back Bay

Show Office Exhibit Hall C

Moveable Airwall

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Wednesday, June 15, 2022 6 a.m. to 6:30 p.m.

Registration

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6:30 to 7:30 a.m.

IFT: International Fast Talk

Room 210

7:30 to 8 a.m.

Opening Ceremony

Ballroom A/B

8 to 9:30 a.m.

S1: William J. von Liebig Forum

Ballroom A/B

8 a.m. to 5 p.m.

SVN Annual Meeting

Room 302

8 a.m. to 5 p.m.

VQI@VAM (VQI Annual Meeting)

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9:30 to 9:45 a.m.

Coffee Break

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9:45 to 10:45 a.m.

S2: Plenary Session 2

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10:45 a.m. to 12:15 p.m.

F1: E. Stanley Crawford Critical Issues Forum: Ballroom A/B

12:15 to 1 p.m.

Lunch Break (on own)

12:45 to 6:30 p.m.

VESS Paper Session

Ballroom A/B

1 to 2 p.m.

A1: Proximal DVT

Room 310

1 to 2:30 p.m.

C1: Progressing and Sustaining our Vascular Surgery Workforce into the Future through Innovation in Surgical Education

Room 309

2 to 2:30 p.m.

Policy/Advocacy Session 1

Room 206

2:30 to 3 p.m.

Coffee Break

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3 to 4 p.m.

A2: Cost Effectiveness in Vascular Surgery

Room 310

3 to 4:30 p.m.

C2: “Endovation”

Room 210

5 to 6 p.m.

World Federation of Vascular Societies Reception

Back Bay Ballroom C (Sheraton)

6:15 to 7:15 p.m.

General Surgery Resident/Medical Student Reception

Independence West (Sheraton)

7 to 9:30 p.m.

SVN Gala: Cheers to 40 Years

Oval Room (Fairmont Copley)

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THE SOCIETY FOR VASCULAR Surgery (SVS) is emulating singer-songwriter Dave Loggins in imploring members and interested vascular professionals to “Please Come to Boston” in June for VAM. Post-VAM, SVS can mimic another group, the Mighty Mighty Bosstones, in saying “They Came to Boston.” That’s because Boston will be the place to be June 15–18 for the annual meeting of vascular professionals. Besides education, learning, networking and fun at the meeting itself, attendees and family members will find the city of Boston a place worth exploring for its history, food, universities and, of course, Red Sox baseball. Boston Common, the country’s first public park, and Boston Public Garden, which in the warm weather is the location of the iconic Swan Boats, are among the city’s attractions. There is the Boston Museum of Fine Arts and the beautiful Boston Public Library. Others include the Emerald Necklace, a 1,100acre chain of parks linked by parkways and waterways in Boston and Brookline. The Boston Common and Boston Public Garden both are part of the necklace. Then there is Fenway Park, home of the Boston Red Sox since it opened in 1912. Major League Baseball offers tours, departing at the top of each hour, with tickets available up to 30 days before the tour date. Detroit plays Boston June 20 to 22. Historic attractions also, of course, abound. Visit www.BostonUSA.com for more on what to see and do in Boston.—Beth Bales

BOSTON AT-A-GLANCE

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Quality Vascular Surgery Care for All

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From top: A view from Boston Common; the city’s famous Fenway Park; and inside Boston Public Library

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AAA

OPEN REPAIR OF INFRARENAL AORTIC ANEURYSM PROVES PREFERABLE TO ENDOVASCULAR REPAIR

As part of the International Fast Talk session on Wednesday, Emiliano Chisci, MD, from San Giovanni di Dio Hospital in Florence, Italy, will be presenting the results of a 15-year follow-up of open repair (OSR) of an infrarenal abdominal aortic aneurysm (AAA). The results demonstrate, Chisci will explain, that open repair of an infrarenal AAA is superior to endovascular aneurysm repair (EVAR), even in case of sac shrinkage, writes Clare Tierney

CHISCI ET AL, IN THEIR REPORT, will detail long-term results from 1,777 consecutive AAA repairs in a single tertiary hospital between 2003 and 2018. In their written abstract, they note primary outcomes of all-cause mortality, AAA-related mortality,

and reintervention rate. Open repair was offered to patients whose functional capacity was greater than, or equal to, four metabolic equivalents (METs), who were also predicted to live longer than 10 years. In contrast, the authors explain, EVAR was performed

where patients had a hostile abdomen, they could be deemed anatomically feasible for a standard endovascular graft, and where their functional capacity was lower than four METs. Of the 1,777 repairs included in the study, 47% (n=828) were open repairs and 53% (n=949) were EVARs. The mean age of patients was 78.3 years, 93.5% (n=1,661) were male, and mean follow-up was 79 months. Also of note, the authors define sac shrinkage as “a reduction of both anterior-posterior and latero-lateral diameter of the sac of at least 5mm at the last follow-up versus the first postoperative follow-up imaging.” According to Chisci et al’s findings, the study yielded results showing that 30-day mortality was 0.7% (n=6) and 0.6% (n=6) for open repair and EVAR, respectively. Survival rate was 97.6% and 94% at one year, 83.6% and 75% at five years, 59.6% and 45.8% at 10 years, and 33.1% and 20.7% at 15 (p<0.001). The reseacrhers specify, that where patients had sac shrinkage, a statistical

YOUR SVS SVS special membership sections stage education sessions For the first time, all those who are part of the five SVS membership sections have educational presentations geared specifically to them VAM HAS OFFERED EDUCATION TARGETED to vascular physician assistants (PAs) for several years, with a section for those in the outptient-based setting added after that. The SVS recently established three additional membership sections, for women, young surgeons and those in community practice. This year, all have educational meetings tailored to their needs and career settings and stages. “These sessions let those who lead those membership sections present what they believe are the most pressing topics and issues for these membership groups,” said William Robinson III, MD, chair of the SVS Postgraduate Education Committee, which oversees this and a host of other educational programming. “They all work in the vascular surgery field, yes. But the needs of young surgeons differ from older surgeons in specific ways. Women and PAs, likewise, have issues specific to them. We’re very excited to add these personalized educational sessions this year.” Thursday sessions are for PAs, women and young surgeons. Friday will feature programming for community practitioners and those in the outpatient setting, now known as the Sub-Section on Outpatient and Office Vascular Care (SOOVC); those sessions will be highlighted in the on-site editions of Vascular Specialist@ VAM, the new name of the VAM daily newspaper. Physician Assistants: PAs will enjoy lunch and networking from 11:30 a.m.–1 p.m., with their education session following from 1 to 5 p.m (Room 304/306). “We selected the topics based on a combination of a PA education survey, topics of interest and what we have enjoyed at past conferences,” said Holly Grunebach, PA-C, chair of the PA Section Steering Committee. The goal, she said, is to present a meaningful program plus get as many physician assistants involved as possible. Topics include several presentations on imaging,

including one from the Society of Vascular Ultrasound; complex abdominal aortic repair cases; managing penetrating vascular trauma; chronic limb-threatening ischemia; and a case presentation on acute aortic occlusion in a COVID-19 patient. The group will also hear presentations on leadership; multidisciplinary management; venous insufficiency and varicose veins; managing venous ulcerations wounds. The session will end with “Optimal imaging modalities and interpretation review for aortic disease” and “Detecting and treating the silent killer: Review of abdominal aortic aneurysms from presentation to intervention.” The hope is that PAs “gain clinical knowledge, explore new ways to practice and make connections with providers working in the same specialty,” said Grunebach. It is what makes the membership section “so unique and valuable to physician assistants practicing in vascular surgery,” she added. Women’s Section: Audra Duncan, MD, and Maureen Sheehan, MD, will co-moderate the women’s section session, “Supporting Women Vascular Surgeons, from Recruitment Through Senior Leadership,” from 1:30–3 p.m. Thursday (Room 210). Duncan co-chairs the section Steering Committee with Palma Shaw, MD, who will introduce the program. The 90-minute presentation will cover items of particu-

“The needs of young surgeons differ from older surgeons in specific ways. Women and PAs, likewise, have issues specific to them” WILLIAM ROBINSON III

difference was found (p=0.1). With regard to AAA-related mortality, at final follow-up, deaths were 1.8% (n=15) vs. 2.4% (n=23) in the open repair and EVAR patient groups (p=0.37). Lastly, freedom from intervention in the open repair vs. EVAR groups was 97% and 96% at one year, 96.5% and 88.4% at five years, 95.8% compared with 81.7% at 10 years, and 94.6% vs. 72.3% at 15 years (p<0.001). Furthermore, the authors detail that reinterventions were greater in number in the EVAR group, although the sac shrinkage subgroup (p<0.001) underwent fewer reinterventions. However, this number remains greater than those in the open repair group. By way of conclusion, Chisci et al opine that open repair of an infrarenal AAA is superior to EVAR, even in the case of sac shrinkage at very long-term follow-up. This, they state, is in line with current guidelines, and consequently, they offer the recommendation that the “[open repair] proportion of AAA repair should not be less than 40–45% in a vascular center.”

lar importance to women surgeons, including radiation, logistics and wellness for pregnant surgeons, and optimal practice partnership scenarios for women. The various stages of a woman’s career also will be discussed, including those of the youngest generation of women vascular surgeons, the impact of mentors and sponsors on leadership advancement. Julie Freischlag, MD, SVS’ only female president to date and the current president of the American College of Surgeons, will discuss leaving a legacy. “We worked together with our steering committee, which includes representatives from four stages of careers (trainee, early-career, mid-career and senior surgeon) and tried to address a critical issue at each stage,” said Duncan. “In addition, we wanted topics that would address support of women’s careers that would speak to both men and women who want to mentor, hire, retain and guide women surgeons.” Young Surgeons Section: The needs of young surgeons are front and center in the session devoted to the new section: “Navigating the Launch of Your Career as a Young Surgeon,” from 3:30–5 p.m. Thursday (Room 210). Topics include how to become indispensable in that first year of practice, navigating workplace politics and mentors, sponsors and coaches. Michael McNally will tell attendees all about the “Worst mistakes I made in my first years of practice.” The final two talks will focus on research collaboration and the Vascular Quality Initiative, and leadership. Moderators are Edward Gifford, MD, Chelsea Dorsey, MD, member and chair, respectively of the section Steering Committee, and Jeanwan Kang, MD. Community Practice Section: Community practitioners will meet from 1:30–3 p.m. Friday (Room 210) to discuss “Starting Your Own Independent Practice— What you Need to Know.” The session is being co-moderated by Daniel McDevitt, MD, and Sean Lyden, MD. Sub-Section on Outpatient and Office Vascular Care: Members will be discussing “Providing Outpatient Vascular Care in the Office-based Lab (OBL)— Evaluating Trends, Quality and Value-based Care” from 3:30 to 5 p.m. in Room 210, also on Friday. Robert Molnar, MD and Jayer Chung, MD, will be at the helm.—Beth Bales

Vascular Specialist | May/June 2022

INDUSTRY@VAM A-Z EXHIBITOR LIST Exhibiting As

Booth City

Booth State

Booth Zip

Booth Country

Booth Contact URL

Booth Label

Exhibiting As

Booth City

Booth State

Booth Zip

Booth Country

Booth Contact URL

Booth Label

3M Health Care

St. Paul

55144-1000

United States

http://www.3M.com/medical

515

Medistim

Plymouth

55447

United States

http://www.medistim.com

510

Abbott

Santa Clara

95054-2807

United States

http://www.abbott.com

215

Medtronic

Minneapolis

55432

United States

http://www.medtronic.com

414

Advanced Oxygen Therapy Inc.

Oceanside

92056

United States

http://www.aotinc.net

307

Medtronic Meeting Suite

Minneapolis

55432

United States

http://www.medtronic.com

737

Ahn Surgical Innovation

Dallas

75208

United States

http://www.ahnsurgical.com

107

Mercy Clinic

Saint Louis

63141

United States

https://careers.mercy.net/

111

Aidoc

Tel Aviv

6706703

Israel

aidoc.com

104

MiMedx Group, Inc

Marietta

30062-2254

United States

http://www.mimedx.com

811

American Limb Preservation Society (ALPS)

Redwood City

94065

United States

http://www.limbpreservationsociety.org

T-128

MIMOSA Diagnostics

Toronto

M5C 2B5

Canada

https://mimosadiagnostics.com/

1110

Mindray

Mahwah

7430

United States

https://www.mindraynorthamerica.com

1106

Amputee Associates

Nashville

37210

United States

amputeeassoicatesl.com

527

Nor’easter Medical LLC

Lincoln

2865

United States

https://noreastermedical.com

800

AngioAdvancements

North Fort Myers

33917

United States

http://angioadvancements.com/US.html

301

Penumbra, Inc.

Alameda

94502

United States

http://www.penumbrainc.com

223

AngioDynamics

Latham

12110

United States

http://www.angiodynamics.com

702

Philips

Bothell

98117

United States

http://www.medical.philips.com

1009

Argon Medical Devices Inc.

Athens

75751

United States

http://www.argonmedical.com

907

Philips Meeting Suite

Bothell

98117

United States

http://www.medical.philips.com

1036

Prisma Health

Greenville

29601

United States

http://www.prismahealth.org

109

Artivion

Kennesaw

30144

United States

http://www.cryolife.com

302

ProPharma Group

Western Springs

60558

United States

http://www.propharmagroup.com

1121

Astute Imaging

Kirkland

98033

United States

http://astuteimaging.com

110

Remington Medical, Inc.

Alpharetta

30005

United States

https://remmed.com/

906

AtriCure, Inc.

Mason

45040

United States

https://www.atricure.com/

726

Retia Medical

Valhalla

10595

United States

https://retiamedical.com/

802

Avatar Medical

Paris

75015

France

http://www.avatarmedical.ai

624

Ronin Surgical Corp.

Los Angeles

90064

United States

https://www.roninsurgical.com/

622

Tempe

85281

United States

http://www.bd.com

815

Rooke Products by Osborn Medical

Centennial

80112

United States

http://www.rookeproducts.com

619

Billings Clinic Health System

Billings

59101

United States

www.billingsclinicphysicians.com

1007

Rose Micro Solutions

West Seneca

14224

United States

http://www.rosemicrosolutions.com

700

Boston Scientific

Minneapolis

55311

United States

http://www.bostonscientific.com

915

Scanlan International, Inc.

St. Paul

55107

United States

http://www.scanlaninternational.com

411

Cardiovascular Systems, Inc.

St. Paul

55112

United States

https://csi360.com/

523

Shape Memory Medical

Santa Clara

95054

United States

http://www.shapemem.com

525

Shockwave Medical

Santa Clara

95054

United States

http://shockwavemedical.com

306

Centerline Biomedical, Inc.

Cleveland

44106

United States

http://www.centerlinebiomedical.com

1119

Shockwave Medical Meeting Suite

Santa Clara

95054

United States

http://shockwavemedical.com

842

ConvaTec

Skillman

8558

United States

http://www.convatec.com

210

Silk Road Medical

Sunnyvale

94089

United States

http://www.silkroadmedical.com

806

Cook Medical

Bloomington

47404

United States

http://www.cookmedical.com

715

Society for Clinical Vascular Surgery

Beverly

1915

United States

http://www.scvs.org

T-114

Cook Medical Meeting Suite

Bloomington

47404

United States

http://www.cookmedical.com

837

Society for Vascular Ultrasound

Lanham

20706

United States

http://www.svunet.org

T-124

Cordis®

Santa Clara

95054

United States

http://www.cardinalhealth.com/cordis

406

South Asian American Vascular Society

CAROL STREAM

60188

United States

http://saavsociety.org

T-118

CutisCare

Boca Raton

33431

United States

http://cutiscareusa.com

1021

1915

United States

http://www.savs.org

T-120

Bohemia

11716

United States

http://www.designsforvision.com

511

Southern Association for Vascular Surgery (SAVS)

Beverly

Designs for Vision, Inc. Edwards Lifesciences

Irvine

92614

United States

http://www.edwards.com

407

Surgical Affiliates Management Group, Inc.

SACRAMENTO

95834

United States

https://www.samgi.com/

627

Elsevier, Inc.

Philadelphia

19103-2899

United States

http://www.elsevierhealth.com

201

SurgiTel

Ann Arbor

48103

United States

http://www.surgitel.com

1006

Endologix

Irvine

92618

United States

http://www.endologix.com

206

Surmodics, Inc

Eden Prairie

55344

United States

https://www.surmodics.com

910

Endovascular Today

Wayne

19087

United States

http://www.evtoday.com

410

Tactile Medical

Minneapolis

55416

United States

http://www.tactilemedical.com

211

Fivos (formerly Medstreaming)

West Lebanon

3784

United States

http://www.fivoshealth.com

507

Terumo Aortic

Somerset

8873

United States

http://www.terumois.com

615

GE Healthcare

Chicago

60661

United States

http://www.gehealthcare.com

311

Traverse City

49684

United States

https://www.thompsonsurgical.com

519

Getinge

Wayne

7470

United States

http://www.getinge.com

614

Thompson Surgical Instruments, Inc.

Gore & Associates

Flagstaff

86005

United States

http://www.goremedical.com

422

Tisgenx, Inc.

Irvine

92618

United States

http://www.tisgenx.com

701

Gore & Associates Meeting Suite

Flagstaff

86005

United States

http://www.goremedical.com

836

TMD LAB

Seoul

4799

Korea (South)

http://www.tmdlab.com

1010

UltraLight Optics Inc

Costa Mesa

92626

United States

http://www.ultralightoptics.com

911

Haemonetics

Boston

2110

United States

http://haemonetics.com

901

Unetixs

Warwick

2886

United States

http://www.unetixs.com

300

Hayes Locums

Fort Lauderdale

33309

United States

https://www.hayeslocums.com/

108

Vascular Cures

Redwood City

94065

United States

http://vascularcures.org

T-126

HMP CardioVascular

Malvern

19355

United States

https://www.iset.org/

T-130

London

SW6 5NR

T-122

Durham

27713

United States

http://www.humacyte.com

116

United Kingdom

https://vascularnews.com/

Humacyte, Inc.

Vascular News / Charing Cross Symposium

Illuminate

Overland Park

66212

United States

https://www.illuminate.ai/

807

Vascular Technology Inc.

Nashua

3062

United States

http://www.vti-online.com

606

Inari Medical

Irvine

92618

United States

http://inarimedical.com

1015

Vasorum USA, Inc

Charlotte

28203

United States

http://www.vasorum.ie

801

International Vein Congress (IVC)

Woodbury

6798

United States

http://www.ivcmiami.com

T-132

Veryan Medical

Horsham

West Sussex

RH13 5PL

United Kingdom

http://www.veryanmed.com

626

Janssen Pharmaceuticals, Inc.

Titusville

8560

United States

https://www.janssen.com

214

VQI (Vascular Quality Initiative)

West Lebanon

3784

United States

https://www.vqi.org/

610

LeMaitre

Burlington

1803

United States

https://www.lemaitre.com

207

Watson Clinic LLP

Lakeland

33805

United States

http://www.watsonclinic.com

900

LifeLike BioTissue

London

N6G 4X8

Canada

http://www.lifelikebiotissue.com

1008

Western Vascular Society

Anacortes

98221

United States

http://www.westernvascularsociety.org

T-116

LifeNet Health

Virginia Beach

23453

United States

http://www.lifenethealth.org

506

Wexler Surgical, Inc.

Houston

77035

United States

http://www.wexlersurgical.com

310

Industry-supported sessions on the VAM menu

VAM attendees are invited to the satellite symposia offered by industry. These sessions are not part of the Accreditation Council for Continuing Medical Education (ACCME)-accredited portion of the meeting WEDNESDAY EVENING 6:30 to 8 p.m.

Vascular Fellows: Preparing for Practice Sponsored by Gore & Associates Description: Panelists will address clinical complexities of being an early-career vascular surgeon. The session also will provide an opportunity to learn from peer experiences and offer guidance on the role of social media in your practice Location: Sheraton Boston Hotel, Republic Ballroom B Completion Control in Open Surgery: Lessons learned Sponsored by Medistim USA, Inc.

Description: Join us as Professor Vikatmaa and Dr. Karl Illig share their experiences with transit time flow measurement and high-frequency ultrasound imaging as completion control in peripheral bypass, carotid endarterectomy and AV access surgeries. Location: Sheraton Boston Hotel, Constitution Ballroom B

Sponsored by Boston Scientific and Philips Description: Please join our panel of physician experts as they share realworld evidence and challenging clinical cases on how they have incorporated IVUS imaging as part of their decisionmaking process in both peripheral arterial disease (PAD) and venous procedures. Location: Room 312

B3: Redefining Thrombectomy with Hydrodynamic Maceration and Powerful Aspiration Sponsored by Abbott Location: Room 304

THURSDAY MORNING

B2: Clinical Insights in PAD: Reducing the Risk of Major Thrombotic Vascular Events Sponsored by Janssen Pharmaceuticals, Inc. Description: This lecture will discuss treatment and reduction in the risk of major thrombotic vascular events in PAD patients. Location: Room 306

Real Life Experience with the Gore Thoracic Branch Endoprosthesis Sponsored by Gore & Associates

6:45 to 8 a.m. Hynes Convention Center B1: What You See is Not What You Get … A Case-Based Discussion on the Role of IVUS in Peripheral Interventions

THURSDAY EVEINING

6:30 to 8 p.m. Sheraton Boston Hotel; Republic Ballroom B

This listing was correct at the time of going to print on May 31, 2022.

www.vascularspecialistonline.com

VASCULAR LIVE

Be sure to save time for the Vascular Live theater-in-the-round presentations in the Exhibit Hall. These sessions, on a variety of topics of importance to vascular surgeons, frequently play to big crowds, writes Beth Bales ALL VASCULAR LIVE EVENTS WILL TAKE PLACE AT the Vascular Live stage, at the back of Aisle 700 in the Exhibit Hall, on Level 2 of the Hynes Convention Center.

THURSDAY, JUNE 16

10–10:25 a.m. Tips and Tricks for Suture-Mediated Closure and Repair for Arterial Access Sites Sponsored by Abbott Speaker: Elena Rinehardt, MD 12:15–12:40 p.m. Real-World Clinical Strategies with the Venovo Venous Stent System Sponsored by BD Speaker: Patrick Muck, MD

1–1:25 p.m. Overcoming Challenges in TEVAR, Today and Tomorrow Sponsored by Gore Speaker: To be Announced 3–3:25 p.m. Reimagine Aspiration With Hydrodynamic Thrombectomy Systems Sponsored by Abbott Speaker: Loay Kabbani, MD 5:15–5:40 pm Treating Complex VTE in My Practice Sponsored by Penumbra Speaker: Carlos Bechara, MD Overview: This presentation will focus on the use of Lightning 7 Intelligent Aspiration in cases and to assist in treating complex venous thromboembolism cases.

FRIDAY, JUNE 17

9:30 –9:55 a.m. Advancing Health Equity by Addressing Disparities with TWO2 Homecare Therapy Sponsored by Advanced Oxygen Therapy Speakers: Mike Griffiths, MD, and Anil Hingorani, MD Synopsis: Non-healing venous leg ulcers and diabetic foot ulcers pose a disproportionate impact on minority and low-socioeconomic populations. Advanced Oxygen Therapy’s unique cyclical-pressure Topical Wound Oxygen (TWO2) therapy offers hope for addressing such health ineq-

uities. The growing body of randomized controlled trial and real-world evidence demonstrating significantly-reduced ulcer recurrence, hospitalizations and amputations will be reviewed. The impact that more durable wound healing has on both patientand payer-centric outcomes will also be explored. 12:15–12:40 p.m. Remove with Rotarex Sponsored by BD Speakers: Frank Arko, MD, and Bryan Fisher, MD 1–1:25 p.m. The Role of Covered Stent Grafts in the Treatment of Complex Aortoiliac Occlusive Disease Sponsored by Gore Speaker: To be announced 3 to 3:25 p.m. TCAR: The Road to Standard of Sare Sponsored by Silk Road Medical Speakers: Marc Schermerhorn, MD, Megan Dermody, MD, and Jeffrey Jim, MD Presentations: n “TCAR in 2022 and beyond: The current and future state of TCAR” n How can TCAR improve efficiencies within your practice” nT CAR: Perspectives from a practicing physician: How TCAR can benefit patients” Vascular Live presentations are not eligible for CME credit. Listing is correct as of May 31, 2022.

Vascular Specialist | May/June 2022

PRIORITIES

Regional society leaders look forward to VAM and beyond We asked the presidents of all five major regional vascular societies in the United States for an update on the latest goings-on in their organizations, how their presidencies are progressing, and what papers and talks they are looking out for at this year’s VAM. Andres Schanzer, MD, president of the New England Society for Vascular Surgery (NESVS), Robert Rhee, MD, the current Eastern Vascular Society (EVS) president, President William Jordan, MD, from the Southern Association for Vascular Surgery (SAVS), Raghu Motaganahalli, MD, president of the Midwestern Vascular Surgical Society (MVSS), and Western Vascular Society President Vincent Rowe, MD, fill in Bryan Kay

1. Can you tell us a little about the latest developments across your society? Andres Schanzer: We introduced a new research fellowship that leverages the Vascular Study Group of New England (VSGNE)/NESVS relationship and the many strong investigators in our region who will be providing the teaching content. This course, designed and led by Kimberly Malka, MD, will help to jumpstart high-impact research careers for junior members in our region. We have tried to increase our region’s social media presence in order to better serve our members. This effort, initiated by Alan Dardik, MD, during his presidency last year, has been an enormous success. The NESVS now has more than 1,000 followers on Twitter, and regularly posts on this platform and others like Instagram. We continue to work on our society’s diversity, equity, and inclusion (DEI), and want our society membership to look like our patients. Beth Blazick, MD, and Patricia Furey, MD, chair our DEI committee. Finally, we have put significant effort into making the NESVS a home for all who take care of vascular surgery patients. Our Allied Health program continues to grow. Robert Rhee: We have in the past had quite selective, exclusive committees at the EVS—we have in excess of 20 committees. In the past, the president would appoint people he knows, people who are in the academic circle. What I did this year was to open it up to any member who wants to serve. Even if you are one year out of a fellowship, and if you’re a laboratory tech, or a physician’s assistant, and you want to serve to help advance the treatment of vascular disease, you can. Our committees are much larger, we have a lot more manpower, and we’re going to use that manpower to develop more robust, web-based content, in terms of patient testimonials, and interviews of experienced vascular specialists doing certain procedures. We aim to be a society not just focused on an annual meeting, but a year-round service to all the members. William Jordan: In January of 2022, many of our members were able to gather in Florida for our annual meeting as were emerged from the pandemic. The science shared in the plenaries was inspiring, and the techniques shown in the postgraduate course were truly innovative. SAVS has the distinction of having the highest proportion of meeting manuscripts published in the Journal of Vascular Surgery (JVS). We are also proud of progress we’ve made in attracting underrepresented groups to our society. Over the last five application cycles, nearly 40% of our new Active members have been from underrepresented groups—including females and ethnic minorities. We are excited for our continued growth in this area. Raghu Montaganahalli: The MVSS established a new DEI Committee, led by Bernadette Aulivola, MD, and Lee Kirksey, MD, as chairs. Several recommendations were made from the committee, including scholarships for health disparities research. We will implement them at this year’s meeting in Grand Rapids, Michigan. We continue to host the popular New Horizons webinar series. At each of these events, we’ve presented topics on new technologies and debated on controversial topics. These programs were well attended by our members and trainees. Our society has invested in medical students who want to pursue a career in vascular surgery by giving them access to our educational webinars, travel scholarships and our residency fair. Our Medical Student and Resident Committee has done a great job of connecting with vascular special interest groups in order to attract the best and brightest for our specialty. Vincent Rowe: This year, the WVS has re-instituted the Mock Oral examinations, led by Warren Chow, MD, from University of Washington. We have also had webinars for our DEI Committee and Vascular Surgery Interest Group.

2. What priorities did you set for your presidential year, and how are they progressing? AS: My priorities for this year included introducing a new research fellowship for NESVS members that leverages our relationship with the VSGNE and the many talented investigators in our region; expanding our social media presence; integrating DEI consideration into every single decision/appointment we make; growing our APP program/offerings; and using the shared SVS/NESVS membership lists to perform a focused membership drive, with the goal of all SVS members in our region also being members of NESVS. RR: For my presidential year, I’ve really focused on making this medical society a little bit more inclusive. One of the things I initiated—and will be legislated and enacted by our annual meeting in September—is no longer requiring an MD or DO as a membership requirement, meaning that we have been, for the last several years, pushing to get Allied Health (physicians assistants, techs, nurses, anybody who is involved in vascular care) to join the EVS as an equal voting member. The days of stuffy old physicians’ societies are gone. Those are significant changes for a 750-member regional society. WJ: Our primary focus heading into this term is building upon the success of our last meeting, and continuing to foster a great sense of togetherness. We are excited to welcome more in-person attendees to our next annual meeting in Puerto Rico in January of 2023. We are confident that eased COVID-19 restrictions, coupled with a beautiful setting, will lead to even more engagement amongst our members. My priority as president is to bring our society and specialty closer together in order to advance the science and understanding of vascular disease to better serve our patients. RM: During my presidential year, my main priority is to increase the membership of the MVSS. Membership engagement at all levels is a top priority for the society. Be it Active, Candidate or Medical Student members, we want to strengthen the organization at the grassroots level by continuing to host successful membership drives throughout the year. We want to make sure we welcome as many vascular surgery practitioners and trainees in the Midwest as possible, and encourage them to become members of the MVSS. I am also passionate about our new DEI Committee and its mission to promote diversity, equity and inclusion amongst our general membership, committee volunteers and society leadership. We are committed to mentoring a diverse group of medical students and trainees, and to set the example for others for follow. It is our intent to not only sustain these efforts, but to continuously improve and expand our goals.

3. What paper on the VAM 2022 schedule are you most looking forward to and why? AS: There are many excellent studies on a broad array of topics, covering every aspect of vascular surgery. One presentation I am particularly excited about hearing is by a group of authors from Hamburg, Germany, who are at the very front edge of procedural imaging technology using Fiber Optic RealShape (FORS; Philips). This technology allows catheter and wires to be visualized in 3D without the use of radiation. They are presenting their first 50 complex aortic patients that they have treated with this technology. It will be exciting to hear about how well this technology performs, where the gaps are, and what future developments might be necessary for FORS to become more widespread. RR: The papers that I’ll be looking for at VAM are those that are relevant to the everyday vascular surgeon. Those papers that are going to help the in-the-trenches vascular specialist to do their job well, and not really the esoteric procedures that are limited to certain institutions. WM: I am looking forward to the paper presented by Olamide Alabi, MD, Luke Brewster, MD, and Yazan Duwayri, MD—three members of our outstanding Emory faculty—comparing 90-day peripheral arterial disease (PAD) outcomes in office-based labs versus outpatient procedures. RM: Every year, I look forward to the E. Stanley Crawford Critical Issues Forum. This year, the program focuses on “Quality Vascular Surgery Care for All—An Aspirational Goal of Merit.” This will be an opportunity to learn more about the chasms in vascular care as it applies to urban and rural America, workforce issues, as well as DEI challenges with access to vascular care. These are hot-button topics, and I am sure this will be a great learning experience for all of us. VR: Right now, I am curious about the paper from Beth Israel Deaconess Medical Center to better understand how social determinants effect outcomes in vascular disease—”The impact of neighborhood social disadvantage on peripheral artery disease presentation and management.”

Left-to-right: Andres Schanzer, Robert Rhee, William Jordan, Raghu Motaganahalli and Vincent Rowe

Vascular Specialist | May/June 2022

SVN PREVIEW

Vascular nurses celebrate 40th anniversary conference Founding Society for Vascular Nursing (SVN) member and the SVN’s first president, Jeanne Doyle recalls 40 years of vascular nursing history ahead of the this year’s big anniversary party. Here, she tells Beth Bales about how the association was birthed, the part played by vascular surgeons, and the many challenges faced along the way THE SVN WILL CELEBRATE ITS 40TH ANNUAL Conference in June in the place where it all began: Boston. In fact, the vascular nurses will mark the occasion at a reception in the same place as the original meeting 40 years ago, where the association was born. Founder and first president, Jeanne Doyle, was working in Boston in the early 1980s with SVS member (now retired) Jim Menzoian, MD, trying to learn as much as possible about the diagnosis and management of peripheral vascular disease. “I literally followed him for months (though not regularly in the OR), soaking in as much as I could about this vastly prevalent and often debilitating disease and its treatment.” Though she knew she was learning the basics from the medical perspective, she realized there was little information to help develop her nursing expertise. She started looking for other nurses in the Boston area so they could learn from each other. She wrote a short letter to the editor of the American Journal of Nursing (AJN) and received a polite but deflating note in return. Due to letter volume, hers would probably never be published. Later that year, another surgeon mentor, SVS member Frank LoGerfo, MD, returned from the American College of Surgeons meeting in Atlanta with the news that he had met a nurse who also worked in a similar role. Doyle reached out to Nancy Jasinkowski, a nurse at the Jobst Vascular Institute in Toledo, Ohio—and then the thing that wasn’t supposed to happen did, and the AJN published Doyle’s letter. She said, “I started hearing from other nurses around the country. I was so excited!” In the pre-email, pre-internet era, communication was slow, but Doyle and Jasinkowski, over time, assembled a core group of eight nurses working in the vascular arena. The first order of business: discuss organizing a specialty association. They sent out a multi-page questionnaire to many other nurses to survey interest. “The response rate and results were encouraging,” said Doyle. They decided to meet during the SVS 1982 Vascular Annual Meeting, being held in Boston. With no such educational meeting for vascular nurses, all eight were planning to attend. They met a few days before the conference, in the hotel bar, to brainstorm. “Where else?” quipped Doyle. No “Robert’s Rules of Order” for this group—during that meeting, Doyle left the table for a few minutes and returned to discover she’d been “elected” president. “Prior to meeting for the first time, we had each spoken with our surgeon colleagues and asked them to finance a get-together in Boston, if we could pull it off. So, we had a little bit of a budget for a wine and cheese reception at the Copley Plaza (hotel),” Doyle said. “We posted flyers in the SVS headquarters hotel and asked nurses to come to explore the idea of organizing an association.” More than 100 nurses showed up, to the group’s aston-

The eight founding members are (left-to-right): Patricia Baum, UMASS Medical Center, Worcester, Massachusetts, who had recently relocated from the Medical College of Wisconsin, Milwaukee, Wisconsin; Jeanne Doyle, University Hospital (now Boston Medical Center), Boston; Mitzi Ekers, teaching for Resource Applications, recently relocated to Tampa, Florida, from St. Anthony Hospital, Columbus, Ohio; Vicki Fahey, Northwestern Medical Center, Chicago; Jackie Helt, NYU-Langone Medical Center, New York City; Nancy Jasinkowski, Jobst Vascular Center, Toledo, Ohio; Patricia McGlone, Ohio State University Medical Center, Columbus, Ohio; and Sheila White-Flores, Montefiore Medical Center, New York City

ishment. “We were overwhelmed with the amount of support,” said Doyle. The organization, then the Society for Peripheral Vascular Nursing, was born that evening. This year, to commemorate that longago meeting, vascular nurses, including many of the eight founders, will return to Boston. They’ll return to the Fairmont Copley Plaza Hotel, in fact, on Wednesday, June 15, “where our roots are,” said Doyle. Besides toasting the past at the Copley Plaza to mark the 40th anniversary milestone, participants also will take a trip in the Wayback Machine throughout the confer-

“It’s a pretty impressive record legacy for eight nurses from 40 years ago” JEANNE DOYLE ence, with reminders of how the diagnosis and treatment of peripheral vascular diseases have changed between 1982 and 2022. The course of the four decades has not always been smooth, with financial challenges along the way. At one point, Doyle resigned from the Board of Directors and took over as executive director, to help keep the society running. In 2017, again facing challenges, the SVN began making its management home with the SVS and has held its conference in tandem with VAM since 2018. Doyle said it’s hard to maintain

SVN meeting details The SVN Annual Conference takes place from 8 a.m.–5 p.m. Wednesday and Thursday, June 15 and 16. The meeting features two days filled with networking events, educational offerings, the latest research in vascular nursing and the celebration of the Society’s 40th anniversary. Presentations run the gamut of vascular disease, including endovascular aortic arch repair, measuring blood flow in the foot, COVID-19-associated acute limb ischemia, assessing peripheral artery disease symptoms, case reports, a quality improvement project on improving completion rates of supervised exercise therapy programs, TCAR, carotid artery disease, vasculitis, venous thromboembolism, lymphedema therapy, lipedema, nutrition and more. The SVN “Cheers to 40 Years” Gala takes place 7–9:30 p.m. Wednesday in the Oval Room at the Fairmont Copley Plaza Hotel. The nurses will celebrate the meeting of the core group of nurses who met in June of 1982 at the same location, to discuss establishing a society that would officially recognize vascular nursing as a specialty practice. Learn more on the Society website at svnnet.org.

momentum. “Nursing is such a transient profession,” Doyle said. “There are so many opportunities. A nurse may spend time in a vascular setting and then move on.” And, in 40 years, things change. Current Society President Barb Vogel notes that “Our vascular nurses are spread out across the country and in some cases, around the globe. It can be challenging to create an organizational structure that allows for the professional development of all our members. We love our annual conference, but we want to reach our members year-round.” For a long time, that meant local chapters. But in recent years, said Vogel, leaders realized the chapter format was no longer working. With changes in technology, SVN members can connect with each other and the society throughout the year. This includes an SVN discussion board on the SVSConnect online community, and virtual roundtables offered each quarter. Each roundtable is hosted by a member and focuses on a specific topic and all members are encouraged to attend. Vogel said the society’s leadership continues to look for ways to engage members all year round and not just at the annual conference. Doyle said she does not often step back and reflect on the impact of SVN on patient care. “It’s a pretty impressive legacy for eight nurses from 40 years ago,” she acknowledged. Vogel added, “You and the other original members should be very proud of this.”

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VS@VAM BRIEFS INTERNATIONAL POSTER COMPETITION MOVES TO OPENING RECEPTION

Something new has been added to the VAM’s Opening Reception: The International Poster Competition. Now there will be two sets of posters available for reception guests to view: the just-added international posters and those that are part of the Interactive Poster Session, long been a staple of the evening. “This provides all poster authors the same opportunity to present their work to the crowds at the reception,” said William P. Robinson, III, MD, of the Postgraduate Education Committee, which helps oversee the poster sessions. “We think it’s going to be a great addition to the reception.” The three events take place from 5 to 6:30 p.m. Thursday, June 16, in the Hynes Convention Center Exhibit Hall C, second floor. Winners of the International Poster Competition will be announced Friday morning.

WIN BIG THURSDAY AND FRIDAY IN THE EXHIBIT HALL

Besides viewing exhibitors’ devices and other offerings, enjoying appetizers and drinks, visiting the SVS Booth and viewing posters, guests to the Exhibit Hall have three chances to win gift cards worth $250 and $500. At Thursday’s opening reception, attendees can simply drop their business card in the entry drum located at the SVS Booth (No. 607). The drawing for a $500 Amazon gift card will be held at 6:15 p.m., just a quarter-hour before the reception ends. The owner of the lucky business card must be present to win. Two winners will be selected on Friday. Each will receive a $250 Amazon gift card. The process is identical; hopefuls will drop their business cards once again in the drum at the SVS Booth in the Exhibit Hall. Drawings will be held at 1 and 4 p.m. Winners need not be present.

CAN’T TRAVEL TO VAM? HERE’S HOW TO STREAM

For a variety of reasons, not everyone who wants to attend VAM can actually make it to Boston in June. Institution travel restrictions could still be a factor, or perhaps a surgeon can’t take four days out of his or her schedule at the moment. Whatever the reason, the Society for Vascular Surgery has an answer: livestreaming.

Introduced in 2021, livestreaming proved so popular it’s back— and expanded—for 2022. All plenary sessions, international sessions, the Presidential Address, special lectures and more will be livestreamed. Every single day of the meeting there will be an entire day’s worth of livestreamed programming. For more information about VAM and to register for either the in-person meeting or livestreaming, visit vascular.org/VAM.

GET YOUR TICKETS NOW FOR CERTAIN VAM EVENTS

The vast majority of VAM programming is included in the registration fee. However, some courses and events require a ticket, even if there is no fee associated with it. Attendees must arrange for tickets via registration for these events, which are free of charge: n Breakfast sessions, including industry-sponsored breakfasts n Lunches in the Exhibit Hall n SVS Member Business Meeting and Lunch, for SVS members only Special events: These events are included in the registration fee unless otherwise noted. Tickets are required. n VQI@VAM ($300); Livestreaming, $210 n Concurrent Session, “Endovation:” Endovascular Innovation for Urgent and Emergency Complex Aortic Disorders (rapid-case discussion and networking), free n International/World Federation of Vascular Societies Guest Reception, open to all international attended and guests, two-ticket maximum, free n Society for Vascular Nursing Annual Conference, registration fee required n SVS Physician Assistant Section/ SVN Box Lunch on Thursday, free n Meet the Leaders Luncheon and SVS Leadership Development Program graduation, free n SVS Women’s Leadership Section Meeting, free n SVS Young Surgeons Section Meeting, free n Opening Reception with Exhibitors, free n Networking Reception for Women, Leadership, Diversity and Young Surgeons, free n Women’s Leadership Dinner, $95 n SVS Community Practice Section Meeting, free n SVS Section for Office-Based Vascular Office-Based Lab Section, free n Registered Physician in Vascular Interpretation (RPVI) Exam Review Course, additional fee of between $25 and $200. Registrants may choose to attend only this course, the first step toward achieving board certification in vascular surgery. Those who select that option will not be able to attend VAM sessions or have access to recorded VAM content after the meeting Be sure to include ticketed sessions in your registration or return to registration to add them. Visit vascular. org/VAM-2022/Registration.

Compiled by Beth Bales, Kristin Crowe and Bryan Kay BRING YOUR SOCIAL MEDIA GAME TO BOSTON —OR PLAY FROM HOME!

Social media connects people around the world – including the vascular health community. After a successful debut in San Diego in 2021, the Social Media Challenge returns this year to Boston. Sponsored by the SVS Social Media Subcommittee, participants in San Diego competed in several challenges, sharing pictures of their VAM 2021 experience on social with a #VAM21 hashtag and, frequently, pictures, such as Meryl Simon Logan, MD, with Matthew Mell, MD, one of her residency mentors. Contestants in the At-Home Challenge shared their livestreamed experience with posts and hashtags as well. Matthew Smeds, MD, won first prize in 2021, receiving free registration for this year’s meeting. Will he win again with his trusty phone and social media savvy? Be ready to compete in June and be looking for upcoming details on Challenge 2022.

EARN EDUCATIONAL CREDITS AT VAM

Besides the knowledge attendees gain at VAM, physicians can garner another benefit: the ability to earn Continuing Medical Education (CME) and self-assessment credits. Many sessions—all the plenaries, the six SVS (as opposed to industry-sponsored) breakfast presentations, the postgraduate courses, the concurrent sessions and more – will offer CMEs. Some of those same presentations also will offer self-assessment credits (SA-CME). Both CME and SA-CME can be applied toward your American Board of Surgery (ABS) Continuous Certification, formerly known as Maintenance of Certification (MOC). Those attending in person can earn up to 34 CMEs, of which 22.75 can be SA-CME credits. Those who select the livestreaming option can earn up to 27 CMEs, of which 16 can be SA-CMEs. See the attached chart for which sessions offer credits. Contact the SVS Education Department at education@vascularsociety.org with any questions. The SVS is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Society for Vascular Surgery designates the 2022 Vascular Annual Meeting for 34 AMA PRA Category 1 Credit(s)™. Physicians should only claim the credit commensurate with the extent of their participation in the activity. VAM 2022 also includes a self-assessment component for select sessions that meets the requirements of the American Board of Surgery Continuous Certification Program Physician Assistants: PAs who attend Thursday’s special programming developed for them have the ability to earn a certificate of participation. VQI: Anyone who is registered and attends the VQI will be able to earn a certificate of participation. Nurses: Vascular nurses who attend the Society for Vascular Nursing Annual Conference can earn up to 13.75 contact hours. Those registered for both the conference and for VAM are eligible to attend educational sessions on Friday and Saturday for a certificate of attendance. Session Name

In-person CME

Postgraduate Courses 1-2

Postgraduate Course 3

Plenaries 1 - 8

E. Stanley Crawford Critical Issues Forum

VESS Paper Session

Ask the Experts Sesssions 1-5

Concurrent Sessions 1, 2 and 7

Concurrent Sessions 3-6

Policy/Advocacy Sessions 1 and 2

Breakfast Sessions 4-9

International Fast Talk

International Chapter Forum

International Young Surgeons Competition

Resident, Med Student breakfasts

JVS Special Session

“How I Do It” Video Session

Women’s, Young Surgeons, Community Practice, OBL and Physician Assistant sections

Mock Interviews Practice Session

World Federation of Vascular Societies

RPVI Review Course

VQI Annual Meeting (Also receives VQI certificate of participation)

Livestream CME

SA-CME *

* *

* * *

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ALZHEIMER’S STUDY A new pathway for preventing dementia? Craig Weinkauf, MD, is leading a trial looking into a connection with carotid stenosis. ‘We want to try to quantify the brain: volumes, structural connectivity, functional connectivity and other relevant findings associated with neurodegeneration,’ he tells Beth Bales

ociety for Vascular Surgery (SVS) member Craig Weinkauf, MD, enrolled patient No. 1 just a few months ago in a National Institutes of Health (NIH) study to determine the impact of carotid disease on cognitive impairment and Alzheimer’s disease. Alzheimer’s affects an estimated 5.8 million Americans and is the fifth-leading cause of death among those 65 and older. It is the most common type of dementia. Carotid disease can be slowed or reduced though lifestyle management, medication and surgical intervention. Because it’s modifiable, finding a connection between carotid disease and Alzheimer’s could provide a new pathway for decreasing dementia risk, Weinkauf said.. He is leading the study, funded by a $4.9 million NIH grant, working with a host of other experts in neuroimaging, magnetic resonance imaging, vascular disease, Alzheimer’s disease and neurocognitive function. Weinkauf is an assistant professor in the Department of Surgery’s division of vascular and endovascular surgery at the University of Arizona College of Medicine. Carotid disease, in which vessels carrying blood to the brain become occluded, causes 10 to 20% of strokes. Weinkauf said that many physicians might not consider it a major problem if one or two of these blood-carrying vessels are occluded because the brain still has so much collateral blood flow. The point of the study, he said, is what if this thinking is wrong? “We’re looking into this question: does carotid disease infer specific risk for Alzheimer’s disease beyond that of baseline cardiovascular-risk factors?” Weinkauf said. “We’re looking beyond stroke,

beyond general cardiovascular risk factors, at how blockages in the arteries that lead to your brain affect your brain health?” Researchers started in March and will continue over the next five years to recruit roughly 240 patients, primarily in Arizona. Then, with advanced imaging, neurocognitive testing, and other specialized tests the researchers will investigate which specific pathological changes specific to Alzheimer’s are associated with carotid disease; how (and if ) carotid disease leads to those changes; and which treatments for carotid disease are effective at preventing or improving Alzheimer’s-associated neurodegeneration. The team will start by determining patients’ baseline cognitive function, and what constitutes a normal decline that comes with aging. This trial continues research from an earlier project in which Weinkauf and close collaborators tried to see if they could quantify cognitive function and changes in the brain. They quantified various aspects of cognition and brain structure, including brain volumes of the Hippocampus, the portion of the brain that supports memory—especially new memories, learning, navigation and space perception. It is also thought to perhaps play a role in Alzheimer’s disease. The brains in Alzheimer’s patients have a “quantifiably smaller” Hippocampus, said Weinkauf. “We found the same thing in patients with severe carotid stenosis (defined as >70% steno-

PUBLIC AWARENESS

SVS HAS PATIENT RESOURCES AND GUIDELINES ON STROKES May was Stroke Awareness Month, and the Society for Vascular Surgery (SVS) and SVS Foundation offer educational resources for Society members to provide as a resource to their patients at risk of the potentially devastating disease no matter the time of year, writes Beth Bales

sis) compared to well matched controls with <50% carotid stenosis bilaterally. “It’s something you can quantify to see if something’s changing. The project started by asking these kinds of questions. “We want to try to quantify the brain: volumes, structural connectivity, functional connectivity and other relevant findings associated with neurodegeneration,” he continued. “We didn’t have these tools 20 years ago, or even five years ago in some cases, so even if someone had thought of this then they wouldn’t have necessarily had the tools to investigate.

“We’re looking beyond stroke, beyond general cardiovascular risk factors, at how blockages in the arteries that lead to your brain affect your brain health?” CRAIG WEINKAUF “We’re lucky to have surgical treatments for this problem,” he said. “We will also be able to follow that population to see if they have key structural and functional brain changes that improve with intervention.” Related questions are being asked in various ways by other groups as well, including the CREST-H

THE SOCIETY ALSO HAS CREATED clinical practice guidelines that evaluate the evidence in the scientific literature, assess the likely benefits and harms of a particular treatment, and enable healthcare providers to select the best care for a unique patient based on his or her preferences. SVS guidelines aid members and their patients in the decision-making process. Visit vascular.org/CPG to see the guidelines. Patient resources include detailed information about strokes, including symptoms, causes, diagnosis, treatments and prevention. In addition, SVS offers patient fliers on carotid artery disease, cholesterol, smoking and physical activity, all of which impact vascular health and disease. As members know all too well, smoking is a major cause of strokes and cardiovascular disease leading to strokes. Physical activity, likewise, helps prevent strokes and other vascular conditions and illness. Members can download patient education fliers from the patient-education portion of the SVS website at vascular.org, or via the members-only Brand-

(hemodynamics) part of the CREST-2 trial. “It is clear that these types of questions are in the air and hopefully as a field we will be able to improve care for our vascular patients by better understanding the connection between carotid artery stenosis and brain health.” Some carotid patients have told him that, following a procedure for carotid disease, their vision, hearing and thinking all improved, he said. “I think there’s more overlap between these two large patient populations, those with carotid and those at risk for Alzheimer’s than is currently appreciated. The research team hopes to be able to determine if baseline factors can identify those people at increased risk for Alzheimer’s and/or other forms of cognitive impairment and dementia. In a similar fashion they will be looking to determine which baseline factors may help define who benefits from intervention. “This strategy gets at a key deficit in how we currently approach carotid disease management: there is minimal patient selection for defining subpopulations of patients with carotid disease who may benefit most from treatment,” Weinkauf added. “Risk-stratification of this population will be integral for honing/improving our vascular care and obtaining important objectives like personalization of carotid vascular care. We hope that our study can help us better understand brain health in our patients and define key, quantifiable markers that help guide our surgical care.” For more information or to learn about enrolling patients contact Weinkauf at cweinkauf@surgery.arizona.edu.

ing Toolkit; those materials can be customized with a member’s name, practice and contact information. Any of the materials can then be available in members’ offices or mailed or emailed to at-risk patients. “We all know the numbers,” said SVS President Ali AbuRahma, MD. “We know that up to 5% of people older than 65 have carotid artery disease, which increases the risk of stroke, that cholesterol is a top factor when it comes to vascular disease, and that lifestyle changes such as quitting smoking and increasing physical activity are major preventive measures. “Help your patients by helping educate them,” he said. “You never know what piece of information might make the difference and turn things around.” The Branding Toolkit also includes condition fliers, including one on claudication, that can be customized and sent to referring conditions. Visit vascular.org/PatientFliers for the patient fliers, and vascular.org/BrandingToolkit for all other materials.

Vascular Specialist | May/June 2022

AORTIC INTERVENTIONS

Artificial intelligence could make endovascular aortic repair outcomes more predictable, CX 2022 hears By Jocelyn Hudson AT THE 2022 CHARING CROSS (CX) INTERNATIONAL Symposium (April 26–28) in London, England, Tom Carrell, MD, a vascular surgeon in Cambridge, England, and founder of Cydar Medical, delivered a Podium 1st presentation titled “Making endovascular aortic repair outcomes more predictable: Artificial intelligence [AI] takes on a 20-yearold challenge.” “Given any individual patient with some anatomic complexity, do we really know—particularly with the ever-expanding range of treatment options— what is going to be the outcome for them?” According to Carrell, this is the key question at the center of the 20-year-old challenge the speaker referred to in the title of his talk. Twenty years ago, he detailed, the pioneers of endovascular surgery recognized that anatomic severity was a major determinant of outcomes and therefore probably required reporting standards. “A scoring system would need to strike a balance between having enough granular detail to be useful and also being simple enough to be usable in everyday practice,” he said. A scoring system was built, with the expectation being that subsequent clinical investigations to test the system would be used to modify it. In the 20 years since then, Carrell highlighted that a number of papers on the anatomic severity grade scoring system have been published, showing that it does indeed predict outcomes and complications. However, “there has not been quite so much progress in terms of using that data to modify the schemes,” Carrell pointed out. The speaker noted that there are probably a number of reasons for this, one being that “some of the things that go into the scoring schemes turn out to be rather complicated.” For example, he said, measuring infrarenal neck angulation is “really contentious,” with “very high intraobserver variability.”

“Can AI offer both that detail and simplicity?” Carrell asked, highlighting a key question in 2022. He explained that Cydar Medical is developing an extended capability to operate with what the company calls Intelligent Maps. “The concept is that when you plan a case, you are being informed by the outcomes of previous patients with similar anatomy and disease,” he explained. The company’s current product, which is used for planning, guiding, and reviewing endovascular surgery, uses “virtual guidewires.” Carrell elaborated: “We use [virtual guidewires] for planning, but the main function is to identify where you are going to be operating, so that your planning is rendered in the form of a map and overlaid on a live fluoroscopy. As your real guidewires deform the anatomy, the virtual guidewires deform the map so that you have an

overlay that reflects the real-time anatomy.” Carrell provided some details on where the software is headed: “What we are doing with Intelligent Maps is taking that capability with the virtual guidewires and the AI that we have in the system and the data from all the thousands of patients who have been treated with Cydar EV Maps and building tools to analyze anatomy.” He added that these tools are a combination of deterministic algorithms using the virtual wires and also using simulated neural networks, or deep learning, to not just segment the vessels, but also to label the aorta and the iliacs according to what branches are coming off at each level. “For each patient, you bring these things together so that you have your geometry, but you have it in the context of where you are right the way along the aorta and the iliac system. This is highly deterministic, so you put the CT [computed tomography] scan in and these measures come out, put the same CT scan in or a similar CT scan in and you get the same things coming out.” One of Carrell’s key takeaway messages was that this software has relevance for helping inform decision-making. “You take one patient that produces the analytics and then we use it to match to other patients in the database already, patients who have similar anatomy. It is literally as simple as entering in the CT scan and finding those matching patients. We can then find out what treatment those patients had, what type of approach they had.” Next, Cydar will be working on bringing in the “final steps” of the technology—the outcome metrics for the surgical strategy that was used. “We want to close that 20-year ambition to have the feedback loop in there to modify the scoring system,” Carrell concluded.

“Given any individual patient with some anatomic complexity, do we really know—particularly with the ever-expanding range of treatment options— what is going to be the outcome for them?” TOM CARRELL

COMPLEX REPAIR

Cloud-based fusion imaging found to improve operative metrics during FEVAR

single-center retrospective review demonstrated a trend towards shorter operative times, and significant reductions in both iodinated contrast use and radiation exposure during fenestrated endovascular aneurysm repair (FEVAR) using Cydar’s EV Intelligent Maps—representing the first report of an improvement in metrics with the Zenith Fenestrated (ZFEN) graft while utilizing the fusion imaging system, according to the study authors. “Intelligent map

guidance improves the efficiency of complex endovascular aneurysm repair, providing a safer intervention for both patient and practitioner,” concluded Charles J. Bailey, MD, and colleagues from the University of South Florida and Tampa General Hospital. Results from the study were presented during the 2022 annual meeting of the Southern Association for Vascular Surgery (SAVS) held in Manalapan ( Jan. 19–22). A retrospective review of a prospectively maintained aortic database was performed to identify all patients who underwent commercially available FEVAR between 2013 and 2020, as well as all endovascular aneurysm repairs performed using Cydar’s cloud-based fusion imaging platform at the institution starting from 2018. Being solely focused on de novo FEVARs, a comparative analysis was performed on 53 FEVAR procedures carried out without, and

63 with, EV Intelligent Maps. Cohorts were found to be similar in terms of patient demographics, medical comorbidities and aortic aneurysm characteristics. Bailey highlighted that body mass index was the same across both cohorts—”something to consider, as the larger the patient, the more radiation they will require.” No significant difference in major adverse postoperative events, length of stay, or length of intensive care unit stay was detected between the groups, the research team noted. Use of EV Intelligent Maps resulted in non-significant decreases in mean fluoroscopy time (69.3 vs. 66.2 minutes, p=0.598), and a positive trend towards shorter operative times (204.4 vs. 186 minutes, p=0.278). Notably, a statistically significant decrease in both iodinated contrast volume (104.7 vs. 83.8ml, p=0.005), and patient radiation exposure via dose-area product (1049841 vs.

630990mGy/cm2, p<0.001) was observed in patients undergoing FEVAR with Cydar EV Intelligent Maps, the researchers reported. Furthermore, Bailey noted the learning-curve element involved in use of the imaging platform, describing how the team took the relevant 63 patients and divided them into groups of 10. “After the 10th case, there was a significant and sustained reduction in radiation exposure,” he said. Baily told SAVS 2022: “This is a single center retrospective review. There is a learning curve to any novel technology. Maybe there is a bias to how much attention we pay to distance from operator … practitioner to radiation source, but it’s what we have embraced to do these complex procedures safely, both to us and the patient and practitioners in the room. This is where we should be thinking with complex endovascular devices.”—Bryan Kay

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DRUG-COATED TECHNOLOGY IN.PACT AV Access: Three-year data support use of paclitaxel-coated balloon as ‘standard of care’ in fistula maintenance By Jamie Bell THE 36-MONTH RESULTS FROM THE IN.PACT AV Access study—which were presented for the first time during a Vascular Access Masterclass session at the 2022 Charing Cross (CX) International Symposium in London, England (April 26–28)—indicate that end-stage kidney disease (ESKD) patients treated with Medtronic’s IN.PACT AV drug-coated balloon (DCB) remained intervention-free for longer than those who received a standard percutaneous transluminal angioplasty (PTA). Andrew Holden, MBChB, of Auckland,

New Zealand, reported that a “significant difference” in target-lesion primary patency (TLPP) between the study’s DCB and PTA treatment groups was seen through the three-year follow-up timepoint, maintaining the trend observed in the 24-month IN.PACT AV Access data, which Holden delivered virtually at CX 2021. This investigational device exemption (IDE) study is seeking to assess the safety and effectiveness of the IN.PACT AV DCB, which delivers the antiproliferative drug paclitaxel to inhibit neointimal hyperplasia and treat this leading cause of arteriovenous fistula (AVF) stenosis in ESKD patients. The trial is comparing use of IN.PACT AV in a DCB group to standard PTA in a control group, and initially enrolled 330 patients with a de novo or non-stented restenotic native fistula who are undergoing hemodialysis. Holden relayed a TLPP rate of 43.1% in the DCB group, compared to 28.6% in the PTA group, through 36 months. He also reported that a 21.3% reduction in reinterventions was associated with DCB use, with 255 reinterventions to maintain TLPP being required through 36 months in the DCB

PACLITAXEL TISSUE SAMPLES SHOW DRUG EFFECT IN MINORITY OF CLTI PATIENTS RECEIVING DCB ANGIOPLASTY, STUDY FINDS PACLITAXEL EFFECT WAS witnessed in tissue specimens of a minority of chronic limb-threatening ischemia (CLTI) patients treated with drug-coated balloons (DCBs)—but was not dependent on DCB type, nor the dose level of the drug administered, and was not associated with major adverse limb or clinical events, a new single-center analysis of debrided and amputated tissue found. Researchers behind the study said the evidence supports the safety of using DCBs in patients with CLTI. Rabih Chaer, MD, from the University of Pittsburgh Medical Center Presbyterian, Pittsburgh, and colleagues worked on the hypothesis that “the paclitaxel dose administered might play a role in the pathogenesis of any possible side effects associated with its use,” looking at the impact on wound healing. They prospectively enrolled 50 patients with Rutherford class 5 and 6 ischemia who received angioplasty with either an IN.PACT Admiral (27) or Lutonix (23) DCB in the superficial femoral or popliteal arteries and who also had planned minor amputation or debridement within 90 days. Collected tissue samples were analyzed for medial necrosis, medial arterial wall inflam-

mation, foreign-body reaction, emboli and paclitaxel crystals, Chaer said. Results showed that 66.7% of patients healed or improved; 29 underwent planned minor amputations, with 20 improving, four worsening, and six eventually requiring major amputation due to non-reconstructable tibial disease or infection. Chaer revealed the data during the 2022 Annual Symposium of the Society for Clinical Vascular Surgery (SCVS) in Las Vegas (March 19–23). Some 18 patients underwent wound debridement—11 improving, one worsening, and six eventually undergoing major amputation, Chaer continued. “Major amputation-free survival at six months was 71.4%,” he told SCVS 2022. “Evidence of medial necrosis was observed in 10 specimens, with no difference among DCB type. “There was no correlation between paclitaxel and major amputation or wound healing, and between DCB type and wound healing.” Primary patency was 97.1% at six months, Chaer noted, with overall survival nearly 88% at six months and 63.7% at Rabih one year.— Chaer Bryan Kay

DCB group and 16.6% in the PTA group. He labelled this difference as being “significant” too, and noted a similar reduction (20.7%) in the number of reinterventions required to maintain ACPP within the DCB group. Some 311 reinterventions were necessary in the DCB group, compared to 392 in the PTA group. He pointed out an all-cause mortality rate of 26.6% in the DCB group and 30.8% in the PTA group, and highlighted the fact that the mortality rate among “all-comer” hemodialysis patients from the United States Renal Data System (USRDS) through three years is higher than in both groups, at 41.9%.

Andrew Holden

TLPP RATE

group versus 324 in the PTA group. Holden then moved on to detail 36-month access circuit primary patency (ACPP) rates—stating that a “similar trend” was observed here, with a rate of 26.4% in the

43.1% 28.6% PTA group

DCB group 3

YEARS

SIROLIMUS

New data provide encouragement despite ‘potentially disappointing’ efficacy results THE RESULTS OF A SMALL-SCALE PILOT STUDY FROM ASIA HAVE INDICATED “potentially disappointing” results with a novel drug-eluting balloon in treating dysfunctional arteriovenous access for dialysis. The findings were delivered by Tjun Tang, MD, via a Podium 1st presentation during the 2022 Charing Cross (CX) International Symposium. Tang presented 12-month results from the ISABELLA (Intervention with Selution SLR agent balloon for endovascular latent limus therapy for failing AV fistulas) trial, which assessed the utility of the Selution SLR sirolimus-eluting balloon (MedAlliance) for minimizing the effect of neointimal hyperplasia and treating arteriovenous fistula (AVF) stenosis. He noted that ISABELLA had a recruitment target of 40 patients, with 34 of these patients (85%) ultimately being evaluated at the 12-month follow-up timepoint in November 2021. He also detailed that the majority of these patients had either radiocephalic or brachiocephalic fistulas with recurrent lesions requiring treatment—and the most common indication for intervening was a drop in access flow, observed in 61.5% of cases. Tang reported a target-lesion primary patency (TLPP) rate of 44% (16/36 lesions) and a circuit access patency rate of 31% (10/32 lesions), which represented decreases from 72% and 63%, respectively, at six months. In addition, he stated that the overall rate of secondary patency—defined as freedom from access circuit abandonment—was 94.1% (32/34 patients) at 12 months compared to the 97.2% (35/36 patients) observed at six months. “In conclusion, the ISABELLA study showed excellent technical and clinical success rates [100%],” Tang said. He also relayed that the use of Selution SLR in patients with AVF stenosis appears safe, with no serious adverse events, such as pulmonary embolism or bronchopneumonia, being associated with its use in the study. And, in terms of efficacy, Tang added that—while the results are “potentially disappointing”—this is a small, exploratory study and alluded to possible confounding factors within these findings. “We do need longer-term data and randomized controlled studies […] if we are going to move forward seriously within this field, and with this technology,” Tang concluded. He noted the importance of being careful when interpreting the results of an exploratory pilot study—especially one that was designed to power a randomized controlled trial, as this one has been. “I do not think it is actually a setback at all,” he continued. “In fact, I think it is very encouraging. I think the fact we are not getting any serious adverse events with the balloon […] is reassuring.” Tang added that with the exception of the IN.PACT AV Access study, a similar drop-off in patency rates between six and 12 months had been observed in several previous studies using paclitaxel to treat dysfunctional dialysis access.—Jamie Bell

www.vascularspecialistonline.com

OPEN ACCESS Collaborators not cases: Engaging patients with aortic dissections as partners in patient-centered outcomes research The latest issue of Seminars in Vascular Surgery focuses on the work being carried out by the Aortic Dissection Collaborative. Guest editor Sherene Shalhub, MD, who founded the patient-centered organization, and the journal’s editor-in-chief, Caitlin Hicks, MD, tell Vascular Specialist about the importance of the publication— and why it represents a landmark in the field of aortic dissection treatment

o date, research in aortic dissection has focused on management and outcomes around technical results and survival. Little is known about what is important to patients living with or at risk for aortic dissection. The Aortic Dissection Collaborative was founded to bring patients’ voices into the conversation, to develop research priorities informed by all members of the aortic dissection community and advance patient-centered research in this area. With initial funding from the Patient-Centered Outcomes Research Institute (PCORI), the Aortic Dissection Collaborative was founded in 2019 by Sherene Shalhub, MD, associate professor of vascular surgery at the University of Washington in Seattle. Led by an advisory group of patients and family members who have experienced aortic dissection, along with a stakeholder group of nearly 100 patients, advocacy organizations, family members, clinicians, and researchers, the Aortic Dissection Collaborative has been conducting foundational work to bring together a cohesive aortic dissection community and better understand patient experiences and needs in aortic dissection. This work is presented in the March 2022 edition of Seminars in Vascular Surgery. This fully open access edition contains 11 articles reporting on the detailed methods used to engage the aortic dissection community; the results of landscape reviews of the seven key topics identified as important to the community (education, genetics, medication, mental health, pregnancy, surgery and telemedicine);

important findings from in-depth interviews conducted with individuals with or at risk for aortic dissection; and results of a survey assessing the impacts of COVID-19 on this community. “This is a landmark in aortic dissection research, and it would not be possible without our nearly 100 stakeholder partners,” says Shalhub. “Not only did our partners contribute to the work itself, but several organizations who are part of the Collaborative provided funds to help us make this an entirely open access issue.” Most of the major national and international advocacy and research organizations focusing on aortic dissection are partners in the Aortic Dissection Collaborative, including Aortic Dissection Awareness UK & Ireland, the Ehlers-Danlos Society, the Genetic Aortic Disorders Association (GADA) Canada, the International Registry of Acute Aortic Dissections (IRAD), the John Ritter Foundation for Aortic Health, the Loeys-Dietz Syndrome Foundation, the Montalcino Aortic Consortium, the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and the Cardiovascular Conditions (GenTAC), The Marfan Foundation, The VEDS Movement, Think Aorta, Vascular Cures, the Vascular Low Frequency Disease Consortium, the Vascular Surgery COVID-19 Collaborative (VASCC), and the VEDS Collaborative. “This special issue of Seminars in Vascular Surgery not only shares findings relevant and important to the aortic

JVS

ENJOY OPEN ACCESS TO SVS JOURNALS

The Journal of Vascular Surgery (JVS) and JVS-Venous and Lymphatic Disorders (JVS-VL) offer open access to four articles each in May, while JVS offers an additional four for June. Articles selected as being “Editor’s Choice,” those included as abstracts in the European Journal of Vascular and Endovascular Surgery (EJVES) and those offering continuing medical education (CME) credit all are designated MAY JVS PAPERS

n “Prevalence of abdominal aortic aneu-

rysms in patients with lung cancer” (Editor’s Choice, CME offered) n “ Physical and psychological functioning of patients with chronic limb ischemia during a one-year period after endovascular revascularization”

n “ Outcomes of balloon-expandable

versus self-expandable stent graft for endovascular repair of iliac aneurysms using iliac branch endoprosthesis” n “Contemporary management of acute and chronic mesenteric ischemia: 10-year experience from a multihospital healthcare system”

Caitlin Hicks and Sherene Shalhub

dissection community that we can use as a roadmap in the years ahead to guide research in aortic dissection, but it also provides a model that others can use as a template for involving patients and other stakeholders in research in other disease processes,” says Shalhub. Seminars in Vascular Surgery is an invitation-only journal that examines the latest thinking on a particular clinical problem in vascular surgery. “The work that Dr. Shalhub and the Aortic Dissection Collaborative is doing to better understand aortic dissection from multiple stakeholder perspectives is absolutely cutting-edge, and well-aligned with the mission of Seminars in Vascular Surgery,” says Caitlin W. Hicks, MD, editor-in-chief of the journal. “I was thrilled to work with Dr. Shalhub to publish this important work in an international forum that is accessible to readers from all backgrounds.” Following the work reported in Seminars in Vascular Surgery, the Aortic Dissection Collaborative translated identified research topics into patient-centered outcomes and comparative effectiveness research questions and surveyed the aortic dissection community for their priorities in research as well as their willingness to participate in future research. Results of this survey will be available later this year.—Bryan Kay

“This is a landmark in aortic dissection research, and it would not be possible without our nearly 100 stakeholder partners” SHERENE SHALHUB

MAY JVS-VL PAPERS

n “Surgical resection and graft

replacement for primary inferior vena cava leiomyosarcoma: A multicenter experience” n “Ten-year follow-up of a randomized controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980nm) using local tumescent anesthesia” (Editor’s Choice, EJVES) n “Severity of disease and treatment outcomes of anterior accessory great saphenous veins compared to the great saphenous vein” n “Comparative analysis of the results of cyanoacrylate ablation and radiofrequency ablation in the treatment of venous insufficiency” (EJVES, CME offered)

JUNE JVS PAPERS

n “Long-term outcome results after

endovascular aortoiliac aneurysm repair with the bifurcated Excluder endoprosthesis” n “Female gender increases risk of stroke and readmission after CEA and CAS” (Editor’s Choice, CME offered) n “Frequency and type of interval adverse events during the waiting time to complex aortic endovascular repair” n “Disposable, lightweight shield decreases operator eye and brain radiation dose when attached to safety eyewear during fluoroscopically guided interventions” Society for Vascular Surgery (SVS) Active members receive access to the JVS group of journals for free; other members receive discounts as a benefit of their SVS membership. May’s articles will be freely available through July 31 and June’s through Aug. 31. Visit www.jvascsurg.org.

Vascular Specialist | May/June 2022

CODING AND CPVI

REGISTER TODAY FOR TWO SVS COURSES Registration has opened—along with early-bird pricing—for two Society for Vascular Surgery (SVS) in-person courses in coding and reimbursement, and peripheral artery disease skills. Both will be held in October after being postponed in 2021 because of a surge in COVID-19 cases (see tables opposite for a complete pricing guide)

BOTH COURSES WILL BE HELD IN THE OLC Education and Conference Center, in the SVS Headquarters Office, 9400 W. Higgins Road, Rosemont, Ill. The building is minutes from Chicago’s O’Hare International Airport. The SVS Coding and Reimbursement Workshop, with an optional workshop for evaluation and management (E&M) codes, will be held Oct. 1 and 2. This intensive course provides a comprehensive review of current coding and reimbursement information, including critical updates. It is one of the only vascular surgery-specific review courses in the country and is designed for vascular surgeons and office staff such as practice managers, physician assistants, nurses and nurse practitioners, surgery schedulers and coders. The optional E&M Coding Workshop will be from 8 a.m. to 12 p.m. Oct. 1. Registration for the main course

opens at noon that same day, with the course set for 1 to 3:30 p.m. Oct. 1 and from 7:30 a.m. to 4:30 p.m. Oct. 2. Registration on the second day opens at 7 a.m. Learn more and see the preliminary agenda at vascular.org/ Coding22. The two-day SVS Complex Peripheral Vascular Intervention (CPVI) Skills Course will be Oct. 23 and 24. Participants will learn from expert faculty through a combination of didactic and case-based presentations and practicing the latest procedures on cadavers and benchtop models during small-group simulations. “Treatment of patients with peripheral arterial disease (PAD), especially chronic limb-threatening ischemia (CLTI), remains the one of the largest clinical areas for vascular surgeons in the U.S.,” said course co-director Vikram Kashyap, MD. “Thus, surgeons should be familiar with the latest treatments and technology so they can provide the best patient care possible,” he said. “We have tremendous innovations in treating occlusive disease,” he said. “SVS members have asked for this type of course to keep up to date with their endovascular skills.” The course also will include a demonstration of a percutaneous deep vein arterialization system. The procedure is designed to restore blood flow to the ischemic foot, when all other options have been exhausted, in so-called no-option patients. Course hours are 9 a.m.–4:45 p.m. Oct. 23 and 7:30 a.m.–4 p.m. Oct. 24. Learn more, including viewing the agenda, at vascular.org/PeripheralIntervention22.—Beth Bales

“SVS members have asked for this type of course to keep up to date with their endovascular skills” VIKRAM KASHYAP

COURSE PRICING GUIDE AT-A-GLANCE Optional E&M Coding Workshop (Oct. 1) Category

Early-bird Rate (through 9/1/22)

Regular Rate (Starting 9/2/22)

Candidate Member

$100

$150

Non-member Candidate

$125

$175

Member

$200

$250

Non-member

$250

$300

Office Staff

$200

$250

Coding, Reimbursement Workshop (Oct. 1-2) Category

Early-bird Rate (through 9/1/22)

Regular Rate (Starting 9/2/22)

Candidate Member

$325

$425

Non-member Candidate

$350

$475

Member

$925

$995

Non-Member

$995

$1,095

Office Staff

$925

$995

CPVI Skills Course (Oct. 23-24) Category

Early-bird Rate (through 9/23/22)

Regular Rate (Starting 9/24/22)

Member

$995

$1,100

Candidate Member

$800

$895

Non-member Candidate

$825

$920

Non-Member

$1,695

$1,895

www.vascularspecialistonline.com

CODING Volunteer for Advocacy Council committees By Sunita Srivastava, MD

he recent shifts in the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule relative value units (RVUs) have impacted vascular surgery reimbursement, creating a greater awareness and focus on our specialty’s financial future. Members of the Society for Vascular Surgery (SVS) Advocacy Council (formerly the Policy and Advocacy Council), Executive Board, and Coding Committee have worked tirelessly over the years to advocate for an equitable distribution of Medicare dollars and to limit losses for all vascular providers. This SVS leadership is founded on the historical tradition of the Society and its role in the evolution of procedural coding through the Current Procedural Terminology (CPT) process and reimbursement through the Relative Value Scale Update Committee (RUC) process. The American Medical Association (AMA) CPT Editorial Panel reviews new and revised coding applications submitted by societies, industry and individuals. The CPT process has been ongoing since the 1960s; the AMA

PAC LEGISLATION CAN AFFECT A CAREER FOR DECADES By Andrew Barleben, MD, and Roan Glocker, MD SVS PAC, THE POLITICAL ACTION Committee for the Society for Vascular Surgery (SVS), is one of the most powerful tools we have to advance and promote legislation affecting the practice of medicine. Supporting the SVS PAC provides SVS members with the unique opportunity to pool their financial contributions to speak as one voice to support federal candidates for elective office who will champion and protect the interests of vascular surgery and the patients they serve. By building strong relationships with members of Congress, the SVS PAC increases its chances of having a seat at the “decision-making table” on issues that will impact the specialty now and in the future. Although the SVS PAC is supported by members of all different practice settings, backgrounds and ages, no one stands to benefit more from its efforts than young vascular surgeons, who have the most to gain (or potentially lose) through advocating for their field. The parable of “The Persian Chessboard” describes a king placing grains of rice on successive squares of a chessboard until the entire room is filled with rice. A more modern description might be the principles surrounding compound interest. Both exam-

RUC was formed in 1992 when the Physician Fee Schedule was established to ensure that medicine had a voice in shaping physician payment. The SVS has been active in both processes and continues to serve as a champion for vascular surgery. Early vascular leaders, including Anton Sidawy, MD, Gary Seabrook, MD, and Robert Zwolak, MD, worked arduously to revise and create procedural codes and operative details, and to recommend RVUs. Hundreds of vascular surgical procedures have been written, surveyed by the membership, and valued over the years by this core team. With the advent of endovascular procedures, the need for new CPT codes and correct RVUs and practice expense payment has been growing. Getting these codes and adequate values across the CPT, RUC and CMS finish line has been the responsibility of our CPT and RUC advisors, alternate advisors and a core administrative team. Sean Roddy, MD, (CPT advi-

ples highlight the idea that what we do today can have profound impacts on what we are able to achieve later on. If you are a surgeon early in your career, the legislative and regulatory actions under consideration now will impact your professional life for the next 25–30 or more years. For example, proposed changes to Medicare payments over the last several years would have meant devastating cuts to vascular surgeons. Thankfully, and due to our combined advocacy efforts, the severity of the cuts was reduced via year-end Congressional action. The SVS PAC remains one of our most valuable tools to educate members of Congress. Without it, vascular surgeons would have faced the full breadth of the scheduled payment reductions, including: 1. Expiration of the 3.75% adjustment to the conversion factor 2. The 5% payment cut to be phased in over four years due to the update in payments for clinical labor in the CY 2022 Medicare Physician Fee Schedule, with some individual codes even higher 3. Expiration of the moratorium on the 2% sequestration cut from the Budget Control Act of 2010 4. An automatic across-the-board 4% cut in Medicare payments derived from PAYGO (pay as you go budget rules requiring that tax cuts and mandatory spending increases be offset) rules that were triggered by the passage of the American Rescue Plan in the spring of 2021 When looking at those numbers most of our minds turn to the immediate effects on our

sor) and Matthew Sideman, MD, (RUC advisor) have been instrumental in presenting new codes to the CPT Panel and recommending RVUs to the RUC for the ever-evolving vascular surgery procedures. But, the SVS presence does not stop there. David Han, MD, plays a vital role as vice chair of the RUC Practice Expense Subcommittee and Zwolak was recently elected as alternate vice chair of the RUC. While the SVS Coding Committee is very involved in representing the Society and membership on coverage and payment issues, the ongoing need for new codes and relative valuation requires even more attention and time. The commitment to the CPT/RUC process continues to grow, and requires participation from members. The committee has recently sent a general invitation to SVS members who may be interested in embarking on a threeyear training position in the CPT and RUC arenas to Sunita Srivastava become future SVS leaders

in these venues. In addition, the SVS Advocacy Council is developing a health policy leadership program. Selected participants will rotate on all the satellite committees for broader understanding of advocacy issues. These opportunities ensure the future health of our specialty, and foster greater knowledge and experience in the ever-changing landscape of physician reimbursement and advocacy. Currently, the SVS has recruited trainees motivated to help shape the future positively and train the next generation of vascular surgery leaders. Please help us meet these challenges by volunteering for committees within the Advocacy Council. In addition, your contributions and participation towards the SVS Political Action Committee (PAC) will expand the presence and advocacy of the SVS within Washington, D.C., and among government leaders. Donate today at vascular.org/PAC.

Will I need to cut staff? How many more cases do I need to do—or patients do I need to see—just to break even?

the big picture and the long term. Those combined cuts compounded over the course of a career could have profound effects on the viability of our specialty and our ability to serve the needs of our ever-growing patient population. No one stands to benefit more from the work of the SVS PAC, or reap more rewards from a PAC contribution, than a vascular surgeon at the start of his or her career. Please consider giving even a small amount today! Donate at vascular.org/PAC.

practice: Will I need to cut staff ? How many more cases do I need to do—or patients do I need to see—just to break even? Can I even stay in business in my current model? But perhaps more importantly, proposed changes like this force us to think about

SUNITA SRIVASTAVA, MD, is chair of the SVS Coding Committee.

ANDREW BARLEBEN and ROAN GLOCKER are members of the SVS Political Action Steering Committee.

Vascular Specialist | May/June 2022

SOCIETY BRIEFS

Compiled by Beth Bales and Kristin Crowe

SVS FOUNDATION ANNOUNCES 2022 STUDENT RESEARCH FELLOWSHIP AWARDS The SVS Foundation annually recognizes outstanding student researchers, undergraduate and medical school students attending universities in the U.S. and Canada. The awards are intended to introduce the student to rigorous scientific methods to clinical problems and underlying biologic processes important to patients with vascular disease THE 2022 RECIPIENTS ARE: ◆ Samridhi Banskota, Emory University School of Medicine Sponsor: Elliot Chaikof, MD Project Title: “Prothrombotic biomarkers of pancreatic cancer” ◆ Alexa Berezowitz, Yale University Sponsor: Raul Guzman, MD Project Title: “The role of p38 MAPK in PDE10A-mediated vascular smooth muscle cell calcification” ◆ Dominique Dockery, Alpert Medical School of Brown University Sponsor: Robert Patterson, MD Project Title: “A pilot study on the prevalence of peripheral arterial disease in Kigali, Rwanda” ◆ Alexander J. Lu, Texas A&M College of Medicine Sponsor: Eric K. Peden, MD

Project Title: “Discovery of biomarkers of early vein neointimal hyperplasia in the human model of arteriovenous fistula” ◆ William Gregory Montgomery, Eastern Virginia Medical School Sponsor: Gilbert R. Upchurch Jr., MD Project Title: “CXCR2 signaling axis plays a role in the trafficking of granulocytic MDSCs in abdominal aortic aneurysm formation” ◆ Anush Raghunandan Motaganahalli, Indiana University-Bloomington Sponsor: Michael Murphy, MD Project Title: “Intraoperative application of drug-containing hydrogels by in situ bioprinting for treatment of experimental AAA” ◆ Raj Patel, Medical University of South Carolina Sponsor: Jean Marie Ruddy, MD Project Title: “Stretch-induced VSMC cytokine expression promotes monocyte/macrophage migration”

75 facts in 75 days to celebrate 75 years ALTON OCHSNER, MD, was the first president of the Society for Vascular Surgery (SVS), which was formed in 1946. The first annual meeting—a half-day affair—was held in Atlantic City, New Jersey, June 8, 1947. Julie Ann Freischlag, MD, was the first woman president (and to date the only one). And the first 10 people to serve as SVS president were all among the 31 charter/founding members. During the 2022 Vascular Annual Meeting (VAM) in June, the SVS will officially end a year-long celebration of its 75th anniversary. To help mark the occasion, the SVS is publishing 75 Facts in 75 Days. The short facts have been running daily since April 5, 75 days out from VAM’s close on June 18 (weekend posts appear the following Monday). “This is the brainchild of the Communication Committee’s Social Media Chair Dr. Meryl Logan,” said Communications Committee chair Amy Reed, MD. “As chair, I encouraged the rest of the committee to brainstorm thoughts and ideas. It was fun to hear all the interesting tidbits the committee members gave!” That’s when Logan developed the idea for 75 facts. “We were all thinking about creative ways to celebrate the upcoming 75th VAM, and the idea of a ‘75-day countdown’ came to me as a fun way to not only celebrate this anniversary, but also promote the meeting,” said Logan. “We’ve been posting these little tidbits to social media and they include not only VAM history, but also SVS and vascular surgery historical facts and firsts. I think it’s been an engaging and entertaining social media endeavor.”

◆ Niveditta Ramkumar, Geisel School of Medicine at Dartmouth Sponsor: Philip P. Goodney, MD Project Title: “Comparing treatment effects for patients undergoing intervention for PAD in a clinical registry versus randomized trial” ◆ Melina Recarey, George Washington University School of Medicine and Health Sciences Sponsor: Bao-Ngoc Nguyen, MD Project Title: “The role of beta-2 spectrin in diabetic wound healing” ◆ Keyuree Kirtikumar Satam, Yale School of Medicine Sponsor: Alan Dardik, MD Project Title: “Do male and female mice have different innate and adaptive immune system responses during arteriovenous fistula maturation?” ◆ Michael Tu, Emory University Sponsor: Luke Brewster, MD Project Title: “Uncovering CCN2 pathways that contribute to plaque formation ◆ Max Jordan Zhu, Boston University School of Medicine Sponsor: Frank W. LoGerfo, MD Project Title: “Perivascular anti-TSP2 siRNA delivery to decrease intimal hyperplasia in vascular injury”

SVS online community adds quality improvement group

THE SVS QUALITY IMPROVEMENT COMMITTEE has created a community on the subject matter on SVSConnect. This will be a forum for QI education and discussion. The committee invites SVS members to join, then post their questions, challenges and successes. These will be reviewed and responded to by committee members. Those interested should search for “Quality Improvement Community” on the main SVSConnect page and request to join the community. “We hope to have a lively forum for sharing challenges and successes in quality improvement,” said committee Chair Jessica Simons, MD. “We welcome your input regarding the issues you’re facing.” Visit the SVSConnect homepage at svsconnect.vascular.org.

SVS Foundation continues call for VISTA project applicants The SVS Foundation VISTA (Vascular Volunteers In Service To All) pilot project continues to seek applications for innovative, community-based projects. The initiative grants support for those projects designed to explore solutions to the significant disparities in vascular surgical care across the U.S. Up to $150,000 will be awarded to SVS members, with priority given to projects that provide outreach, screening, and other resources to patients impacted by lack of access, inadequate resources, or distance from modern health care facilities. Visit vascular.org/VISTA.

Memorial service set as endowment fund-raising started in honor of vascular pioneer A MEMORIAL SERVICE IS BEING held for the late vascular surgeon Richard McCann, MD, who spent nearly 50 years at Duke University and is considered one of the founding fathers of the institution’s aortic surgery program, on Oct. 2 at St. Philip’s Episcopal Church in Durham, North Carolina. McCann’s family and friends at Duke have also begun a fundraising effort to establish an endowment to honor his legacy at Duke. To make a gift online visit gifts.duke. edu/dmaa (and search for Richard McCann MD Surgery Fund). The mailing address is Alumni and Development Records, Duke University, Box 90581, Durham, N.C., 27708. McCann passed away on Feb. 5, 2021. He was 72.

SVS PA Section has new leaders

WITH PREVIOUS TERMS ENDING, new members have been named to the Steering Committee for the SVS Physician Assistant Membership Section. Holly Grunebach, PA-C, MSPH, chairs the committee. Other members are Jessica Fernandes, Katherine Ann Kinser, Stephen Robischon, Robert Skasko Jr. and Connor Westfall, all PA-C; and Danielle Scribani, O, PA. The PA section is the Society for Vascular Surgery’s oldest membership section, having been added in 2017. It provides a “professional home” to PAs working in vascular care and now has approximately 200 members. For information on the PA section visit vascular.org/JoinSVS/PASection.

GET READY FOR THE AMERICAN Board of Surgery Vascular Surgery Board (ABS-VSB) qualifying exam in September by attending a comprehensive review course in August. The University of California, Los Angeles, and the Society for Vascular Surgery (SVS) collaborate on the “UCLA/SVS Symposium: A Comprehensive review and Update of What’s New in Vascular and Endovascular Surgery.” The seventh annual course will be Aug. 25–28 at the Beverly Hilton, in Beverly Hills, California. The course emphasizes four major pillars of vascular surgery practice: open, endovascular, medical and imaging. Learn more at vascular.org/ReviewSymposium22.

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CLINICAL&DEVICENEWS Compiled by Jocelyn Hudson, Jamie Bell, Clare Tierney and Bryan Kay

VENOVO VENOUS STENT RETURNS TO US MARKET AFTER 2021 RECALL BD recently announced that its Venovo venous stent is back on the U.S. market following a recall last year. In 2019, the company reported that the Food and Drug Administration (FDA) had granted premarket approval for the Venovo venous stent. In a recall notification dated May 12, 2021. However, BD communicated that the company had expanded a safety notice issued earlier in the year for the Venovo venous stent system to include all sizes and lots within expiry date. The company lists the Venovo device as a flexible nitinol stent specifically designed to reopen blocked iliac and femoral veins in order to maintain adequate blood flow. It is designed with a balance of radial strength, compression resistance and flexibility needed for the treatment of symptomatic post-thrombotic and non-thrombotic iliofemoral lesions, the company details. Additionally, the broad stent sizing allows clinicians to treat large diameter veins and long lesion lengths, BD says. “The unique attributes of the Venovo stent make it particularly well-suited to treat iliofemoral occlusive disease,” says Michael Dake, MD, from the University of Arizona, Tucson, Arizona, the principal investigator for the Venovo investigational device exemption (IDE) trial. “Most importantly,” says Dake, “it is purpose-built for application in veins, and engineered to address the special challenges of venous lesions that are very different than those posed by arterial narrowing.” SCAI RELEASES MULTI-SOCIETY POSITION STATEMENT FOCUSED ON CORE COMPETENCIES FOR ENDOVASCULAR SPECIALISTS PROVIDING CARE FOR CLTI The Society for Cardiovascular Angiography & Interventions (SCAI) has released a position statement outlining competencies for endovascular specialists who provide care for chronic limb-threatening ischemia (CLTI). The first-of-its-kind document, “SCAI/ ACR/APMA/SCVS/SIR/SVM/SVS/VESS position statement on competencies for endovascular specialists providing CLTI care,”was published in the Journal of the Society for Cardiovascular Angiography & Interventions (JSCAI), Journal of the American Podiatric Medical Association (JAPMA), Journal of Vascular Surgery (JVS), and Vascular Medicine (VMJ). It is the result of a collaborative effort from eight societies representing many specialties engaged in the care of CLTI patients. The expert writing group aims to standardize expected competencies for endovascular specialists to help ensure patient-centric and evidence-based therapy is delivered to this unique patient population. “Care for patients with CLTI is typically complex, multifaceted, and multidisciplinary. Standardizing expected competencies for endovascular specialists is an important step to ensure that patient-centric and evidencebased therapy is delivered,” said Beau M. Hawkins, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City, chair of the writing group for the document. The position statement details the key skills that all endovascular specialists should possess to deliver successful outcomes for CLTI patients. The skillsets are categorized into six core competencies based on the Accreditation Council for Graduate Medical Education (ACGME) core competencies

framework: medical knowledge, patient care and procedural skills, systemsbased practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. To account for a range in complexity across the competencies, the writing group also provides examples stratified into “fundamental” and “advanced” categories. The statement also discusses institutional requirements and resources necessary for learners to obtain the necessary skillsets. Recommendations for formal training or independent courses in a posttraining practice are also included. The position statement was endorsed by the American College of Radiology (ACR), American Podiatric Medical Association (APMA), Society for Cardiovascular Angiography and Interventions (SCAI), Society for Interventional Radiology (SIR), Society for Vascular Medicine (SVM), Society for Vascular Surgery (SVS), Society for Clinical Vascular Surgery (SCVS), and Vascular and Endovascular Surgical Society (VESS). NEW LONG-TERM DATA OF PACLITAXEL DEVICES CONTINUE TO SHOW NO INCREASED MORTALITY COMPARED TO NON-DRUG COATED DEVICES New long-term data from the SAFE-PAD (Safety assessment of femoropopliteal endovascular treatment with paclitaxelcoated devices) demonstrated no meaningful difference in survival between patients treated with a paclitaxel drugcoated device and those treated with a non-drug-coated device for up to six years after the index procedure, regardless of the patient’s mortality risk and device type. They were presented at the Society for Cardiovascular Angiography & Interventions (SCAI) 2022 Scientific Sessions (May 19–22) in Atlanta.

FDA APPROVES EXPANDED INDICATIONS FOR TCAR’S ENROUTE STENT The Food and Drug Administration (FDA) approved expanded indications for the Enroute stent system (Silk Road Medical)—part of the transcarotid artery revascularization (TCAR) procedure—to include patients at standard risk for adverse events from carotid endarterectomy (CEA), the compnay announced. Previously, the stent was approved for use only in patients with anatomic or physiological criteria that put them at high risk of complications from more invasive surgical procedures. Silk Road submitted a premarket approval supplement, which included data extracted from the Vascular Quality Initiative (VQI) representing real-world outcomes in 20,264 patients considered at standard surgical risk, the company said. Those data demonstrated that use of the TCAR system is statistically non-inferior in stroke and death outcomes to CEA, while showing a ninefold reduction in cranial nerve injury (CNI) (2.7% vs 0.3%, p<0.001), the press release added. “Pairing the right patient with the right treatment results in significantly improved physician and patient experiences and outcomes. I speak for the vascular community in welcoming this label expansion for TCAR, and recognizing this as a vital advancement in the treatment paradigm for patients at risk of stroke,” said Marc L. Schermerhorn, MD, chief in the division of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston. “The decision regarding which patients to treat with TCAR is no longer restricted to patients at high surgical risk, providing a greater opportunity for the care team to pursue the less invasive approach for a broader set of their patients.” The Enroute stent is intended to be used in conjunction with TCAR’s Enroute neuroprotection system. The system combines surgical principles of neuroprotection with minimally invasive endovascular techniques.

Vascular Specialist–May/June 2022

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