18 minute read
From the Editor
Medical Editor Malachi Sheahan III, MD
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Bernadette Aulivola, MD | O. William Brown, MD | Elliot L. Chaikof, MD, PhD | Carlo Dall’Olmo, MD | Alan M. Dietzek MD, RPVI, FACS | Professor HansHenning Eckstein, MD | John F. Eidt, MD | Robert Fitridge, MD | Dennis R. Gable, MD | Linda Harris, MD | Krishna Jain, MD | Larry Kraiss, MD | Joann Lohr, MD | James McKinsey, MD | Joseph Mills, MD | Erica L. Mitchell, MD, MEd, FACS | Leila Mureebe, MD | Frank Pomposelli, MD | David Rigberg, MD | Clifford Sales, MD | Bhagwan Satiani, MD | Larry Scher, MD | Marc Schermerhorn, MD | Murray L. Shames, MD | Niten Singh, MD | Frank J. Veith, MD | Robert Eugene Zierler, MD
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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
A modest proposal: Let’s eat the trauma surgeons
By Malachi Sheahan III, MD
Well 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
continued on page 4
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,
continued from page 2
➽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!
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
➽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 candidates 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 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
Matthew Eagleton and Amy Reed
FROM THE COVER OVERTREATMENT IN VENOUS DISEASE:
FINANCIAL INCENTIVES ARE ‘THE ELEPHANT IN THE ROOM’ continued from page 1
➽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 presentation 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
Steve Elias
MANJ GOHEL
