Vascular Specialist–September 2022

RESEARCHERS STUDY ROLE OF FRAILTY MORTALITYPOST-DISCHARGEIN

See page 6 Society for Vascular Surgery (SVS) President Michael Dalsing, MD, has added two more liaisons—Vincent Rowe, MD, and Palma Shaw, MD—to the SVS Executive Board in a bid to “increase the diversity of perspective,” (writes Beth Bales).

See page 5

MIDWESTERN VASCULAR

They will serve for the remainder of the fiscal year and join Linda Harris, MD, the recently re-elected

An exploration of the open procedure and its merits among patients‘good-risk’today

ortobifemoral grafting for aortoiliac occlusive dis ease (AIOD) probably remains “very safe” in the era of endovascular repair, according to the senior author behind a new paper exploring optimal ap proaches to the often burdensome condition. The research team, led by Jonathan Bath, MD, an associate professor of surgery and the vascular surgery fellow ship program director at the University of Missouri in Columbia, Missouri, carried out a comparative analysis of outcomes of endovascular repair and aortobifemoral bypass for AIOD over a five-year period (2016–2021) at their institution, exploring adult patients with Trans-At

Aortobifemoralbypass

SOCIETY FOR VASCULAR Surgery (SVS) members have developed new methods and tools to assess patient frailty and possible surgical outcomes more simply before patients undergo vascular surgical procedures.LarryKraiss, MD, Shipra Arya, MD, SM, and Julie Hales, MS, RN, discussed these methods and tools and their use during a session entitled “Tracking Frailty in the VQI” as part of the 2022 Vascular Quality Initiative (VQI) annualKraiss,meeting.whoisa professor of Surgery at the University of Utah in Salt Lake City, Utah, noted that he and his team have created a frailty assessment tool that maps variables already

A

pecialistsascularVCHANGESERVICEREQUESTED 9400W.HigginsRoad, Suite Rosemont,315IL60018 In this issue: www.vascularspecialistonline.comTHE OFFICIAL NEWSPAPER OF THE SEPTEMBER 2022 Volume 18 Number 09 PresortedStandard U.S. KY384PostagePAIDPermitNo.LebanonJct. 10 Corner Stitch Audible Bleeding cuts down to the vascular core 21 VascularWestern Study probes which chronic kidney patientsdiseasebenefit from endovascular AAA repair 2 Guest editorial No time like the present: The moral imperative for advocacy in vascular surgery 4 AMA Society ofAMAseatandmembershipreachestargetretainsinHouseDelegates Thank you to our sponsors Join the movement to get moving! charityfootprints.com/vascular

SVS CHARTS ITS COURSE AHEAD FOR DIVERSITY, EQUITY AND INCLUSION

By Bryan Kay

By Beth Bales and Jocelyn Hudson

See page 6

endovasculargraftingAortobifemoralintheera:

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As practicing vascular surgeons on the South Side of Chicago, we treat individuals from our local community and from all over the Midwest. It is reasonable to surmise that most physicians who find themselves in this partic ular corner of the city chose to work here to plant roots at an innovative medical institution with the ability to provide outstanding care to all patients regardless of race, ethnicity, gender, sexual orientation, and insurance status. To deny us the ability to do so feels like a dereliction of duty and a contradiction to the Hippocratic oath we all

GUEST EDITORIAL

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No time like the present: The moral imperative for advocacy in vascular surgery

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The patient was seen multiple times preoperatively, and the trial was explained to him in detail. He was eager to partic ipate, something not always encountered given the under

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standable mistrust of the research process often seen in Black patients. His anatomy was evaluated by the review board, and he was found to be an excellent candidate for the investigative device. The patient was scheduled for the two-part surgery in early August. After being notified of the denial, we participated in a lengthy peer-to-peer conversation with a physician representative from the patient’s Medicaid provider, but our efforts failed. The procedure was canceled. And there we were—highly trained surgeons technically able to offer all options to the patient but handcuffed to an open approach, which carried with it a much higher morbidity and mortality for this particular patient.

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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.

Like so many of our vulnerable patients on the underserved South Side of Chicago, this man’s path towards a repair was anything but linear. The patient was originally diagnosed in 2015 but was lost to follow-up for several years. He re-presented to our institution in March 2022 as a victim of gun violence in an altercation where he suffered an injury to his left arm—his wife and son were killed in the incident. A trauma pan-scan at the time showed that his TBAD had grown significantly and therefore met criteria for repair. The dissection remained distal to the left subclavian, and the aneurysmal portion was predominantly in the descending thoracic aorta. The patient had, in the intervening seven years, also suffered a stroke and myocardial infarction. Given that his multiple comorbidities also included morbid obesity and diabetes, the patient was not an optimal candidate for an open thoracoabdominal repair. Furthermore, the patient was anatomically not a candidate for a TEVAR with or without traditional debranching to allow for landing in zone 1 or 2. Given these findings, the patient was enrolled in the Nex us-ENDOSPAN trial for an arch device with zone 0 landing.

The investigational process is well regulated by both federal (Food and Drug Administration, or FDA) and in stitutional (IRB) oversight committees. The oversight and approval process has been in place for many years, and, at its core, has the safety of patients in mind. Clinical trials provide safe access to novel devices for select patients with complex problems.

By Chelsea Dorsey, MD, Luka Pocivavsek, MD, and Ross Milner, MD

’m so sorry but we have to cancel your surgery”—10 words any warm-blooded surgeon dreads uttering. This time around, it was not for the typical reasons. Our patients’ blood pressure wasn’t sky high in pre-op, and our case wasn’t being bumped for the trauma du jour. Regrettably, Medicaid unexpectedly denied approval of an investigational thoracic endovascular repair (TEVAR) for this 65-year-old Black male with a known history of a complicated type B aor tic dissection (TBAD) two weeks prior to his planned intervention. Though insurance denials are not uncommon for “out-of-network patients” at our institution (an issue ripe for a follow-up editorial at a later date), our team was both surprised and dev astated to find that this patient’s “in-network” procedure was denied because cardiovascular trial devices were not covered under his Illinois Medicaid insurance policy—with no excep tions. Our surgical plan was not only toast, but this man’s hopes of obtaining a cutting-edge thoracic repair were gone simply because of his reliance on state medical aid.

Content Director Urmila Kerslake

P2ublished

As for “select”— this is an interesting word choice in this context. Typically, patients must meet specific eligi bility criteria to be enrolled in a clinical trial. The criteria commonly include such factors as a minimum and maxi mum age. In addition, specific anatomic characteristics are assessed as part of the trial design and vary based on the investigational device. As a frequent site for clinical trials, our institution commonly uses such standards in our decision-making on who is safe to be treated and who is not. Noticeably absent from this algorithm is the catego rization of patients based on their insurance status. This is an appropriate omission given that uniformly that data point is irrelevant in deciding whether a patient should or should not be entered into a trial. In other words, patients should never be “selected” or excluded due to their insurance status. This unfair decision specifically targets an already marginalized group of patients. Clinical trials should be available to all patients. This fact is highlighted by the paradoxical elimination of a high-risk patient as seen in this scenario. The reality is that this is a patient who unequivocally needs our care the most.

| Robert Fitridge, MD | Dennis R. Gable, MD | Linda Harris, MD | Krishna Jain, MD | Larry Kraiss, MD | Joann Lohr, MD

Clinical trials should be available to all patients. This fact is highlighted by the paradoxical elimination of a high-risk patient as seen in this scenario. The reality is that this is a patient who unequivocally needs our care the most

Vascular Specialist | September 2022

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Kristin Crowe

“I

4. Participate. ACS https://www.facs.org/advocacy/getinvolved/.

EDITORIAL

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THE SOCIETY FOR VASCULAR SURGERY (SVS) HAS exceeded the necessary compliance threshold required to retain its seat in the American Medical Association (AMA) House of Delegates, the Society has announced.

4 Vascular Specialist | September 2022

1. Political advocacy in surgery: The case for individual engagement. The Bulletin engagement/political-advocacy-in-surgery-the-case-for-individual-https://bulletin.facs.org/2015/08/(2015).

References

or you may find avenues to get more deeply involved with specific local, state, or national healthcare policy.1 In recent years, the Society for Vascular Surgery (SVS) and larger organizations like the American College of Surgeons (ACS) have made it easier for us to get involved by providing educational resources and offering ample opportunities to have our surgical voice heard on Capitol Hill.3,4 Whether we like it or not, times have changed. No longer can we ignore or choose not to acknowledge that the clinical care we provide is intimately intertwined in the complex social circumstances of our patients. Advocacy is in our DNA as vascular surgeons. The sooner we acknowledge it, the sooner we can get to work.

swore to uphold. The challenges we faced with this particular patient also bring to light a much larger question of how advocacy plays a role in our daily lives as vascular surgeons. Collectively, our reasons for entering the field are varied, but fundamentally we all have an interest in serving patients and providing the best surgi cal care possible. Advocates are defined as individuals who fight for a cause or a particular group, so it is no stretch of the imagination to think advocacy is actually intimately involved in our work as surgeons.1 Moreover, for many of us who work in under-resourced regions, our efforts in this area are not only important, but in many cases life- and limb-salvaging.Forsome,the idea of becoming an “advocate” may seem daunting, especially given the paucity of information that is passed along to surgeons during their training sur rounding this topic.2 In thinking about how to approach this issue, it is important to keep in mind that advocacy comes in all shapes and sizes. For us and this situation, we began by contacting the clinical leadership team at our hospital to better understand the policies preventing this patient from obtaining care through this clinical trial. This ultimately led to further discussions with the institu tion’s leadership as well as those involved in government relations for the university as a whole. We have recently connected with our state’s legislators, and we are now working to ensure this patient’s story is heard loud and clear in our state’s capitol in the coming months.

GUEST

Alternatively, for some, there may be an urge to get more involved with grassroots organizations, depending upon the issue at hand. In other circumstances, you may feel inclined to contact your local legislator directly,

2. Surgeon advocacy in action: Challenges, accomplishments, and futuredirection. The Bulletin accomplishments-and-future-direction/org/2021/08/surgeon-advocacy-in-action-challenges-https://bulletin.facs.(2021).

NO TIME LIKE THE PRESENT: THE MORAL IMPERATIVE FOR ADVOCACY IN VASCULAR SURGERY continued from page 2

SVS meets DelegatesretainsmembershipAMAthreshold,Houseofseat

3. News & Advocacy | Society for Vascular Surgery. https:// vascular.org/news-advocacy.

CHELSEA DORSEY is an associate professor of surgery at The University of Chicago. LUKA POCIVAVSEK is an assistant professor at the same institution. ROSS MILNER is the The University of Chicago’s vascular section chief.

Members were informed that the SVS had received an official notification from the AMA confirming it had met the requirement just before the Labor Day weekend. Had the SVS not met the requisite membership threshold, said Megan Marcinko, the Society’s advocacy director, “the SVS would have been stripped of its seat within the House of Delegates,” and its position as a member of the RVS (Relative Value Scale) Update Committee [RUC].

The AMA stipulates that in order to maintain a seat in its House of Delegates, a 20% share of SVS members also must hold AMA “Representationmembership.attheRUC is critical as it serves as the main advisory body to the Centers for Medicare and Medicaid Services [CMS] on relative values for new and revised Current Procedural Technology [CPT] codes,” Marcinko said. “Actively engaging with the AMA also provides various benefits beyond the House of Dele gates and CPT/RUC activities, including participation in coalition activities, promoting the interests of vascular surgery, and ensuring collaboration across the House of Medicine.”— Bryan Kay

The study data also highlighted significant differences in sizes of the iliac, common femoral and superficial femoral arteries be

With all of that being said, Bath finishes, “it is true that the aor tobifemoral by pass group was

B [lesions]—i.e. there would a difference between the aortobifemoral bypass group and the UBE—but that did not really play out. So, it really does say that, a) we need a bit more research on the TASC C and D lesions, but b) aortobifemoral grafting is still an excellent option for patients.”

He adds: “We really don’t have a great comparison group from the unibody endo graft group, so, in this day and age, when there really is a thrust and desire to perform a lot of endovascular therapies, should we be discounting the aortobifemoral bypass graft in patients who are good risk, younger, who may be female with smaller arteries, and who can tolerate an aortobifemoral bypass graft? You would think these TASC C and D lesions would have a greater num ber of interventions than the TASC A and

FROM THE COVER: AORTOBIFEMORAL GRAFTING IN THE ENDOVASCULAR ERA: AN EXPLORATION OF THE OPEN PROCEDURE AND ITS MERITS AMONG ‘GOOD-RISK’ PATIENTS continued from page 1 “

Trainingimplications

The study also recalls the issue of open aortic training volumes amid declining numbers of open abdominal aortic aneurysm (AAA) repairs. During the 2022 Annual Symposium of the Society for Clinical Vascular Surgery (SCVS) in Las Ve gas earlier this

“The thrust of this is that surgeons have been doing aortobifemoral by pass since the 1950s and 60s, and it is well enshrined in vascular surgery as a great option for many patients,” Bath explains in an interview with Vascular Specialist ahead of the MVSS meeting.

“We no longer perform as many open an eurysm repairs,” he says, “we no longer per form as many aortobifemoral bypass grafts, and many trainees won’t graduate with the same numbers that we did five and 10 years ago. There has been talk of having open aortic fellowships.” But, like Sheahan, Bath looks toward the bypass further down the vascular tree—not as a panacea but a part of a larger solution. “I would argue that the aor tobifemoral bypass graft, although it doesn’t have the same aspects as the aneurysm re

www.vascularspecialistonline.com 5

pair—one cannot say they are comparable— it does teach you many of the principles of open aortic surgery, which is safe exposure and rapid exposure, finding adequate clamp sites; these are all important tenets sewing on an aorta, which oftentimes, people don’t get to do,” he says. “So, I like this operation for that reason. I think we have a bit of a bias, probably, toward performing an aorto bifemoral bypass graft in most patients who can tolerate it. And I think it’s good for our trainees.”Returning to the core of his new study, Bath acknowledges that “there are limita tions, there are biases,” saying: “This is a sin gle institution study; surgeons definitely have their biases towards aortobifemoral bypass graft vs. UBE; but I really think this paper demonstrates that aortobifemoral bypass grafting can be performed safely, and has the added benefit of being able to teach residents and trainees how to perform aortic surgery. I think it’s an operation that should remain.” Should we aortobifemoraldiscountingbethe bypass graft in patients who are good risk, younger, who may be female and who can tolerate an bypassaortobifemoralgraft?”

The researchers established equivalent outcomes between those treated with both aortobifemoral bypass grafting and unibody endografts (UBEs) in terms of such occur rences as stroke, major adverse cardiac events (MACE) and myocardial infarction (MI). They also reported mid-term out comes for patency and survival that were similar across the two treatment modalities. The team further found that the best option for TASC C and D lesions—those deemed most com plex—remains unclear.

tween genders—all were smaller in females, BathThenotes.senior author also describes points of interest in terms of study outcomes. “The [patient cohorts] are very similar in terms of the overall outcomes; honestly speaking, there were very few differences in areas such as patency, stroke, MACE and MI in a pop ulation that is similar. What that really says, probably, is that aortobifemoral bypass graft ing is still very safe, even in the endovascular era.” There were also specific differences in the size of the arteries in terms of gender, he explains. “That always has implications

regarding whether or not an endovascular therapy is going to be superior, or inferior, or the same, versus an open therapy,” Bath says. “Again, artery size was associated with an overall reintervention risk, so we know the size of the artery does portend a risk of having a rein tervention. That might be—in the case of an aortobifemoral bypass graft—that the limb thromboses, and you have to perform a thrombectomy, or, in the case of a unibody en dograft, that you may have to extend things, or you may have to perform thrombolysis or some similar procedure in order to maintain patency.”

with smaller arteries,

year, Malachi Sheahan III, MD, chair in the di vision of vascular and endovascular surgery at Louisiana State University Health Sciences Center in New Orleans, pointed out that aor tobifemoral bypass surgery should be part of conversations about trainee involvement in open aortic surgery in discussion over how to tackle shortfalls in the number of such cases tackled by trainees. Bath weighs in on train ing deficits and the postion of aortobifemo ral bypasses in the discussion, describing the ongoing hot topic of the last decade as “the deskilling of our specialty with burgeoning endovascular use.”

JONATHAN BATH

They presented the results at the 2022 an nual meeting of the Midwestern Vascular Surgical Society (MVSS), which was held in Grand Rapids, Michigan (Sept. 15–17).

more complex and had a greater number of TASC C and D lesions.”

lantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) II A-D lesions at their institution.

“However, we’ve obviously had this endovascular evolution. It is not an entirely new topic but the series have been small, so we don’t have a—col lectively—large amount of data to guide us as to which therapy is more appropriate.”Hecontinues: “We’ve looked at our institutional experience, which, again, is relatively small and modest compared to many, but it has decent, moderate follow-up—36-months in our study. We tried to cohort patients who were similar. If you look at de mographics between patients, they really aren’t dissimilar, so we are try ing to do an apples-to-apples compar ison. We are also going to perform a subgroup analysis on the TASC C and D lesions, the more complex lesions. That was a significant difference between studies: Most of the unibody endografts, or UBEs—the Endologix device—were more TASC A and B patients, with fewer TASC C and D lesions, when compared to the aor tobifemoral bypass graft. Obviously, this is a retrospective study; we certainly didn’t randomize these patients. This is operator preference.”Thestudy included 133 patients who had complete data, 82 of whom had AIOD only. Twenty one of these patients were treated with a UBE (26%), while 61 underwent aor tobifemoral bypass grafting (74%). Signif icant differences in perioperative variables included surgery length (UBE: 213 min utes; bypass: 360), pre- and postoperative ankle-brachial indices (the UBE was lower than the bypass), and sizes of the iliofemoral arteries (larger in the case of the UBE).

133 patients 21withtreatedUBE 82 61AIODwithonlyreceivedbypass BathJonathan

frailty improved in 40% of patients. Lowerextremity revascularization was found to be the procedure that most frequently caused frailty statusHaleschanges.relayed a preliminary conclusion that these centers are using CFS differently. “There is a need for future analysis to calibrate the CFS score to a common gold standard, such as the VQI frailty scale, or the risk analysis index,

Though the SVS “has made significant progress in many ways, it was clear that SVS

must not rest on its laurels and needs to stay vigilant and committed to the current trajectory of change.”

Other topics and speakers includ ed Daniel Bertges, MD, who discuss ed strategies and updates on SVS discussions around Epic and Pow erChart, covering ways to integrate vascular-specific documentation requirements and streamlining data entry. London Guidry, MD, covered how smaller independent groups can effectively use EMRs in daily practice and/or the OBL setting, including barriers, challenges and advantages.

The VAM DEI session in question, “Building Diversity and Equitable Systems in Vascular Surgery,” is available to view on the VAM 2022 website: vascular.org/Planner22

continued from page 1

This tool allows comparison of the expected natural history of a vascular condition to be compared with expected nine-month mortality after surgical repair.

In another presentation, Arya, who is an associate professor of surgery at Stanford University in Stanford, California, outlined a 30-second frailty screening tool called the Risk Analysis Index (RAI) she and her research team developed, and then demonstrated how surgeons can use the RAI to measure frailty.

FROM THE COVER:

SVS CHARTS ITS COURSE AHEAD FOR DIVERSITY, EQUITY AND INCLUSION

The assessment is an exhaustive survey, taking 90 or so minutes to complete, and is used in order to estimate longevity.Forthe new tool, the team added two variables known to be associated with frailty but not included in the CGA. Using a VQI dataset containing 265,000 arterial reconstructions, researchers tested how well a frailty tool encompassing these data elements correlated with perioperative and long-termFocusingsurvival.onVQI long-term mortality measured at nine months, they discovered the model has “excellent predictive power.”

VASCULAR SURGEONS GOT a glimpse into how to make electron ic medical records (EMRs) work for them at a webinar Sept. 7. The ses sion, sponsored jointly by the Society for Vascular Surgery’s Community Practice Section and the Health In formation Technology and Wellness committees, saw panelists discuss how to manage records to benefit daily practice needs; using EMRs in small independent practices, includ ing outpatient-based lab (OBL) facili ties; and how to manage the burnout so many physicians and surgeons feel as a result of dealing with elec tronicMalachirecords.Sheahan III, MD, who has written extensively on EMR issues, led “Stating the problem of whether the EMR works for us or the other way around,” as well as burnout, mitigation strategies and SVS’ role in resolving the issue.

or both,” the presenter commented.

She and her team have used the RAI with Veterans Affairs data and in a modified format in the VQI (VQI-RAI), finding it “highly predictive.”Inaddition, research into frailty and surgery has shown that vascular surgery “definitely is a specialty with a much higher burden of frailty,” she said, with almost 20% of patients in a highriskShecategory.alsohas researched the stress of surgery itself, with data indicating that in the frailest patients, the six-month mortality figure is 30 to 40%, “no matter the procedure.”

In addition, the SVS has hired a consultant in diversity, equity and inclusion (DEI) to develop a translational webinar and guide in DEI principles and values that will be mandatory for all elected and appointed members of boards, councils, committees, sections and task forces.

substantive changes in SVS governance andHebylaws.isforming a Special Bylaws Subcommittee to review and discuss potential changes that could be implemented for this current fiscal year. Any proposals that impact bylaws to take effect before the year ends on March 31, 2023, would require a special member referendum before Jan. 31, Dalsing2023.asked members to “stay positive, hopeful and deeply engaged with the SVS. It is the only way to ensure that the Society will advance and meet its optimal potential for all members.”

“I knew the old methods wouldn’t work,” she said. “We need the tool to be rapid, able to be used by anyone, not be variable in terms of who’s using it, and easily administered.”

representative of the SVS Strategic Board of Directors, to the Executive Board.

“You can consider it to be a simple eyeball test,” said Kraiss during the VQI gathering, which took place during the 2022 Vascular Annual Meeting (VAM) in Boston (June 15–18). Using a continuum from one to eight (with nine being a special category for the terminally ill), researchers found the division is between four and five, between “non-frail but vulnerable,” to “mildly frail,” typically including an inability to shop independently and possibly requiring help with activities such as cooking and“CFShousework.whenapplied by a geriatrician correlated very well with frailty scoring using CGA,” said Kraiss. “It’s appealing for use in surgery clinic; no additional testing is required,

Other ideas proposed at the retreat need more thought, Dalsing said, and may lead to

Kraiss said that the team found only seven of the tested variables were necessary to accurately model long-term postoperative mortality. The variables were congestive heart failure, renal impairment, chronic obstructive pulmonary disease (COPD), compromised ambulatory status, not living at home, anemia and being severely underweight.

Thus far, researchers have had an “encouraging single-site experience,” though the presenter brought up the question of whether CFS can be used “in multiple institutions by multiple providers and still retain its Hales,accuracy.”who has been a research nurse and the VQI data manager at the University of Utah’s Division of Vascular Surgery for the past seven years, presented on a multi-institution experience with CFS.

Arya concluded that RAI offers a “robust tool” for frailty assessment, and suggested that frailty assessment in the VQI could be improved by adding two to three more variables such as cognition, cancer comorbidity and granular function measures.

James Craven, MD, dealt with the employed vascular surgeon expe rience. And Jeniann Yi, MD, talked through the challenges and oppor tunities of integrating different EMRs.—Beth Bales

surgeryforthemhowdemonstrateswebinarEMRs:NavigatingSVStomakeworkvascular

Michael Dalsing

Hales and colleagues charted CFS scores over three years at four participating centers in order to evaluate whether CFS is being accurately and consistently used across the centers.Their data included 336 paired scores, which show how frailty status changed after a VQI procedure.Thepresenter reported that 14% of those deemed non-frail before a procedure declined to frail status and that preoperative

Immediate actions were hiring the consultant, plus planning for a follow-up “DEI summit” across vascular surgery in January.

A recording of the webinar will be available soon

Arya has been studying frailty and surgery since 2014.

In response to concerns that even the shortened VQI frailty assessment tool was too cumbersome to use in a busy surgical clinic, the University of Utah team has been exploring use of the Clinical Frailty Scale (CFS).

6 Vascular Specialist | September 2022

The move, approved by the board, came as a result of listening to multiple groups and member constituencies within the SVS following a sparsely attended session on DEI at the 2022 Vascular Annual Meeting (VAM) and relatively low participation of members participating in the online office election held prior to VAM.

FROM THE RESEARCHERSCOVER:STUDY ROLE OF FRAILTY IN POST-DISCHARGE MORTALITY continued from page 1

and it’s quick and simple.”

The study into clinical use of RAI continues, with a four-year VA funded trial on improving outcomes, using a “bundled-care” approach.

The presenter remarked on the overarching significance of the work: “We’re learning a lot about how to put specialists together to discuss how to optimize outcomes for the high-risk patient, do less-invasive or noninvasive procedures and provide goalconcordant care.”

DEI issues were front and center during the Executive Board retreat in late July, where members debated many potential ideas on promoting DEI values.

Collaboration also will be increased between the DEI and Communications committees in order to help shape SVS focus and messaging consistently.

JULIE HALES

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“ There is a need for future analysis to calibrate the CFS score to a common goal standard, such as the VQI frailty scale, or the risk analysis index, or both”

The team developed a 12-question, 14-point assessment around the five domains of function, physical, cognitive, nutritional and social.“The score robustly predicts who is going to die in the next six months,” she said. “As the score increases, we see an exponential rise in six-month mortality.”

used in the comprehensive geriatric assessment (CGA) to established VQI variables.

“There are important racial differences in demographic, clinical, and procedural characteristics for patients undergoing rAAA repair,” Li and colleagues concluded.“Inparticular, the door-to-intervention time for Black patients of 168 minutes does not meet the Society for Vascular Surgery [SVS] recommendation of 90 minutes.“Despite these differences, eight-year mortality is similar for Black and White patients. Future studies should assess reasons for these disparities and [what] opportunities exist to improve rAAA care for Black patients.”—Bryan Kay

After adjusting for differences in demographic, clinical, and procedural

“The paucity of data on LEA in LMICs is of particular concern”

The finding is part of data on the impact of race on outcomes following rAAA repair presented by Ben Li, MD, a vascular surgery resident at the University of To ronto in Toronto, Ontario, and colleagues

Li and colleagues plumbed the VQI database for all Black and White patients who underwent endovascular or open rAAA repair between 2003 and 2019.

8 Vascular Specialist | September 2022 INTERNATIONAL

The WFVS, Society for Vascular Surgery (SVS) and the European Society for Vascular Surgery ESVS) all collaborated on the Global Vascular Guidelines. Philippe Kolh, MD, who will give the presentation on a possible update, was the ESVS editor for the guidelines.

The study included data on 180,595 lower-limb amputations and surgical revisions of amputations, with toe amputations (45%) and major amputations (33%) being the most frequent types of sur geries. Biagioni and colleagues report a significant increase in the rates of both of these procedures. They add that peripheral arterial disease (PAD) was found to be the most frequent underlying diagno sis for LEA, followed by diabetes mellitus, with an increasing trend for both over the last 12 years. Furthermore, they also observed seasonality in procedure rates, with peaks in August in all years.

is included with the VE ITHSymposium fee (visit www.veithsympo sium.org). Learn more about WFVS at www. worldfvs.org. Contact the society at info@ worldfvs.org.—Beth Bales

“Lower-limb amputations represent a high social, economic and health burden,” Rodrigo Bruno Biagioni, MD, a vascular surgeon at Hospital do Servidro Público Estadual de São Paulo, São Pau lo, Brazil, et al write. According to the authors, most lower-limb amputations are preventable, and reflect areas for improvement in healthcare. For these reasons, they stress that it is “essential” to know the epidemiology of these amputations.

The 90-minute session will be held from 5 to 6:30 p.m. Eastern Standard Time, on Fri day, Nov. 18, at the VEITH host site, the New York Hilton Midtown, 1335 Avenue of the Americas, NYC.

The investigators detail that LEA rates are “highly variable” across the world and that LEA trends are “conflicting.” These factors, they say, necessitate population-based studies in particular, “not only to truly know the local epidemiology of LEA, which reflects the quality of the health system, but also to build a global panorama in order to establish standards and goals.”

LOWER-LIMB GLOBALINCOMEAMERICANEPIDEMIOLOGYAMPUTATIONINALATINLOW-ANDMIDDLE-COUNTRYEMERGESSOUTH WFVSFEDERATIONTOVEITHSYMPOSIUMINCLUDEWORLDSESSION

THE WORLD FEDERATION OF Vascular Societies (WFVS) is set to hold a ses sion in November during the VEITHsympo sium in New York City.

Biagioni et al’s study was a retrospective, population-based, cross-sectional analysis on all lower-limb amputations performed

study recently published in the World Journal of Surgery claims to be the first to provide comprehensive population-level data on the epidemiology of lower-extremity amputation (LEA) in a Latin American low- and middle-income country (LMIC). The investiga tors write that their data, which focus on the Brazilian state of São Paulo, are “crucial to plan strategies to reduce the burden of LEA.”

The study’s primary outcomes were in-hospital and eight-year mortality. Some 310 Black and 4,679 White patients were included.Li

Also being covered will be whether primary open bypass treatment is better for diabetic patients with chronic limb-threatening isch emia (CLTI) and substantial foot necrosis; the failure of single-stage brachiobasilic arterio-ve nous fistula; barriers to vascular care for CLTI patients; whether the 2019 Global Vascular Guidelines on CLTI already needs a significant update; and guideline and aortic changes after thoracic endovascular aortic repair (TEVAR) for acute aortic dissection.

characteristics, in-hospital mortality was similar for Black and White patients, they revealed. There was no difference in eightyear survival between Black and White patients, “which persisted when stratified by endovascular and open repair,” the investigators added.

WFVS member societies include the SVS, ESVS, the Japanese Society for Vascular Sur gery, the Vascular Society of Southern Africa, the Vascular Society of India, the Australian and New Zealand Society for Vascular Sur gery, the Asian Society for Vascular Surgery and the Latin American Association for Vas cularRegistrationSurgery.

Black patients wait more than twice as long as White patients for rAAA repair, VQI analysis finds

in public hospitals in São Paulo between 2009 and 2020. The authors relay that they used a public database to evaluate types, rates and trends of the amputations performed, main etiologies leading to the indication for amputation, hospital length of stay and in-hospital mortality rates, demographics of the amputees and procedure costs.

The authors also reveal that most patients were male (69.3%), Caucasians (55.6%) and elderly. Other findings included a 6.6% rate of in-hospital mortality and lower-limb amputations and total of $67,675,875.55 reimbursed by the government. Based on these findings, the authors propose some preventive strategies—namely foot ulcer screening, multidisciplinary diabetic foot care, and en couraging revascularization procedures, which, they claim, have not significantly increased in the city of São Paulo since 2008.

RODRIGO BRUNO BIAGIONI ET AL

at the annual meeting of the Canadian Society for Vascular Surgery (CSVS) in Vancouver, British Columbia (Sept. 9–10).

Furthermore, Biagioni et al address the finding that August showed the highest number of amputations in all years of their study. They write that, although this contrasts a previously reported finding from Hong Kong, in this study the main underlying diag nosis was PAD, and it is possible there may be a worsening in PAD during winter.—Jocelyn Hudson STUDY TO ELUCIDATE

BLACK PATIENTS SAW SIGNIFICANT ly delayed care for ruptured abdominal aortic aneurysms (rAAAs), with a Vascular Quality Initiative (VQI) analysis showing a median time from hospital admission to intervention of 168 vs. 78 minutes com pared to White patients.

The session will include presentations from across the globe reflecting each society’s con tribution to the WFVS educational mission. A 20-minute discussion period will follow the 11 Topicstalks.will include a presentation on a glob al program to advance vascular surgery in lowand middle-income countries, the huge inter national variation in carotid surgery, infected abdominal aortic and common iliac artery aneurysms, frozen elephant trunk, abdomi nal aortic and iliac artery aneurysms, repair in vascular Ehlers-Danlos Syndrome, and a national Japanese study of surgical treatment for popliteal artery entrapment syndrome in the Far East country.

According to the authors, several countries in Europe, North America and Australasia have reported their amputation epidemi ology, with most data coming from high-income countries (HICs). “Data from [LMICs] are scarce,” they write, noting that in Latin America no such study existed before the present analysis, to the best of their knowledge. “The paucity of data on LEA in LMICs is of particular concern,” the researchers note, “as the burden of PAD and [diabetes mellitus] is increasing in rates higher in LMICs than those observed in HICs.”

The WFVS includes member societies of federated national and affiliate member vascu lar societies. Its aim is to improve the quality of care of vascular patients worldwide by provid ing a forum for the international exchange of scientific and educational knowledge related to the diagnosis, treatment and prevention of vascular diseases.

In the discussion of their results, the research team considers some possible explanations for PAD being the main underlying di agnosis for all LEA in Sao Paulo, one of which is that Brazil is “late in the epidemiological transition concerning LEA.” They predict that it is likely Brazil will reach similar statistics to those found in most recent nationwide studies—which point to diabetes mellitus as the most common underlying cause of LEA—in the coming years, as the prevalence of smoking is reducing and diabetes mellitus rising.

FIRST

et al found that a greater proportion of Black patients received endovascular repair (73.2% vs. 56.1%), were younger and more likely to be female, and that a greater proportion were uninsured (4.8% vs. “Although3.3%).Black patients were more likely to have cardiovascular comorbidi ties, they were not more likely to receive risk reduction medications,” Li reported.

A

CORNER STITCH

AUDIBLE BLEEDING CUTS DOWN TO VASCULAR CORE

AJ: There are tons of great podcasts out there for vascular surgeons. Behind the Knife, of course, has great content for vascular surgeons and general surgeons. Backtable is a very high-quality podcast put out by a group of interventional radiologists that has a lot of content that vascular surgeons would find useful. Let’s Talk Surgery is put out by the Royal College of Surgeons of Edinburgh and is one I have started listening to while I have been in the United Kingdom. The Retrograde Approach is a podcast out of Australia that has some great review episodes. And finally, Yale Vascular Review is put out by a couple of trainees from Yale that give short summaries of recently published articles grouped by clinical topic.

VS: Last question, I promise. Looking into the future, what do you hope Audible Bleeding will grow into?

AJdevelop?&KK:

So instead of competing with us, they figured they would offer to support us. We were sufficiently listenersupported, so we didn’t need the funding, but we figured our team wouldn’t be running the podcast forever, and

KK: To my knowledge there are a couple others. We have not done significant collaborations. Audible Bleeding has done multiple crossover episodes with Behind The Knife in attempts at educating and drawing general surgery trainees in to vascular.

VS: What advice would you give to current vascular surgery trainees for conceiving and maintaining a start-up during training or as faculty?

VS: Bravo to Dr. Smith. That name makes perfect sense to the vascular surgeon and is intriguing enough to get non-vascular surgeons to want to figure out what the podcast is about. So now, what were some of the goals for the Audible Bleeding podcast when it first started, and have you met some of them?

JOHNSON is a vascular surgery fellow at Cornell/ Columbia New York Presbyterian Hospital, and is current director of Audible Bleeding KNIERY is a vascular surgeon at Brooke Army Medical Center in San Antonio, Texas. Here’s what they had to say.

AJ: Our initial goal was to highlight the stories of surgeons within vascular surgery to give trainees broader insight into the field. We then started creating free study resources to help trainees learn basic concepts within vascular surgery. Within our first year, we had name recognition with almost every trainee I met, and they all found it a valuable resource—so we had already met our initial goal by the end of our first year!

KK: I remember texting back and forth names, I think one that may have come up was “Behind The Wire.” Dr. Matt Smith came up with Audible Bleeding, and it was an immediate hit given the double entendre.

AJ: Hmm…good question: I think it all comes to value. What is the value that you are hoping to provide to your community, and what value is this endeavor providing to you? If you see start-ups and innovation and a getrich-quick scheme, you might be successful, but you’ll likely get frustrated. If you find something that provides value to yourself and your community beyond financial reimbursement, then you’ll find yourself wanting to work on it, no matter the time of day, and you will find people around you supporting your work.

AJ: Yeah, that’s how I remembered it, too. As he mentioned, Kevin and I were medical school classmates at Tulane, and I had been a huge fan of his work with Behind the Knife. I approached him about whether I could get involved, and he suggested that there might be a role for a whole new podcast just for vascular surgery. During these conversations in early 2018, I applied for a vascular fellowship and matched at the New York-Presbyterian Columbia/Cornell program, so it turned out he would be my senior fellow!

VS: Ok, so you guys definitely hit a nerve and tapped into a whole new generation of trainees who love podcasts. Today, Audible Bleeding is supported by the Society for Vascular Surgery. How did that partnership

KK: I couldn’t agree more with AJ. But I also think it is all about finding the right team, which is impossible to know at first. A good place to start is finding a small core group that is passionate about the same vision or goal. You may have one idea and then you collaborate with others with differing view points and experiences and then the idea matures and becomes much bigger and better than you initially anticipated.

Dr. Ellozy started approaching his network of surgeons, and we decided to publish our first interview with Dr. Frank Veith in the fall of 2018, right before the VEITHsymposium meeting. We got some initial excitement, and guests kept saying yes to coming to the podcast.

VS: That sounds fortuitous, really, and not too dissimilar from how some other famous brands got their start. But, as you know, brand names are important. How did you come up with the name Audible Bleeding?

Many Corner Stitch readers subscribe to Audible Bleeding, the vascular surgery podcast for updates on all things vascular—from vascular knowledge, to reviewing key Journal of Vascular Surgery (JVS) papers, to speaking on diversity, equity and inclusion (DEI) efforts, and even looking at the history of vascular surgery, Audible Bleeding has been engaging the audience and providing much needed content. This month, we were lucky to pick the brains of founders Adam Johnson, MD, and Kevin Kniery, MD.

We plan to re-publish our review episodes starting in November for a simple, free, and easily accessible study schedule to prepare for the U.S. in-training exams. Keep a look out for more details this fall!

VS: Starting a podcast is very hard thing to do, especially during training. Can you give a brief history of how it all started?

KK: We wanted to bring vascular surgery education to a podcast platform. We started with interviewing leaders in the field and learning from them, and then it slowly branched out to what it is today.

Adam Johnson Kevin Kniery

year.During COVID-19, however, we started to really increase our content and hold some webinars and help with a multi-institutional lecture series based on Wake Forest. We helped to host a few events for the SVS, and they were impressed with the work we were doing. Dr. Kim Hodgson, the president at the time, reached out to us to see if we wanted to be the official podcast for the SVS. They had thought about having a Society-affiliated podcast for a while and recognized we had a quality product in that space.

VS: I’m sure you’re not the only team that has thought of a vascular surgery-centric podcast. Are there others out there? And do you partner with them?

AJ: One of our big pushes this year is to provide a more comprehensive online resource for exam preparation. We will be publishing a free e-book this fall to accompany our exam prep episodes.

10 Vascular Specialist | September 2022

affiliating with the SVS would help us to recruit and maintain team members moving forward.

COMMENT& ANALYSIS

So, essentially we were already doing many collaborations with them, and they were trying to find new ways to connect with the younger generation, so it was a perfect fit. In addition, Dr. Ken Slaw, executive director of the SVS, was also very involved with our transition.

By chance, a friend of mine from medical school, Adam, was coming to the same fellowship, and we had talked about working on BTK for some vascular related episodes in the past. So, late in my first year of fellowship, it all came together with Adam about to move to New York, and my co-fellow, Matt Smith, was super excited about the idea. Dr. Ellozy was a perfect senior mentor having the knowledge, experience and connections, and, Nicole Rich, the other incoming fellow, also thought it would be a fun project to work on.

This process was a bit more organic than we would have expected. Initially, we started out as an LLC with a small investment from each of our team members. We all agreed from the beginning that the intent of the investment was just to get the podcast off the ground, and we had no interest or expectation for a financial return on the investment. We then received some unexpected donations from listeners, and the podcast became listener-supported pretty much by our second

KK: I remember all the way back to my fellowship interviews, Dr. Sharif Ellozy was very interested in my work with Behind The Knife [BTK]. Having a podcast on your CV wasn’t always viewed in high esteem so that really stuck out to me. I think given his experience and work in surgical education, he was drawn to it.

Trial

The primary efficacy outcome was the hierarchical com posite of death due to venous or arterial thrombosis, pul monary embolism, clinically evident deep vein thrombosis (DVT), type 1 myocardial infarction, ischemic stroke, system ic embolic event or acute limb ischemia, or clinically silent DVT, through hospital discharge or 28 days. Primary efficacy analyses included an unmatched win ratio and a time-to-first event analysis during treatment.

COVID-PACT shows that fulldose anticoagulation more effectively prevents the clotting complications of COVID-19”

In the antiplatelet analysis, there were no differences in the risks of clotting complications or of fatal or life-threatening bleeding in patients treated with clopidogrel compared with no antiplatelet therapy.

By Jocelyn Hudson and Will Date

In the discussion of their findings, Hügel and colleagues claim that their study is the first to systematically explore predictors of venous stent occlusion that can be incorpo rated into the decision-making process prior to an Theyintervention.alsoacknowledge “several” limita tions to their study, noting, for example, that the sample size was “moderate” and that the retrospective, single-center design and mid term follow-up duration limit the general izability of the results. “Insufficient venous inflow as assessed by low peak velocities in the CFV and FV as well as post-thrombotic findings represent reliable risk predictors for stent occlusion, warranting their inclusion into the decision-making process for invasive treatment of PTO,” the authors conclude.— Jocelyn Hudson

18 Vascular Specialist | September 2022

detail that the mean follow-up duration was 41±26 months and that participants, 46.3% of whom were women, had a mean age of 47.4±15.4 years. They add that 90 (83.3%) patients had PTO and 18 (16.7%) had NIVLs. Loss of patency occurred in 20 (18.5%) patients who were all treated for PTO, the authors communi cate, noting also that comorbidities, side of intervention and sex did not differ between patients with occluded and patent stents.

N

The authors of the study—Ulrike Hügel, MD, from Bern University Hospital, Bern, Switzerland and colleagues—write that endovenous stent placement has become a first-line approach to prevent post-throm botic syndrome in patients with chronic post-thrombotic obstruction (PTO) or non-thrombotic iliac vein lesions (NIVLs) if conservative management fails. “This study aims to identify factors associated with loss of patency to facilitate patient selection for endovenous stenting,” Hügel et al state.

sus standard dose (6.4%; hazard ratio [HR] ratio 1.95; 95% confidence interval [CI] 1.08–3.55; p=0.028). Results were consistent in the time-to-event analysis (19 [9.9%] events on the full dose vs. 29 [15.2%] on the standard dose; HR 0.56; 95% CI 0.32–0.99; p=0.046).

successful endovenous stenting for chronic vein obstruction performed at a single insti tution from January 2008–July 2020. They explain their methods in the  JVS-VL paper: “Using multivariable logistic regression, we explored potential predictive factors for loss of stent patency, including baseline de mographics, post-thrombotic changes, as well as peak flow velocities measured in the common femoral vein (CFV), deep femo ral vein (DFV) and femoral vein (FV) using duplexHügelultrasound.”andcolleagues

Use of unfractionated heparin (UFH) or low-molecu lar-weight heparin (LMWH) for either regimen was at the discretion of the managing clinicians. In patients without another indication for antiplatelet therapy, there was an ad ditional randomization to either the antiplatelet clopidogrel or no antiplatelet therapy. Patients were assessed clinically and with lower-extremity venous ultrasounds 10 to 14 days after randomization, and followed until hospital discharge or for 28 days, whichever occurred first.

“This discordant advice has left many clinicians confused about what to do, particularly in COVID-19 patients at the border-zone of needing ICU-level care. The recommenda tion for ICU patients is largely based on a trial which found that full-dose anticoagulation, compared with the standard dose, did not decrease the number of days alive without organ support in critically ill patients with COVID-19,” Berg

C M Y CM MY CY CMY K CLINICAL PRACTICE

“may be predicted by low peak flow veloc ity and post-thrombotic changes in inflow veins” and that endovascular venous stent ing for chronic outflow obstructions is an “efficacious and safe” treatment in selected patients. These findings were recently pub lished online in the  Journal of Vascular Sur gery: Venous and Lymphatic Disorders (JVS-VL).

The authors also reveal that lower duplex ultrasound peak velocity in the CFV (odds ratio [OR] 7.52; 95% confidence interval [CI] 2.54–22.28; p<0.001) and FV (OR 10.75; 95% CI 2.07–55.82; p<0.005) was a preinterven tional predictive factor for stent occlusion. Post-thrombotic changes in the DFV (OR 4.51; 95% CI 1.53–13.25; p=0.006) and FV (OR 3.62; 95% CI 1.11–11.84; p=0.033), they add, was another predictive factor. Finally, the authors state that peak velocities of ≤7cm/s (interquartile range 0–20) in the CVF and ≤8cm/s (IQR 5–10) in the FV were “sig nificantly associated with loss of patency.”

A total of 390 patients were randomized (390 to an anti coagulation strategy and 292 to an antiplatelet strategy). In the primary efficacy analysis of anticoagulation, a greater proportion of wins occurred with the full dose (12.3%) ver

“COVID-PACTadded shows that full-dose anticoagulation more effectively prevents the clotting complications of COVID-19, which may be a more appropriate focus for antithrombot ic therapy as a preventive intervention, and is the basis for anticoagulation recommendations in ICU patients without COVID-19.”

ew data indicate that venous stent failure

The COVID-PACT trial evaluated whether a higher in tensity of anticoagulation and/or the use of antiplatelet therapy prevents blood clots with an acceptable safety profile in patients with severe COVID-19 infection. COVID-PACT was a 2×2 factorial, randomized controlled trial in critically ill patients with COVID-19 conducted at 34 sites in the U.S.

The primary safety outcome of fatal or life-threatening bleeding occurred in four patients (2.1%) on full-dose anti coagulation and one patient (0.5%) on standard-dose antico agulation (p=0.19); all of these were life-threatening bleeds, and there were no fatal bleeding events. There was no differ ence in all-cause mortality between groups (HR 0.91; 95% CI 0.56–1.48; p=0.70).

“

DAVID BERG

“Stent occlusion was more common with increasing number of stents implanted (p<0.001), and with distal stent extension into and beyond the CFV (p<0.001),” Hü gel et al report in JVS-VL

VENOUS RETROSPECTIVESTENTING STUDY IS ‘FIRST TO SYSTEMATICALLY EXPLORE PREDICTORS OF VENOUS STENT OCCLUSION’

Patients requiring ICU-level care (invasive mechanical venti lation, non-invasive positive pressure ventilation, high-flow nasal cannula, or vasopressors) were randomized to either full-dose or standard-dose prophylactic anticoagulation.

The investigators retrospectively ana lyzed 108 consecutive patients following

patientsinbloodtoanticoagulationfull-dosesupportspreventclotsCOVID-19

TREATMENT OF CRITICALLY ILL COVID-19 patients with full-dose anticoagulation lowers the risk of venous and arterial clotting complications by 44% compared with the standard dose, according to late-breaking research presented in a Hot Line session at ESC Congress 2022 (Aug. 26–29) in Barcelona, Spain. The addition of clopidogrel did not provide further protection.

David Berg, MD, a cardiologist from Brigham and Wom en’s Hospital and Harvard Medical School in Boston, said: “COVID-19 treatment guidelines recommend full-dose an ticoagulation for hospitalized patients outside the ICU and the standard dose for those in the ICU.

All the speakers were excellent. It was a perfect overview, and I was able to look back at the sessions on-demand

CX Aortic Vienna was a revolution in aortic approaches and updated our knowledge in the speciality

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It was a great use of my time.learning!Intensive

contributors.Editorsare former SVS presidents and editors of the Journal of Vascular Surgery, Bruce Perler, MD, and Anton Sidawy, MD. Updates for the new edition include:

Anton Sidawy

4.5% of the Option deployments (p=0.44), the research team

EASTERN VASCULAR

“Although the price of the Denali IVC fil ter is nearly double that of Option, tilting or hooking occurred significantly less often with Denali,” the researchers concluded. “These factors, which make retrieval more difficult, resulted in shorter procedure and fluoroscop ic times with [the] Denali and, ultimately, in lower retrieval costs, offsetting the initial expense of the filter.”—Bryan Kay

TRAINEES REVIEW

This month’s JVS, JVS-VL open access papers OptionIVC

Retrieval was attempted in 57 Denali and 44 Option IVC filters, with secondary proce dures attempted in none of the Denali cases vs.

THE NEW, 10TH EDITION OF RUTHERFORD’S Vascular Surgery and Endovascular Therapy, thoroughly revised, is available for purchase. And SVS members get a 30% discount on the two-volume resource.

◆ Completely updated chapters, providing the latest evidence-based diagnostic and therapeutic strategies.

3. Risk factors and classification of reintervention following deep venous stenting for acute iliofemoral deep vein thrombosis. vsweb.org/JVSVL-StentingDVT0922

2. Clinical presentation of isolated calf deep vein thrombosis in inpatients and prevalence of associated pulmonary embolism (CME available). vsweb.org/ JVSVL-CalfDVT0922

T

he research team behind the analysis—which was de signed to compare outcomes and costs of IVC filter re trieval when using the two most commonly deployed devices for the procedure—showed that use of the Denali filter resulted in lower retrieval costs owing to shorter pro cedure and fluoroscopic times, “offsetting the initial [higher] expense of the filter.”

Tilting or hooking occurred significantly less often in the process of retrieving the Denali inferior vena cava (IVC) filter than with the Option IVC device, a retrospective review at a tertiary care center has established.

Bhinder et al looked at all patients who underwent IVC filter retrieval or attempted retrieval at the university-affiliated medical center over a five-year period across demo graphics, comorbidities, filter brand, proce dural data, retrieval cost and complications.

Theyreports.further find that Denali filters “were less likely to have significant tilt of greater than 5° [14.0% vs. 38.6%] or have the hook embedded in the IVC wall [0% vs. 11.4%; p< 0.001].” Device fracture (1.8% vs. 0%) was similar (p=0.38), Bhinder and colleagues demonstrate. Months to retrieval was 12.4 for Denali vs. 11.2 for Option (p=0.75). The Bard retrieval device was used in 89.5% of Denali and 71.7% of Option cases (p =0.09).

◆ Chapters with concise and comprehensive diagnostic and therapeutic algorithms vital to the evaluation and management of patients with the discussed conditions. This provides an immediate and concise reference for practitioners. Material is now more focused, with larger numbers of relatively shorter chapters (more than 200).

◆ New chapters in the section include “Development

The Journal of Vascular Surgery (JVS) and JVS-Vascular and Lymphatic Disorders (JVS-VL) offer four free-access articles in each publication. JVS publishes monthly and JVS-VL, bi-monthly.

New study indicates cost-effectiveness of Denali IVC filter over Option device

◆ Up-to-date coverage of the rapidly evolving endovascular treatment of complex aortic disease, including thoracic and thoracoabdominal aneurysms.

JVS

1. Impact of an emergency EVAR protocol on 30-day ruptured abdominal aortic aneurysm mortality (Editor’s Choice). Visit vsweb.org/JVS-EVARonAAA

Bhinder

Rutherford’s is considered the definitive word in terms of vascular disease and its medical, surgical and interventional management, and a welcome reference for all those involved in vascular disease. It is published in association with the Society for Vascular Surgery, with writing from multidisciplinary and international

and Operation of LabsOperationand“DevelopmentCenters,”DialysisOutpatientSuccessfulofOffice-basedandAmbulatorySurgery Centers” and “Development and Successful Operation of Multispecialty Cardiovascular Centers,” including insights from those who have developed and are practicing in such settings.

20 Vascular Specialist | September 2022

JVS-VL

2. Severity of stenosis in symptomatic patients undergoing carotid interventions may influence perioperative neurologic events (continuing medical education [CME] credit is available). vsweb.org/JVS- JVS-Stenosis0922

plications (0% vs 4.3%; p=0.08), the team adds. The Dena li device also had shorter fluoroscopy time (7.4 minutes vs. 22.2 minutes; p=0.001), procedural time (32.0 minutes vs. 60.7 minutes; p<0.001), total hospital costs ($3,154 vs. $5,245; p<0.001), and procedure costs ($1,333 vs. $1,985; p<0.001).Whensecondary retrieval attempts were included, hospi tal costs—distributed across all Option retrievals—increased to $5,981 and procedural costs to $2,098, Bhinder et reveal. The average price of the Denali filter is $1,675 vs. $850 for the Option, they note.

◆ A new comprehensive section on “The Use of Technology Platforms and Social Media in Vascular Surgery.” The COVID-19 pandemic has caused telemedicine to play an increasingly important role in patient care, and this new approach may endure. One chapter specifically addresses telemedicine in vascular surgery. The new edition also includes new chapters on “Internet-Based Surveillance of Vascular Disease and Reconstructions,” “Social Media in Vascular Surgery Practice” and a chapter focusing on “The Quality and Fidelity of Vascular Information on the Internet.”

Eight free articles for September are available on the JVS websites through Nov. 1.

DenaliIVCJasmine

Jasmine Bhinder, MD, and colleagues University at Buffalo in Buffalo, New York, were delivering the findings at the Eastern Vascular Society (EVS) annual meet ing in Philadelphia (Sept. 29–Oct. 1).

Bruce Perler

◆ Inclusion of not only comprehensive coverage of routine vascular surgical care but also relatively esoteric topics, such as a new chapter on “Acute Vascular Occlusion” in the pediatric population.— Beth Bales

Additionally, the Denali was more likely to be successfully re trieved on first attempt (94.7% vs. 79.5%; p =0.019), with sim ilar overall success following secondary attempts (94.7% vs. 81.8%; p=0.056), they show. Need for adjunctive procedures was similar (0% vs. 8.7%; p=0.08), as were procedure-related com

1. Treatment of superficial venous insufficiency in a large patient cohort with retrograde administration of ultrasound-guided polidocanol endovenous microfoam versus endovenous laser ablation (Editor’s Choice). Visit vsweb.org/JVSVL-MicrofoamVsAblation0922

4. A single-center experience of anterior accessory saphenous vein endothermal ablation demonstrates safety and efficacy. SaphenousVeinAblastion0922vsweb.org/JVSVL-

◆ Coverage of the business of vascular surgery, including outpatient practice; effective social media strategies; and telemedicine, to serve as a valuable resource not only in the care of the specific vascular condition but also in managing one’s practice in general.

SVS members receive the 30% discount when using the discount code SVS30. To learn more and purchase Rutherford’s, visit vascular.org/Rutherford10.

4. Impact of iliac tortuosity on the outcomes after iliac branch procedures. Visit vsweb.org/JVSIliacTortuosity0922

PEER

REVISED RUTHERFORD’S TEXTBOOK AVAILABLE FOR PURCHASE

3. The preservation of accessory renal arteries should be considered the treatment of choice in complex endovascular aortic repair. vsweb.org/JVSRenalArteries0922

CKD 3b, 4, and 5 had the longest operative times, they find. Khoury and colleagues comment that their study is noteworthy owing to the fact that it suggested CKD 5 patients being intervened on for AAAs less than 5.5cm “may be harmed if offered EVAR.”

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They explain: “The indication for repair for AAAs <5.5cm is unclear in this study. Nonetheless, we did find that CKD 5, in ad dition to CKD 1, had the highest proportion of patients with concomitant iliac artery an eurysms. Therefore, there is a possibility that the indication for repair was the iliac artery aneurysm rather than the AAA. This would lead to an underestimation of the predicted one-year mortality rate in these patients since the rupture risk of the iliac artery aneurysm was not accounted for with our methodolo

MITRI KHOURY

In an interview with Vascular Specialist, Khoury explained that combining the Gagne index and the predictive aneurysm-related mortality based off aneurysm size yields the prediction without repair. “We compared the prediction of one-year mortality without EVAR vs. what their actual one-year mortal ity is with EVAR, and then figure out which patients may benefit for repair,” he said.

“This is obviously not a randomized-con trolled trial, but what we found suggests that with advanced CKD patients, the un derlying comorbidities are so high, the size threshold should be a little bit higher in these patients.”

(CKD)

at the 2022 Western Vascular Society annual meeting in Victoria, British Columbia, Canada (Sept. 17–20). Those with CKD ranked 3b, 4, and 5—found to be high-risk—had worse one-year mortality rates compared to the re mainder of the cohort, Khoury et al report, with CKD 1–3b patients showing a one-year mortality benefit following EVAR regardless of AAA size. “CKD 4 patients had no de monstrable benefit following EVAR at any AAA size. CKD 5 patients had worse actual one-year mortality rates with EVAR than pre dicted one-year mortality without EVAR for AAAs <5.5cm, although there was a mortali ty benefit with EVAR for AAAs >7.0cm in the CKD 5 group,” they elaborate.

THAT WAS AMONG THE CHIEF findings in a paper presented by Mitri Khoury, MD, who recently completed his residency at the University of Texas Southwestern in Dal las and a current fellow at the Massachusetts General Hospital, and colleagues, presented

randomized-controlled

By Bryan Kay

STUDY PROBES WHO KIDNEYWITHAMONGFROMBENEFITSEVARPATIENTSCHRONICDISEASE

“ This is obviously not a trial, but what we found suggests that with advanced CKD patients, the underlying comorbidities are so high, the size threshold may need to be a little bit higher in these patients”

Mitri Khoury

a high-risk group who may not benefit from endovascularelectiveaneurysm repair (EVAR) for

(AAAs) under

gy. The VQI defines an iliac artery aneurysm as anything greater than 2cm, which is be low the recommended threshold for repair of 3.5cm, so we are unable to ascertain in the current study whether the iliac artery an eurysm was the indication for repair among patients with AAAs <5.5cm.”

The patient pool was derived from the Vascular Quality Initiative (VQI), with near ly 35,000 patients meeting the study criteria. Some 8,183 (23.4%) were classed as CKD 1 patients, 16,888 (48.4%) CKD 2, 6,038 (17.3%) 3a, 2,708 (7.8%) 3b, 624 (1.8%) 4, and 485 (1.4%) CKD 5. The research team noted no table differences in the baseline and operative characteristics: CKD 5 patients were less like ly to be fully functional and were more likely to have a prior aortic aneurysm repair than the remainder of the cohort, while patients with CKD 1 and 2 had the lowest Gagne Indi ces, the measure used “to understand which subset of patients with CKD are most likely to experience a survival benefit following elective EVAR for AAAs,” while patients with CKD 3b and 4 had the highest. Patients with

Patients with advanced chronic kidney disease represent abdominal aortic aneurysms traditional sizing criteria.

“

22 Vascular Specialist | September 2022

◆ Help surgeons and their team get it right the first time. That’s important because odds for full reimbursement decrease upon re-submission

◆ Relative value units (RVUs) and physician compensation: Concerned that all RVUs are not being captured? Make sure the “count” is correct

DON’T NECESSARILY BELIEVE THAT OLD SAW, “What you don’t know can’t hurt you.” When it comes to coding procedures for reimbursement, that adage is com pletely incorrect. What vascular surgeons and their staffs don’t know definitely can—and does—hurt the bottom line.

Proper coding and documentation will:

Critical updates to be covered include:

◆ Audit targets, risk areas for vascular surgeons and respond ing to a payer audit. RAC, UPIC and OIG audits, CBR let

◆ 2022–2023 Medicare update: proposed reduction in the physician fee schedule for 2023

◆ Does practicing in an outpatient-based facility an OBL put a surgeon at higher risk? What about a vein center?

The optional E&M workshop will provide an understanding of and incorporating the new guidelines for outpatient E&M coding, a first look at the new 2023 Facility E&M guidelines plus code revisions and deletions.

That’s just one of the reasons the Society for Vascular Sur gery holds a Coding and Reimbursement Workshop annually.

What you don’t know can hurt you

◆ The course, which particularly attracts surgeons’ staff coders, will be in the OLC Education and Conference Center at 9400 W. Higgins Road, Rosemont, Illinois

CODING WORKSHOP

Learn more, see the agendas and register at vascular.org/ Coding22.

The optional E&M Workshop will be from 8 a.m. to 12

Correct coding is key to reimbursement and correct documentation is key to proper coding ”

◆ Give surgeons all the appropriate reimbursement to which they are entitled

“Correct coding is key to reimbursement and correct doc umentation is key to proper coding,” said course director Sean Roddy, MD. The information participants learn at this course helps surgeons reduce their risk for an audit. “And an audit—even if the outcome is favorable to the surgeon – costs staff time and money.”

ters—understanding the alphabet soup of Medicare audits

SEAN RODDY

p.m. CDT Oct. 1 and the main workshop will follow, from 1 to 5 p.m. that same day and from 7:30 a.m. to 4:30 p.m. Oct. 2. The optional E&M Workshop is available only to those registering for the full Coding Workshop.

SVS members and their staffs receive a discount on reg istration. Cost for the main workshop is $425 for candidate members and $475 for non-member can didates; $995 for members and office staff; and $1,095 for non-mem bers.Cost for the optional workshop is $150 for candi date members and $175 for non-member candidates; $250 for members and office staff; and $300 for non-members.—Beth Bales

It’s the only vascular surgery-specific coding course in the country and covers all the details vascular surgeons and their staffs need to know for coding. It is invaluable for teaching attendees how to get reimbursement and documentation down pat the first time.

◆ Reduce the risk and hassle of an audit

It’s better to get it right the first time around, he stressed, because odds for successful reimbursement decrease with each submission. “We have participants tell us that what they learn can more than pay for the course in very short order.”The workshop is designed for all members of the vascu lar team, including surgeons and their office staff such as practice managers, nurse practi tioners, physician assistants, nurses, surgery schedulers and coders.

www.vascularspecialistonline.com 23 ADVOCACY

withmomentumBuildinggrassroots

It is our opportunity to organize (let them see that we are thoughtful and united), to educate (help them plainly see the conse quences of inaction) and to advocate (pres ent them with viable proposals and ask for their support).

Although lawmakers are accustomed to meeting with lobbyists and other organizational representa tives, what really matters most to them is you— their constituents. As a result, all SVS members

Donate to the PAC at vascular.org/PAC

During one such event with Rep. Angie Craig (MN-2nd District), Dr. Patrick Ryan was able to eloquently outline the plight of office-based practices as well as the im mense value these practic es offer in terms of provid ing care in an efficient and cost-effectiveFollowingmanner.the ex change, Rep. Craig vowed to further investigate the issue and articulated an interest in becoming more involved. This is the

We must continue to build a coalition of congressional representatives who are will ing to bring our issues to light to the Con gress. We need to guide these representatives so that appropriate legislation can be drafted and passed such as recent legislative success es. Our engagement as individuals, group practices and academic centers is crucial to thisPACcause!donations raise money needed to gain audience with members of Congress and build our platform. More importantly the percentage of us donating is a direct and tangible metric demonstrating our level of commitment.Writingtoour local representatives has been stressed by the lawmakers with whom we have met, especially in “vulnerable” dis tricts. Everyone’s congressional representa tive needs to know that there is a healthcare crisis that is threatening their constituents’ access to vascular care!

D

The week occurs during Congress’ critical September work period; members will be asked to participate in a series of simple, short advocacyrelated activities, such as contacting their lawmakers. This special Week of Action will offer all SVS members an opportunity to collaboratively amplify the Society’s messages on Capitol Hill.

eep in to the second half of the year, there is no rest for the weary regarding Society for Vascular Surgery (SVS) advocacy ini tiatives. In July the Centers for Medicare & Medicaid Services (CMS) released its calen dar year 2023 proposed rule to revise pay ment policies under the Medicare physician fee schedule. Thus, we are now poised to fight yet another round of payment cuts that could significantly impact vascular surgery. Having submitted a detailed comment letter to CMS at the start of this month, we are now redoubling our efforts to engage law makers on Capitol Hill and ensure policies to mitigate the pending cuts are included in must-pass legislation before the end of the year. With this scenario on the horizon, and an acute need for increased engagement from SVS members, it feels like a good time to provide a refresher regarding our advocacy offerings.AsIhope

This easy-to-use grassroots platform al lows SVS members to send pre-written mes sages to their lawmakers to articulate the SVS’ position on a variety of active legislative or regulatory issues. This sort of “at-home” engagement is often an essential component for securing a lawmaker’s support for a piece of legislation or sign-on letter.

ADVOCACY WEEK OF ACTION PLANNED FOR SEPT. 26 TO 30

Society for Vascular Surgery members should mark their calendars for Sept. 26 to 30 for a special virtual “Week of Action” on advocacy.

Various threads on SVSConnect have pointed out that financial decisions by CMS affect all of us and our ability to plan for our practices and deliver high-quality care to our patients. Recent SVSConnect posts have stressed that we are all in this together. Having these dis cussions is healthy and resolving differences of opinion in a healthy fashion will help us solidify our message and our ability to support the specialty. However, we must also transform these discussions into action and work collaboratively to ensure that the strength of each of the afore mentioned advocacy tools contin ues to grow.

Since mid-2020, SVS members have sent more than 5,000 messages to their federal lawmakers. This is a great measure of en gagement, but we still have room to grow and continue to leverage this important ad vocacy strategy. To help provide a more com prehensive foundation for our grassroots outreach, the SVS has launched a new key contacts program—REACH 535—to identify contacts for each legislative district and ultimately amplify our mes sages to lawmakers.

KENNETH MADSEN is a member of the SVS Political Action Committee Steering Committee.

type of dialogue SVS PAC helps to facilitate. Members of Congress are busy on many fronts and are often not familiar with these healthcare issues.

SVS ADVOCACY IN ACTION: PROTECTING AND ADVANCING THE INTERESTS OF VASCULAR SURGERY

Working the legislative process

To learn more about this critical program, I encourage you to contact our advocacy team at SVSadvocacy@vascularsociey.org or visit v REACH535ascular.org/ .

Our challenge: Building a unified coalition

strategies to facilitate healthcare provider well-being and launch a campaign encour aging health care workers to seek assistance when needed. The bill was signed into law by President Joseph Biden in March 2022.

Our representatives need to know that it is not fiscally responsible for us to invest in staff, supplies or in any other meaningful ways when we know that there will be budget cuts looming every single year. The repre sentatives are sympathetic to these issues but only when the issues are put before them in a direct and concise manner.

you are aware, the SVS utilizes a multi-faceted approach for advocacy with an overarching goal of protecting and ad vancing the interests of vascular surgery. This includes traditional legislative advoca cy and lobbying with federal lawmakers on Capitol Hill, activating our SVS colleagues to engage in grassroots campaigns via our “Voter Voice” system and supporting the campaigns of candidate and incum bent lawmakers through the SVS’ political action committee, SVS Political Action Committee (PAC).

By Kenneth Madsen, MD

should be looking for, and participating in, every “Voter Voice” grassroots call to ac tion they receive.

Tying it together with SVS PAC SVS PAC is the collective voice of vascular surgery on Capitol Hill and serves as the po litical arm of our ongoing advocacy efforts. Via contributions from our members, the SVS PAC supports incumbent lawmakers and candidates who will champion the is sues important to vascular surgery and the patients we serve. SVS PAC is non-partisan andWithissue-driven.morethan 4,000 federally registered political action committees, SVS PAC is the only one focused on identifying and support ing pro-vascular surgery lawmakers. To help facilitate the development of strong relation ships with lawmakers, representatives from the SVS PAC Committee and/or our Advo cacy staff, attend fundrais ing events where SVS’ top legislative priorities are discussed directly with the member of Congress and his or her top staff.

Kenneth Madsen

By simultaneously engaging in these core tenets of effective advocacy, the SVS has achieved many successes over the last several years, including (but not limited to): mitigat ing scheduled Medicare physician payment reductions, securing passage of legislation to address physician wellness and garnering significant bipartisan and bicameral support for legislation designed to ease the burdens of prior authorizations. But let’s take a clos er look at each of these advocacy tools in action.

More information will be available in early September.

This is not the time for complacency. Just as surely as night follows day, we find our selves on the brink of additional reimburse ment cut proposals that will surface in the coming weeks. Thanks to all who are doing their part but now is the time for all members of the SVS to step up!

A significant achievement during the current 117th Congress was passage of the Dr. Lorna Breen Health Care Provider Protection Act (H.R. 1667). This critical legislation autho rized grants for programs that offer behav ioral health services for front-line healthcare workers. It also requires the Department of Health and Human Services to recommend

In addition, the SVS, in collaboration with a broad coalition of physician organi zations, has successfully sought legislation over the last two years to significantly reduce scheduled payment cuts within the Medi care physician fee schedule. Led by physi cian lawmakers Reps. Drs. Larry Bucshon, MD (R-IN), and Ami Bera, MD (D-CA), the physician community continues to make the strong argument that the payment system is broken, and Congress must act to provide greater stability while relevant stakeholders and lawmakers can identify long-term policy reforms.Inaddition to sponsoring legislation and delivering letters to both CMS and congres sional leadership, Bucshon and Bera have worked to raise awareness among their col leagues regarding this healthcare crisis and are in the process of facilitating a roundtable meeting to discuss this ongoing issue and build upon our work over the last two years to advance the goal of systemic payment reform.With few healthcare professionals in Con gress, the support of Bucshon and Bera is critical, as they are important assets in terms of the cumbersome process of educating lawmakers who are not fa miliar with the healthcare delivery system and/or the intricacies associated with physician payment. The SVS is engaging in similar efforts this year and we anticipate contin ued work on these issues through the remainder of the year.

V A S C U L A R . O R G C

24 Vascular Specialist | September 2022

All proceeds will go to the SVS Founda tion, which will use the generated funds to assist vascular patients with exercise therapy.TheVascular Health Step Challenge was created to take place during Nation al Peripheral Arterial Awareness (PAD) Month. Vascular surgeons frequently see patients with PAD, which can cause pain while walking and threaten overall health. Walking can improve that pain, plus benefit hypertension and cholesterol levels and even slow the growth of abdominal aortic

“ We want cardiovascularbenefits,widewalkingtoparticularlypeople—patients—understandthatprovidesarangeofhealthparticularlyforhealth”

regional teams. Community participants can form their own team or join an existing one. Then, between Sept.1–30, participants get walking, logging the steps and transfer ring them to the website. Walkers can seek donors for an overall amount or a per-step contribution, such as a donation for each 100, 1,000 or 10,000 steps.

WITH THE TURN OF THE calendar page to Thursday, Sept. 1, vascular surgeons, their families, friends and the general public began taking a step or 10 to highlight the significant health benefits of Bywalking.theend of August, more than 250 people had signed up for the Society for Vascular Surgery Foundation’s Vascular Health Step Challenge, urging individuals to walk 60 miles during the month’s 30 days. The 60 miles represent the 60,000 miles of blood vessels, arteries and capillar ies in the human body.

aneurysms.“Wewant people—particularly pa tients—to understand that walking provides a wide range of health benefits, particularly for cardiovascular health,” said Benjamin Pearce, MD, chair of the SVS

Subcommittee. As of Sept. 1, the 250 participants had already raised more than $25,000.Whyare members walking? Karen Woo, MD, said she is “committed to improving the care of our patients with vascular disease and promoting vascular habits. Leigh Ann O’Banion, MD, added that the inaugural health challenge “will amplify the importance of vascular health while promoting healthy habits across the country.” Pearce urged all SVS mem bers to get involved. “Step up!” he said.

It’s not too late for anyone who still wants to join the movement to get walking. Visit abrands)Fitbitpairprintsawebsite,lengevascular.org/VascularHealthChaltoreachtheCharityFootprintswhichishostingtheinitiativefromtechnicalstandpoint.ParticipantsdownloadtheCharityFootappontheirsmartphonesandthentheirpersonalfitnessdevices,suchasaorAppleWatch(aswellassixothertothesite.Thosewhodonothavefitnesstrackercanenterstepsmanually.ParticipatingSVSmembersarecreating

SURGEONS

BENJAMIN PEARCE

P V I

SVS Vascular Health Step Challenge participants can register by region

PAD

By Beth Bales START STEPPING

OFF FOR SVS VASCULAR HEALTH STEP CHALLENGE O C T O B E R 2 3 - 2 4 , 2 0 2 2 R O S E M O N T , I L L I N O I S

/

“We’re crossing a horizon with a lot of new interventions, especially in the below-the-knee space,” said O’Banion. “In travascular ultrasounds, retrograde pedal access, Shockwave lithotripsy … these are all new tools we can use to treat pa tients with advanced chronic limb-threatening ischemia.”

training for these really challenging patients that all of us are seeing more and more frequently in our clinical envi ronment.”Beyondlearning new skills, think of “fun” as a bonus rea son to “Anyattend.timeyou can network with your colleagues, where there are that many people in a room passionate about PAD, where instructors are pushing the limits of limb salvage, constitutes a good experience,” said O’Banion.

Limited spots are available for the course, designed by vascular surgeons for vascular surgeons.

CANADIAN VASCULAR

There were no differences in MACE. “Among subgroups, there were no differences in [amputation-free survival], major amputation or death,” Jacob-Brassard et al report. “Endovas cular revascularization resulted in lower long-term MALE for those with infrainguinal disease only and those with tissue loss. There was no difference in MACE.”—Bryan Kay

www.vascularspecialistonline.com 25

11,20317,661

JOHN WHITE

Learn more and register today at vascular.org/CLTIroundtable2.

◆ How WIfI staging drives triaging of care (Armstrong)

The three sessions feature one sample patient for whom to design treatment strategies; session leaders and speakers will use this patient to demonstrate how to put the global vascular care guidelines into practice. Surgeons also will cover the importance of repetitive staging to guide the course of treatment and review potential changes in the treatment plan if such alterations are required.Thethird and final session, “Revascularization,” will be Monday, Oct. 10. Conte, who was the lead author for the Global Vascular Guidelines, will moderate the session. This concept and content of this educational was solely developed by the Society for Vascular Surgery. This activity is partially funded by a block grant from W.L. Gore and Associates, Inc.—Beth Bales

The speakers are Elina Quiroga, MD, MPH, of University of Washington; Nobuyoshi Azuma, MD, of Asahikawa Medical University in Japan; Sanjay Misra, MD, Mayo Clinic; and David Armstrong, DPM, PhD, of the University of Southern California. Joseph Mills, MD, will lead the session, joined by co-moderators Michael Conte, MD, and John White, MD.This is the second session of “Translating Guidelines into Practice: Global Vascular Guideline on the Management of Patients with CLTI.”

said White, of determining “how these recommendations apply to our own patients. These three instructional webinars are devoted to informing you how to apply the guidelines to the care of your patients, the limb and anatomy.”

◆ Current approaches and limitations to hemodynamic assessment and

CPVI

Among the 28,864 patients identified as having been revas cularized for PAD, 39% (n=11,203) underwent endovascular revascularization. Median follow-up time was 4.42 years.

The two-day course, with a dedicated hands-on com ponent, will be Oct. 23 and 24 at the OLC Education and Learning Center at 9400 W. Higgins Road, Rosemont, Ill. The center is minutes from O’Hare International Airport. Discounted early-bird pricing ends Sept. 23.

The first, on overall medical care of CLTI patients, drew nearly 450 participants.. The sessions answer the challenge for practicing physicians,

LIMB STAGING IS OF KEY importance in triaging care for patients with chronic limbthreatening ischemia (CLTI).

perfusion measurement in the foot and how they are employed in both pre- and post-revascularization (Misra)

Wound, Ischemia and Foot Infection (WIfI) staging, and hemodynamics and foot assessment are the main focus of the September session, said Mills. Topics will include:

o matter if you’re a surgeon with a few years—or a few decades—of experience, faculty members of a new, up coming Society for Vascular Surgery course say you’re sure to learn valuable skills and strategies to help in treating patients with peripheral arterial disease.

With limited openings, “Run, don’t walk, to sign up for this incredible course,” said faculty member Venita Chandra, MD.

“I’m excited to go peek at some of the tables and watch Dr. Dan Clair teaching LimFlow and watch Dr. Venita Chandra do a retrograde peroneal access. There are always new things you can be learning at every stage of your career. We can all learn from each other.”—Beth Bales

Learn how to roundtablefreelimbsanddiagnosestageat

The findings are part of research presented at the Canadian Society for Vascular Surgery (CSVS) annual meeting in Van couver, British Columbia (Sept. 9–10) by Jean Jacob-Brassard, MD, and colleagues from the Department of Surgery at the University of Toronto. The investigators looked at all Ontar ians 40 years or older revascularized between April 1, 2005, and March 31, 2020, through either an endo vascular or open approach, with a primary outcome of amputation-free survival and secondary outcomes of major amputation, death, major adverse limb events (MALE), and major adverse cardiovascular events (MACE). They used Cox proportional haz ards models to compare patients undergoing endovascular vs. open revascularization, with weighting by propensity score-based overlap weights to account for baseline character istics. Analyses were repeated for pre-specified subgroups: diabetes, isolated infrainguinal disease, and tissue loss.

A REAL-WORLD ANALYSIS OF PERIPHERAL arterial disease (PAD) patients in Canada indicated open revas cularization may not offer a long-term benefit over endovas cular intervention. In a population-based retrospective cohort study, researchers from the University of Toronto in Toronto, Ontario, found that in PAD patients eligible for both strategies, endovascular revascularization is associated with “superior or not significantly different outcomes” relative to open repair.

And surgeons at all career stages can add these skills as useful tools in their toolboxes, she added.

Learn more, get the course lineup and register at vascular.org/ CPVI. PAD: ‘Run, don’t walk, to sign up for this incredible course’

Treating

CLTI

WIFI system

“ These webinarsinstructionalthreeare devoted to informing you how to apply the guidelines to the care of your patients, the limb and anatomy”

Innovations and new devices and technologies in patient treatment are introduced frequently, spurring surgeons to keep themselves updated, O’Banion said. “Maybe I’m biased as a faculty member, but I see value in this course for all vascular surgeons.”

classification

◆ WIfI staging and the use of the WIfI stage calculator (Quiroga)

In the full cohort weighted analyses, endovascular revascu larization was associated with better amputation-free surviv al, no difference in major amputation, lower mortality, and lower hazard of MALE after four years, the researchers found.

PAD: REVASCULARIZATIONENDOVASCULAR ‘SUPERIOR OR NOT DIFFERENTSIGNIFICANTLYOUTCOMES’ VERSUS OPEN REPAIR

N

“This is going to be a great course with experts in the field teaching novel endovascular technologies,” said Leigh Ann O’Banion, MD, one of 18 faculty members for the Society for Vascular Surgery’s Complex Peripheral Vascular Intervention (CPVI) Skills course.

Four internationally known surgeons/speakers in peripheral arterial disease (PAD) will discuss developing a sequence of stages Sept. 12 during the second of three sessions on helping surgeons apply guidelines for CLTI care into their practices. The virtual, free roundtable, “Diagnosis and Staging of the Limb,” will be from 6 to 7:30 p.m. CDT.

“I don’t think there’s a better course out there to give sur geons a comprehensive hands-on experience and advanced

◆ A review of contemporary data on the relationship between WIfI staging and important clinical outcomes in CLTI patients (Azuma)

Compiled by Beth Bales

Gore has announced the acquisition of InnAVasc Medical, a privately held medical technology company focused on advancing care for patients with end-stage renal disease who utilize graft circuits for dialysis treatment. Jeffrey Lawson, MD, PhD, and Shawn Gage, PA-C, of Duke University School of Medicine’s Department of Surgery in Durham, North Carolina, developed the InnAVasc device, which is specifically designed to allow for safe, easy, reproduceable and durable access for dialysis treatment of patients with graft

SOCIETY BRIEFS SVS 535’PROGRAMLAUNCHESTO‘REACHLAWMAKERS

WILLIAM T. MALONEY, 88, of Manchester-By-The-Sea, Massachu setts, died July 30. Maloney was for many years the executive director of the Society for Vascular Surgery/International Society for Cardio vascular Surgery, North American Chapter; the two merged in 2003 to become the Society for Vascular Surgery. He is the only non-doctor interviewed for the SVS History Project. Visit vascular.org/Histo ryProject for a list of the video interviewees.

Selution SLR receives second FDA IDE approval

Selution SLR, MedAlliance’s sirolimuseluting balloon, has received conditional Food and Drug Administration (FDA) investigational device exemption (IDE) approval to initiate its pivotal clinical trial for the treatment of occlusive disease of the superficial femoral artery (SFA). This comes only a few months after the company received IDE approval for Selution SLR in the treatment of belowthe-knee (BTK) indications (May 2022). Enrollment will begin in the SELUTION SLR IDE SFA study later this year. It will be conducted at over 20 centers in the U.S. and an additional 20 centers around the world.This study will enroll 300 patients to demonstrate superiority over balloon angioplasty (POBA). The principal investigator of this study is George Adams, MD, the director of cardiovascular and peripheral vascular research at Rex Hospital in Raleigh, North Carolina.

GIVE GIFT OF SVS MEMBERSHIP TO VASCULAR NURSES

Compiled by Jocelyn Hudson, Will Date and Bryan Kay

Vascular experts establish appropriate use of IVUS in peripheral interventions Royal Philips announced an important milestone in the evolving standard of care for treating patients with peripheral vascular disease: the establishment of the first-ever global consensus for the appropriate use of intravascular ultrasound (IVUS) in lower-extremity arterial and venous interventions.

SEPT. 4 TO 10 IS VASCULAR NURSES WEEK. IT’S THE perfect opportunity for Society for Vascular Surgery mem bers to “give the gift of dual membership” to both SVS and the Society for Vascular Nursing to their vascular nurses.

Vascular Specialist | September 2022

The Auryon laser can be used to treat all infrainguinal lesion types, including above-the-knee (ATK), below-the-knee (BTK), and ISR, and to date, has been used to treat more than 21,000 patients in the U.S., a company press release reported.

The FDA recently cleared the expanded indication for the Auryon system’s 2mm and 2.35mm catheters to include adjacent thrombus aspiration when treating stenoses in native and stented infrainguinal arteries. Both catheters have aspiration capabilities as atherectomy devices, including in-stent restenosis (ISR).

AngioDynamics announces FDA clearance of expanded indications for Auryon atherectomy system

Gore InnAVascacquiresMedical

Joining the CPT team in represen tation are Jonathan Thompson and Xiaoyi Teng, and for the RUC team are Mark Iafrati and Justin Hurie. The SVS coding and reimbursement team look forward to training the new leaders.

Trainees step up to learn reimbursementcoding,

The SVS has a long tradition of ad vocacy training under leaders such as David Han, MD, Sunita Srivastava, MD, and Matthew Sideman, MD, plus Robert Zwolak, MD, in creat ing procedural codes, descriptions of work and relative value (RVU) rec ommendations. These leaders help guide appropriate reimbursement of vascular surgeons’ work and practice expenses. The SVS actively trains fu ture leaders in the physician payment

All members who give this gift will be recognized. A group discount of 10% is available for those who give four dual memberships. Incoming SVN President Kristen Alix said, “I joined as a novice bedside nurse, only expecting to glean knowledge of the vascular patient. There was that and so much more. SVN gives the ability to network with national nursing leaders, provides expert content and encourages in dividual professional growth. I never thought I would lecture on a national stage, be a part of a Board of Directors, or add to vascular education and research.”

Thecircuits.investigational InnAVasc device is designed to protect the graft from backwall punctures and reduce the damage associated with frequent needle sticks. This can lead to circuit failure and shortened circuit life. “To be stuck with two needles three times a week for hemodialysis for 52 weeks, that’s 312 times a needle goes into a patient’s graft each year,” said Stephen Hohmann, MD, vascular surgeon at Texas Vascular Associates in Dallas.

26

TO LEVERAGE THE POWER OF direct engagement with lawmakers on the part of constituents—the SVS Advocacy team is launching a grassroots advocacy plan to help foster this direct communication between SVS members and their federal lawmakers.

“We are very excited that U.S. patients suffering from PAD [peripheral arterial disease] will have the opportunity to receive this novel sirolimus drug-coated balloon technology. This is yet another advancement in the field of treating vascular disease and we are confident that this study will enroll quickly,” Adams commented.

system or Resource-Based Relative Value Scale (RBRVS) to advocate for present and future coding and reimbursement. Two panels within the American Medical Association (AMA), the Relative Value Scale Up date Committee (RUC) and the Cur rent Procedural Terminology (CPT) panels, are critical to ensure the SVS has a voice in shaping CPT, RVUs and Medicare reimbursement.

The Society for Vascular Surgery’s (SVS) efforts in coding and reim bursement work have taken another step forward, with four new doctors now in training to learn the ins and outs of the entire process.

The advisory work and AMA pro cess representation workload is divid ed among CPT and RUC teams, each with an advisor, alternate advisors and trainees. The SVS is pleased to announce four new trainees.

“The voting panelists considered a variety of clinical scenarios and based on their extensive experience, arrived at a strong consensus,” according to lead author Eric A. Secemsky, MD, from Beth Israel Deaconess Medical Center in Boston.“Theyrecommend routine use of IVUS as a preferred imaging modality in all phases for many peripheral interventions, both diagnostic and therapeutic, as it enables such exquisite visualization of the target vessel and lesion.

The program will serve two purposes, said SVS Advocacy Council Chair Matthew Sideman, MD: connecting SVS members with their lawmakers to establish tangible channels for vascular surgeons to personally advocate on issues that significantly impact their practices and their patients; and establishing a concrete mechanism for the SVS to amplify its advocacy efforts by ensuring advocacy team members can quickly REACH the 535 decision-makers on Capitol Hill

To become a key contact in REACH 535, members should complete the sign-up form to identify their federal representatives and senators.

CLINICAL&DEVICENEWS

AngioDynamics recently announced receiving Food and Drug Administration (FDA) 510(k) clearance of an expanded indication for the Auryon atherectomy system to include arterial thrombectomy.

The form is available at vascular.org/ REACH535form. Information also is available by emailing vascularsociety.org.SVSAdvocacy@

Obituary

“Their recommendations, which withstood the rigor of peer review, can now be considered in the formulation of clinical guidelines for the diagnosis and treatment of peripheral vascular disease.”

Published in the August 2022 issue of the Journal of the American College of Cardiology: Cardiovascular Interventions, the new consensus document from 30 global vascular experts recommends routine use of IVUS as a preferred imaging modality in all phases in many peripheral vascular disease procedures.

The Society for Vascular Nursing (SVN) has made its man agement home with the Society for Vascular Surgery (SVS) since 2017. All Active SVN members automatically receive affiliate SVS membership as part of their SVN dues. This permits these vascular nurses to receive SVS communica tions and e-newsletters, discounts on the Journal of Vascular Surgery and SVS meetings, the SVS job board, and the SVN and SVS online communities on SVSConnect. It’s two mem berships for the price of one. And it’s as simple as filling out a form, at vascular.org/GiveSVNmembership. “We celebrate vascular nurses throughout the year, but especially during Vascular Nurses Week,” said SVS President Michael Dalsing. “This week celebrates the commitment and dedication that vascular nurses display every day on behalf of their patients, who are our patients. They are invaluable to the vascular surgery world.”

differences in the outcomes are attribut able to the risk profile of these patients. Patients with distal DVT were younger, more likely to have had DVT in the setting of transient provoking factors such as surgery or hormonal use but less likely to have serious comorbidities such as cancer or anemia. “Our findings may have implications for risk stratification and for practice,” said Bikdeli. “While we find less ominous outcomes for isolated, distal DVTs, they are not entirely benign. Even among patients who received initial anticoagulation treatment, almost half had signs or symptoms of post-thrombotic syndrome, a chronic manifestation of these clots.”

Writing in BJS, the authors report that a one to two week period of compression was associated with a mean reduction of 11 (95% confidence interval [CI] 8–13) points in pain score on a 100mm visual analogue scale compared with shorter duration (p<0.001). Mohamed that this was associated with improved HRQoL and patient satisfaction, however note that greater than two weeks’ compression did not add further benefit.

A NEW STUDY HIGHLIGHTS KEY differences in clinical features and comor bidities, as well as short-term and also long-term outcomes for patients with distal deep vein thrombosis (DVT) versus proximal DVT. The findings were recently published in JAMA Cardiology

www.vascularspecialistonline.com 27

VENOUS

POSTPROCEDURAL COMPRESSION OF ONE TO two weeks after superficial venous incompetence (SVI) treatment is associated with reduced pain compared with a shorter duration. This is according to a study published in the August edition of the British Journal of Surgery (BJS).

prising 2,584 treated limbs in their systematic review. Compression was compared with no compression in four studies, nine studies compared different durations of compression, and a further five compared different types of compression, Mohamed and colleagues relay.

The investigators included a total of 18 studies com

In order to investigate this gap in the literature, the researchers conducted a multicenter, international cohort study in participating sites of the Registro Infor matizado Enfermedad Tromboembólica (RIETE) registry from March 1, 2001, though Feb. 28, 2021. The team found that patients with isolated distal DVT had low er comorbidity burden and a lower risk of 90-day mortality. They were also at lower risk of developing a pulmonary embolism or a new venous thromboembolism (VTE) in one year.

The authors note that some of the

BEHNOOD BIKDELI

The differences between the clinical presentation, short-term and long-term outcomes for patients with isolated distal DVT (smaller thrombi in veins below the knee) versus proximal DVT have been un clear, Behnood Bikdeli, MD, from Brigham and Women’s Hospital in Boston, and colleagues write.

Compression of one to two withfoundtreatmentafterpostprocedureweeksSVIisassociatedreducedpain

Mohamed et al write that they used the UK National Institute for Health and Care Excellence’s Healthcare Data bases Advanced Search Engine to identify all English-lan guage RCTs of compression following treatment for SVI. Postprocedural pain, venous thromboembolism (VTE), health-related quality of life (HRQoL) and anatomical occlusion were the main outcomes of interest, they note.

In their conclusion, Mohamed evidence gaps that persist: “The optimal interface pressure and type of compression, and the impact on [VTE] risk, remain to be determined.”—

“There was low-quality evidence suggesting that 35mmHg compression with eccentric thigh compression achieved lower pain scores than lower interface pressures,” the authors add, noting also, “there were no significant dif ferences in [VTE] rates or technical success in any group, including no compression”.

Compression duration affects pain during superficial studyintervention,venousfinds

KEY DIFFERENCES IN PRESENTATION, OUTCOMES FOR DISTAL VERSUS PROXIMAL DVT UNCOVERED

“ While we find less ominous outcomes for isolated, distal DVTs, they are not entirely benign”

“ The optimal interface pressure and type of compression, and the impact on [VTE] risk,

Authors Abduraheem H. Mohamed, of Hull York Medical School in Hull, England, and colleagues note that international guidelines recommend postprocedural com pression when treating symptomatic SVI. However, they stress that there is no agreed timescale for this. In order to investigate the optimal application of postprocedural com pression, the research team carried out a systematic review of randomized controlled trials (RCTs).