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FROM THE COVER DIVERSITY IN CARE ‘FROM BEING EXCLUSIVE TO MORE INCLUSIVE’ the SVS in 2019. “At a time of unfortunate xenophobia in our culture, the SVS has always been an open international society, and this is no better reflected than in the backgrounds of so many of our past leaders,” he will tell attendees. The “unparalleled leadership of the SVS” in the field of vascular disease “reflects not only the wisdom of our past leaders,” but the organization’s commitment to evolution going forward, AbuRahma will say. The chief of vascular and endovascular surgery at West Virginia University School of Medicine/Charleston Area Medical Center in Charleston, West Virginia, will spotlight how this evolution at the SVS has played out at the structural and committee levels. “In the early SVS years, and during the first 50 years, there were very limited numbers of standing committees, including the membership, program, nominating [committees], and a committee on arrangements for VAM,” he plans to say. AbuRahma will outline how the membership has expanded and become more inclusive, and how new dedicated membership sections for women, young surgeons and physician assistants, and for areas such as community practice and office-based labs, have broadened discussion and educational offerings. He also will point out how changes at the SVS Nominating Committee level capture the essence of the Society’s evolution. “In the past, the SVS Nominating Committee consisted of three members appointed by the president one month before VAM, usually the three immediate past presidents, and its function was to compile a slate of officers to be presented to the Executive Council
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and members at the VAM,” AbuRahma will inform attendees. “Currently, it consists of seven members—the three most recent and surviving and available past presidents with the most senior as chair, one member that is elected annually from and by the 11 representatives of the regional and vascular societies serving on the Strategic Board, one member-at-large elected from the SVS membership who is not currently serving on the Executive Board, the vice-chair of the Community Practice Section, and the chair of Leadership and Diversity Committee.” Looking ahead, AbuRahma will go on, the SVS must maintain focus on key areas, such as branding the specialty, continuing the fight for “fair and appropriate payment,” and continuing the support for those in community practice: “We must be united and have a common message across members and keep investing in embracing diversity and cultural change,” he will tell delegates. “We should keep investing in our health and wellness and our early-career members which is critical for our future. We must continue to embrace quality in vascular patient care and finally we must work towards finding a common pathway in working with other non-vascular surgeon providers who practice endovascular therapy based on acceptable dedicated training in endovascular intervention.” That harkens back to AbuRahma’s chosen topic for last year’s E. Stanley Crawford Critical Issues Forum in San Diego. The then incoming SVS president focused on the role of multispecialty care in vascular and endovascular surgery, hoping to get at least some answers to the question: Can the competing specialties of the vasculature work together? AbuRahma assembled a panel of physi-
cians covering every specialty involved in the treatment of vascular disease for the VAM 2021 event. During the Forum, AbuRahma himself declared: “Vascular providers must have defined, dedicated vascular and endovascular training during their formal residency or fellowship. Multispecialty practice, if feasible, will enhance and improve vascular care.” At VAM 2022, AbuRahma is set to return to the topic, and will pose such questions as what strategy vascular surgery should deploy in order to ensure vascular procedures are carried out by appropriately trained specialists. “Many specialties are attracted to performing vascular procedures in light of workforce shortage, and mal-distribution creates access issues to vascular surgeons,” he will say. “Advances in treatment and device technology make therapy for an increasing number of vascular conditions within the perceived scope of other specialists, some
“The conduit used, and whether or not the patient has undergone prior vascular interventions, are the key predictors of [lowerextremity bypass] failure” ALI ABURAHMA
of whom are without adequate training. The current policies and incentives are rewarding the wrong behavior with consequences of quality challenges, increased complications landing in vascular surgery practices, payment inefficiencies with overutilization and unnecessary procedures.” He will once again raise the virtues of multispecialty practice, which traces its roots to his state—West Virginia—and the concept of a Vascular Center of Excellence model, such as the one developed at his institution: eight board-certified vascular surgeons, two board-certified cardiologists/vascular interventionists, one board-certified vascular medicine interventionist and one board-certified interventional radiologist. AbuRahma conducted a survey of SVS members to assess the level of interest in multispecialty models of practice. Among the results, he found more than 50% of respondents saw cardiologists/interventional cardiologists and interventional radiologists as a threat among non-vascular surgeon providers performing procedures for vascular disease, while 58% said they did not form part of a multispecialty group that includes non-vascular surgeons. What, then, should the strategy be? AbuRahma will ask: “How can the SVS best position itself to take the lead in shaping the future of vascular surgery care delivery, and optimizing patient outcomes? Can demonstrated competence and quality metrics be established and agreed upon across specialties? Who are the critical partners to engage in the dialogue?” And, he will add, “are there highly successful multispecialty models to be demonstrated? All of us know politics are local. Can we or should we influence and or impact training guidelines?”—Bryan Kay
MULTIDISCIPLINARY CARE VASCULAR SURGEONS ‘HAVE A ROLE TO PLAY’ IN TRANSCATHETER AORTIC VALVE REPLACEMENT PROCEDURES VA S C U L A R S U RG E RY A S S I S TA N C E I N transcatheter aortic valve replacement (TAVR) can facilitate safe and effective device introduction through cases involving challenging femoral or iliac access. This was the conclusion delivered by Enrico Gallitto, MD, from the University of Bologna, Bologna, Italy in a presentation looking at the role of the vascular surgeon in transcatheter aortic valve implantation. During Thursday’s Plenary Session 3, Gallitto delivered the findings of an analysis of TAVR procedures assisted by vascular surgeons between 2016 and 2020—in what Gallitto describes as a “high-volume tertiary hospital.” Gallitto noted that TAVR has become the standard treatment for severe aortic valve stenosis among patients at both high and intermediate operative risk for surgical valve replacement. Percutaneous transfemoral access is the preferred route for the procedure, he added, due to its low invasiveness and lower perioperative morbidity and mortality compared to transapical, transaxillary or transaortic approaches. However, Gallitto added that vascular access complications occurring from the transfemoral access are associated with prolonged hospitalization and 30-day mortality, and the presence of severe peripheral arterial diseases as well as aortic aneurysm or cerebrovascular insufficiency may necessitate concomitant endovascular management.
“A multidisciplinary team with interventional cardiologists and vascular surgeons may minimize the rate of vascular access complications in patients with challenging femoral/ iliac access and significant disease of other vascular districts,” he added, noting that this may be important to optimize the outcome of transfemoral TAVR. The study sought to evaluate the role of vascular surgeons in transfemoral TAVR. Gallitto and colleagues looked at pre-, intra- and postoperative data for the given time period, which were clustered and retrospectively analyzed by a dedicated group of both interventional cardiologists and vascular surgeons. Vascular access complications were defined according with the Valve Academic Research Consortium (VARC) 2 guidelines, and the outcomes of TAVR procedures with vascular surgeon involvement were assessed as the study’s endpoints. Overall, Gallitto and colleagues assessed a total of 937 TAVR procedures performed with a transfemoral approach ranging between 78% (2016) and 98% (2020). Vascular surgeons were involved in 67 (7%) procedures. Of these, three (4%) had indications for concomitant abdominal aortic aneurysm (endovascular aneurysm repair [EVAR]+TAVR), two (3%) with severe carotid stenosis (TAVR+CAS), and 62 (93%) had hostile femoral or iliac access or vascular access complications. Balloon angioplasty of iliac artery pre-TAVR was per-
formed in 51 cases (conventional percutaneous transluminal angioplasty [PTA]: 38/51‒75%; conventional PTA+intravascular lithotripsy [IVL]: 13/51–25%). The TAVR procedure was successfully completed via the percutaneous transfemoral approach in all 62 cases with challenging femoral/iliac access, Gallitto reported. Vascular access complications necessitating interventions occurred in 18 out of the 937 (2%) cases, localized to the common femoral or common/external iliac artery in 15/18 (83%) and 3/18 (17%) cases, respectively. They were managed by surgical or endovascular maneuvers in 3/18 (83%) and 15/18 (25%) cases, respectively. Fifteen/18 (83%) vascular access complications were treated during the index procedure, Gallitto reported, adding that there were no instances of procedure-related mortality or 30-day readmissions. In his concluding remarks, Gallitto commented that the necessity of vascular surgeon assistance in TAVR procedures is “not infrequent”, and participation by vascular specialists allows safe and effective device introduction through challenging femoral/iliac access, for example. “Similarly, the concomitant significant disease of other vascular districts can be safely addressed potentially reducing postoperative related mortality/morbidity,” he noted. “The organization of composite cardiological and vascular surgery teams should be encouraged wherever possible.”
