Vascular Specialist January 2022

16

SOCIAL MEDIA

#SoMe4Vascular

New recommendations emerge on appropriate use of social media for vascular surgeons

2

VASCULAR COOLNESS

Attracting bright young minds to the specialty

10

VETERANS AFFAIRS

How to cut through research red tape

STRENGTH IN NUMBERS

The global VASCC COVID-19 registries have already helped identify a framework to tackle delayed cases with applicability both inside the context of the pandemic—and beyond

BY BRYAN KAY

BY BRYAN KAY

WHEN ROBERT CUFF, and Max Wohlauer, MD, first launched the Vascular Surgery COVID-19 Collaborative (VASCC) back in the spring of 2020, the pandemic was still in its first wave, and the goal of a new vascular surgery registry to leverage key data with the the goal of preparing for the fallout from future outbreaks was in its nascent stages.

19–20

CORNER STITCH

Introducing our new resident/fellow editor

Fast forward to the waning weeks of 2021, as the Omicron variant ravaged

Priorities and objectives will guide 2022 SVS programs

BY BETH BALES

Whether it’s branding, advocacy or determining research initiatives, the process of setting Society for Vascular Surgery (SVS) priorities and objectives begins with SVS members. The SVS conducts a census, which includes asking members to rank-order priorities, every other year. In the off-years, such as this one, SVS adds new and emerging priorities to the existing list and asks members of the Strategic Board of Directors (SBOD), and council and committee volunteers, to do new rank-ordering for the next fiscal year.

The SBOD will meet virtually Jan. 14–15 to set priorities, programming and activities for the 2022–23 fiscal year, which begins April 1. The meeting was to have been in-person, but the Omicron variant forced a

Conveying vascular surgery’s essential ‘coolness’

BY PETER R. NELSON, MD

Let’s start with a question: how do we communicate coolness? No, I am not referring to a cool or cold foot in the emergency room in need of assessment for acute limb ischemia. We have validated clinical scales to communicate that information effectively. At the risk of dating myself by invoking the spirit of Arthur Herbert Fonzarelli from Happy Days, what I am talking about is, how do we communicate how cool (i.e., chill, sick, drip, Gucci, hip, trendy) our specialty is to bright young minds contemplating their career choices? Biased as I may be, I think if they really knew how cool vascular surgery is, many more would pursue it as a career. This is obviously important for us to recruit the best people to our field. It is specifically important for the learner in their pursuit to find their best fit, but it is also critically important to address the shortage and maldistribution of vascular providers we currently and will continue to face.

THIS TOPIC CAME UP DURING DINNER WITH a recent visiting professor. We were discussing our newly formed group in Tulsa, and I was asked to reflect. I said something like what I appreciate most is that we have assembled a really “cool” group of vascular and podiatric surgeons. What I was referring to in part was the individuals themselves—their personalities, their passion for the field, and their passion for clinical care, education, and research. But I was also reflecting on the fact that we, as a team, complement each other very well in each of those areas, support each other both professionally and personally, address challenges with unified advocacy, and, importantly, have fun working together. No disrespect to Simon Sinek who promotes with “Start with why”… I might offer it is important to “Start with who,” and/or “The who is the why” for a team leader.

During the presentations that day, wellness data were presented to the faculty, trainees and students across the entire campus. As is often the case with this discussion, one slide depicted data from a study on distress and career satisfaction compared amongst surgical specialties, and vascular surgery faired poorly. We were dead last in

wanting to pursue surgery as a career for either ourselves if we had to do it over again, or for our children. We were second worst in burnout rates, fifth in screening for depression and sixth in low mental quality of life.

A more recent introspective look by the SVS Wellness Task Force shows that vascular surgeons still have high rates of burnout in part due to advancing age, work-related physical pain, and workhome imbalance that led to higher risk for depression and suicidal ideation. This seems paradoxical to our impression of our specialty’s coolness. To be fair, our group has even contributed to this literature showing job dissatisfaction amongst vascular surgeons influenced by factors including unhealthy work-life balance, insufficient hospital support, hostile hospital culture, discontent with supervision, and unhappiness with career choice leading to early retirement. Although alarming and important, these typical metrics somehow miss the mark in being able to

Peter R.

Nelson

convey just how cool our specialty really is and how we have very cool people working hard to address these more visible statistics.

VASCULAR SPECIALIST

Medical Editor Malachi Sheahan III, MD

Associate Medical Editors Bernadette Aulivola, MD, O. William Brown, MD, Elliot L. Chaikof, MD, PhD, Carlo Dall’Olmo, MD, Alan M. Dietzek, MD, RPVI, FACS, Professor Hans-Henning Eckstein, MD, John F. Eidt, MD, Robert Fitridge, MD, Dennis R. Gable, MD, Linda Harris, MD, Krishna Jain, MD, Larry Kraiss, MD, Joann Lohr, MD, James McKinsey, MD, Joseph Mills, MD, Erica L. Mitchell, MD, MEd, FACS, Leila Mureebe, MD, Frank Pomposelli, MD, David Rigberg, MD, Clifford Sales, MD, Bhagwan Satiani, MD, Larry Scher, MD, Marc Schermerhorn, MD, Murray L. Shames, MD, Niten Singh, MD, Frank J. Veith, MD, Robert Eugene Zierler, MD

Resident/Fellow Editor Christopher Audu, MD

Executive Director SVS Kenneth M. Slaw, PhD

Director of Membership, Marketing and Communications Tara J. Spiess, CAE

Managing Editor SVS Beth Bales

Marketing & Membership Specialist Anna Vecchio

Assistant Marketing & Social Media Manager

Kristin Crowe

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.

Do we have data on coolness? Well, if you do a simple internet search on how we define or quantify coolness, you get entries describing Fahrenheit, Celsius, Kelvin, etc., as ways to measure temperature. Then you see a few entries on coolness as defined as “a quality lacking friendliness or enthusiasm,” which, for the sake of this discussion, is the “anti-cool.” If you dig a little deeper, you see that the business world, and especially marketing, understandably grapples with this concept extensively in order to predict the next cool product, company or brand. Research in business suggests that descriptors that define cool include: “authentic,” “inspiring,” “creative,” “attractive,” “edgy,” “rebellious,” “surprising,” “mysterious,” “unique” and “takes risks.” One strategy in the business world is to “let cool find you,” meaning if they create a brand that satisfies these criteria, then millennials or members of Gen Z— who are very bright, savvy, and, importantly, informationfocused—will find it and make it cool. We can’t do that in vascular surgery, or at least haven’t been able to until now, because the information available to them, as discussed above, is largely negative and works against our brand. If you search for what makes a surgical specialty cool, you get little specific or quantifiable information. On one end of the spectrum, you will find opinion pieces which commonly portray surgeons as masochists who endure pain, or as cantankerous, dominant, arrogant, hostile, impersonal, egocentric people who don’t communicate well. If they are fair, you might find that we get some credit for being decisive, well organized, practical and hard-working.

If you search for what makes a surgical specialty cool, you get little specific or quantifiable information

continued on page 4

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STRENGTH IN NUMBERS

continued from page 1

the globe, and Cuff, Wohlauer and a burgeoning team of VASCC collaborators were already counting the positive impact of interim data gathered from one of two core VASCC projects.

One of the most interesting aspects of the data emerging out of VASCC Project 1—covering the impact of COVID-19 on scheduled vascular operations—so far surrounds its use outside of the pandemic context, explains Cuff, a co-founder of the registries with Wohlauer.

“At our institution, we’ve been delaying a lot of surgeries, not necessarily because of our COVID numbers, but because we’re facing a large nursing shortage and therefore our bed capacity has decreased, as we don’t have people to take care of them,” says Cuff, program director for integrated vascular surgery residency at Spectrum Health-Michigan State University in Grand Rapids, Michigan.

“This is a nationwide problem. Every surgeon I have talked to is facing the same issues. So although the data that we gather in VASCC is on delays due to the pandemic, that data is going to be helpful in determining what patients should be delayed for in other situations like the one we’re facing now.”

It comes down to weighing competing priorities, Cuff explains.

“We have several aneurysm and open surgery patients who have been delayed for almost a month from their originally scheduled surgery, and this data that we developed was actually helpful in trying to figure out: should we move them up regardless, versus patients who have carotid disease or other disease,” he says.

“Maybe we can delay them a little longer in order to use beds as wisely as we can. So this is not just applicable to the pandemic or the COVID situation, but it is actually providing a framework for looking at delays for any reason that may be outside of a short-term situation for a few days, to help give guidance as to which patients may have to be treated sooner or later when it comes down to a bed crunch.”

things,” says Wohlauer. “We found that the overall mortality in our aortic group was about 5%, ESRD was about a 6% perioperative mortality, and I think 2% or maybe 4% died while waiting for their surgery. We found that patients with CLTI had about a 4% risk of decompensating while waiting for their operation, and that those patients who required an emergency surgery did very poorly—about 60% of them ended up having an amputation. We found in this group of patients with CLTI that diabetes has a strong association with major adverse limb events. And we found that, overall, with venous and carotid procedures in our cohort, patients were postponed and rescheduled with minimal complications.”

The international breadth of the VASCC endeavor has opened doors and broken some fresh ground, while also

and levels of seniority in order “to get a sense of what’s happening around the world with patients whose surgeries were postponed during the pandemic,” he shares.

Chiming in from Italy, Tinelli lauded the international scope of the collaborative. “This is a great opportunity to create a real network in Europe and around the world,” he says. “VASCC is a great opportunity inside the COVID pandemic because the real great solution from the vascular registry is that it is taking place during the first, second, third and now fourth wave.”

Mahmood Kabeil, MD, a research scholar at the University of Colorado assisting the VASCC projects, highlights the far-reaching nature of the surgeons and institutions inputting data—from Ireland to Australia and multiple points in between. The latest involvement

“So this is not just applicable to the pandemic or the COVID situation, but it is actually providing a framework for looking at delays for any reason” Robert Cuff

on their local circumstances. “It offers a real-time opportunity to look at each country and see how they’re dealing with it,” Moore adds.

Perioperative risk stratification

Meanwhile, as VASCC looks ahead, Kathryn Colborn, MD, an associate professor at the University of Colorado and biostatistician working on the registries, details the use of a novel risk stratification system developed within thoracic surgery named the Surgical Risk Preoperative Assessment System (SURPAS).

SURPAS utilized American College of Surgeons National Surgical Quality Improvement (ACS NSQIP) data to develop a preoperative risk surveillance system, she explains. In short, it involves a logistic regression model with eight variables collected at the preoperative visit to estimate the risk of 12 postoperative complications, thus producing a risk score. The system helps in a number of ways, Colborn explains, such as enabling discussion with patients preoperatively about their risk and also to risk adjust rates postoperatively.

“The goal for VASCC was to incorporate SURPAS so we could estimate observedto-expected event ratios in these patients,” she says. “In some patients, we might expect certain complications. But if we can evaluate their preoperative risk, we can evaluate whether we had higher-thanexpected event rates in this population.”

Meanwhile, Wohlauer describes a specialty equipped to deal with the vagaries of COVID-19. “In vascular surgery, we are like cobblers—each shoe is a little different. That’s how we see ourselves,” he says. Ultimately, VASCC is a team effort, Wohlauer reflects, and what the research aims to do is use high-quality data to understand best practices, and in which situations a certain operation works best.

Interim data presented at fall 2021 meetings

Fellow co-founder Wohlauer, a vascular surgeon at the University of ColoradoAnschutz in Aurora, Colorado, summarized interim results delivered at high-profile vascular meetings in the second half of last year, giving some insight into the type of findings Project 1 yielded. “At VAM, we presented our interim data analysis for aortic disease, chronic limb-threatening ischemia [CLTI], venous disease and end-stage renal disease [ESRD], and at the European Society for Vascular Surgery [ESVS] annual meeting, our impact on carotid disease interim data analysis—and we found some interesting

posing unique challenges. Alongside Project 2, which is focused on thrombotic complications of COVID-19, Project 1 lives at three separate locations, which each governing specific geographical area for the VASCC registries: the European hub in Rome, Italy, led by Giovanni Tinelli, MD; the U.S. hub at the University of Colorado; and the international hub, managed by Susan Heard at CPC Clinical Research, which is affiliated with the University of Colorado. While Project 1 looks at outcomes following delays to vascular procedures related to the virus (across the five modules of carotid, aortic, peripheral, venous and hemodialysis), Project 2 probes COVID-related thrombotic issues in cases of acute limb ischemia (ALI), acute mesenteric ischemia, symptomatic venous thromboembolism (VTE) and stroke. Data privacy concerns and regulatory differences across borders complicate the management of a VASCC database that spans the U.S. and Europe, Wohlauer says. The single database at three locations is aimed at facilitating widespread participation among vascular surgeons from different countries, practice types

numbers show around 250 sites in almost 50 countries, and “the collaboration is growing,” Kabeil discloses.

As manager of the international hub, Heard—CPC’s clinical data manager—says VASCC is treading largely virgin territory in terms of information gathering. “To my knowledge, this is a fairly novel approach in terms of using REDCap as our data collection tool. Because we have three completely separate instances in three different locations but we’re using the same database structure, as any changes need to be made, it’s very easy for us to be able to do that so that our databases continue to sync as we are collecting data separately but together.”

Ethan Moore, a research assistant at the University of Colorado assigned to work on VASCC, detailed a list of physician meetings drawn from disparate locations across the globe—recently Ireland and Indonesia, later Japan and Australia—that proved an eye-opening experience in terms of the vantage point they provided into how different countries are dealing with the pandemic at different times depending

“There are clinical trials like BEST-CLI that are helping answer these questions as well. I think they are really healthy for our community to be answering these questions in this way,” he continues.

“This organization shows we can custom-build a database to answer a specific question, and that harmonizes with the important work national registries do, which have less plasticity—and they collect orders of magnitude more data than we do.”

VASCC also demonstrates a proof of concept, Wohlauer says. “The projects that we’re completing right now show this proof of concept: taking a working group of experts in the field, making sure we have diverse representation of views— seniority, gender, ethnicity, country of origin—to make sure we’re asking the questions the way we want to answer them; spending a lot of time with our registry managers building the registry; and also thinking a lot about the data analysis before even looking at the data.” All of this was accomplished during a time of great limitation—not only on procedure scheduling, but on doing research, he adds. “We found a way to do it.”

Medicare reimbursement cuts averted until 2023

BY BETH BALES

After tireless work from the Society for Vascular Surgery (SVS) Medicare Cuts Task Force, the U.S. House of Representatives and Senate both passed legislation in December 2021 to halt the Medicare physician payment cuts that were scheduled to take effect on Jan. 1. President Joe Biden has signed the legislation as well, and the Centers for Medicare and Medicaid Services (CMS) has published an updated conversion factor.

Highlights of the physician payment provisions include a delay in resuming the 2% Medicare sequester for three months (Jan. 1–March 31, 2022), followed by a reduction to 1% for three months (April 1–June 30, 2022); a one-year increase over the published final Medicare Physician Fee Schedule Conversion Factor of 3% (0.75% less than the conversion factor “patch” provided for 2021); and the erasure of the 4% Medicare PAYGO cut and prevention of any additional PAY-GO cuts through 2022.

The Task Force and many SVS members have spent months educating legislators and regulators, meeting with members of Congress, writing letters, growing the SVS Political Action Committee (PAC) and other activities to fight these cuts.

“Thank you to the many SVS members who wrote, called and donated to the PAC,” said Matthew Sideman, MD, chair of the SVS Medicare Cuts Task Force and of the SVS Policy and Advocacy Council. “These efforts were essential. Congress doesn't always move quickly, but in December lawmakers took a big step in the right direction of remedying the cuts and preserving patient access to care.”

Much work remains to reach a permanent solution, he warned. “The care that vascular surgeons provide is valuable, life-saving work, and we will not rest until our healthcare system recognizes that value with real, long-term solutions to reimbursement.”

“We may be a small medical society, but we are mighty, and we illustrate what can happen when we work together,” said SVS Executive Director Kenneth M. Slaw, PhD.

The SVS Task Force will continue its mission into the new year, said Sideman, working towards ending automatic cuts.

Conveying vascular surgery’s essential ‘coolness’

Fortunately, on the other end, you will find some practical information aimed at informing and preparing students for a career in surgery. Some of the business attributes listed above seem relevant to defining cool when it comes to a medical specialty, but we should work to define the specific characteristics that apply to our field. We currently spend a significant amount of time with students during clerkships, sub-internships, vascular surgery interest group (VSIG) meetings, regional and national programs like the Next Generation program at the Vascular and Endovascular Surgery Society (VESS) and the SVS Medical Student and Resident Program, trying to convey the concept of the coolness of vascular surgery. We, or at least I, think we do a pretty good job getting the message across, but better defining what coolness means in our case would help us

Members involved in suggesting topics for VAM sessions

BY BETH BALES

Society for Vascular Surgery (SVS) program planners are finalizing the lineup and topics for several types of educational session for the 2022 Vascular Annual Meeting (VAM). VAM is set for June 15–18 in Boston, with educational programming across all four days.

SVS MEMBERS ARE BECOMING MORE involved and engaged in proposing topics for many of the sessions they would like to see at VAM, said William Robinson, MD, chair of the SVS Postgraduate Education Committee (PGEC).

For 2022, members submitted 58 proposals for breakfast and concurrent sessions, postgraduate courses and the always popular “Ask the Expert” small-group sessions, explained Robinson.

The number of member submissions has increased steadily since the process began several years ago. For this year, the committee worked to increase awareness and engagement among members. And the PGEC altered the process to provide for blind review of proposals, to enhance fairness and assure “the most welldeveloped and thoughtful proposals were selected,” said Robinson. “This helps us get the best programming—with both clinical and nonclinical topics—and also lets us look ahead and create a well-balanced program.”

Frequently similar topics come in, so committee members ask those who proposed content to work together and with the PGEC to develop content in more depth. “It gets more people involved and provides for more viewpoints,” said Robinson.

This year, the PGEC Committee also is

communicate with the target audience more effectively. Unfortunately, our ability to convey coolness has been hampered by virtual meetings, virtual interviews, and the inability to interact in person. Several creative adaptations have been developed, including virtual open houses, virtual conferences allowing multi-institutional or even multinational attendance, virtual away rotations, etc., which have enabled us to be somewhat effective. I am not a psychologist, but it seems likely that the sense of coolness of any individual or group is best conveyed and, importantly, best perceived in person. It seems we are making our way back to in-person interaction—VAM 2021 was a success, other regional and national meetings are getting back to in-person or at least hybrid formats, and our visiting professor meeting mentioned above was our first in-person visiting professor in over 18 months—so

Unfortunately, our ability to convey coolness has been hampered by virtual meetings, virtual interviews, and the inability to interact in person

incorporating programming specifically from and for four SVS membership “sections”: Community Practice (SVSCPS), Outpatient and Office Vascular Care (SOOVC), as well as Women’s and Young Surgeons. Three are new sections. “This allows these section leaders, working with the PGEC, to deliver content their members think is important and relevant to the SVS membership,” said Robinson.

With programs close to finalization and scheduling completed, “I am thrilled with the program that is shaping up” he said. The 21 invited sessions include 13 clinical and eight nonclinical topics. The section sessions, plus one for the Journal of Vascular Surgery publications and others, bring the total to 28.

VAM organizers also continue the practice of recent years—responding to member feedback— of scheduling days to minimize overlap; the general goal is to have three or fewer similar sessions happening simultaneously. “There’s a balance between hitting a breadth of topics and just having too much going on,” said Robinson.

“We try to be inclusive and incorporate as many ideas as we can if it’s reasonably possible,” he said. “Even really good proposals had to be deferred, because they were similar to sessions last year. It doesn’t mean they are not worthwhile. It just may be better for an upcoming year.”

The committee aims to broadly cover the topics inherent in vascular surgery practice. Not every topic can be covered in detail every year, so planners try to make sure important topics get detailed treatment every two to three years, said Robinson. Generally, topics all vascular beds, plus thoracic outlet syndrome and other less common pathologies. Meanwhile, invited sessions include five “Ask the Expert” small-group sessions.

“We try to be inclusive and incorporate as many ideas as we can if it’s reasonably possible” William Robinson

hopefully these opportunities for direct interaction will re-emerge. More positive data are surfacing in several areas. These include how important vascular surgery is to a healthcare system; data regarding the prevalence of vascular disease in a still aging population; data on disparity of care and the need for outreach to underserved communities; data on projected need for vascular surgeons to provide this outreach; data on salaries of vascular surgeons; and data on how we favorably compare to competitive interventional specialties.

Let’s add to this objective (and subjective) data as to our coolness. Do we need a focused, well-designed qualitative study that specifically asks: “What makes vascular surgery cool?” In the meantime, there is currently a large amount of effort being put forth to promote our specialty, so let’s support the SVS DEI and Wellness committees, the SVS branding efforts, and similar efforts from other vascular societies. And during this interview season, let’s show everyone just how cool we really are.

TRANSFORM YOUR AV FISTULA CREATION

Ellipsys™

Vascular Access System

91.6% cumulative patency at two years1

3,000+ successful endoAVF procedures2

18+ peer-reviewed publications2 HIGH technical success, maturation, and cannulation rates1,3,4

A balance is required with non-compete agreements in surgical practice

BY BHAGWAN SATIANI, MD, AND O. WILLIAM BROWN, MD

Unless prohibited by state law, most physicians employed by hospitals or physician groups are required to sign non-compete agreements (NCAs). A recent survey of 2,000 primary care providers (PCPs) in five states, 50% of office-based and 37% of hospitalbased or free-standing centers, had signed an NCA.1,2 Our experience is that almost all surgical specialists are required to sign one.

NCAs are generally subject to state regulation, not federal. The Federal Trade Commission (FTC) convened a workshop in 2020 on whether it could justify NCA actions through rule making rather than legislation. Both the American Medical Association (AMA) and American Bar Association (ABA) were against the proposal. Some of the opposition is based upon federalism arguments, which favor these regulations to be left to the states. In most states, like Ohio, NCAs are enforceable provided “the restrictions are no greater than necessary to protect the employer’s legitimate business interests; they do not impose an undue hardship on the employee; and the restrictions would not injure the public.”3 Other factors include that the NCA must be part of an employment contract in writing, narrowly tailored and have reasonable limits of distance and duration. In Columbus, two major health systems restrict their physicians from practicing within 20–25 miles for one to two years. Most courts will enforce a “reasonable” NCA and rule on factual, case-by-case situation. (BDO Seidman vs. Hirschberg, 93 N.Y.2d 382 1999). Many states—such as Colorado (limited ban), Delaware, Massachusetts, Louisiana, North Dakota—ban NCAs. Others, such as Connecticut, limit the geographical distance to 13 miles from the primary site of practice and the duration to one year.

It is believed that NCAs limit worker movement, entrepreneurship, and information-sharing such as academic or scientific discoveries. However, a complete ban on NCAs will hurt the ability of companies to protect trade secrets, especially for small- and medium-sized businesses.

There is evidence that about 50% of private sector businesses require some employees to sign an NCA. Some wonder if healthcare executives also sign NCAs. That depends on many factors, but, in general, senior executives, especially in private corporations, may be required to sign one. Similarly, most private practices also require NCAs.

2 Data on file at Medtronic.

3 Hull JE, Jennings WC, Cooper RI, Waheed U, Schaefer ME, Narayan R. The Pivotal Multicenter Trial of Ultrasound-Guided Percutaneous Arteriovenous Fistula Creation for Hemodialysis Access. J Vasc Interv Radiol. February 2018;29(2):149-158.e5.

4 Shahverdyan R. Comparison of Surgical (sAVF) and Percutaneous (pAVF) Arteriovenous Fistulae. Presented at LINC. January 2021.

Brief Statement

Indications

The Ellipsys™ system is indicated for the creation of a proximal radial artery to perforating vein anastomosis via a retrograde venous access approach in patients with a minimum vessel diameter of 2.0 mm and less than 1.5 mm of separation between the artery and vein at the fistula creation site who have chronic kidney disease requiring dialysis.

Contraindications

The Ellipsys system is contraindicated for use in patients with target vessels that are < 2 mm in diameter. The Ellipsys System is contraindicated for use in patients who have a distance between the target artery and vein > 1.5 mm.

Warnings §The Ellipsys system has only been studied for the creation of an AV fistula

It is common in technical and executive positions, and it is estimated that 36–60 million Americans have signed an NCA. Among these workers, about 45% of primary care physicians are estimated to have signed an NCA.2

Even if the NCA is heavy handed and unduly restrictive, health systems know that physicians may not have the resources and time to contest them in court. Another contractual option maybe to have themselves or their new employer negotiate the payout (if there is one) with the previous employer.

The Hamilton Project suggests several proposals to balance the interests of firms and workers: require that

employees be informed in advance that a NCA will be required to be signed; compensate existing employees who are asked to sign a new or revised NCA without retaliation; stop the state from allowing judges to modify existing NCAs; give state attorneys general power to end unenforceable NCAs; and, finally, institute regulations to allow easier enforcements of NCAs.4

If located in a large metropolitan area with multiple hospitals, it may be necessary to undertake some planning before signing an NCA in case a move becomes necessary. However, could this common practice in many industries may be changing?

President Joseph Biden signed an executive order on July 9, 2021, called “Promoting Competition in the American Economy.”5 The order urges the Federal Trade Commission (FTC) to “curtail unfair use” of NCAs. It is likely that this order is directed at lower income or hourly workers, who probably do not hold any trade secrets.

For instance, the District of Columbia passed a law banning an NCA for low-wage workers. However, the ban excluded physicians with incomes greater than $250,000, provided the physician was shown the non-compete clause at least 14 days before signing an NCA.

In fact, 70% of people in some management positions are asked to sign an NCA after receiving a job offer, and almost half sign on their first day or after they join a company.2

It is too early to say whether this strike against NCAs will have any long-term impact on their widespread use in physician employment agreements.

Finally, physicians should remember that termination of an employee, with or without cause, should result in the termination of an NCA.

References

1. Lavetti K, Simon C, White WD. The impacts of restricting mobility of skilled service workers: Evidence from physicians. http://kurtlavetti.com/UIPNC_vf.pdf

2. Has your career been affected by a non-compete clause? https://www.medscape.com/viewarticle/943622

3. Are non-compete agreements enforceable in Ohio? https:// ohio-employmentlawyer.com/ohio-noncompete-agreements/ 4. Marx M. Reforming non-competes to support workers. https://www.hamiltonproject.org/papers/ reforming_non_competes_to_support_workers

5. https://www.whitehouse.gov/briefing-room/ presidential-actions/2021/07/09/executive-order-onpromoting-competition-in-the-american-economy/

“Even if the NCA is heavy handed and unduly restrictive, health systems know that physicians may not have the resources and time to contest them in court”

using the proximal radial artery and the adjacent perforating vein. It has not been studied in subjects who are candidates for surgical fistula creation at other locations, including sites distal to this location.

§The Ellipsys system is not intended to treat patients with significant vascular disease or calcification in the target vessels.

§The Ellipsys system has only been studied in subjects who had a patent palmar arch and no evidence of ulnar artery insufficiency.

§Use only with the Ellipsys™ Power Controller, Model No. AMI-1001.

§The Ellipsys Catheter has been designed to be used with the 6 F Terumo

Glidesheath Slender . If using a different sheath, verify the catheter can be advanced through the sheath without resistance prior to use.

§Use ultrasound imaging to ensure proper placement of the catheter tip in the artery before retracting the sheath, since once the distal tip of the catheter has been advanced into the artery, it cannot be easily removed without creation of the anastomosis. If the distal tip is advanced into the artery at an improper location, complete the procedure and remove the catheter as indicated in the directions for use. It is recommended that a follow-up evaluation of the patient is performed using appropriate clinical standards of care for surgical fistulae to determine if any clinically significant flow develops that require further clinical action.

Precautions

§This product is sterilized by ethylene oxide gas.

§Additional procedures are expected to be required to increase and direct blood flow into the AVF target outflow vein and to maintain patency of the

BHAGWAN SATIANI is professor emeritus in the division of vascular diseases and surgery in the College of Medicine at The Ohio State University. O. WILLIAM BROWN is chief of the section of vascular surgery at William Beaumont Hospital, Bingham Farms, Michigan. He is also a professor of surgery at Oakland University/William Beaumont School of Medicine and an adjunct professor of law at Michigan State University College of Law.

AVF. Care should be taken to proactively plan for any fistula maturation procedures when using the device.

§ In the Ellipsys study, 99% of subjects required balloon dilatation (PTA) to increase flow to the optimal access vessel and 62% of subjects required embolization coil placement in competing veins to direct blood flow to the optimal access vessel. Prior to the procedure, care should be taken to assess the optimal access vessel for maturation, the additional procedures that may be required to successfully achieve maturation, and appropriate patient follow-up. Please refer to the “Arteriovenous Fistula (AVF) Maturation” section of the labeling for guidance about fistula flow, embolization coil placement, and other procedures to assist fistula maturation and maintenance.

§The Ellipsys System is intended to only be used by physicians trained in ultrasound guided percutaneous endovascular interventional techniques using appropriate clinical standards for care for fistula maintenance and maturation including balloon dilatation and coil embolization.

§Precautions to prevent or reduce acute or longer-term clotting potential should be considered. Physician experience and discretion will determine the appropriate anticoagulant/antiplatelet therapy for each patient using appropriate clinical standards of care.

Potential Adverse Events

Potential complications that may be associated with creation and maintenance of an arteriovenous fistula include, but may not be limited to, the following:

§Total occlusion, partial occlusion or stenosis of the anastomosis or adjacent outflow vein

§Stenosis of the central AVF outflow requiring treatment per the treatment center’s standard of care

§Failure to achieve fistula maturation

§Incomplete vessel ligation when using embolization coil to direct flow

§Steal Syndrome

§Hematoma

§Infection or other complications

§Need for vessel superficialization or other maturation assistance procedures.

CAUTION: Federal (USA) law restricts this device to sale by or on the order of a physician.

Important Information: Indications, contraindications, warnings, and instructions for use can be found in the product labelling supplied with each device.

less time in the OR* (compared to CEA)

Protection

from

stroke

And so much more

TCAR is designed to give the vascular specialist more options when treating carotid artery disease. TCAR is a complete procedural solution that is less invasive, takes less time to perform and results in significantly less risk of CNI and in-hospital MI in comparison to CEA.* All while protecting the patient from surgery-related stroke with rates as low as 0.6%.** Brighter patient outcomes through brighter clinical thinking. Silk Road Medical. Brighter. silkroadmed.com/tcar

* Malas MB, et al. TransCarotid Revascularization with Dynamic Flow reversal versus Carotid Endarterectomy in the Vascular Quality Initiative Surveillance Project [published online ahead of print, 2020 Sep 15]. Ann Surg. 2020;10.1097/SLA.0000000000004496.

** Kashyap VS, et al. Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease. Stroke. 2020 Sep;51(9):2620-29.

Collaborative effort key to investigating potential biomarker of acute aortic syndrome

BY JOCELYN HUDSON

Research indicates that plasma desmosine has the potential to act as a biomarker of acute aortic syndrome and could, in the future, be used as a diagnostic tool for the condition in the acute setting.

PRESENTING THE FINDINGS OF A BRITISH Heart Foundation-funded study during the Sol Cohen Prize Session at the UK Vascular Societies’ Annual Scientific Meeting (VSASM 2021) held Dec. 1–3, in Manchester, England, Maaz Syed, a medical student at the University of Edinburgh, Scotland, concluded that a multicenter, collaborative effort is needed to propel future investigation. The study, published as an abstract in Heart, was a collaborative effort between the University of Edinburgh and Anna Maria Choy, MBBS, and her team at the University of Dundee, Scotland.

Acute aortic syndrome “poses challenges in diagnosis, is unpredictable and is catastrophic,” Syed told the VSASM audience. It is known that patients with abdominal aortic aneurysms (AAAs) have raised desmosine, but, according to Syed, it has never been tested in patients with acute aortic syndrome before. Therefore, the research team set out to compare plasma desmosine concentrations in patients with acute aortic syndrome compared to healthy controls, with the primary aim of determining whether desmosine concentrations change with respect to the phase of disease.

The investigators analyzed plasma desmosine concentrations in 53 patients with acute aortic syndrome and compared them to 106 controls, Syed relayed. The presenter noted that the groups were “reasonably well matched,” although patients in the acute aortic syndrome

group were slightly older on average, more likely to be male and had lower blood pressures than the patients in the control group as they were on antihypertensive therapy.

“As we had hypothesized, plasma desmosine concentration was increased in patients with acute aortic syndrome compared to controls,” the presenter informed VSASM attendees. He added that this was true across all three sub-pathologies: aortic dissections, intramural hematomas and penetrating aortic ulcers.

The researchers were mainly interested in phase of disease, Syed detailed, noting that the majority of patients the team recruited belonged to the acute, subacute and chronic groups. The team started noticing a trend: “It looked like the closer you got to the event, the higher the plasma desmosine we observed.”

In light of this finding, Syed and colleagues then collected blood from the three patients who had presented with chest pain and later gone on to develop acute aortic syndrome or be diagnosed with acute aortic syndrome. “We thought that their plasma desmosine would be higher, but we were not expecting to see such a high level,” he remarked.

The team developed a simple linear regression model to check that it was not a change in baseline demographics that was influencing the levels of plasma desmosine. “Plasma desmosine presentation had a three-fold increase compared to 106 healthy controls independent of their age, their sex and their smoking status, and this was statistically significant,” he explained.

The presenter detailed that, while the phase of disease helps clinicians work out morphologically how the aorta is going to behave, it does not necessarily reflect the pathobiological properties of the aorta with respect to time. Therefore, the team also wanted to see how plasma desmosine concentrations differed

with respect to time as a continuous variable. One of their key findings was that plasma desmosine level peaked at presentation and gradually decreased with respect to time, but that even patients who are many years out of the initial event had a raised desmosine level. Finally, Syed and colleagues wanted to determine if plasma desmosine can influence the prediction of longitudinal outcomes. They developed another linear regression model, this time fitting aortic growth against desmosine and conventional clinical predictors. “Desmosine outperformed things like aortic diameter and the age of the dissection or the intramural haematoma,” he reported. “We have demonstrated not only that plasma desmosine is increased in patients with acute aortic syndrome, but that it is detectable within 24 hours of symptom onset,” Syed summarized, stressing that this has implications for the use of plasma desmosine as a potential diagnostic tool in the emergency department. Plasma desmosine also appears to be associated with aortic expansion independent of things like aortic diameter, the presenter added.

53 patients 106 controls

“We thought that their plasma desmosine would be higher, but we were not expecting to see such a high level” Maaz Syed

Powell: Studies linking EVAR and cancer risk continue to mount

BY BRYAN KAY

Evidence continues to accumulate of a link between endovascular aneurysm repair (EVAR) and cancer, with even small amounts of radiation potentially converting epithelial cells “to a precancerous or a cancerous state in smokers or ex-smokers,” according to world-renowned vascular disease researcher Janet Powell, MD.

THE IMPERIAL COLLEGE LONDON, England-based professor of vascular biology and medicine was speaking on the increasing concern that emerged about 12 years ago over CT surveillance of endografts and the associated radiation burden this might contribute to patients. Back in 2011, explained Powell before an audience of 2021 VEITHsymposium

(Nov. 16–20) attendees in Orlando, Florida, she and colleagues were preparing “the very long-term follow-up” of the EVAR1 trial, which included testing a hypothesis that late cancer deaths would be higher in the group of patients treated with EVAR vs. those who received open repair.

Over an eight-year period, the team

Discussion following Syed’s presentation delved further into the findings, with Richard Gibbs, MBChB, a consultant vascular surgeon at Imperial College Healthcare NHS Trust, London, keen to know if the researchers had data on plasma desmosine levels in patients with connective tissue disorders. Syed noted that in the one patient they assessed who had Marfan syndrome, the team noticed a fiveto six-fold increase in his plasma desmosine. Two weeks later, the patient developed a dissection. The presenter said it was such findings “that made us think maybe this is an important biomarker in patients with acute aortic syndrome, and we are now systematically testing plasma desmosine in patients with connective tissue disorders for that reason.”

Closing his presentation, Syed added: “The trust was set up in 2015 by a group of MPs who had sadly experienced loss of life in young members of their families due to this catastrophic disease, and one of the benefits of presenting research such as this in this forum is that we can gauge interest among the vascular community in developing a biomarker to diagnose acute aortic syndrome and improve risk stratification.”

found no difference in the rate of cancer deaths between the two groups. Beyond eight years, however, “the rate in the EVAR group escalated to 4.2 per 100 person years. This was almost twice as much as in the open repair group,” said Powell.

A year later, she continued, another group in London showed that radiation also causes DNA damage in the lymphocytes of EVAR operators.

Another couple of years on, Powell explained, and an English populationbased cohort study demonstrated that after seven years, the hazard ratio of all cancers was 1.09 in patients treated with EVAR vs. those undergoing open repair—“a significant difference, with a particularly significant difference for abdominal cancers.”

A year after that, she said, a study that emerged out of South Korea looked at a population who had undergone aneurysm

repair after an initial diagnosis of cancer and showed that the patients treated with EVAR had “a much higher proportional death rate from cancer than those treated with open repair.”

“So now that’s three separate studies: increasing risk of cancer after EVAR,” Powell told VEITH 2021 delegates. She then turned to the specter of patients who continue to smoke and EVAR treatment. “What’s the etiology? Actually, what have we forgotten?” Powell asked. “What we have forgotten is that the cancer risk of smoking and radiation are multiplicative and not additive. And the evidence of this comes from a variety of studies.” At the cellular level, Powell added, the damage to DNA from smoking increases over time. “When radiation hits, the damage to non-smokers’ cells is limited,” Powell said. “But it escalates to those who are still smoking to produce cancerous cells.”

Cutting through the ‘red tape’ of research

BY SHARON C. KIANG, MD

Creating an academic career with a perfect blend of clinical work and protected time for productive research is a struggle for many surgeon-scientists. Many have viewed a surgical career in the Veterans Health Administration as a perfect opportunity to achieve that amalgamation. The 2018 revision to the Common Rule has simplified and increased the efficiency of the regulatory components for human subject research.

The Common Rule, established in 1981, is a code of ethics that governs biomedical and behavioral research for human subjects in the United States at the level of the Institutional Review Board (IRB). It followed the 1975 Declaration of Helsinki and is included in the 1991 U.S. Department of Health and Human Services (Title 45 CFR 46 Subparts A, B, C and D). The Common Rule is considered the baseline code of ethics for government-funded research in the U.S. The details for Common Rule compliance can be tedious and burdensome, deterring some from pursuing human subject research. The 2018 revision simplified some of this tediousness, with leaders hoping to maintain human subject safety while decreasing the administrative burden. Major changes in Common Rule regulations that impact surgeon-scientists include development of 1) new exemption categories, 2) allowance of a Limited IRB, 3) allowance of a Single IRB Mandate, and 4) implementation of a Designated Research and Development Review. The new categories are summarized below.

New exemption categories (after 1/29/2019)

Studies qualified for exemption are not subject to the requirements of the Common Rule. Oversight of exempt studies are reviewed by the IRB and the Veterans Affairs (VA) Research and Development Committee (R&D) for continuing reviews and amendments and must still remain compliant with the Privacy Rule or Act. In addition, the Research Compliance Office (RCO) retains the right to audit these studies for compliance. The new exempt categories are as follows:

1. Exemption category 1: Education research (38 CFR 16.104d(1))

“Research conducted in established or commonly accepted education settings, that specifically involved normal education practices that are not likely to adversely impact students’ opportunity to learn required educational content or the

assessment of educators who provide instruction.” Broadly speaking, this pertains to research on education strategies or the effectiveness and/or comparison of strategies, curricula or classroom management.

2. Category 2: Education tests/survey/ interviews/observations (§ 16.104(d) (2))

“Research that only includes interactions involving educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures, or observation of public behavior (including visual or auditory recording),” as long as one of the following is met: 1) Identity cannot be readily ascertained, 2) there is no risk of criminal/ civil liability/ financial standing/ employability/ educational advancement/ reputation or 3) the IRB conducts a limited review.

3. Category 3: Benign behavioral interventions (brief, harmless, painless) (§ 16.104(d)(3))

“Research involving benign behavioral interventions in conjunction with the collection of information from an adult subject through verbal or written responses (including data entry), or audiovisual recording” as long as one of the following is met: 1) Identity cannot be readily ascertained, 2) there is no risk of criminal/ civil liability/ financial standing/ employability/ educational advancement/ reputation or

3) the IRB carries out a limited review.

4. Category 4: Secondary research (§ 16.104(d)(4))

“Secondary research for which consent is not required, secondary research use of identifiable private information or identifiable biospecimens,” as long as one of the following is met: 1) Information is publicly available or 2) Subject specimen is not identifiable and the investigator does not contact or try to re-identify subjects.

Limited IRB Review

One of the changes to the Common Rule also allows for the use of the Limited IRB Review, permitting the initial approval to be expedited. After the initial approval, the study still falls under IRB oversight (amendment, reporting, etc.), but the study no longer requires a Continuing Review. Most local policies still request an “Annual Update” submission. However, there is no regulatory requirements of a continuing review in order for the study to continue. The Limited IRB review category is allowed for Exemption categories 2 and 3—as long as the IRB can assure the privacy of patients and confidentiality of their data (HIPAA waiver).

Single IRB Mandate

A robust research program is critical to not only the faculty, but also to the new faculty just starting their academic careers

The Single IRB Mandate is simplifying the ability for Veterans Affairs (VA) studies to be part of multiinstitutional studies outside of a VA Cooperative Study. The VA can now enter into agreements to rely on commercial IRBs as IRBs of record for multicenter trials to have only one IRB review. The Single IRB allows for increased ability to bring in funded, sponsored research in addition to collaborating as a trial site for other government institutions, such as the National Institutes of Health (NIH).

R&D designated review process

The inclusion of this new category is intended to increase efficiency for review of appropriate studies.

Rather than follow through with the tedious process of initially undergoing an IRB review only to be subsequently sent for a full R&D Committee review, the following activities may be approved by the chair of the R&D Committee, or a voting member designated by the chair:

1. Minor changes to a protocol required by the R&D Committee, following full board review

2. Final approval for protocols approved contingent on the full approval of a subcommittee, if the subcommittee had not required major changes (as defined in local standard operating procedures) to the protocol since the R&D Committee conducted its review

3. Final approval for protocols approved contingent upon completion of the privacy officer (PO) and information system security officer (ISSO) review

4. Exempt human subject research protocols and protocols approved by expedited review by the IRB

5. Single patient expanded access protocols approved by the IRB chair or another appropriate IRB voting member

6. Protocols that do not involve human subjects; biosafety level (BSL-3) or higher containment; use of select agents or non-exempt quantities of select toxins; U.S. Department of Agriculture (USDA)-regulated animal species or any animal research involving more than momentary pain or distress to the animals

A robust research program is critical to not only the faculty, but also to the new faculty just starting their academic careers. The new changes in the common rule ease the administrative burden and increase the efficiency of the regulatory process, thus encouraging a lifelong career of cutting-edge clinical practice alongside a productive research enterprise for young faculty joining the VA.

SHARON C. KIANG, chief of the division of vascular surgery at the VA Loma Linda Healthcare System in Loma Linda, California,, is a member of the Society for Vascular Surgery VA Vascular Surgeons Committee.

Sharon C. Kiang

WFVS seeks to help shape future of global vascular training through technology and collaboration

BY JOCELYN HUDSON

The World Federation of Vascular Societies (WFVS) recently entered a new era of governance with the aim of better disseminating science and best practices for vascular surgeons operating in every corner of the globe. Palma Shaw, MD, WFVS secretary-general, speaks to Vascular Specialist about some of the strides made so far and what plans are in store for future progress in vascular training— including collaborative efforts and the potential use of simulation.

SHAW, A PROFESSOR OF SURGERY AT UPSTATE Medical University in Syracuse, New York, details that the WFVS identified a need to focus on education and training following discussions with council representatives from various societies across the world. This will involve leveraging digital strategies, she explains: “We are working on developing access for a virtual education program, like the Society for Vascular Surgery [SVS] has already developed.”

Simulation, or virtual learning, will also be used for the purposes of education and training, Shaw adds. In fact, the WFVS has been exploring opportunities with different companies to try to see what is available and

what might work for its purposes. “We will try to increase access, especially in those countries that are underserved, and we would like to really get ultimately all vascular surgeons to a minimum level of training,” Shaw outlines. Collaboration will also be key to attaining the WFVS’ education and training goals. The secretary-general communicates that the new webpage and portal, currently in its design phase, “will serve as a hub for scientific exchange, collaboration and networking between members of the global vascular community” once completed. In this vein, the WFVS also intends to identify societies across the world that it might be able

to connect with in order to help augment training in various locations.

Looking to the future

Considering what lies ahead for the WFVS, Shaw sketches a future plan to reach out to various quality initiatives—including the Clinical Practice Project or the Vascular Registry Project of the SVS, the Vascular Surgery COVID-19 Collaborative (VASCC) started by Max Wohlauer, MD, of the University of Colorado Anschutz Medical Campus, Aurora, Colorado, or the International Consortium of Vascular Registries—in order to help disseminate the work of the WFVS and “reach further out into the globe and expand our knowledge base.” Shaw also mentions the future involvement of the WFVS in global guidelines being developed for diabetic foot management. “That will be a several-year project.”

Finally, Shaw highlights that the federation would like to offer mentorship in the coming years. This may involve not only a web-based platform for education, but also hands-on learning. “We can be a connector for those countries that need more on-site training, and those that are able to offer that to them.”

Visit vascularspecialistonline.com to view a video interview with Palma Shaw on the rebooted WFVS. “We can be a connector for those countries that need more on-site training, and those that are able to offer that to them” Palma Shaw

Priorities and objectives will guide 2022 SVS programs

continued from page 1

change. “What we do begins with input from our members: Learning about their biggest concerns and determining how the SVS should address them,” said SVS Executive Director Kenneth M. Slaw, PhD. The five SVS councils each address priorities that fall within their purviews, establishing two or three objectives for potential programs that allow the Society to make progress on those priorities. The Executive Board addresses priorities of several other committees and programs.

“The method is not haphazard but, rather, data-driven and focused, with the SBOD shaping strategic policy to realize members’ key priorities,” said SVS President-Elect Michael Dalsing, MD. Then, “Council and committee volunteers plan, implement and monitor for success projects to help realize the strategic plan with the support of the administrative staff.”

Late last year members declared advocacy the No. 1 priority for this fiscal year, which ends March 31. Through digging further into the survey data, payment emerged as the important point within that priority. “So the Policy and Advocacy Council discussed challenges with payment and what we could proactively do going forward in the new year,” said Slaw.

Last July’s virtual fly-ins with lawmakers—resumed after a COVID-induced hiatus—directly addressed the payment issue, as will next summer’s advocacy skills-building course. The course will be geared to those interested in learning more about how advocacy affects healthcare decisions and policies in Washington, D.C.

Of course, members saw payment return to center stage during the summer, after the Centers for Medicare and Medicaid Services (CMS) released its preliminary Physician Fee Schedule, which included large cuts to vascular surgery reimbursement. Combined with a number of other planned reductions, vascular surgeons were facing cuts that for some members could total nearly 20%. The Policy and Advocacy Council has worked for months to meet with lawmakers to encourage legislation to reduce or delay the devastating reimbursement reductions and encourage grassroots efforts on the part of SVS members. Congress ultimately voted to delay some of the cuts, but more work remains.

All signs, said Slaw and Council Chair Matthew Sideman, MD, point to advocacy, payment and reimbursement remaining one of the top items on the FY22–23 priority list.

While the core of the initiatives process focuses on what members want and need, the SBOD also tries to broaden its focus to what’s on the horizon—what experts are saying that might impact medicine, surgery and vascular surgery in the coming three to five years. “We discuss those at the Strategic Board retreat as well, to make sure we’re not missing something critical on the larger landscape,” said Slaw.

“Reflecting on the next three to five years, change is a certainty,” said Dalsing. “Whether it is a friend or foe is up to us. We will have to embrace change over and over again as we reshape ourselves into the vascular surgeons and SVS of the future. Changing political winds, increasing regulation, new payment structures, population health, surgical innovations and other future forces will provide us the opportunity to be even more influential advocates for our patients. We have to be up to the task and, if past experience is foreshadowing, we will be successful.”

Following discussion of member priorities and accompanying programming ideas from respective councils, the Strategic Board reviews all ideas and further prioritizes them into the top three or four in each council that will move forward.

Then, said Slaw, “all those programs and ideas become part of the budgeting process, so we can make sure we have

the resources available to move programs forward. We try to include as many as we can accommodate in the budget, which is approved in March, to go into implementation beginning April 1.”

Late in 2021, with surveying and ranking ongoing, council chairs nonetheless offered their early opinions as to priorities for 2022–23 and discussed the value of the overall process.

Clinical Practice Council

Chaired by William Shutze, MD, this council oversees the Community Practice Section, which includes the Sub-Section on Outpatient and Office Vascular Care (SOOVC); the Physician Health and Wellness Committee (formerly Task Force); the Health Information Technology Committee; and the Population Health Task Force, whose work is winding down.

The SBOD retreat provides the very real benefits of getting a wide range of people, viewpoints, backgrounds and areas of focus together, said Shutze. Members sometimes bring up suggestions others hadn’t considered, or a concern that’s not currently on the radar. “Everyone is able to weigh in with their ideas,” he said.

Shutze said that clinical practice is “kind of the translational end of quality and research; how do you translate those components into clinical practice?” Shutze added, “We also look at issues uniquely related to clinical practices, such as physician value and the physician workforce. That’s why the Wellness Committee—and wellness is an important issue—and the Community Practice Section are part of the Clinical Practice Council.”

The council works with the others in terms of this translational effect, providing feedback on how other issues affect—positively or negatively—clinical practice. For example, payment cuts could speed retirements and impact workforce issues, he said.

The entire process of setting priorities began earlier this year, with an impetus to think in visionary terms when investigating ideas at the retreat, he said, adding, “We’ve had three or four terrific suggestions for 2023 Clinical Practice Council goals” the council hopes to bring to the retreat for discussion.

On surveys, Shutze noted, “The information is vitally important, but response rates remain an issue.” They will be a valuable way for the SVS to understand itself and its direction, he added.

Education Council

Important changes are ahead for members in terms of the education SVS offers, said Linda Harris, MD, chair of the Education Council. The council oversees the Education, Leadership Development, Postgraduate Education, Program, Resident and Student Outreach, and VAM Video committees.

Atop the list is introducing the SVS’ new 2022–2025 education strategic plan. This includes adding a framework and cataloging for its educational offerings and stresses collaboration, coordination and shared planning among councils, committees and SVS staff.

All councils and committees have ideas for educational offerings, said Harris. Each is subject to three questions: “Is a new product helping our members, improving patient care or the healthcare systems, or our members’ own health? Is it fulfilling one of those three?”

Appropriate benchmarks also are important, she said. “New product development has to be based on what

our membership needs, not what we assume is a good idea. We want what our membership wants, not what we think they want.”

The new strategic plan focuses on five pillars: A porfolio approach, shared content planning, a global plan for content use/reuse, using best practices in formal education methodologies, and enhancing the SVS governance structure to accelerate the development and implementation of education of importance to members and their patients.

Plan tactics incude a universal content framework to catalog current educational offerings. “We will know what we currently have to offer within our educational portfolio and where the gaps are. All education will be categorized before and as it’s being created, rather than after the fact,” said Harris. “For example, if the Clinical Practice Council hosts a webinar, organizers would tag it appropriately as they’re preparing the webinar.”

The goal is simple. “We want SVS to be the premier source for education. And that means our offerings have to be searchable to allow for ease

Clinical Practice Council in action

n Conversion of the Community Practice Committee to a section, which also includes the SOOVC sub-section, into a section. “It’s high on our list to support these two sections as they launch,” said Shutze

n Conversion of the Wellness Task Force into a committee

n Setting the initiatives and objectives of the Population Health Task Force, which has completed its original mission to deliver a white paper on the topic to the SVS Executive Board

n Refinement and completion of the process of sending out member and practice surveys

of use and reuse.”

Harris

credited Education Committee Kellie Brown, MD, for spearheading the framework project. “It was an enormous undertaking, and I thank the Education Committee for this herculean effort. SVS is now in a great place to roll this out for use in 2022.”

Other parts of the plan include:

● Plans to re-use and share content, avoiding duplication of efforts

● Enhanced communication across the councils and with staff to determine what new content should be created in this portfolio approach

● Developing a methodology in order to

consistently assess SVS programs and offerings

● Considering how to move forward with educational offerings. With remote learning now part of the mix, that includes possibly collaborating with regional and other national societies

● Analyzing the recently completed Educational Needs Assessment Survey, which has provided a wealth of information

One of the council’s biggest issues from an overall education perspective and with financial ramifications is, “What’s COVID done to us,” said Harris. “There are huge issues going forward. How do we integrate changes? Hybrid is much more expensive, and virtual education has its own

The SVS is looking ahead to memberdriven priorities for 2022

person, exist, she said. “And we know we can offer more opportunities both online and in-person.” At the same time, Harris stressed that while remote and hybrid opportunities have their pluses, human interaction is vitally important and cannot be duplicated. “We expect an in-person meeting to remain a key factor for SVS for many years to come.”

Advocacy and Policy Council

Matthew Sideman, MD, chairs the Advocacy and Policy Council, but it’s his additional position as co-chair of the SVS Medicare Cuts Task Force that helped with SVS members’ No. 1 priority during the current fiscal year: payment.

The latter entity was created in the summer of 2021 after CMS released the 2022 Medicare Physician Fee Schedule, which included a 3.75% cut for vascular surgeons. This cut, plus four others, meant vascular surgeons were facing cuts of more than 20%, depending on practice setting and other factors.

In mid-December, after months of work by the task force and council, Congress moved to delay some of the cuts.

However, warned Sideman and others, the job isn’t done.

“There is still a lot of work to be done to reach a permanent solution. Vascular surgeons provide valuable, life-saving work to society’s most vulnerable patients. We are not going to rest until our healthcare system recognizes that value with real, long-term solutions to reimbursement.”

Task force members will work toward ending automatic cuts and provide suggestions for payment answers.

set of issues. How do we continue to evolve the VAM? We’ve already transitioned to year-long education—one benefit of the pandemic. But we have to look at what people can afford both financially and in time away from work and family. We must find an appropriate, forward-thinking plan to deliver education when and where people need it.”

The SVS’ new new learning management system (LMS) is making education accessible, but more opportunities, both online and in-

“This remaining work will undoubtedly be a major focus in setting priorities,” he said. He added, in tandem with other council chairs, that payment issues can trigger other changes—such as retirements and career changes—which could impact workforce shortages. Payment could also lead to possible difficulty in paying dues or program fees, which would impact overall SVS revenue and the Society’s ability to offer robust programming.

“We have our work cut out for us,” said Sideman in mid-December. “After an incredibly busy time fighting this latest round, we will get a brief respite over the holidays and begin again in January on more permanent answers.”

Dalsing offered his own personal reflection on the “big picture” of medicine. “All of us in the medical profession are in the same boat but do not seem to realize it,” he said. “We have been forced to bicker over slices of a small and shrinking financial pie resulting from a lack of cost-of-living increase perpetuated over decades, which other stakeholders in the medical space have not had to endure. Eventually, all physicians—with vascular surgery at the leadership table—will have to find a solution to this conundrum.”

Research Council

The Research Council, chaired by Raul Guzman, MD, will soon have a new set of research priorities. A list of some 10 priorities cover such areas as carotid, aortic, and lowerextremity arterial and venous disease; dialysis; healthcare disparities; and vascular medicine/vascular health.

The SVS strategic plan guided the Research Council in drafting the new priorities, which the SBOD will discuss, tweak and approve at the retreat, said Guzman. This is especially true of three specific proposed new priorities “aimed at improving quality and appropriateness, optimizing vascular intervention, and assessing population health measures,” he said.

These priorities are expected to guide research initiatives for the coming decade. While noting again that priorities are yet to be finalized, Guzman believes one of his council’s top concerns is related to identifying areas within vascular surgery that would benefit from increased investigational

efforts. “Results from studies in these priority domains will be important for moving forward with guidelines and appropriate use criteria for many of our major areas of interest,” he said.

Quality Council

“Quality is job one,” said Thomas Forbes, MD, offering his apologies in advance to Ford Motor Co. for using the automaker’s slogan in relating what members emphasized in previous surveys.

“I think tracking quality outcomes has always been in the DNA of vascular surgeons. It’s in our blood,” noted Forbes, chair of the Quality Council. And over the past several years, he said, “The SVS has invested in quality in terms of people, time and expertise.”

“We heard loudly and clearly that patients should have quality of care, regardless of where they live and who they’re being treated by,” he said. Quality initiatives have and continue to include the creation of clinical practice guidelines, a “distillation of the current body of evidence … that indicates how we should be treating our patients.” Under the direction of Ruth Bush, MD, and the Document Oversight Committee, a number of guidelines are being prepared.

“We will have to embrace change over and over again as we reshape ourselves into the vascular surgeons and SVS of the future” Michael Dalsing

Appropriate use criteria (AUC), an exciting initiative chaired by Adam Beck, MD, is another. The first AUC, on peripheral arterial disease (PAD), is in the finalization phases. These criteria account for some “specific nuances of very specific clinical situations,” based on the “best of the current review of the evidence.”

Then there is the Vascular Center Verification and Quality Improvement Program (VCV&QIP), being spearheaded by Kim Hodgson, MD, and Anton Sidawy, MD. “You can’t talk about quality without talking about this program,” said Forbes. Now nearing the end of its pilot phase, the program is nearly ready for official kick off, with both inpatient and outpatient facilities able to enroll in the accreditation process. “And the whole purpose is improving patient care,” he emphasized.

The Vascular Quality Initiative (VQI), an SVS Patient Safety Organization (PSO) program, meanwhile, has seen an investment of time and money make “huge inroads into the general quality initiative of the SVS over the last number of years,” said Forbes. But because not all SVS members participate in VQI, “it’s important to have a culture of quality both within and outside VQI.”

The new Quality Improvement Committee, which is advancing the overall strategy of quality and engagement within and outside VQI, is “an opportunity for other national registries to be used,” he said. “It’s made huge inroads and will continue to do so.”

SVS Health and Vitality

The SVS Health and Vitality umbrella includes a large number of committees, overseen by the SVS Executive Board. The Communications Committee and its three subcommittees, in fact, owe their creation to a previous SVS initiative of a few years ago. The Diversity, Equity and Inclusion (DEI) Committee, likewise, graduated from task force status as a result of its important work in its previous form and the SBOD’s commitment to DEI issues.

The Executive Committee oversees these diverse committees, and manages the everyday challenges and opportunities that surface in an active society, said Dalsing. “It is a structure built for innovation and success in a constantly changing world.”

Streaming to return at VAM 2022

After a successful debut in 2021, live-streaming of a variety of sessions will return to the Society for Vascular Surgery (SVS) Vascular Annual Meeting (VAM) this year, writes Beth Bales

VAM 2022 will be June 15–18 at the Hynes Convention Center in Boston and will be the Society’s 75th meeting. The meeting will feature educational content—and livestreams—across all four days; exhibits will be open June 16–17.

“We will follow many of the guidelines we established in 2021: stream all scientific plenary sessions, special lectures and forums, with the Presidential Address also among them,” said SVS Program Committee Chair

Andres Schanzer, MD. “We want to offer exciting, interesting sessions that will give the at-home viewers needed cutting-edge research, educational content, diverse food for thought, and useful tips for their practices.”

Organizers have already implemented one scheduling change from 2021: moving international sessions to early morning, because of time zone differences. This will enable international attendees to watch sessions particularly applicable to them during their daytimes, and not late at night, said Schanzer.

Currently scheduled for live-streaming are:

n VQI@VAM, the Vascular Quality Initiative annual meeting, on Tuesday and Wednesday

n International Fast Talk, International Chapter Forum, the meeting of the World Federation of Vascular Surgery (WFVS), and the International Young Surgeons Competition

n All eight plenary sessions

n The Vascular and Endovascular Surgery Society (VESS) session

n The E. Stanley Crawford Critical Issues Forum

n The Roy Greenberg and John Homans lectures

n The Awards Ceremony

n Two concurrent sessions each on Thursday and Friday

n The Presidential Address

n A postgraduate course on Saturday

The Opening Ceremony also may be live-streamed. Details, Schanzer cautioned, are subject to change. Learn more about VAM 2022 at vascular.org/VAM.

Giving November initiative brings in $50,000-plus to SVS Foundation

The SVS Foundation’s extension of Giving Today into Giving November was a big success, with more than $50,000 donated to Foundation research, grants, awards and projects.

A host of Society for Vascular Surgery (SVS) members provided matching funds of more than $20,000 in giving challenges for both Giving November and Giving Tuesday. The latter is the global day of giving held annually on the Tuesday after Thanksgiving—which was Nov. 30 in 2021.

The SVS Executive Board of Directors and the SVS Foundation Board of Directors, plus the chairs of the SVS Development Committee, banded together to match up to $20,000 in donations. That goal was reached well before the month’s end, said Peter Nelson, MD, chair of the Development Committee.

In all, the Foundation received $29,910 from 183 individuals and one society— including the Giving Tuesday campaign. A separate SVS staff challenge resulted in $1,315 in donations from 17 staff

Last call for Community Practice accolade

LESS THAN A MONTH REMAINS TO submit nominations for the 2022 Society for Vascular Surgery (SVS) Excellence in Community Practice Award.

The honor is exclusively for those who practice in the community setting, including members in the office-based lab (OBL) setting. Nominations are due by Feb. 1 (the accolade was previously called the Excellence in Community Service Award).

So what denote “excellence”? Past recipients have mentored students, brought vascular service to underserved areas and/or to patients’ homes, developed training or other educational programs, developed practice guidelines covering high-risk vascular patients, and been active in SVS or local and state vascular organizations

To be considered, applicants must be community practitioners and have been in practice as a vascular surgeon for at least 20 years; been an SVS member for at least five years; and show evidence of impact on vascular care or community health.—Beth Bales

Learn more at vascular.org/ CommunityPracticeAward.

and contracted individuals, with that amount matched by donations from Executive Director Kenneth M. Slaw, PhD, and SVS Foundation Executive Director Rupa Brosseau.

“Our members have made November 2021 one of the most monumental and memorable months that the Foundation has ever seen,” said Nelson.

“SVS members have really stepped up in the past few years, with not only larger donation totals but also more members participating,” added Foundation Chair Peter Lawrence, MD. “Both factors are pivotal to the success of our mission. Without money, there is no mission. I am grateful to our members and also to our leadership’s example in leading the way to a strong SVS Foundation.”

Visit vascular.org/SVSFoundation to learn more about the Foundation and its programs and mission.—Beth Bales

Spotlight

$29,910

York.

In memoriam

Senior member John M. Keshishian, 98, a cardiothoracic and vascular surgeon who had a private practice in Washington, D.C., practiced at Washington Hospital Center, and also was a clinical professor of surgery at George Washington University’s medical school, died Nov. 5, 2021.

SVS to hold Surgical Coaching Program webinar Jan. 24

Professional athletes and musicians have coaches to help them “up their games.” It follows then that vascular surgeons can benefit from coaching within the specialty.

The Society for Vascular Surgery (SVS) will hold a webinar on surgical coaching from 6–7 p.m. Central Standard Time on Monday, Jan. 24. Panelists will discuss what surgical coaching is, how surgical coaching contributes to wellness, additional benefits of surgical coaching and the background of the SVS Surgical Coaching Program through a collaboration with the Academy for Surgical Coaching. Coaches will share their experience and the webinar will also include a question-and-answer period with coaches, SVS members and representatives of the Academy for Surgical Coaching.

“Even the best of the best can benefit from coaching,” said Dawn Coleman, MD, co-chair of the SVS Wellness Committee, which oversees the coaching program.

“We’ve worked closely with the Academy for Surgical Coaching, which has trained a number of SVS members and vascular surgeon leaders to serve as peer surgical coaches.”

“The program offers expert advice from vascular surgeon colleagues in the field,” she said.

“Our committee can’t recommend coaching highly enough to improve problem-solving and negotiating skills, feel better and take your career up a notch.” Register at vascular.org/TBD.—

Beth Bales

Intraoperative vascular consults have risen 529% in last 15 years, single-center analysis finds

BY BETH BALES AND BRYAN KAY

According to researchers from the University of Washington (UW) level 1 trauma center, the number of intraoperative vascular surgeon consultations has increased enormously over the past decade. The group conducted a study reported in the November 2021 issue of the  Journal of Vascular Surgery (JVS)

“THE EVOLVING ROLE OF THE VASCULAR surgeon in the management of intraoperative emergencies involving trauma patients remains undefined,” said first-named author Jake Hemingway, MD, of UW. “The primary aims of this study included determining the prevalence of intraoperative vascular consultation in trauma, describing how these interactions have changed over time and characterizing the outcomes achieved by

vascular surgeons in this setting.”

UW researchers led by chief of vascular surgery Benjamin Starnes, MD, performed a single-center retrospective evaluation of 234 intraoperative consultations by vascular surgeons at their Seattle hospital from 2002–2017.

The team found that over the course of 15 years, the number of consultations increased by 529%. Some 65% of these consultations required an immediate intraoperative response. Further, there was a 1,400% increase in general/trauma surgery consultations per year throughout this period.

Consultations were for trauma (81%), latrogenic injury (14%) and unusual pathology (5%), with indications for consultation recorded as extremity ischemia (37%), hemorrhage (26%), arterial injury (20%) and need for exposure (6%).

“The most common reason for the increase in vascular involvement in the management of a trauma patient is likely multifactorial, but may be influenced by a declining trauma surgeon familiarity with vascular repair. Multiple studies have demonstrated the decreasing vascular experience of general surgery residents over time,” said Hemingway.

This changing role has significant financial implications, he continued. “As vascular surgeons become increasingly essential team members at a level 1 trauma center, one may argue that the 24-hour, in-house availability of

234

intraoperative consultations

75

%

requiring an immediate intraoperative response

vascular surgeons might be mandated,” Hemingway said. “Looking forward, it will be important to quantify the financial and safety implications of these changing trends in order to demonstrate the value that vascular surgeons bring to a level 1 trauma center outside of standard clinical practice.”

This study reinforces the increasing value that vascular surgeons bring to hospital systems and patient care, and highlights vascular surgeons are critical to a safe operating room environment, according to  JVS editors.

“These trends are not explained by endovascular capabilities, and instead may be explained by decreased trauma surgeon familiarity with vascular repairs, based on the changes in the experience provided by a general surgery residency over time,” Hemingway et al concluded in their JVS paper.

“Despite these trends, vascular surgeons continue to provide timely and effective care.”

“Multiple studies have demonstrated the decreasing vascular experience of general surgery residents over time”

Jake Hemingway

New recommendations promote ‘appropriate and effective’ use of social media in medicine

BY JOCELYN HUDSON

In response to a rapid augmentation of social media use in medicine over the past five years, the Society for Vascular Surgery (SVS) has published a set of recommendations on appropriate practice. The document aims to provide guidance on “how to interact online in a transparent, collegial and ethical manner while all along protecting patient privacy,” Nicolas J. Mouawad, MD, chief and medical director of vascular and endovascular surgery at McLaren Health System, Bay City, Michigan, tells Vascular Specialist. In this interview, Mouawad, along with joint first author Edward D. Gifford, MD, of Hartford HealthCare in Hartford, Connecticut, outline the document’s key messages, detail how COVID-19 has “catapulted” the use of virtual communication, and consider how the use of social media in medicine might evolve moving forward.

VS: What are the key takeaway messages from the new recommendations document?

NW: The SVS is committed to supporting the appropriate and effective use of social media through honest, transparent and well-informed content. The Young Surgeons Committee of the SVS convened a diverse writing group of SVS members in different practice patterns and employment models, geographic locations, cultural backgrounds and clinical experiences to help craft a document to help guide both novice and experienced users to the use of social media platforms in vascular surgery. Key takeaway messages in a nutshell are (1) absolutely protect patient privacy, (2) obtain consent when using and sharing images, (3) ensure you follow your institution’s requirements, (4) disclose conflicts of interest, and (5) maintain an amicable and professional online environment as there are multiple specialties involved in vascular care.

EG: Adding to that, social media is a great melting pot of different medical specialties. We have a lot we can learn from each other, and while we may not always agree on a case that is shared, we wanted to advocate for trying to find common ground where possible while avoiding ad hominem attacks or other cyber-bullying behavior.

VS: What do you think are the main benefits and drawbacks of social media in medicine?

NW: Social media is a powerful tool to disseminate information, educate patients and providers, and allow for exchange of ideas, resources and knowledge, literally at the recipient’s fingertips. However, with this great ability comes responsibility and accountability. I believe the main benefit is the ease of information transmission, and the ability to learn and network from other healthcare professionals that you may have never interacted with or been able to reach. The drawbacks in my mind are how to ensure the credibility of the information (to minimize the spread of disinformation) and the legitimate concern for breaching patient privacy. We must protect that at all costs!

EG: Social media can pull us out of our medical comfort zone. Often, new technology or procedures are limited to vascular surgery. For instance, at an endovascular-focused conference we might be exposed to novel therapeutic options. By comparison, how often do we find ourselves at a plastic surgery or orthopedic trauma conference?

Social media brings data from those specialties that might be very relevant to our field right to our fingertips. Take for instance the use of pie-crusting to allow for delayed primary closure of fasciotomy incisions. This technique

was popularized on social media by Yelena Bogdan, an orthopedic trauma surgeon. However, it has now been shared among many vascular surgeons on social media, and we in our group have even used it with success after learning about it online. The rapid dissemination of information, and the ability to interact with other specialists in realtime, can have a real positive impact on how we practice both the art and science of medicine. Of course, this is tempered with some legitimate drawbacks. First and foremost, in my opinion, is the risk to patient privacy. Just as the reach of social media goes well beyond that of a traditional lecture hall, so too does our use of an illustrative case run the risk of violating a patient’s privacy.

access to a large vascular surgery interest group (VSIG) at their home institution. As COVID-19 encouraged online interaction for many of us, we felt that the SVS taking a positive stance on social media use was more important than ever.

VS: How do you think social media use in medicine has changed in the COVID-19 era?

NW: COVID-19 has forced us to practically move and live online. It has been very challenging in the beginning months but we have found that although we are socially distant, we have never been closer. The world has become even smaller, with all of us able to communicate with colleagues internationally and learn from them as they learn from us depending on what COVID-19 wave is occurring and where. Social media during the COVID-19 era allowed us to build new friendships and foster new relationships that continue strong. As a matter of fact, some of us on this social media writing group have actually never even met each other in person. We have communicated over social media and electronically to complete the guidelines and have e-met online.

“Vascular surgeons are at the cutting edge of new technology and devices, and are very tech savvy”

Nicolas J. Mouawad

VS: Why do you think it was necessary to produce such a document and at this particular time?

NW: Vascular surgeons are at the cutting edge of new technology and devices, and are very tech savvy. It is no surprise to me that most are very active on social media already. The idea was borne of the Young Surgeons Committee of the SVS, and really was focused on providing guidelines on how to interact online in a transparent, collegial and ethical manner while all along protecting patient privacy. In addition, I really do believe that COVID-19 catapulted our use of social media in an effort to maintain physical distancing and other public health parameters.

EG: That is a great question, and I think it is important to keep in mind that the presence of vascular surgery and vascular surgeons on social media has changed a lot from when we first contemplated this document. The idea for this sprang from the Young Surgeons Committee. We noticed that more and more vascular surgeons were using social media, in particular Twitter. Personally, as a young member of that group, I was looking for some guidance about how to deal with some of the conflicts already mentioned. Could I share images of an interesting case? What is the best way to go about doing that? We also felt that social media was a great medium to interact with trainees and medical students who might be interested in vascular surgery, but maybe did not have

EG: Almost two years into COVID-19, it is impossible to not have days where we feel isolated. A lot of this was heightened early in the pandemic when we could not rely on in-person meetings to connect with trainees, peers and mentors. Social media was a great forum to bring many of us together. Online, we have been able to interact with vascular surgeons and other healthcare workers from around the country and the world, and we have built some truly worthwhile connections along the way. I love seeing colleagues share everything from a new community initiative on limb salvage, to how to tackle large varicose veins after ablation, to Play-Doh vascular anatomy.

VS: How do you think the use of social media in medicine might evolve in the future?

NW: Social media will continue to evolve— there is no doubt in my mind about that. We have seen how meetings have moved into the virtual space, as well as full annual conferences. Applicants and interviews are being conducted this way nowadays for ease of access and cost savings, alongside online open houses for candidates. Even interest groups are becoming well developed in the online sphere. This, in my opinion, is an excellent opportunity to advertise to the younger generation and literally show them with images and videos our specialty.

EG: I think certain things adopted during the pandemic may be here to stay, at least in one form or another. Take for instance the virtual interview process of our residency and fellowship applicants. There will likely be some virtual component to application season in perpetuity. Whether this is a virtual open-house to learn about a program, faculty vignettes, or online journal-clubs, I think we are going to see use of social media for these group endeavors increase. While I hesitate to say that we are going to be providing patientspecific medical care on social media, we are already seeing community education events via social media forums such as Facebook Live. The reality is that a lot of our patients use social media. If we want to provide factual education about vascular disease to them, social media might provide a lot of opportunity for that. Lastly, as we anticipate the intersection of social media and medicine growing, this may result in some form of oversight or regulation.

SVS issues new guidelines covering carotid disease, popliteal aneurysms

BY BETH BALES

The Society for Vascular Surgery (SVS) has released updated clinical practice guidelines for the management of extracranial cerebrovascular disease and popliteal artery aneurysms in a special supplement, “The Care of Patients with Extracranial Cerebrovascular Disease and Popliteal Artery Aneurysms: The Society for Vascular Surgery Clinical Practice Guidelines,” published in the January issue of the Journal

THE SUPPLEMENT ALSO INCLUDES a systematic review supporting the SVS guidelines on managing carotid artery disease, plus a systematic review and meta-analysis of treatment and the natural history of popliteal artery aneurysms. Ali AbuRahma, MD, SVS president, and Alik Farber, MD, led the respective writing groups in developing the clinical practice documents, which offer recommendations to inform the diagnosis, evaluation, treatment options and follow-up of affected patients. “The expert writing groups included world-renowned vascular surgeons who analyzed the most recent evidence and performed systematic reviews to bring forth these clinical practice guidelines,” according to Ruth Bush, MD, chair, and Marc Schermerhorn, MD, vice chair, of the SVS Document Oversight Committee (DOC).

The carotid guideline includes an update of the 2011 version and provides graded evidence-based recommendations on the role of surgical therapy over medical therapy alone for asymptomatic low-risk patients; the role of carotid endarterectomy (CEA) vs. stenting for symptomatic low-risk patients; the optimal timing of interventions after acute stroke; screening for carotid artery

interventions for patients undergoing intervention for diseases in both vascular beds. Because of the volume of the literature, information and additional topics with more critical details, the writing group also created a separate implementation document as a supporting companion resource.

The clinical practice guideline on popliteal artery aneurysms presents evidence- and consensus-based recommendations regarding the evaluation of patients with this disease. They provide recommendations for open surgical repair vs. endovascular stent-graft repair for specific patient populations according to life expectancy, plus recommendations for urgent treatment of thrombosed popliteal aneurysms according to the Rutherford acute ischemia stage at presentation.

“This [clinical practice guideline] is a unique contribution that has amassed the available data and current treatments for this disease process,” Bush and Schermerhorn explained.

Since publication of the SVS’ 2011 update of the clinical practice guidelines for carotid artery disease, several pivotal studies comparing CEA and carotid artery stenting (CAS) have been published. In addition, the literature has demonstrated a confirmation of the need for optimization of medical therapy. Therefore, the updated SVS guideline provides graded

preferred intervention in low-risk patients with symptomatic and asymptomatic disease. Evidence suggests that, once the perioperative period has elapsed, late ipsilateral stroke (at five and nine years) is no different between CEA and CAS, but 30-day death/stroke is significantly higher after transfemoral CAS vs. CEA, especially in the first seven to 14 days after the onset of symptoms.

Back on aneurysms of the popliteal artery—the most common aneurysms outside of the brain and abdominal aorta— these can cause limb loss and, therefore, early diagnosis, careful follow-up, and timely treatment of this condition are paramount.

This SVS guideline offers recommendations to inform the diagnosis, evaluation, treatment options, and followup of patients with popliteal artery aneurysms. Size thresholds for repair, too, are included. Specific circumstances under which aneurysms may be considered for repair at a smaller size are also provided. Recommendations for open vs. endovascular repair are given for specific patient populations based on life expectancy.

“Despite the low certainty of the evidence, [event] rates along with surgical expertise and anatomic feasibility can help patients and surgeons to engage in shared decision-making,” the accompanying

From intentions to gratitude

BY CHRISTOPHER

Formally introducing CHRISTOPHER AUDU

BY BRYAN KAY

The team at Vascular Specialist—led by Malachi Sheahan III, MD—is pleased to announce the appointment of University of Michigan resident Christopher Audu, MD, as our new resident/fellow editor. He replaces Laura Marie Drudi, MD, who last year graduated from fellowship and now practices as a vascular surgeon at Centre Hospitalier de L’Universite de Montréal in Canada. Here, Audu talks us through his vascular journey so far.

Tell us a little about your background and journey into vascular surgery.

CA: I was born and raised in Nigeria, where I lived until after high school, when I was fortunate to pursue a chemistry degree from Purdue University. I then matriculated to Dartmouth for medical and graduate school where I got a Chemistry PhD. My interest in vascular surgery came about circuitously. I did not decide on surgery until the end of my MS3 year, and I began looking for a surgical field that would value what I had to offer as a basic scientist interested in medicinal chemistry. One of my PhD projects had examined the role of endothelin receptor activation as a therapeutic target against rapid vascular smooth muscle cell proliferation (aka intimal hyperplasia), so I was hooked on vascular pathophysiology and the role

Corner Stitch

A time of transition, like the dawn of a New Year, usually commences the mass drive for New Year’s resolutions and intentions. Many of us have had the pleasure of covering the New Year’s call shift, and it was also so striking to see the new fads healthcare professionals began to take on—from green smoothies to workout challenges. But let’s begin this year with some gratitude and predictions.

FIRST, TO OUR DIVERSE READERSHIP, THANK YOU for your continued support in opening up our monthly newspapers, and perusing and sharing our content. Thank you for the feedback you have given because, with your continued involvement, our newspaper becomes stronger with every passing issue. Thank you, and we will continue to serve you and have your voices heard.

To our community of leaders and authors of Vascular Specialist: we have shared stories from nurses and allied

for medicinal chemistry. I attended the 2014 Vascular Annual Meeting (VAM) and walked among the poster boards, and was delighted to see that there was a robust presentation of immunology, biochemistry and pharmacologic projects on display. On return from VAM, I completed my surgery rotation and fell in love with the breadth of expertise that vascular had to offer.

How did your involvement with Vascular Specialist come about?

CA: Ever since starting residency, I would read through Vascular Specialist with keen interest in Resident’s Corner [now Corner Stitch]. I had the opportunity to virtually meet Dr. Laura Drudi last year, and, after chatting for a bit, she asked me to consider writing a post for interns last July. That was my first post, and I guess the lessons I learned from my experiences resonated with enough people that I was asked to become a recurring contributor to the column.

What plans do you have for the paper in your role as resident/fellow editor?

CA: It is an honor and privilege to follow Dr. Drudi’s footsteps in this role, and I am grateful to have her as a mentor. The goal for Corner Stitch has always been to highlight topics that are germane to the vascular trainee in the here and now—from the medical student level up to the graduating resident/fellow. I would like to continue in this tradition and invite

contributions from as diverse a body of trainees as is possible.

What do you feel are the biggest issues with vascular training at the present moment?

That’s a great question. The number one goal as a vascular trainee is to become proficient, confident, compassionate surgeons who offer our patients the full gamut of comprehensive vascular care— and who are humble enough to learn new techniques, or refer to an expert if a particular skill is not in our wheelhouse. Ultimately, the patient in front of us is who matters foremost. I do believe our current training paradigms allow us to meet this goal, even though there is variation in regional practice and training patterns. Notwithstanding, the biggest issues with vascular training, I think, are twofold: inflow to the specialty and a need for wellness initiatives that are meaningful for the trainee.

Do you have any key advice for students and trainees eyeing vascular surgery?

CA: To students and others looking into vascular surgery, I’d encourage you to attend local and/or national vascular conferences. While there, see if the specialty checks the boxes of what you are looking for in a surgical career. Introduce yourself to people, or, if you are there with a mentor, have them introduce you to people. Finally, apply for residency/fellowship and don’t give up. We need you.

healthcare professionals trying to stay afloat during this pandemic; struggles and barriers surgeons face daily to deliver comprehensive vascular care; and stories from leaders on how they have navigated and led their teams in times of crisis.

Despite the challenges, we are all to be commended on not only surviving a difficult year, but for being present for our patients, colleagues, families and ourselves. Thank you all, and we will continue to serve you and have your voices heard.

And finally to our Society for Vascular Surgery (from the leaders to the membership): the SVS has shown tremendous resilience in the face of the COVID-19 pandemic, and has been at the forefront in complete transparency with virtual webinars, Town Halls, and ongoing initiatives to aid the membership. Wellness has been at the forefront of our society before the pandemic, but has truly been—a priority during this time of crisis.

The SVS Wellness Committee (formerly Task Force) under the leadership of Drs. Dawn Coleman Malachi Sheahan III, and others have brought peer support and coaching to SVS members. Thank you all for the work that you do. We will continue to serve the SVS and have all voices heard.

Now, here are a few predictions for what we may learn in 2022. We will have to circle back at the end of the year to see if any of these comes to pass.

Prediction #1

First off, a return to in-person interviews. We hope that, with widespread vaccine availability and growing scientific advances towards therapeutics (see here for latest wonder drug against COVID-19 that is currently in clinical trials), we will have a return to inperson interviews, both for residency and fellowship. While video conferencing has been a natural substitute, most programs take pride in showing off their facilities, their towns/ cities, and their trainees in person. It’s just not the same, and we hope 2022 brings things back to some sense of semi-normalcy.

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VAM travel scholarship applications available this month

Medical students and general surgery residents will be able to apply this month for travel scholarships to attend the 2022 Society for Vascular Surgery (SVS) Vascular Annual Meeting (VAM), which takes place June 15–18 in Boston.

The SVS offers the SVS General Surgery Resident/ Medical Student VAM Travel Scholarship and the SVS Diversity Medical Student VAM Travel Scholarship. Each provides a travel award to underwrite expenses to attend the meeting, as well as complimentary registration, a mentorship program, and a dedicated educational and networking program.

Diversity scholarship winners also will participate in the Meet the Leaders Luncheon.

More information is available at vascular.org/ VAMTravel1 and vascular. org/VAMTravelDiversity.— Beth Bales

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Prediction #2

We will finally know if carotid endarterectomy is better than stenting for stroke prevention. The CREST-2 trial, currently ongoing, is predicted to have a primary completion date of December this year. While we may not have the official trial results in print for another year or so, we predict that 2022 will bring more clarity on this important subject. We will be watching conference abstracts closely for result teasers.

Prediction #3

More vascular surgery residency spots. OK, so this is pure speculation on our part, but we hope that more slots for the 0+5 residency training paradigm open up. This will continue to help increase the pipeline and number of vascular surgeons in the next decade. We predict five to 10 more spots for trainees to choose

While video conferencing has been a natural substitute, most programs take pride in showing off their facilities, their towns/cities, and their trainees in person

from. And yet, most of all this year, we look forward to working with you, our readers. Email us your topic pitch, or tell us what you may want to read about. What is most germane to you?

In 2022, we look forward to meaningful interviews, wisdom and write-ups that challenge us to expand our thinking—and help us perfect that sometimes elusive, but exquisitely important, Corner Stitch column.

CHRISTOPHER AUDU is a vascular surgery resident at the University of Michigan in Ann Arbor, Michigan, and the newly installed resident/fellow editor of Vascular Specialist. His predecessor, LAURA MARIE DRUDI, is a vascular surgeon at Centre Hospitalier de L’Universite de Montréal in Montreal Canada.

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*The GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis indication includes de novo or restenotic lesions in iliac arteries, including those at the aortic bifurcation. The GORE® VIABAHN® Endoprosthesis indication includes lesions in the iliac arteries only.

† As used by Gore, Heparin Bioactive Surface refers to Gore’s proprietary CBAS Heparin Surface.

1. Piazza M, Squizzato F, Dall’Antonia A, et al. Outcomes of self expanding PTFE covered stent versus bare metal stent for chronic iliac artery occlusion in matched cohorts using propensity score modelling. European Journal of Vascular & Endovascular Surgery. 2017;54(2):177-185.

2. Panneton JM, Bismuth J, Gray BH, Holden A. Three-year follow-up of patients with iliac occlusive disease treated with the Viabahn BalloonExpandable Endoprosthesis. Journal of Endovascular Therapy. 2020;27(5):1.

Please see accompanying prescribing information in this journal. Products listed may not be available in all markets. GORE, Together, improving life, VBX, VIABAHN and designs are trademarks of W. L. Gore & Associates.

GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis

GORE® VIABAHN® Endoprosthesis with Heparin Bioactive Surface†