Welcome to Vascular Team Talk, a podcast mini-series by the Society for Vascular Surgery Physician Assistant Section and Audible Bleeding.  In this podcast, we interview people who work in the vascular world and discuss their roles and life on their vascular team to learn more about how different vascular teams are built and function.  We look to highlight the good and learn from the bad so that we can take those experiences back to our teams and make positive changes that will make our teams more robust and improve the care we provide to our patients.

In this first episode, Steve Robischon, PA-C, and Laura Needler, APNP, both advanced practice providers at the Medical College of Wisconsin (MCW), review the history of the physician assistant and nurse practitioner professions, discuss similarities and differences in their training, and describe how they function on their vascular team.  They also interview Dr. Nate Kugler, a vascular surgeon at MCW, regarding his experiences working with PAs and NPs both during his training and now as a practicing surgeon.

Show Guests:

• Steve Robischon, PA-C, is a physician assistant in the Division of Vascular & Endovascular Surgery at the Medical College of Wisconsin in Milwaukee, WI, and he’s currently the Lead Outpatient APP for the Division.  He’s also a member of the SVS PA Steering Committee.  He received his Master of Physician Assistant Studies from Marquette University in 2007
• Laura Needler, APNP, is a nurse practitioner in the Division of Vascular & Endovascular Surgery at the Medical College of Wisconsin in Milwaukee, WI, and she’s currently the Lead Inpatient APP for the Division.  Laura received her Master of Science in Nursing from Concordia University of Wisconsin in 2013
• Dr. Nate Kugler is a vascular surgeon and assistant professor in the Division of Vascular & Endovascular Surgery at the Medical College of Wisconsin in Milwaukee, WI. He completed medical school at Southern Illinois University in 2012, followed by both his general surgery residency and vascular surgery fellowship training at MCW which he completed in 2021.

Show Links:

• American Academy of Physician Assistants / Associates (AAPA)
• American Association of Nurse Practitioners (AANP)
• SVS Physician Assistant Section
• Society of Vascular Nursing
• MCW Division of Vascular & Endovascular Surgery

Audible Bleeding editor Wen (@WenKawaji) is joined by 3rd year general surgery resident Ryan Ellis discussing robotic vascular surgery with Dr. Judith Lin (@JudithLin4) and Dr. Petr Stadler. Dr. Lin and Dr. Stadler will share their personal journey in robotic vascular surgery, cases they have done, and what think the future looks like.  This is part one of our robotic vascular series. Our next episode will feature Dr. Lumsden and Dr. Bavare from Houston Methodist. 

Show Guests:

• Dr. Judith Lin: professor and chief of vascular surgery in the Department of Surgery at Michigan State University’s College of Human Medicine

• Dr. Petr Stadler: Professor of Surgery, Head of Vascular Surgery Department, Na Homolce Hospital, Prague, Czech Republic

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Nicole Rich, Adam Johnson, and Kevin Kniery review cerebrovascular.

Vascular Surgery Exam Prep Ebook - Cerebrovascular

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Drs. Kevin Kniery, Adham Elmously, and Todd Rasmussen discuss vascular trauma of the major abdominal veins.  Originally published Jan 18, 2020, and was created in collaboration with Behind the Knife: The Premier Surgery Podcast.

Vascular Surgery Exam Prep eBook - Trauma: Abdomen Venous

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Audible Bleeding editors Matt (@chia_md) and Gowri (@GowriGowda11) are joined by 3rd year General Surgery resident Sasank Kalipatnapu (@ksasank), 2nd year medical student Nishi Vootukuru (@Nishi_Vootukuru), JVS editor-in-chief Dr. Thomas Forbes (@TL_Forbes), and JVS-VL Associate Editor Dr. Meryl Logan (@ProleneQueen), to discuss two great articles in the JVS family of journals regarding treatment of asymptomatic carotid artery disease and comparison of venous insufficiency treatment via radiofrequency ablation and microfoam ablation. This episode hosts Dr. Robert Chang, Dr. Stephanie Talutis, and Dr. Juan Carlos Jimenez, the authors of the following papers: 

Articles:

JVS: A comparative effectiveness study of carotid intervention for long-term stroke prevention in patients with severe asymptomatic stenosis from a large integrated health system by Chang et al. 

JVS-VL: Comparison of outcomes following polidocanol microfoam and radiofrequency ablation of incompetent thigh great and accessory saphenous veins by Talutis et al. 

Additional article discussed for JVS-VL: Adjunctive techniques to minimize thrombotic complications following microfoam sclerotherapy of saphenous trunks and tributaries by Jimenez et al.

Show Guests:

• Dr. Robert Chang – Assistant Chair of Vascular Surgery, Adjunct Investigator, KP Division of Research Northern California

• Dr. Stephanie Talutis - Assistant Professor of Vascular Surgery, Tufts Medical Center

• Dr. Juan Carlos Jimenez, Clinical Professor of Surgery, Director, Gonda Venous Center, Vice-Chair for Justice, Equity, Diversity, and Inclusion at UCLA

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In this episode, Sasank Kalipatnapu (@ksasank) and Leana Dogbe (@ldogbe4) sit down with Dr.Joseph Mills(@jmills1955), Dr. Douglas Jones and Dr. Premchand Gupta (@pcvasc) to discuss the origin of the SVS Step Challenge. This episode features a conversation about the history behind the SVS Step challenge and the role of walking in treating peripheral artery disease (PAD). It also covers the origin of “Walkathon”, the Indian equivalent of SVS Step Challenge. 

Dr. Joseph Mills is Professor and Chief of the Division of Vascular Surgery and Endovascular Therapy at Michael E DeBakey Department of Surgery at Baylor College of Medicine in Houston, Texas. He is also the John W. Reid and Josephine L. Reid Endowed Professorship in Surgery and is currently the chair of the SVS Foundation. 

Dr. Douglas Jones is an associate professor of Vascular Surgery at UMass Chan Medical School, Worcester, MA. He currently leads the Limb Preservation Center at UMass Memorial Health. 

Dr. PC Gupta is the clinical director of vascular and endovascular surgery and vascular interventional radiology at the Care Hospitals in Hyderabad, India. He is President of the Vascular Society of India and now President of the World Federation of Vascular Societies.

Relevant links: 

SVS Step Challenge - Home Page - Link to look up the details of the Step Challenge

vascular.org/step2024 - Link to sign up for the Step Challenge 2024

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Vascular Origin Stories is a podcast series that explores the fun and engaging stories that shaped vascular surgery.

Today’s episode will be the second part of a multi-episode series exploring how the young battalion surgeons serving in MASH units in the Korean war pioneered wartime vascular repair. Today we’ll explore in detail the individual stories of adversity, courage, and perseverance that led to the re-introduction of arterial repair in the military. Representative images, significant sources for the episode, and a complete reference list can be found on the episode webpage.

Author + Host:

Marlene Garcia-Neuer (@GarciaNeuer) is a PGY1 General Surgery Resident at Mayo Clinic Arizona.

We are calling all medical students!

Submit your questions for the mailbag episode! Ask us any question related to vascular surgery, and have it answered on the podcast. 

Include the following

• Your name, school, and year

• Who do you want to address the question to (resident, fellow, attending, or someone specific)

• Please send them in writing or voice-recorded format.

Please share your feedback through our Listener Survey!

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Music by ZakharValaha and Kaazom from Pixabay,

In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovates, and Techniques (JVS-CIT). Editorials and Abstracts are read by members of the SVS Social Media Ambassadors.

Readers:

David Ebertz (@EbertzDavid)

Kori Snider (@KoriSnider)

Nabeeha Khan (@Nabeeha_Khan_)

Hosts:

John Culhane (@Johnculhanemd)

Nishi Vootukuru (@Nishi_Vootukuru)

Reference Articles:

Sutureless endovascular bypass technique in long femoropopliteal occlusions

Technical feasibility and device stability of the Gore Excluder iliac branch endoprosthesis as abdominal aortic bifurcated device

Retrograde aortic dissection during thoracic endovascular aortic repair: How to prevent and treat

Retroperitoneal approach for ilio-superior mesenteric artery bypass: Technique and case series

Randomized controlled trials in emergency settings: Taking a HEADSTART on acute type A aortic dissection trials

Presentation and management of true aneurysms of the pancreaticoduodenal arcade with concomitant celiac artery stenosis using the endovascular approach

Regarding “Aortic rupture during STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique”

Temporary mesenteric venous shunting for portal vein reconstruction: A novel technical adjunct

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*Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovations, and Techniques (JVS-CIT). Editorials and Abstracts are read by members of our SVS Social Media Ambassadors and authors.

Readers:

Shourya Verma (@shourya__verma)

Nabeeha Khan (@Nabeeha_Khan_)

Miguel Fernandez (@MGfernandez21)

Amit Chaudhary (@VascularKGMU)

Dr. Jayer Chung (@Jayer_Chung)

Hosts:

Nishi Vootukuru (@Nishi_Vootukuru)

John Culhane (@Johnculhanemd)

Editorials (E) and Abstracts (A):

E- Arteries of fibromuscular dysplasia tell a sympathetic story

A- Transcarotid arterial revascularization is feasible and safe with concomitant inferior vena cava occlusion

A- Surgical anteriorization of the left common iliac vein results in improved venous outflow and quality of life for May-Thurner syndrome

E- Longer is better, discussing length of coverage and timing of intervention in type B aortic dissection

A-Endovascular repair of ascending aortic pathologies in patients unfit for open surgery: Case series and literature review

A-Improved gait parameters following surgical revascularization in patients with intermittent claudication

A- Totally percutaneous endovascular renal allograft salvage for common iliac artery pseudoaneurysm

A- Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms

E- Impact of the infrapopliteal bypass with distal arteriovenous fistula and distal cuffs in the management of small arterial disease

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Audible Bleeding editor Wen (@WenKawaji) is joined by 3rd year medical student Nishi (@Nishi_Vootukuru), JVS editor Dr. Forbes (@TL_Forbes), and JVS social media liaison Dr. Haurani to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Marc Schermerhorn, Dr. Andrew Sanders, Dr. Mitchell Cox and Dr. Junji Tsukagoshi, the authors of the following papers. 

Articles:

• Ten Years of Physician Modified Endografts

• Peri-operative and intermediate outcomes of patients with pulmonary embolism undergoing catheter-directed thrombolysis vs. percutaneous mechanical thrombectomy

Show Guests 

• Dr. Marc Schermerhorn: Chief of vascular and endovascular surgery at Beth Israel Deaconess and professor of surgery, Harvard Medical School 

• Dr. Andrew Sanders: PGY4 general surgery resident at Beth Israel Deaconess 

• Dr. Mitchell Cox: Division chief of vascular surgery and endovascular therapy, program director of the vascular surgery residency program at the University of Texas Medical Branch. 

• Dr. Junji Tsukagoshi: Fourth year vascular surgery resident at the University of Texas Medical Branch in Galveston Texas. 

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Audible Bleeding editor Adam Johnson (@Adam_mdmph) is joined by MD/Ph.D. student Rahul Ghosh (@ghoshrx) and JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd) to discuss the second highlighted article for January in the JVS family of journals.  Dr. David Gordon and Dr. David Williams, the authors of the following paper, join them: 

“Pathologic characteristics of human venous in-stent stenosis and stent occlusion” by Williams et al.

Show Guests:

• Dr. David Gordon (faculty page) is the Emeritus Professor of Pathology at the University of Michigan, and serves as the Director for Cardiovascular Pathology.  He has also had much experience with both human cardiovascular and associated animal model research. 
• Dr. David Williams (faculty page) is the Kyung J. Cho Collegiate Professor of Radiology in the Division of Vascular and Interventional Radiology at the University of Michigan Medical School

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Drs. Kevin Kniery, Marlin "Wayne" Causey, and Todd Rasmussen discuss endovascular management of vascular trauma, particularly focusing on blunt thoracic aortic injuries.  Originally published on Feb 9, 2021, and was created in collaboration with Behind the Knife: The Premier Surgery Podcast.

Vascular Surgery Exam Prep eBook - Trauma: Endovascular

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In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovations, and Techniques (JVS-CIT). Editorials and Abstracts are read by members of the SVS Social Media Ambassadors.

Guests:

Dr. Gregory Magee, MD (@gregamagee)

The past, present, and future of abdominal aortic aneurysm repair

Dr. Eric Pillado, MD (@drpillado)

The need for standardizing care for pediatric and geriatric vascular trauma patients

Dr. Ben Li, MD (@ben_li123)

Advanced chronic venous insufficiency and the role of the incompetent perforator vein: A 100-year quest for the right strategy

Pediatric carotid body tumors: A case report and systematic review

Early experience with baroreflex activation therapy from a vascular surgery perspective

Dr. Donald Baril, MD (@DonaldBaril)

Early graft failure following lower extremity bypass

Dr. Michael Malinowski, MD

Current challenges to vascular trauma training across levels and regions

Hosts:

John Culhane (@JohnCulhaneMD)

Nishi Vootukuru (@Nishi_Vootukuru)

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*Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

In today’s episode, Dr. Rachael Forsythe (@ROForsythe), consultant vascular surgeon at NHS Lothian, leads a fictional case-based discussion with leaders in managing diabetic foot ulcers. Joining the conversation are Professor Andrew Boulton, Mr. Patrick Coughlin, Dr. David Armstrong, Dr. Dane Wukich, and Dr. Edgar Peters.

Professor Boulton is a professor of medicine at Manchester University in England and is co-chair of the Malvern  Diabetic Foot Conference meeting. He served as president of numerous distinguished societies, including the International Diabetes Federation.

Dr.  Coughlin (@Coughlin_pa) is a consultant vascular surgeon in Leeds, England. He is a very active member of the Vascular Society of Great Britain and Ireland Council and has a special academic and clinical interest in peripheral artery disease.

Dr. Armstrong (@DGArmstrong) is a podiatric surgeon and professor of surgery at Keck School of Medicine of the University of California and director of the Southwestern Academic Limb Salvage Alliance. Dr. Armstrong is very well known for his work on amputation prevention, the diabetic foot and wound healing.

Dr. Wukich (@DaneWukich) is a professor and chair of the Department of Orthopedics at the University of Texas, Southwestern and Medical Director of Orthopedic Surgery at UT Southwestern University Hospitals. Dr. Wich has an interest in foot and ankle surgery, including the management of diabetes-related complications.

Dr. Edgar Peters is an associate professor of internal medicine, infectious diseases, and acute medicine at Amsterdam University Medical Centers, Dr. Peter's main interest is infection of the musculoskeletal system, particularly in patients with diabetes and is the Scientific Secretary of the International Symposium on the Diabetic Foot. 

Malvern Diabetic Foot Conference info:

https://www.facebook.com/MalvernDiabeticFootConference/

https://eu.eventscloud.com/website/8151/

If this episode was of interest to you, please take a listen to this Transatlantic Series episode where we speak with the authors of the SVS, ESVS, and IWGDFU joint guidelines on the management of peripheral arterial disease (PAD) in patients with diabetes. 

Articles, resources, and societies referenced in the episode:

DF Blog. “Oral Is the New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review @bradspellberg @lacuscmedcenter @usc,” January 1, 2022. https://diabeticfootonline.com/2022/01/01/oral-is-the-new-iv-challenging-decades-of-blood-and-bone-infection-dogma-a-systematic-review-bradspellberg-lacuscmedcenter-usc/.

Gariani, Karim, Truong-Thanh Pham, Benjamin Kressmann, François R Jornayvaz, Giacomo Gastaldi, Dimitrios Stafylakis, Jacques Philippe, Benjamin A Lipsky, and Lker Uçkay. “Three Weeks Versus Six Weeks of Antibiotic Therapy for Diabetic Foot Osteomyelitis: A Prospective, Randomized, Noninferiority Pilot Trial.” Clinical Infectious Diseases 73, no. 7 (October 5, 2021): e1539–45. https://doi.org/10.1093/cid/ciaa1758.

Li, Ho-Kwong, Ines Rombach, Rhea Zambellas, A. Sarah Walker, Martin A. McNally, Bridget L. Atkins, Benjamin A. Lipsky, et al. “Oral versus Intravenous Antibiotics for Bone and Joint Infection.” New England Journal of Medicine 380, no. 5 (January 31, 2019): 425–36. https://doi.org/10.1056/NEJMoa1710926.

Magliano, Dianna, and Edward J. Boyko. IDF Diabetes Atlas. 10th edition. Brussels: International Diabetes Federation, 2021.

Østergaard, Lauge, Mia Marie Pries-Heje, Rasmus Bo Hasselbalch, Magnus Rasmussen, Per Åkesson, Robert Horvath, Jonas Povlsen, et al. “Accelerated Treatment of Endocarditis—The POET II Trial: Ration

ale and Design of a Randomized Controlled Trial.” American Heart Journal 227 (September 2020): 40–46. https://doi.org/10.1016/j.ahj.2020.05.012.

Price, Patricia. “The Diabetic Foot: Quality of Life.” Clinical Infectious Diseases 39 (2004): S129–31.

Sharma, S., C. Kerry, H. Atkins, and G. Rayman. “The Ipswich Touch Test: A Simple and Novel Method to Screen Patients with Diabetes at Home for Increased Risk of Foot Ulceration.” Diabetic Medicine: A Journal of the British Diabetic Association 31, no. 9 (September 2014): 1100–1103. https://doi.org/10.1111/dme.12450.

Shin, Laura, Frank L. Bowling, David G. Armstrong, and Andrew J.M. Boulton. “Saving the Diabetic Foot During the COVID-19 Pandemic: A Tale of Two Cities.” Diabetes Care 43, no. 8 (August 1, 2020): 1704–9. https://doi.org/10.2337/dc20-1176.

Tone, Alina, Sophie Nguyen, Fabrice Devemy, Hélène Topolinski, Michel Valette, Marie Cazaubiel, Armelle Fayard, Éric Beltrand, Christine Lemaire, and Éric Senneville. “Six-Week Versus Twelve-Week Antibiotic Therapy for Nonsurgically Treated Diabetic Foot Osteomyelitis: A Multicenter Open-Label Controlled Randomized Study.” Diabetes Care 38, no. 2 (February 1, 2015): 302–7. https://doi.org/10.2337/dc14-1514.

Wukich, Dane K., Katherine M. Raspovic, and Natalie C. Suder. “Patients With Diabetic Foot Disease Fear Major Lower-Extremity Amputation More Than Death.” Foot & Ankle Specialist 11, no. 1 (February 2018): 17–21. https://doi.org/10.1177/1938640017694722.

This three-episode mini-series republish a webinar that was recorded by the Eastern Vascular Society on important diversity issues in various settings including workplace, academia, training and education.

In this episode, Dr. Sharita Golden will discuss diversity in the workplace. Dr. Sharita Golden is a professor of endocrinology and metabolism and vice president and chief diversity officer at Johns Hopkins Medicine.

Articles highlighted in this episode:

1. Diversity improves performance and outcomes by Gomez et al. https://doi.org/10.1016/j.jnma.2019.01.006

2. Diversity, Representation, and Performance: Evidence about Race and Ethnicity in Public Organizations by Pitts et al. https://doi.org/10.1093/jopart/mui033

3. Integrating the 3Ds—Social determinants, health disparities, and healthcare workforce diversity by LaVeist et al. https://doi.org/10.1177/00333549141291s204

Audible Bleeding contributor and vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by vascular fellow Eva Urrechaga (@urrechisme),  fourth year medical student Leona Dogbe (@ldogbe4), JVS Editor-in-Chief, Dr. Thomas Forbes (@TL_Forbes), and JVS-VS editor Dr. John Curci (@CurciAAA) to discuss two great articles in the JVS family of journals. The first article analyzes amputation trends over 12 years in Oklahoma, and identifies risk factors that can be used to target intervention strategies. The second article explores the role of toll-like receptor 4 in skeletal muscle damage caused by chronic limb-threatening ischemia.  This episode hosts Dr. Kelly Kempe (@KellyKempe) and Dr. Ali Navi (@VascularChap), authors of these two papers.

Articles:

Part 1: “Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions” by Drs. Kempe, Nelson, and colleagues.

Part 2: “Role of toll-like receptor 4 in skeletal muscle damage in chronic limb-threatening ischemia” by Drs. Navi, Tsui, and colleagues.

Show Guests:

Dr. Kelly Kempe: Associate Professor and Vascular Surgery Program Director at the University of Oklahoma in Tulsa, Oklahoma.

Dr. Ali Navi: Consultant Vascular Surgeon at Cambridge University Hospitals, UK.

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Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

Drs. Kush Sharma and Ashraf Mansour review vascular disease affecting the upper extremity.  Originally published on Jan 29, 2021.

Vascular Surgery Exam Prep Ebook - Upper Extremity

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Audible Bleeding editor Wen (@WenKawaji) is joined by 5th year integrated vascular surgery resident Kaitlyn (@DunphyKaitlyn), JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd) and JVS-VL assistant editor Dr. Dua (@AnahitaDua) to discuss two great articles in the JVS family of journals regarding Post-operative stroke risk after carotid endarterectomy and use of Varithena in treating venous leg ulcers. This episode hosts Dr. Levin, Dr. Siracuse and Dr. Shao, the authors of the following papers:

Articles:

•  Postoperative disability and one-year outcomes for patients suffering a stroke after carotid endarterectomy by Levin et al.
• VIEW-VLU observational study of the effect of Varithena on wound healing in the treatment of venous leg ulcers by Shao et al.

Show Guests:

• Dr. Siracuse- Professor of surgery and radiology at Boston University

• Dr. Shao—vascular surgeon at Swedish hospital, Northshore University Healthsystem in Chicago, IL

• Dr. Levin—plastic and reconstructive surgery fellow at the University of California Davis

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Audible Bleeding editor Wen (@WenKawaji) is joined by 5th year general surgery resident Richa Kalsi (@KalsiMD) from University of Maryland Medical Center, 3rd year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Forbes (@TL_Forbes), and JVS-CIT editor Dr. Smeds (@matsmeds) to discuss two great articles in the JVS family of journals regarding endosuture aneurysm repair mid-term follow-up and endovascular repair of thoracic aortic aneurysm with aberrant subclavian artery. This episode hosts Dr. Frank Arko (@farkomd), Dr. Sukgu Han (@SukguH), and Dr. Fernando Fleischman, authors of the following papers:

Articles:

• Five-year outcomes of endosuture aneurysm repair in patients with short neck abdominal aortic aneurysm from the ANCHOR registry by Arko et al

• Sandwich thoracic branch endoprosthesis technique for endovascular repair of thoracic aortic aneurysm with aberrant right subclavian artery by Fleischman and Han et al

Show Guests:

• Dr. Arko is the Chief of Vascular and Endovascular Surgery with Atrium Health, Siverling Endowed Chair of vascular surgery clinical professor at Wake Forest University, and  co-director of Center for Aortic Disease at Sanger Heart and Vascular Institute.

• Dr. Sukgu Han is an Associate Professor of Surgery and Program Director for the residency/fellowship in the Division of Vascular Surgery and Endovascular Therapy at Keck School of Medicine of USC. He is also the Co-Director of the Comprehensive Aortic Center at Keck Hospital of USC. 

• Dr Fernando Fleischman is a cardiothoracic surgeon with extensive aortic expertise at Keck Hospital of USC. He is an Associate Professor of Surgery and Associate Program Director of cardiac surgery at USC. He is also the Co-Director of the Comprehensive Aortic Center. 

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Mr. Mohamed Barkat, Mr. Nicholas Greaves, and Mr. Michael Jenkins discuss thoracoabdominal aneurysms.  Originally published Dec 2, 2021, and was created in collaboration with the Rouleaux Club in the United Kingdom.

Vascular Surgery Exam Prep eBook - TAAA

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Today, Dr. David Ebertz (@EbertzDavid), a rising vascular fellow at St Louis University, and Dr. Jason Turner (@JasonTyTurner), a graduating integrated vascular resident from Case Western Cleveland Medical Center, discuss with multiple leaders in vascular surgery about VESS (@VESurgery) and SVS (@VascularSVS). The Vascular & Endovascular Surgery Society, commonly called VESS, is one of the foremost societies within vascular surgery that was started in 1976. Its mission is to improve the quality and safety of vascular & endovascular surgical procedures and general vascular care through education, scholarship, advocacy & leadership. This episode will feature VESS's history, current status, and pearls of wisdom, from finding mentors to navigating social media to becoming a leader within societies. 

Faculty Guests:

• Dr. Leigh Ann O'Banion (@limbsalvagedr) - Assistant Professor of Vascular Surgery at UCSF-Fresno, California
• Dr. Vikram Kashyap (@VikKashyapMD) - Vice President and Frederik Meijer Chair, Meijer Heart and Vascular Institute in Grand Rapids, Michigan
• Dr. Nick Mouawad (@NickMouawadMD) – Chief of Vascular Surgery at McLaren Health Systems in Bay City, Michigan
• Dr. Saideep Bose (@academicaorta) – Assistant Professor of Vascular Surgery at St Louis University, Missouri
• Dr. Matthew Smeds (@mattsmeds) – Professor of Vascular Surgery at St Louis University, Missouri

Additional Links: 

• VESS Student Mentor Program
• VESS Mentorship Program for young surgeons
• SVS Mentorship Match

Audible Bleeding contributor and first year vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by vascular fellow Donna Bahroloomi (@DonnaBahroloomi),  fourth year general surgery resident, Sasank Kalipatnapu (@ksasank), JVS editor-in-chief, Dr. Thomas Forbes (@TL_Forbes), and JVS-CIT editor Dr. Matt Smeds (@mattsmeds) to discuss two great articles in the JVS family of journals. The first article analyzes seven years worth of VQI data on TCAR, CEA, and TF-CAS to elucidate modern management of carotid disease. The second article provides a simple but powerful method of assessing adequacy of revascularization in the management of hemodialysis access-induced distal ischemia. This episode hosts Dr. Marc Schermerhorn (@MarcScherm), Sabrina Straus MS3 (LinkedIn), and Dr. Yana Etkin (@YanaEtkin), authors of these papers.

Articles:

Part 1: “Seven years of the transcarotid artery revascularization surveillance project, comparison to transfemoral stenting and endarterectomy” by Sabrina Straus, Dr. Schermerhorn, and colleagues.

Part 2: “Proximalization of arterial inflow with adjunctive arterial pressure measurements for management of hemodialysis access-induced distal ischemia” by Dr. Etkin and colleagues.

Show Guests:

1. Sabrina Straus BS, 3rd year medical student at UCSD
2. Dr. Marc Schermerhorn, George H.A. Clowes, Jr. Professor of Surgery, Harvard Medical School and Chief of Vascular and Endovascular Surgery, BIDMC
3. Dr. Yana Etkin- Associate Professor of Surgery at the Zucker School of Medicine at Hofstra/ Northwell, Program Director for the Vascular Surgery Fellowship and Integrated Vascular Surgery Residency and Associate Chief of Vascular Surgery

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Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

We are delighted to review the SVS VAM Diversity and Resident/Medical Student travel scholarships in today's episode. Dr. Ezra Schwartz and Dr. Nakia Sarad speak with three scholarship recipients to explore their reasons for applying, their experience at the 2023 Vascular Annual Meeting, and the impact of their attendance on their goals and aspirations. 

• Nathaniel Forrester (@Nathaniel_For) is a fourth-year medical student at Emory University SOM from Lawrenceville, GA. He will be applying to vascular residencies in this cycle. He received the Diversity Scholarship to attend his first VAM. 
• Gayatri Pillai (@GayatriPillai10) is a third-year medical student from Geisinger Commonwealth School of Medicine. She, too, received the SVS Diversity Scholarship to attend her first VAM.
• Carlo Angello Sánchez Montaño (@carlo_angello) is a first-year vascular surgery resident who transferred from a general surgery program. He is a November 20th National Medical Center trainee in Mexico City, Mexico. He received the General Surgery Resident/Medical Student Travel Scholarship to attend his first VAM.

VAM 2024 will be held in Chicago June 19-22, 2024. The following are links for more information on SVS Awards and Scholarships offered. We encourage you to apply! 

• SVS Awards and Scholarship Page
• SVS General Surgery Resident/Medical Student Vascular Annual Meeting Travel Scholarship
• SVS Diversity Medical Student Vascular Annual Meeting Travel Scholarship

Twitter:

• Dr. Ezra Schwartz (@Ezraschwartz10)
• Dr. Nakia Sarad (@NakSaradDO)
• Nathaniel Forrester (@Nathaniel_For)
• Gayatri Pillai (@GayatriPillai10)
• Dr. Carlo Angello Sánchez Montaño (@carlo_angello)

Drs. Sammy Siada and Rafael Malgor discuss safe access for endovascular surgery.  Originally published on April 29, 2020.  

Vascular Surgery Exam Prep eBook - Endovascular Access

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Authors:

 Sebouh Bazikian - MS4 at Keck School of Medicine of University of Southern California

Gowri Gowda - PGY1 at the University of California Davis Integrated Vascular Surgery Program

Steven Maximus- Vascular surgery attending at the University of California Davis, Director of the Aortic Center

Resources: 

• Rutherford’s 10th Edition Chapters: 88, 89, and 91

• The North American Symptomatic Carotid Endarterectomy

• Asymptomatic Carotid Atherosclerosis Study

• Audible Bleeding’s eBook chapter on cerebrovascular disease

• Houston Methodist CEA Dissection Video:

Part 1: https://www.youtube.com/watch?v=wZ8PzhwmSXQ

Part 2: https://www.youtube.com/watch?v=E_wWpRKBy4w

Outline:

 1. Etiology of Carotid Artery Stenosis

• Risk factors: advanced age, tobacco use, hypertension, diabetes.

• Atherosclerosis as the primary cause.

2. Development of Atherosclerotic Disease and Plaque Formation

   • LDL accumulation in arterial walls initiating plaque formation.

   • Inflammatory response, macrophage transformation, smooth muscle cell proliferation.

   • Role of turbulent blood flow at carotid bifurcation in plaque development.

3. Clinical Features of Carotid Artery Stenosis

   • Asymptomatic nature in many patients.

   • Symptomatic presentation: Transient ischemic attacks, amaurosis fugax, contralateral weakness/sensory deficit.

   • Carotid bruit as a physical finding, limitations in diagnosis.

4. Importance of Evaluating CAS

   • Assessing stenosis severity and stroke risk.

   • Revascularization benefits dependent on stenosis severity.

5. Classification of Stenosis Levels

   • Clinically significant stenosis: ≥ 50% narrowing.

   • Moderate stenosis: 50%–69% narrowing.

   • Severe stenosis: 70%–99% narrowing.

6. Stroke Risk Associated with Carotid Stenosis

   • Annual stroke rate: ~1% for 50-69% stenosis, 2-3% for 70-99% stenosis.

7. Diagnosis and Screening

   • No population-level screening recommendation.

   • Screening for high-risk individuals as per SVS guidelines.

   • Carotid Duplex Ultrasound as primary diagnostic tool.

   • Additional tools: CT angiography, Magnetic Resonance Angiography.

   • Handling of <50% stenosis cases.

8. Imaging Modalities

   • Ultrasound: Noninvasive, cost-effective, potential overestimation of stenosis.

   • CTA: Fast, high resolution, contrast exposure risks.

   • MRA: Contrast-free plaque analysis, possible overestimation of stenosis.

   • Angiography: Gold standard, expensive, stroke risk.

9. Assessing Degree of Stenosis via CDUS

   • Parameters for 50-69% stenosis: Peak Systolic Velocity (PSV) 125-229 cm/sec, End Diastolic Velocity (EDV) 40-100 cm/sec, Internal/Common Carotid peak systolic velocity Ratio 2-4.

   • Parameters for 70-99% stenosis: PSV ≥ 230 cm/sec, EDV > 100 cm/sec, Internal/Common Carotid peak systolic velocity Ratio > 4.

10. Revascularization Criteria

    • Symptomatic Patients: 50-69% or 70-99% stenosis, life expectancy at least three or two years, respectively.

    • Asymptomatic Patients: <50% stenosis, no revascularization; 50-69% stenosis, follow-up and surveillance; >70% stenosis, considering life expectancy.

11. Surgical Indications and Contraindications

    • Indications: symptomatic patients, life expectancy considerations.

    • Contraindications: Stenosis <50%, severe comorbidities, 100% occlusion.

12. Medical Management for All CAS Patients

    • Lifestyle changes, high-intensity statin therapy, antiplatelet therapy.

13. Decision Factors for Surgical Approaches

    • TCAR, stenting, endarterectomy: situational preferences.

14. Carotid Endarterectomy: Surgical Procedure

    • Incision along anterior border of sternocleidomastoid muscle.

    • Electrocautery through platysma muscle and subcutaneous tissues.

    • Protecting the great auricular nerve, dividing the external jugular vein.

    • Retracting sternocleidomastoid muscle, exposing carotid sheath.

    • Dissecting internal jugular vein, ligating facial vein.

    • Avoiding injury to the vagus nerve, dissecting the common carotid artery.

    • Identifying and mobilizing the hypoglossal nerve, addressing the external carotid artery.

    • Extending dissection from common carotid artery to beyond the internal and external carotid bifurcation.

    • Longitudinal arteriotomy, plaque removal using a Freer elevator.

    • Ensuring a smooth transition between endarterectomized artery and normal distal extent.

    • Patch angioplasty for arteriotomy closure, sequential clamp release for de-airing.

15. Neuromonitoring and Plaque Removal

    • Neuromonitoring methods: EEG, SSEPs, TCD, cerebral oximetry, awake patient monitoring.

16. Shunting and Vessel Closure

    • Shunting indications: neurological status changes, EEG alterations.

    • Carotid stump pressure measurement.

17. Postoperative Complications and Management

    • Common complications: stroke, hyperperfusion syndrome, myocardial infarction, cervical hematoma, nerve injuries, infection.

    • Managing hyperperfusion syndrome: blood pressure control, antiepileptic drugs.

    • Cranial nerve injuries: 

    1. Hypoglossal Nerve (CN XII): Injury leads to tongue deviation towards the injured side.

    2. Glossopharyngeal Nerve (CN IX): Injury results in swallowing difficulties and aspiration risk.

    3. Vagus Nerve (CN X): Injury causes hoarseness due to laryngeal muscle involvement.

    4. Marginal Mandibular Branch of Facial Nerve: Injury leads to ipsilateral lip droop.

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In this special series, core faculty members of the SVS Leadership Development Program, Dr. Manuel Garcia-Toca, Dr. Kenneth Slaw, and Steve Robischon, discuss the program origins, research regarding good leadership, and how to join. 

Manuel Garcia-Toca, MD completed his MD at the Universidad Anahuac in Mexico (1999) and MS in Health Policy at Stanford University (2020). Dr. Garcia-Toca completed his residency in General Surgery at Brown University (2008) and a fellowship in Vascular Surgery at Northwestern University (2010). He will serve within the Department of Surgery in the Division of Vascular Surgery and Endovascular Therapy and the Division of Emory Surgery at Grady based primarily at Grady Memorial Hospital.

Kenneth Slaw, PhD is the executive director of the Society for Vascular Surgeons.  Dr. Slaw received his master's and doctoral degrees in educational psychology from the University of Illinois. He has over 35 years of executive leadership experience in the medical society and philanthropic communities, having served in numerous previous roles, including as president of the American Association of Medical Society Executives, as chairman of the board of Make A Wish Illinois, and as senior staff member at the Academy of Pediatrics, where he assisted in efforts with the Pediatric Leadership Alliance Program, which has provided leadership skill building sessions for approximately 3, 000 physicians.

Steve Robischon, PA-C is a Physician Assistant with the Division of Vascular and Endovascular Surgery at the Medical College of Wisconsin in Milwaukee, Wisconsin, and is also a member of the PA Section Steering Committee.

More about the SVS PA Section

More about the SVS Leadership Program

Drs. Matthew Spreadbury, Adham Elmously, Einar Brevik and Joseph Lombardy review aortic dissections.  Originally published November 1, 2021.

Vascular Surgery Exam Prep eBook - Aortic Dissection

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This three-episode mini-series republished a webinar that was recorded by the Easter Vascular Society on important diversity issues in various settings including workplace, academia, training, and education.

In this episode, Dr. Julia Glaser will discuss diversity in education and training. Dr. Julia Glaser is an assistant professor of clinical surgery at University of Pennsylvania department of vascular and endovascular surgery.

Articles highlighted in episode 3:

1. Discrimination, abuse, harassment, and burnout in surgical residency training by Hu et al. https://doi.org/10.1056/nejmsa1903759
2. Experiences of gender discrimination and sexual harassment among residents in general surgery programs across the US by Schlick et al. https://doi.org/10.1001/jamasurg.2021.3195
3. Experiences of LGBTQ+ residents in US general surgery training programs by Heiderscheit et al. https://doi.org/10.1001/jamasurg.2021.5246

Learn more about us at www.audiblebleeding.com and provide us with your feedback via our listener survey.

Audible Bleeding editor Wen (@WenKawaji) is joined by 1st year vascular surgery fellow Richa Kalsi (@KalsiMD), 3rd year medical student Nishi (@Nishi_Vootukuru), 4th-year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Forbes (@TL_Forbes), JVS-VLD associate editor Dr. Arjun Jayaraj and JVS social media liaison Dr. Haurani to discuss some of our favorite articles in the JVS family of journals.

This episode hosts Dr. Amy Felsted, Dr. Salvatore Scali, and Dr. Arjun Jayaraj, the authors of the following papers. Dr. Arjun Jayaraj and Dr. Haurani will also spend time discussing a virtual special issue, centered around iliofemoral venous stenting published in the Journal of Vascular Surgery, Venous and Lymphatic Disorders that includes six articles published between August 2023 and May 2024. 

Articles:

• Part 1: A patient-centered textbook outcome measure effectively discriminates contemporary elective open abdominal aortic aneurysm repair quality by Dr. Felsted, Dr. Scali and colleagues. 

• Part 2: Virtual special issues on contemporary role of iliofemoral venous stenting

Show Guests 

• Dr. Amy Felsted (@aefelsted): Completed fellowship at Dartmouth-Hitchcock, Currently an assistant professor of surgery at Boston University School of Medicine and practicing vascular surgeon at the VA in Boston

• Dr. Salvatore Scali: Professor of Surgery at University of Florida Division of Vascular Surgery and Endovascular Therapy, program director of the vascular fellowship at University of Florida.

• Dr. Arjun Jayaraj: Vascular surgeon at the RANE Center in Jackson, Mississippi with a focus on the management of venous and lymphatic diseases, Associate Editor of JVS-VL. 

Follow us @audiblebleeding

Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

Audible Bleeding editor Wen (@WenKawaji) is joined by 4th-year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Forbes (@TL_Forbes), JVS-VS associate editor Dr. John Curci (@CurciAAA) to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Mota, Dr. Liang and Dr. Weinkauf, authors of the following papers.

Articles:

1. The impact of travel distance in patient outcomes following revascularization for chronic limb-threatening ischemia

2. Serum detection of blood brain barrier injury in subjects with a history of stroke and transient ischemic attack

 Show Guests:

1. Dr. Lucas Mota- third-year general surgery resident at the Beth Israel Deaconess Medical Center

2. Dr. Patrick Liang- assistant professor at Harvard medical school and a practicing vascular surgeon at the Beth Israel Deaconess medical center. 

3. Dr. Weinkauf - assistant professor with the Department of Surgery Division of Vascular and Endovascular Surgery at the University of Arizona College of Medicine 

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In this episode of Audible Bleeding, editor Dr. Imani McElroy (@IEMcElroy) is joined by General Surgery PGY-4 Sasank Kalipatnapu(@ksasank) along with Dr.David Rigberg, MD (@drigberg), and Dr. Guillermo Escobar, MD (@GAEscobarMD) to discuss the Society for Clinical Vascular Surgery (SCVS) Rising Seniors / Incoming Fellows Program. This episode brings out a conversation exploring the history behind the development of the program, the current state of the program, and the overwhelming importance of the program in the current day. The episode also provides a broad overview of the content presented in the program and the reasoning behind the talks. 

Guests:

1. Dr. David Rigberg - Professor of Surgery, Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Program Director for the Vascular fellowship and integrated vascular surgery residency at the David Geffen School of Medicine, UCLA, Los Angeles, California

2. Dr. Guillermo Escobar- Associate Professor, Division of Vascular Surgery and Endovascular Therapy, Program Director for the Vascular Surgery Fellowship and Residency at Emory University School of Medicine

Relevant links:

• Rising Seniors / Incoming Fellows Program - Program Details

• SCVS - Fellows & Chief Residents Program

• SCVS - Young Vascular Surgeons Program

To apply for the Rising Seniors / Incoming Fellows Program, go to apply now!

Audible Bleeding team:

1. Dr. Imani McElroy is 1st year vascular surgery fellow at USC/LA and editor at Audible Bleeding

2. Dr. Sasank Kalipatnapu, PGY-4 general surgery resident, Dept of Surgery, UMass Chan Medical School, Worcester, MA

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*Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

On behalf of the Young Surgeons' Section of the SVS, Dr. Saideep Bose and Gowri Gowda sit down with two editors of the JVS journals and take a behind-the-scenes look at the publishing process and tips and tricks for authors and reviewers.

Show Guests 

• Dr. Thomas Forbes (Faculty Page) is the Surgeon-in-Chief and Chair of the Sprott Department of Surgery at the University Health Network, and Professor of Surgery at the University of Toronto. He is the current Editor in Chief of the Journal of Vascular Surgery. Email: Thomas.Forbes@uhn.ca
  

• Dr. Matthew Smeds (Faculty Page) is a Professor of Surgery at Saint Louis University. He is the current Editor-in-Chief of the Journal of Vascular Surgery – Cases, Innovations, and Techniques. Email: matt.smeds@health.slu.edu
  

JVS Companion Journal Links:

• JVS Venous and Lymphatic Disorders
  
• JVS Cases, Innovations and Techniques
  
• JVS - Vascular Science
  
• JVS - Vascular Insights
  

JVS Internship Program: https://vascularspecialistonline.com/bright-future-predicted-for-jvs-internship-program/

Drs. Kevin Kniery, Nicole Rich, and Todd Rasmussen discuss vascular cerebrovascular trauma of the neck.  Originally published on May 25, 2020, and was created in collaboration with Behind the Knife: The Premier Surgery Podcast.

Vascular Surgery Exam Prep eBook - Trauma: Cerebrovascular

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Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

In this episode, we explore the role of vascular surgeons in oncologic surgery. We will be discussing the nuances of vascular involvement in oncologic resection, common practices, and future directions of this collaborative surgical culture.

Dr. Adam Beck (@AWBeckMD) is a vascular surgeon and Professor of Surgery at the University of Alabama at Birmingham where he serves as the Director of the Division of Vascular Surgery and Endovascular Therapy, holds the Holt A. McDowell, Jr, MD Endowed Chair in Vascular Surgery and serves as the Director of Quality and Associate Chief Medical Quality Officer for the UAB Cardiovascular Institute. Dr. Beck completed his general surgery residency training and a surgical oncology research fellowship at the University of Texas-Southwestern Medical Center. He trained in vascular surgery at the Dartmouth-Hitchcock Medical Center and then completed a fellowship in advanced endovascular techniques, including branched and fenestrated endografts for aortic aneurysmal disease, at the University Medical Center of Groningen in The Netherlands. You can learn more about Dr. Adam Beck here.

Dr. Xavier Berard (@XavierBerardMD)  is a French vascular surgeon and serves as a Consultant in the Department of Vascular Surgery and Professor of Vascular and Endovascular Surgery in Bordeaux University Hospital in Bordeaux, France. He is board certified from the French College of Vascular and Endovascular Surgeons and from the European Society for Vascular and Endovascular Surgery. He has also completed a PhD in Vascular Biomaterials and has built a library of educational video content. He works closely with Institut Bergonié Bordeaux Cancer Center for sarcomas. You can see educational videos and learn more about Dr. Xavier Berard here

Dr. Sharif Ellozy (@SharifEllozy)  is a vascular surgeon at the New York-Presbyterian/Weill Cornell Medical Center where he serves as Associate Professor of Clinical Surgery in the Division of Vascular and Endovascular Surgery, and Program Director of the Vascular Surgery Fellowship program. He is also one of the founders of Audible Bleeding. He is readily involved in oncologic resection at the Memorial Sloan Kettering Cancer Center and works closely with surgical oncologists on operative cases that have vessel involvement.

Authors/Interviewers:

Dr. Sree Kanna, MD - McGill, Montreal (@VulnerableAorta)

Dr. Nakia Sarad, DO, MS - New York-Presbyterian/Queens - Weill Cornell, New York (@NakSaradDO)

Editors:

Morgan Gold, MD,CM candidate - McGill, Montreal (@MorganSGold)

Ezra Schwartz, MD,CM, MS, MMSc-Med Ed candidate - Harvard, Boston (@EzraSchwartz10)

Helpful Resources:

To learn more about sarcoma resections, check out the Schwarzbach papers on lower extremity sarcomas and retroperitoneal sarcomas

Click here to learn more about the NCCN Guidelines on Resectability of Pancreatic Cancers

Click here to learn more about IVC Reconstruction Techniques in Oncologic Surgery

Video of IVC Leiomyosarcoma Reconstructions here (courtesy of Dr. Berard)

Click here to learn more about the Renal Cell Carcinoma Mayo Staging System

Click here to find the original article on the Shamblin Classification for Carotid Body Tumors

Check out this review paper on Oncovascular Surgery 

Check out this paper on spiral endografts here

Video of spiral saphenous vein graft technique here (courtesy of Dr. Berard)

What other topics would you like to hear about? Let us know more about you and what you think of our podcast through our Listener Survey or email us at AudibleBleeding@vascularsociety.org.

Follow us on Twitter @audiblebleeding

Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

Today, Dr. Ezra Schwartz and Dr. Nakia Sarad begin an exploration of how vascular surgeons and patients communicate. We will discuss how we share stories with one another and what may get lost in translation. The first episode in this series features Dr. Anahita Dua in conversation with her patients and their experience with deep venous arterialization.

Faculty Guest:

Dr. Anahita Dua is a vascular surgeon at the Massachusetts General Hospital and an associate professor of surgery at Harvard Medical School. She wears many hats at the MGH including director of the Vascular Lab, co-director of the Peripheral Artery Disease Center and Limb Evaluation and Amputation Program, associate director of the Wound Care Center, director of the Lymphedema Center, associate director of the Vascular Surgery Clerkship, and director of clinical research for the division of vascular surgery.

Dr. Dua completed her undergraduate medical studies at the Aberdeen University School of Medicine in Aberdeen, Scotland. She then completed her general surgery residency at the Medical College of Wisconsin and a vascular fellowship at Stanford University Hospital. She holds multiple master’s degrees, including trauma sciences and business administration in healthcare management. She also completed certificate programs at the Massachusetts Institute of Technology in health economics, outcomes research, and drug and device development.  She has published over 140 peer-reviewed papers and has edited five vascular surgery textbooks.

For more information on the CLariTI Study, click here.

Patient Guests: (Shared with consent)

• John McConnell - patient of Dr. Dua
• Daniel Debovie - son of a patient of Dr. Dua.

Deep Venous Arterialization References:

• Ho, Vy T., Rebecca Gologorsky, Pavel Kibrik, Venita Chandra, Anna Prent, Jisun Lee, and Anahita Dua. “Open, Percutaneous, and Hybrid Deep Venous Arterialization Technique for No-Option Foot Salvage.” Journal of Vascular Surgery 71, no. 6 (June 1, 2020): 2152–60. https://doi.org/10.1016/j.jvs.2019.10.085.
• Shishehbor, Mehdi H., Richard J. Powell, Miguel F. Montero-Baker, Anahita Dua, Jorge L. Martínez-Trabal, Matthew C. Bunte, Arthur C. Lee, et al. “Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia.” New England Journal of Medicine 388, no. 13 (March 30, 2023): 1171–80. https://doi.org/10.1056/NEJMoa2212754.

Twitter:

• Dr. Anahita Dua (@AnahitaDua)
• Dr. Ezra Schwartz (@ezraschwartz10)
• Dr. Nakia Sarad (@NadSaradDO)

Audible Bleeding editor Matt Chia (@chia_md) is joined by MD/PhD student Rahul Ghosh (@ghoshrx), JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd), and JVS-VS Associate Editor Dr. John Curci (@CurciAAA) to discuss two great articles 

in the JVS family of journals. This episode hosts Dr. Sanuja Bose (@SanujaBose), Dr. Caitlin Hicks (@CaitlinWHicks), and Dr. Elizabeth Chou  (@LizChou), the authors of the following papers discussing sex disparities in medical management around carotid revascularization and smooth muscle cell pathobiology in carotid atherosclerosis.

Articles:

• “Females are less likely to receive best medical therapy for stroke prevention before and after carotid revascularization than males” by Bose et al.

• “Vascular smooth muscle cell phenotype switching in carotid atherosclerosis” by Chou et al. 

Show Guests:

• Dr. Sanuja Bose (@SanujaBose) is a graduate from University of Rochester School of Medicine and Johns Hopkins Bloomberg School of Public Health. She is currently a postdoctoral research fellow in the Department of Vascular Surgery at Johns Hopkins.

• Dr. Caitlin Hicks (@CaitlinWHicks) is an associate professor of surgery at the Johns Hopkins Department of Vascular and Endovascular surgery and the research director of the multidisciplinary diabetic foot and wound service.

• Dr. Elizabeth Chou (@LizChou) completed her vascular training at Mass General Hospital in 2022 and is currently a vascular surgeon at Cedars Sinai. Dr. Chou’s research interests include translational research in therapeutic outcomes of aortic and peripheral vascular disease and vascular disease amongst under-represented minorities and women.

Listeners may also be interested in our episode about getting started using the VQI for research. 

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We are excited to bring back part two of our discussion on Robotic Vascular Surgery. Yasong (@yasongyumd) and Eva (@urrechisme) are joined by Dr. Lumsden and Dr. Bavare from Houston Methodist Hospital

Show Guests:

Alan Lumsden: Chair of Cardiovascular Surgery at Houston Methodist and DeBakey Heart and Vascular Center

Charu Bavare: Vascular Surgeon at Houston Methodist and Debakey Heart and Vascular Center

Hosts:

Eva Urrechaga - Vascular fellow at University of Pennsylvania

Yasong Yu - Vascular fellow at University of Chicago

Robotic Vascular Surgery Episode 1 with Dr. Judith Lin and Dr. Petr Stadler

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Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

Audible Bleeding editor Wen (@WenKawaji) is joined by second year medical student Nishi (@Nishi_Vootukuru), third year medical student Leana Dodge (@ldogbe4), JVS editor Dr. Forbes (@TL_Forbes) and JVS-VS associate editor Dr. Curci (@CurciAAA) to discuss two great articles in the JVS family of journals regarding Medicare reimbursement for complex endovascular aortic aneurysm repair and novel drug delivery method involving tissue factor targeting peptides in reducing vascular injury response. This episode hosts Dr.Brinster, Dr. Conte, and Dr. Kim, the authors of the following papers:

Articles:

• Current Medicare reimbursement for complex endovascular aortic repair is inadequate based on results from a multi-institutional cost analysis by Brinster et al.

• Tissue factor targeting peptide enhances nanoparticle binding and delivery of a synthetic specialized pro-resolving lipid mediator to injured arteries by Dr. Levy et al.

Show Guests:

• Dr. Clayton Brinster:  Associate Professor of Surgery at University of Chicago, and Co-Director of Center for Aortic Diseases, Department of Vascular Surgery and Endovascular Therapy

• Dr. Michael Conte: E.J. Wylie Chair, professor and chief of the division of Vascular and Endovascular Surgery at UCSF. Co-Directot of Heart and Vascular Center, Co-Director of UCSF Center for Limb Preservation and Diabetic Foot.

• Dr. Alexander Kim: Vascular surgery fellow and research fellow at UCSF

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Guest:

Dr. Christian de Virgilio is the Chair of the Department of Surgery at Harbor-UCLA Medical Center. He is also Co-Chair of the College of Applied Anatomy and a Professor of Surgery at UCLA's David Geffen School of Medicine.

He completed his undergraduate degree in Biology at Loyola Marymount University and earned his medical degree from UCLA. He then completed his residency in General Surgery at UCLA-Harbor Medical Center followed by a fellowship in Vascular Surgery at the Mayo Clinic.

Resources: 

• Rutherford Chapters (10th ed.): 174, 175, 177, 178

• Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/

• The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext 

• KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/ 

Outline:

1. Steal Syndrome

• Definition & Etiology

• Steal syndrome is an important complication of AV access creation, since access creation diverts arterial blood flow from the hand.

• Steal can be caused by multiple factors—arterial occlusive disease proximal or distal to the AV anastomosis, high flow through the fistula at the expense of distal arterial perfusion, and failure of the distal arterial networks to adapt to this decreased blood flow. 

• Incidence and Risk Factors

• The frequency of steal syndrome is 1.6-9%1,2, depending on the vessels and conduit choice

• Steal syndrome is more common with brachial and axillary artery-based accesses and nonautogenous conduits.

• Other risk factors for steal syndrome are peripheral vascular disease, coronary artery disease, diabetes, advanced age, female sex, larger outflow conduit, multiple prior permanent access procedures, and prior episodes of steal.3,4 

• Long-standing insulin-dependent diabetes causes both medial calcinosis and peripheral neuropathy, which limits arteries’ ability to vasodilate and adjust to decreased blood flow.

• Patient Presentation, Symptoms, Grading

• Steal syndrome is diagnosed clinically. 

• Symptoms after AVG creation occurs within the first few days, since flow in prosthetic grafts tend to reach a maximum value very early after creation.

• Native AVFs take time to mature and flow will slowly increase overtime, leading to more insidious onset of symptoms that can take months or years.

• The patient should have a unilateral complaint in the extremity with the AV access. Symptoms of steal syndrome, in order of increasing severity, include nail changes, occasional tingling, extremity coolness, numbness in fingertips and hands, muscle weakness, rest pain, sensory and motor deficits, fingertip ulcerations, and tissue loss. 

• There could be a weakened radial pulse or weak Doppler signal on the affected side, and these will become stronger after compression of the AV outflow.

• Symptoms are graded on a scale specified by Society of Vascular Surgery (SVS) reporting standards:5 

• Workup

• Duplex ultrasound can be used to analyze flow volumes.

• A high flow volume (in autogenous accesses greater than 800 mL/min, in nonautogenous accesses greater than 1200 mL/min) signifies an outflow issue. The vein or graft is acting as a pressure sink and stealing blood from the distal artery. A low flow volume signifies an inflow issue, meaning that there is a proximal arterial lesion preventing blood from reaching the distal artery.

• Upper extremity angiogram can identify proximal arterial lesions.

• Prevention

• Create the AV access as distal as possible, in order to preserve arterial inflow to the hand and reduce the anastomosis size and outflow diameter. 

• SVS guidelines recommend a 4-6mm arteriotomy diameter to balance the need for sufficient access flow with the risk of steal.

• If a graft is necessary, tapered prosthetic grafts are sometimes used in patients with steal risk factors, using the smaller end of the graft placed at the arterial anastomosis, although this has not yet been proven to reduce the incidence of steal. 

• Indications for Treatment

• Intervention is recommended in lifestyle-limiting cases of Grade II and all Grade III steal cases.

• If left untreated, the natural history of steal syndrome can result in chronic limb ischemia, causing gangrene with loss of digits or limbs.

• Treatment Options

• Conservative management relies on observation and monitoring, as mild cases of steal syndrome may resolve spontaneously.

• Inflow stenosis can be treated with endovascular intervention (angioplasty with or without stent)

• Ligation is the simplest surgical treatment, and it results in loss of the AV access. This is preferred in patients with repetitive failed salvage attempts, venous hypertension, and poor prognoses.

• Flow limiting procedures can address high volumes through the AV access.

• Banding can be performed with surgical cutdown and placement of polypropylene sutures or a Dacron patch around the vein or graft.

• The Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) technique employs a percutaneous endoluminal balloon inflated at the AVF to ensure consistency in diameter while banding

• Plication is when a side-biting running stitch is used to narrow lumen of the vein near the anastomosis.

• A downside of flow-limiting procedures is that it is often difficult to determine how much to narrow the AV access, as these procedures carry a risk of outflow thrombosis.

• There are also surgical treatments focused on reroute arterial inflow.

• The distal revascularization and interval ligation (DRIL) procedure involves creation of a new bypass connecting arterial segments proximal and distal to the AV anastomosis, with ligation of the native artery between the AV anastomosis and the distal anastomosis of the bypass. Reversed saphenous vein with a diameter greater than 3mm is the preferred conduit. Arm vein or prosthetic grafts can be used if needed, but prosthetic material carries higher risk of thrombosis. The new arterial bypass creates a low resistance pathway that increases flow to distal arterial beds, and interval arterial ligation eliminates retrograde flow through the distal artery. 

• The major risk of this procedure is bypass thrombosis, which results in loss of native arterial flow and hand ischemia. Other drawbacks of DRIL include procedural difficulty with smaller arterial anastomoses, sacrifice of saphenous or arm veins, and decreased fistula flow.

• Another possible revision surgery is revision using distal inflow (RUDI). This procedure involves ligation of the fistula at the anastomosis and use of a conduit to connect the outflow vein to a distal artery. The selected distal artery can be the proximal radial or ulnar artery, depending on the preoperative duplex. The more dominant vessel should be spared, allowing for distal arterial beds to have uninterrupted antegrade perfusion. The nondominant vessel is used as distal inflow for the AV access. RUDI increases access length and decreases access diameter, resulting in increased resistance and lower flow volume through the fistula. Unlike DRIL, RUDI preserves native arterial flow. 

• Thrombosis of the conduit would put the fistula at risk, rather than the native artery. 

• The last surgical revision procedure for steal is proximalization of arterial inflow (PAI). In this procedure, the vein is ligated distal to the original anastomosis site and flow is re-established through the fistula with a PTFE interposition graft anastomosed end-to-side with the more proximal axillary artery and end-to-end with the distal vein. Similar to RUDI, PAI increases the length and decreases the diameter of the outflow conduit. Since the axillary artery has a larger diameter than the brachial artery, there is a less significant pressure drop across the arterial anastomosis site and less steal. PAI allows for preservation of native artery’s continuity and does not require vein harvest. 

• Difficulties with PAI arise when deciding the length of the interposition graft to balance AV flow with distal arterial flow.
  
  

2. Ischemic Monomelic Neuropathy

• Definition

• Ischemic monomelic neuropathy (IMN) is a rare but serious form of steal that involves nerve ischemia. Severe sensorimotor dysfunction is experienced immediately after AV access creation.

• Etiology

• IMN affects blood flow to the nerves, but not the skin or muscles because peripheral nerve fibers are more vulnerable to ischemia.

• Incidence and Risk Factors

• IMN is very rare; it has an estimated incidence of 0.1-0.5% of AV access creations.6

• IMN has only been reported in brachial artery-based accesses, since the brachial artery is the sole arterial inflow for distal arteries feeding all forearm nerves.

• IMN is associated with diabetes, peripheral vascular disease, and preexisting peripheral neuropathy that is associated with either of the conditions.

• Patient Presentation

• Symptoms usually present rapidly, within minutes to hours after AV access creation.

• The most common presenting symptom is severe, constant, and deep burning pain of the distal forearm and hand. Patients also report impairment of all sensation, weakness, and hand paralysis.

• Diagnosis of IMN can be delayed due to misattribution of symptoms to anesthetic blockade, postoperative pain, preexisting neuropathy, a heavily bandaged arm precluding neurologic examination.

• Treatment

• Treatment is immediate ligation of the AV access. Delay in treatment will quickly result in permanent sensorimotor loss.

3. Perigraft Seroma

• Definition

• A perigraft seroma is a sterile fluid collection surrounding a vascular prosthesis and is enclosed within a pseudomembrane.

• Etiology and Incidence

• Possible etiologies include: transudative movement of fluid through the graft material, serous fluid collection from traumatized connective tissues (especially the from higher adipose tissue content in the upper arm), inhibition of fibroblast growth with associated failure of the tissue to incorporate the graft, graft “wetting” or kinking during initial operation, increased flow rates, decreased hematocrit causing oncotic pressure difference, or allergy to graft material.

• Seromas most commonly form at anastomosis sites in the early postoperative period.

• Overall seroma incidence rates after AV graft placement range from 1.7–4% and are more common in grafts placed in the upper arm (compared to the forearm) and Dacron grafts (compared to PTFE grafts).7-9

• Patient Presentation and Workup

• Physical exam can show a subcutaneous raised palpable fluid mass

• Seromas can be seen with ultrasound, but it is difficult to differentiate between the types of fluid around the graft (seroma vs. hematoma vs. abscess)

• Indications for Treatment

• Seromas can lead to wound dehiscence, pressure necrosis and erosion through skin, and loss of available puncture area for hemodialysis

• Persistent seromas can also serve as a nidus for infection.

• The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines10 recommend a tailored approach to seroma management, with more aggressive surgical interventions being necessary for persistent, infected-appearing, or late-developing seromas.

• Treatment

• The majority of early postoperative seromas are self-limited and tend to resolve on their own

• Persistent seromas have been treated using a variety of  methods-- incision and evacuation of seroma, complete excision and replacement of the entire graft, and primary bypass of the involved graft segment only.

• Graft replacement with new material and rerouting through a different tissue plane has a higher reported cure rate and lower rate of infection than aspiration alone.9

4. Infection

• Incidence and Etiology

• The reported incidence of infection ranges 4-20% in AVG, which is significantly higher than the rate of infection of 0.56-5% in AVF.11 

• Infection can occur at the time of access creation (earliest presentation), after cannulation for dialysis (later infection), or secondary to another infectious source. Infection can also further complicate a pre-existing access site issue such as infection of a hematoma, thrombosed pseudoaneurysm, or seroma.

• Skin flora from frequent dialysis cannulations result in common pathogens being Staphylococcus, Pseudomonas, or polymicrobial species. Staphylococcus and Pseudomonas are highly virulent and likely to cause anastomotic disruption.
  
  

• Patient Presentation and Workup

• Physical exam will reveal warmth, pain, swelling, erythema, induration, drainage, or pus. Occasionally, patients have nonspecific manifestations of fever or leukocytosis.

• Ultrasound can be used to screen for and determine the extent of graft involvement by the infection.

• Treatments

• In AV fistulas:

• Localized infection can usually be managed with broad spectrum antibiotics. 

• If there are bleeding concerns or infection is seen near the anastomosis site, the fistula should be ligated and re-created in a clean field.

• In AV grafts:

• If infection is localized, partial graft excision is acceptable.

• Total graft excision is recommended if the infection is present throughout the entire graft, involves the anastomoses, occludes the access, or contains particularly virulent organisms

• Total graft excision may also be indicated if a patient develops recurrent bacteremia with no other infectious source identified.

• For graft excision, the venous end of the graft is removed and the vein is oversewn or ligated. If the arterial anastomosis is intact, a small cuff of the graft can be left behind and oversewn. If the arterial anastomosis is involved, the arterial wall must be debrided and ligation, reconstruction with autogenous patch angioplasty, or arterial bypass can be pursued.

References

1. Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. Incidence and Characteristics of Patients with Hand Ischemia after a Hemodialysis Access Procedure. J Surg Res. 1998;74(1):8-10. doi:10.1006/jsre.1997.5206

2. Ballard JL, Bunt TJ, Malone JM. Major complications of angioaccess surgery. Am J Surg. 1992;164(3):229-232. doi:10.1016/S0002-9610(05)81076-1

3. Valentine RJ, Bouch CW, Scott DJ, et al. Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis. J Vasc Surg. 2002;36(2):351-356. doi:10.1067/mva.2002.125848

4. Malik J, Tuka V, Kasalova Z, et al. Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies. J Vasc Access. 2008;9(3):155-166. doi:10.1177/112972980800900301

5. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg. 2002;35(3):603-610. doi:10.1067/mva.2002.122025

6. Thermann F, Kornhuber M. Ischemic Monomelic Neuropathy: A Rare but Important Complication after Hemodialysis Access Placement - a Review. J Vasc Access. 2011;12(2):113-119. doi:10.5301/JVA.2011.6365

7. Dauria DM, Dyk P, Garvin P. Incidence and Management of Seroma after Arteriovenous Graft Placement. J Am Coll Surg. 2006;203(4):506-511. doi:10.1016/j.jamcollsurg.2006.06.002

8. Gargiulo NJ, Veith FJ, Scher LA, Lipsitz EC, Suggs WD, Benros RM. Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas. J Vasc Surg. 2008;48(1):216-217. doi:10.1016/j.jvs.2008.01.046

9. Blumenberg RM, Gelfand ML, Dale WA. Perigraft seromas complicating arterial grafts. Surgery. 1985;97(2):194-204.

10. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164. doi:10.1053/j.ajkd.2019.12.001

11. Padberg FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg. 2008;48(5):S55-S80. doi:10.1016/j.jvs.2008.08.067

Drs. Nedal Katib and Danielle Bajakian discuss chronic limb threatening ischemia.  Originally published on Jan 3, 2021.

Vascular Surgery Exam Prep eBook - Lower Extremity: CLTI

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Endovascular 101

Authors:

Sebouh Bazikian - MS4 at Keck School of Medicine of University of Southern California

Sukgu Han - Associate Professor of Surgery at the University of Southern California. Co-director of Comprehensive Aortic Center at Keck Hospital of USC. Program Director of the Integrated Vascular Surgery Residency and Vascular Fellowship

Editor: Yasong Yu

Reviewers: Matt Chia and Kirthi Bellamkonda

Core Resources:

• Rutherford's Vascular and Endovascular Therapy 10th Edition Chapter#26-28

Additional Resources:

• Relevant Audible Bleeding episodes

• • Holding Pressure Case Prep - AKA/BKA

  • Journal Review in Vascular Surgery: Introduction to Endovascular Surgery – A Prime

  • Peter A. Schneider, MD and Endovascular Skills - history, personal techniques and updates in the 4th Edition

• Closure devices: 

• • Angioseal

  • Mynx

  • Proglide

Endovascular procedures are minimally invasive techniques used to treat conditions affecting blood vessels, such as aneurysms, stenosis, or occlusions, by accessing the affected vessels through an incision in a peripheral artery and using imaging guidance to navigate catheters and devices through the blood vessels to the treatment site. 

Endovascular procedures can be broken down into 4 key steps

1. Establishing arterial access

2. Navigating to target treatment zone or vessel

3. Treating the lesion

4. Closure

Basic definition of wire, sheaths, and catheters

• Wires are thin, flexible metal devices used to navigate through blood vessels and to guide other devices, such as catheters or sheaths, to the target location. They are measured in thousands of an inch

• • A 0.018 wire is 0.018 inch in diameter

  • There are two categories of wires: Flexible and support

Flexible wires are soft and hydrophilic. They are considered the “workhorses” because they are useful for navigating through vessels.

• A common type of wire is called the Glidewire which is  slippery and useful in traveling across tortuous vascular anatomy.

• Support wire are generally a lot stiffer and not hydrophilic. For that reason they are used to deliver and deploy devices

• • A common type of support wire is called the Lunderquist which is used for the deployment of stent grafts in endovascular aortic repair

• Catheters are flexible hollow tubes used in conjunction with wires to navigate vascular anatomy

• • Various characteristics include the degree and shape of the taper, the lengths, and the stiffness.

  • They are inserted inside the sheath 

• Sheaths are hollow tubes of various diameters that are inserted into a blood vessel to provide a pathway for catheters or wires. 

• • They have a one way valve to prevent backflow of arterial blood and a side port that permits aspiration and administration of fluids. 

  • They also come with a dedicated dilator which is used to fill the lumen of the sheath and allows the surgeon to insert the sheath safely into the vessel. 

• If the wire is the rail and the catheter is the train, the sheath is the ground.

Sheaths and catheters sizing

• Both are measured in French

• • 1 French equals 0.33 mm. French size divided by 3 equals the approximate diameter in millimeters. 

  • Another way to think about Fr is roughly the circumference in mm. Divide by 3 instead of 3.14 to get the diameter

  • Sheaths are defined by their inner diameter (ID)

  • Catheters are defined by their outer diameter (OD)

  • This is because catheters go inside the sheath, so the size of a catheter must be smaller or equal to the size of the sheath for it to fit inside.For example, a 5 Fr sheath can accommodate 5 Fr catheter/devices

  • Of note, the hole in the artery will roughly be 2-4Fr larger than the sheath size. This is important when considering the type of closure that will be used at the end of the procedure. 

Step One: Establishing Arterial Access

• Preop preparation: 

• • During physical exam, make sure there’s a palpable femoral pulse to rule out iliofemoral disease

  • Review the CT if available for high femoral bifurcation or presence of vessel disease 

• Patient positioning on the angio table, depends on the access site of choice.

• • Typical position (for retrograde femoral artery access) is supine, arms tucked.  

  • Alternative access sites (ie. radial, brachial, carotid) may require arms to be out and prepped.  

• How do you choose arterial access, location?

• • Depends on location of lesion you are trying to treat and complexity of the path from the access site

  • Size of the access vessel and device size must be considered when deciding on the access site

  • The most common is retrograde femoral artery access

  • When would other access points be used?

  • • Radial artery, brachial, antegrade femoral access. The goal, target location, and path complexity defines the access point.

• Arterial puncture

• • Femoral access:

  • • Look for pulsatile vessel on the US (vein is medial, artery is lateral; “venous penis”)

    • Usually access at the level of femoral head for common femoral artery

  • Seldinger technique is  used to establish access to a vessel or cavity using needle, wire, catheters, and sheath.

  • E.g. using the micropuncture kit:

  • • contralateral arterial CFA access with s 21 gauge needle

    • .018” guidewire is passed through the needle

    • Needle is removed and a short 4 or 5 Fr microcatheter with an inner dilator is passed over the guidewire

    • The dilator and guidewire are removed leaving the catheter in place to maintain access

    • Bigger wire is inserted through the catheter, which is then removed over the wire

    • A sheath is inserted over the wire

• The overall purpose is to start with smaller arterial puncture and exchange to larger size to minimize complication should the access fail

• Often, percutaneous closure devices are preloaded at this step.  We will discuss this later.

Step Two:  Navigating to treatment zone or vessel

With sheath in place, a guidewire is inserted into the vessel under fluoroscopic guidance.

• Continuous fluoroscopy is taken with the C-arm during key steps to visualize wire movement

• • The C-arm can be portable or built into the room

  • X rays are emitted from the X-ray generator below the patient

  • And the subsequent image is generated from the image intensifier above the patient

  • Radiation safety: 

  • • wear protective gear which is made of lead. In addition, use the tableside lead shield whenever possible

    • minimize use of continuous fluoroscopy whenever possible

    • limit use of magnification, and digital subtraction angiography

    • keep the image intensifier as close to the patient as possible to minimize scattering

  • The C-arm can rotate around the patient to get optimal viewing of the vessels

  • • Frequently used terminology: 30 degrees RAO which stands for right anterior oblique, describing the  relationship of image intensifier to the patient

Common projections used for lower extremity angiograms

• Iliacs: 20-30 degrees contralateral anterior oblique

• Femoralsl: 20-30 degrees ipsilateral anterior oblique

• Trifurcation and tibials: anatomic anterior-posterior or 20 degrees ipsilateral anterior oblique with feet in neutral supine position

• Thoracic aorta/distal aortic arch: 30~45 degree LAO

• Renals: AP

• maximizing image quality by limiting patient movement and with breath holding and collimating

• Contrast 

• • Two types of contrasts: Iodinated contrast vs carbon dioxide

  • • Iodinated contrast has better resolution but patients can have allergic reactions and are at risk of contrast induced renal injury. Therefore, CO2 is preferred for patients with compromised renal function in which an image is created by transiently displacing blood. The downside is that it has lower image resolution than iodinated contrast, and rare but potentially serious complications of air locking. 

  • Power injection vs manual injection

  • • When using power injection, you have control over pressure, the amount of contrast, timing, and rate or rise of injection. It allows for rapid filling of large arteries at high flow rates. Manual injection is more efficient for small vessels since you can control dilution and volume

Types of Wires

• Characteristics: wire tip, stiffness, diameter, and length

• Guide wires

• • To assist in catheter placement, navigate different arteries, cross lesions, and deliver devices. 

• The most common sizes used in vascular surgery

• •  Large .035” - generally used for the aorta and iliac.

  • Small .014”/.018” - used for smaller branches like the SFA

• Length: from 120 to 360cm

• • Based on distance from access site to the lesion

  • Long enough to reach target lesions and beyond (inside pt) and deliver catheters (outside pt) but not too long that it’s falling off the table and slowing down exchange

• Flexible vs stiff/support wires

• • How do you decide which wire to use?

  • • Typically, you start with flexible wire inside an angle tip catheter to navigate to the target vessel.  Once you reached and crossed the target vessel, the wire is exchanged to a stiff/support wire, which allows you to deliver

  • common brands and models used that every medical student should know and the settings they are used in?

  • • Example answer:

    • Glidewire (Tumero): a floppy wire with a  hydrophilic coating which is useful for navigating stenosis and tortuous vessels and is used in a variety of different vessels.

    • Lunderquist (Cook): it is very stiff and used for endovascular repairs of AAAs

    • Rosen wire: support wire with a J tip with intermediate stiffness. Less stiff than Lunderquist. Used to catheterize visceral and renal arteries.

    • Bentson: starter wire, that’s short in length with a very long floppy tip that prevents vessel trauma.

Types of Catheters 

• Main purpose of the catheters

• • Allows to approach the target vessel based on the shape of the catheter

  • Allows wire exchange from flexible to stiff

• Sizes are based on Fr (4-5)

• • 5 Fr are the most common.

  • Microcatheters are for embolizations (2.5Fr)

• Nonselective (Angiographic catheter)

• • Common types are omni flush, pigtail, and straight

  • They have multiple side holes along the tip so they can inject high volume of contrast into large blood vessels like the aorta

• Selective catheters/Guide (shape) catheters

• • Have an end hole only with no side holes so they can cannulate specific branch vessels

  • A variety of lengths and shapes depending on the curvature and tortuosity of the pathway to the target vessel.

  • • Catheter with specific shapes can align your vector (the force you are exerting by pushing the wire forward at the access site) to the stenotic lesion.

  • Type of catheter that can be used to cross to the contralateral side at the aortic bifurcation – generally the omni. 

Types of sheaths

• • Size range: 4-26Fr (larger available for endografts)

    • Size is decided by the device you have to deliver to the target lesion

    • Length is based on the support required from the procedure. The distance from the access site to the target site determines the length of the sheath required. 

    • Common lengths range from 5 to 110cm

    • What are some of the common sheaths used and for which procedure?

      • For endovascular aortic repairs, Dryseal sheaths range from 12Fr ~ 26Fr with lengths of 33cm to 65cm.

      • For visceral and renal artery intervention, Ansil or Raabi sheaths range from 5Fr to 9Fr, with lengths of 45cm to 90cm.

      • For lower extermity work, Ansil, Raabi, Balkin sheaths ranging from 4Fr to 7Fr with lengths of 45cm to 110cm.

      • Steerable sheaths can actively articulate the shape of the sheath, allow you to navigate and treat more challenging anatomy.

Step Three: Treating the lesion

• The lesion has to be crossed with wire and catheters before treating the lesion. They may require the need to exchange sheath

• Stent and balloon sizing is measured by diameter in millimeters x length in centimeters

Balloons

• Generally need to exchange wire to stiff support wire through the catheter, then the catheter is exchanged over the wire with the balloon mounted catheter

• Balloons have a wide variety of diameters and lengths

• Nominal vs Burst pressures

• • Nominal: pressure is where the balloon will inflate to the labeled diameter

  • Burst: pressure where 99.9% of tested balloons ruptured

  • Typically you inflate to nominal but can go higher depending on the type of lesion

• Compliant balloon vs a semi-compliant vs non-compliant balloon

• • Most of the time, we use a compliant balloon, but in certain situations where we need high pressure dilation, we use non-compliant balloon.  This has to do with the nature of the lesion and risk of vessel rupture.

• Additional features 

• • Cutting balloons have microblades on the wall. So the idea is to perform control rupture of calcified atherosclerotic lesions, so that the expansion happens more evenly.

  • Drug coated balloons are coated with paclitaxel to reduce the risk of neo-intimal hyperplasia  So, it is sometimes used in peripheral cases where the surgeons feel that the lesions are more prone to developing neo-intimal hyperplasia or areas that have restenosed. 

Stents

• small mesh-like device made of metal that is used to prop open a blocked or narrow blood vessel. It is inserted through a catheter and deployed at the site of the blockage to improve blood flow and reduce the risk of future blockages.

•  balloon expandable vs self-expanding stents

• • Balloon expandable

  • • Better radial force at the time of deployment

    • More accurate deployment

    • Mounted on balloons, so it is more difficult to track them across tight stenosis.

    • May cause damage to the surrounding tissue due to balloon inflation.

  • Self-expanding

  • • Usually more flexible in tortuous vessels

    • More resistant to kinking 

    • Higher risk of migration or dislodgement during deployment

    • Post-dilation is often needed

• covered stents vs bare metal stents

• • Covered stents

  • • Covered by PTFE, polyurethane, or silicone

    • May be more resistant to in-stent restenosis, compared to bare metal stents.

    • useful in ruptured vessel

    • EVAR/TEVAR/FEVAR devices are essentially fancy covered stents.

Step Four: Closure

• Hole in the artery is outer diameter of the sheath, and is bigger than the sheath size since sheath is measured by inner diameter

• Manual compression

• • Direct pressure with fingertips

  • Enough pressure without bleeding, but not too much that it cuts off circulation

  • No peeking!

  • Timing depends on sheath size, coagulation status, and vessel health.

• Closure devices

• • Extravascular plug

  • • Angio-seal: sandwiches the arteriotomy with a biodegradable anchor and collagen sponge. https://www.youtube.com/watch?v=XhgAs2SxNjA

    • Mynx: utilized a small balloon to create temporary hemostasis within the artery and covers the outside with a polyethylene glycol sealant. https://www.youtube.com/watch?v=_kcJM1lnQo8

  • Suture-based

  • • Sometimes placed at beginning of the case for large bore access

    • Proglide: https://www.youtube.com/watch?v=Wol22SlEpxE

• Complications

• • What are the most common complications that you experience and how do you mitigate them?

  • • Access site

    • • Hematoma, pseudoaneruysm, AV fistula, occlusion,  infection

    • Navigation related

    • • Dissection, perforation, thromboembolism

    • Systemic

    • • Contrast induced AKI 

—-----------------------------------------------------------------------------------------------------------------------

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In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovations, and Techniques (JVS-CIT). Editorials and Abstracts are read by members of our SVS Social Media Ambassadors and Editor in Chief of JVS CIT, Dr. Matthew Smeds.

Readers:

Matthew Smeds (@mattsmeds)

Christopher DeHaven (@ChrisDeHavenPSU)

Ethan Vieira

Litton Whittaker

Nicholas Schaper

Nishi Vootukuru (@Nishi_Vootukuru)

Editorials:

Accomplishments and goals: Review of 2023 and previous of 2024 for the Journal of Vascular Surgery Cases, Innovations, and Techniques.

The enduring success of the DRIL technique and new advances in dialysis access.

Abstracts:

Intraprocedural application of a peripheral blood flow monitoring system during endovascular treatment for femoropopliteal disease.

Thoracic outlet syndrome: single-center experience on the transaxillary approach with the aid of the TRIMANO Arthrex arm.

Inferior vena cava hemangioma resected using a novel Toumai robotic surgical platform.

Surgical release of anterior tibial artery entrapment with associated popliteal artery entrapment.

Revisiting Heinz-Lippman disease as a complication of chronic venous insufficiency.

Utilization of coronary computed tomography angiography and computed tomography-derived fractional flow reserve in a critical limb-threatening ischemia cohort.

A rare case of Bannayan-Riley-Ruvalcaba syndrome with concurrent arteriovenous malformation.

Autologous and synthetic pediatric iliofemoral reconstruction: A novel technique for pediatric iliofemoral artery reconstruction.

Follow us @audiblebleeding

Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

Drs. Adam Johnson and Melissa Kirkwood discuss radiation safety.

Vascular Surgery Exam Prep eBook - Radiation Safety

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Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

Dr. Matt Chia and Dr. Ezra Schwartz (@ezraschwartz10) continue the exploration of how vascular surgeons and patients communicate. They discuss how we share stories with one another and what may get lost in translation.

We are excited to welcome Katie Wright (@Translucentone) and Dr. Sherene Shalhub (@ShereneShalhub) to discuss the patient experience of living with Vascular Ehlers-Danlos Syndrome or vEDS.

Katie Wright is the vEDS Natural History Study project coordinator in the Division of Vascular Surgery at Oregon Health & Science University, a podcaster, and a patient advocate. They served as the Director of the Marfan Foundation’s vEDS Division, The VEDS Movement until this past March, and they sit on the VEDS Collaborative (@vEDSCollabo) and Aortic Dissection Collaborative (@ADCollab) advisory board. Katie was diagnosed with vEDS in 2017 at the age of 28. Shortly after diagnosis, they started raising awareness and fostering community through YouTube videos. Katie then began a podcast titled Staying Connected, a space to share the stories of other patients and patient families. In 2018, Katie started volunteering on the advisory board of the vEDS Collaborative, a patient-centered research collaborative group led by Dr. Sherene Shalhub. 

Dr. Sherene Shalhub is the inaugural John M. Porter Chair in Vascular Surgery and Division Head of the Division of Vascular and Endovascular Surgery at Oregon Health & Science University. She is also the Vice Chair of Regional Strategy & Surgical Operations for the Department of Surgery. Dr. Shalhub’s research interests focus on improving healthcare and outcomes for those with genetic vascular conditions. She is the lead investigator for the vEDS Collaborative Natural History Study and the PCORI-funded Aortic Dissection Collaborative. Dr. Shalhub obtained an MPH followed by her medical degree at the University of South Florida. Dr. Shalhub completed her general surgery training at the University of Washington. She then pursued fellowships in trauma research and vascular surgery at the University of Washington.

Resources:

• The VEDS Movement

•  VEDS Collaborative & Natural History Study

• If you are interested in taking part in the study or would like more information, please contact the study team VEDSColl@ohsu.edu

• Donate to the vEDS Natural History Study here.

• Aortic Dissection Collaborative for Patient-Centered Research | BeCertain.org

• Staying connected

• Episode: What Medical Professionals Should Know about VEDS

• Splenic artery pathology presentation, operative interventions, and outcomes in 88 patients with vascular Ehlers-Danlos syndrome

• Open repair of abdominal aortic aneurysms in patients with vascular Ehlers-Danlos syndrome

• Audible Bleeding Exam Prep Aortopathies Episode with Dr. Shalhub

• Free Chime Sound Effects Download - Pixabay

Follow us @audiblebleeding

Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovates, and Techniques (JVS-CIT). Editorials and Abstracts are read by members of the SVS Social Media Ambassadors.

Readers:

Nick Schaper (@schapernj)

Nabeeha Khan (@Nabeeha_Khan_)

Hosts:

John Culhane (@JohnCulhaneMD)

Nishi Vootukuru (@Nishi_Vootukuru)

Reference Articles:

The Gore Iliac Branch Endoprosthesis as an alternate aortic main body: Promising results in select patients

A classic article that has never been read in English

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*Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

Audible Bleeding editors Wen (@WenKawaji) and Matt (@chia_md) are joined by Lara Lopes (@laralopesMD), Nitin Jethmalani (@nijethmalani), JVS editor-in-chief Thomas Forbes (@TL_Forbes), and JVS-VS Associate Editor Gale Tang, to discuss two great articles in the JVS family of journals.  This month’s articles discuss the outcomes of aortic repair after Medicaid expansion, and the process of developing a novel device for repair of aortic injury.  Don’t miss this fantastic discussion with the authors and editors at the forefront of vascular surgery!

Articles:

• Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair by Ramadan et al.

• A dumbbell rescue stent graft facilitates clamp-free repair of aortic injury in a porcine model by Kenawy et al.

Show Guests:

• Omar Ramadan, MD - Chief General Surgery Resident at University of Pennsylvania

• Grace Wang, MD MSCE FACS - Director of the Vascular Lab and Associate Professor of Surgery in the Division of Vascular and Endovascular Surgery at the Hospital of the University of Pennsylvania

• Bryan Tillman, MD PhD - Vascular Surgeon Wexner Medical Center, Associate Professor of Surgery and Director of vascular research at the Ohio State College of Medicine

Audible Bleeding Contributors:

• Lara Lopes, MD - Vascular Surgery Integrated Resident, Northwestern University

• Nitin Jethmalani, MD - General Surgery Resident, Vascular Surgery Research Fellow, NYP Cornell

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Drs. Matthew Chia and Maggie Reilly present a high-yield review on some topics frequently seen on the VSITE examination.

Vascular Surgery Exam Prep eBook - Rapid Review

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Drs. Kevin Kniery, Adham Elmously, and Todd Rasmussen discuss vascular trauma of the abdominal arteries.  Originally published Dec 22, 2019, and was created in collaboration with Behind the Knife: The Premier Surgery Podcast.

Vascular Surgery Exam Prep eBook - Trauma: Abdomen Arterial

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Modern-day evidence-based medicine mandates a strong understanding of current local and international guidelines. Surgeons rely heavily on these reports, but what to do when they differ? We have partnered with the ESVS podcast in creating the Transatlantic Series, where we compare and contrast our respective society guidelines. In this inaugural episode, we explore the SVS carotid artery disease guidelines published in 2022 and the recently updated ESVS guidelines published in 2023.

Representing the American perspective, we are excited to speak with Dr. Ali AbuRahma. Dr. AbuRahma is the former president of the Society of Vascular Surgery, the Chief of Vascular and Endovascular Surgery at the Charleston Area Medical Centre at West Virginia University, and the corresponding author of the latest SVS guidelines on extracranial cerebrovascular disease.

Representing the European perspective, we are delighted to speak with Dr. Barbara Rantner. Dr. Rantner is the co-chair of the 2023 European Society of Vascular Surgery Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease and a leading physician at the Ludwig-Maximillian University Hospital in Munich, Germany.

Further reading and links:

• The North American Symptomatic Carotid Endarterectomy Trial (NASCET) & Audible Bleeding Landmark Papers NASCET Episode 

• Randomized trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST)

• The 2nd European Carotid Surgery Trial (ECST-2): rationale and protocol for a randomized clinical trial comparing immediate revascularisation versus optimized medical therapy alone in patients with symptomatic and asymptomatic carotid stenosis at low to intermediate risk of stroke

• European Stroke Organisation (ESO) guideline on endarterectomy and stenting for carotid artery stenosis

• A comparative effectiveness study of carotid intervention for long-term stroke prevention in patients with severe asymptomatic stenosis from a large integrated health system

• SVS Patient Safety Organization (PSO) TCAR Surveillance Project

• SVS Vascular Quality Initiative (VQI) & VQI TCAR Registry

• Important recommendations of the German-Austrian S3 guidelines on the management of extracranial carotid artery stenosis (Paper only available in German) 

Hosts:

• Laurence Bertrand is a 5th-year vascular surgery resident at the Ludwig Maximilian University Hospitals of Munich, Germany.  She is a medical graduate from KULeuven, Belgium, and has a Master of Science in International Health from the London School of Hygiene and Tropical Medicine.   

• Ezra Schwartz (@EzraSchwartz10) is a medical graduate from McGill University pursuing a Master of Medical Science in Medical Education at Harvard Medical School. He is applying to integrated vascular residency programs this year. 

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In the International Series, we interview international vascular surgeons and trainees with the focus of learning and exploring how vascular surgery is practiced around the world and by doing so, gain new insight into how we practice vascular surgery in the United States. In today’s episode, Ezra Schwartz interviews Dr. Ahmed Kayssi, a vascular surgeon in Canada. 

Dr. Ahmed Kayssi is a vascular surgeon at Sunnybrook Health Sciences Centre, an Assistant Professor at the University of Toronto and an associate scientist in evaluative clinical sciences at the Sunnybrook Research Institute. Dr. Kayssi completed his general surgery residency and vascular surgery fellowship at the University of Toronto and a limb preservation and wound care fellowship under the supervision of Dr. Richard Neville. Dr. Kayssi holds a Master’s degree in Public Health from the Harvard Chan School of Public Health and is currently pursuing a Doctorate of Public Health in Health Policy and Management from the Johns Hopkins School of Public Health under the supervision of Dr. Lilly Engineer. Dr. Kayssi recently joined the editorial board of Seminars in Vascular Surgery. 

Contact Information:  Dr. Ahmed Kayssi 

Email: ahmed.kayssi@sunnybrook.ca

Twitter:

• Dr. Ahmed Kayssi (@ahmedkayssi)
• Dr. Ezra Schwartz (@ezraschwartz10)
• Dr. Morgan Gold (@morgansgold)
• University of Toronto Division of Vascular Surgery

Articles, resources, and societies referenced in the episode:

• Canadian Society of Vascular Surgery Research Committee
• Wounds Canada and Wounds Canada Research Committee
• Canadian Medical Protective Association
• Dr. Charles de Mestral
• University of Toronto Limb Preservation Fellowship
• Dr. Heather Gill,  The PREHAAAB Trial, and Preoperative Exercise Rehabilitation in Cardiac and Vascular Interventions
• International Symposium on the Diabetic Foot
• SVS Vascular Annual Meeting 2024
• Canadian Society of Vascular Surgery Annual Conference
• Health Canada. Canada’s Health Care System - Canada.ca. 
•  Canada: Health system review. Health Systems in Transition

Audible Bleeding editor Wen Kawaji (@WenKawaji) is joined by MD/PhD student Rahul Ghosh (@ghoshrx), JVS editor-in-chief Dr. Thomas Forbes (@TL_Forbes), JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd), and Associate Editor of the Journal of Vascular Surgery-Cases, Innovations and Techniques, Dr. Sherene Shalhub (@ShereneShalhub, @OHSUvascular), to discuss two great articles in the JVS family of journals regarding uncommon vascular conditions, including aberrant subclavian artery/Kommerell’s diverticulum and vascular Ehlers-Danlos syndrome. This episode hosts Dr. Jonathan Bath, Dr. Peter Lawrence, and Dr. Bernardo Mendes, the authors of the following papers: 

 Articles:

• Contemporary Outcomes after Treatment of Aberrant Subclavian Artery and Kommerell’s Diverticulum by Bath et al.

• Open repair of an infected abdominal aortic aneurysm in a patient with vascular Ehlers-Danlos syndrome by Mendes et al.

Show Guests:

• Dr. Jonathan Bath (@MizzouVascular) -  Assistant Professor of Surgery and program director for vascular fellowship at the University of Missouri

• Dr. Peter Lawrence - Professor of surgery at @UCLAVascular, served as senior editor for both JVS and JVS-VL previously. 

• Dr. Benardo Mendes (@drbermendes) - Consultant in the Division of Vascular and Endovascular Surgery at Mayo Clinic, and is Associate Professor of Surgery at Mayo Clinic College of Medicine and Science.

 Additional Notes:

• Vascular Low Frequency Disease Consortium Website 

  • Visit here for a list of completed projects and publications.

• The VEDS Collaborative research study is still enrolling! Any patient interested in enrolling should reach out to VEDSColl@ohsu.edu and follow @VEDSCollabo and @OHSUvascular on Twitter.

• JVS-CIT will be dedicating a full virtual issue to patients with genetic aortopathy and arteriopathy.

• Resources for patients: https://thevedsmovement.org/ and https://www.ehlers-danlos.com/

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In this episode, Imani (@iemcelroy) sits down with Dr. Lyssa Ochoa, vascular surgeon and founder of The San Antonio Vascular and Endovascular (SAVE) Clinic, discussing her efforts to decrease diabetic foot amputations in South Texas. Dr. Ochoa was born and raised along the Texas-Mexico border and attended medical school, general surgery residency, and vascular surgery residency at Baylor College of Medicine in Houston, TX. Understanding that collaboration is key to change health outcomes, Dr. Ochoa has partnered with hospitals, managed care organizations, universities, non-profit organizations, local school districts, city council districts, and clinicians of all kinds to develop amputation prevention programs, awareness platforms, and additional resources.

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In this episode Abena Appah-Sampong (@abenasamp) and Leana Dogbe (@leanadogbe) partner with Vaiva Dabravolskaite (vaivadabravolskaite@gmail.com) from ESVS to host an episode discussing social deprivation in vascular surgery. Dr. Tara Mastracci and Dr. Olamide Alabi join us to offer insights into how social deprivation drives disparities in outcomes and steps to how we can shift practice paradigms to better address our patient needs.

Dr. Tara Mastracci (@aorticsurgeon) is a vascular surgeon with over 15 years of experience treating and managing complex aortic pathologies. She is currently working at St. Bartholomew’s Hospital in London, UK, on the Cardiothoracic Team doing complex aortic surgery. On top of her clinical duties, Dr. Mastracci is dedicated to studying the social and non-clinical factors influencing vascular outcomes. 

Dr. Olamide Alabi (@OAlabiMD) is an Associate Professor of Surgery in the Department of Surgery at Emory University School of Medicine. Her clinical effort focuses on the full scope of vascular disease for patients at Emory University Hospital and the Atlanta VA HealthCare System, however, her academic portfolio and funded research is focused primarily on the intersection of peripheral artery disease, quality, and health equity. 

References:

• Social Deprivation and the Association With Survival Following Fenestrated Endovascular Aneurysm Repair/2021 https://www.annalsofvascularsurgery.com/article/S0890-5096(21)00872-4/fulltext

• Is social deprivation an independent predictor of outcomes following cardiac surgery? An analysis of 240,221 patients from a national registry. BMJ/2015 https://bmjopen.bmj.com/content/5/6/e008287.long  

• Survival Disparity Following Abdominal Aortic Aneurysm Repair Highlights Inequality in Ethnic and Socio-economic Status/ https://www.ejves.com/article/S1078-5884(17)30521-X/fulltext

• Nash, D., McClure, G., Mastracci, T. M., & Anand, S. S. (2022). Social deprivation and peripheral artery disease. Canadian Journal of Cardiology, 38(5), 612-622.

• Vart, P., Coresh, J., Kwak, L., Ballew, S. H., Heiss, G., & Matsushita, K. (2017). Socioeconomic status and incidence of hospitalization with lower‐extremity peripheral artery disease: atherosclerosis risk in communities study. Journal of the American Heart Association, 6(8), e004995.

• Henry, A. J., Hevelone, N. D., Belkin, M., & Nguyen, L. L. (2011). Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. Journal of vascular surgery, 53(2), 330-339.

• Demsas, F., Joiner, M. M., Telma, K., Flores, A. M., Teklu, S., & Ross, E. G. (2022, June). Disparities in peripheral artery disease care: A review and call for action. In Seminars in vascular surgery (Vol. 35, No. 2, pp. 141-154). WB Saunders.

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Audible Bleeding editor Wen (@WenKawaji) is joined by second year medical student Nishi (@Nishi_Vootukuru), 3rd year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Forbes (@TL_Forbes) and JVS-CIT associate editor Dr. O’Banion (@limbsalvagedr) to discuss two great articles in the JVS family of journals regarding endovascular management of acute limb ischemia and ultrasound-based femoral artery calcification score. This episode hosts Dr. Thomas Maldonado (@TomMaldonadoMD) and Dr. Raul J. Guzman, the authors of the following papers:

Articles:

• Safety and efficacy of mechanical aspiration thrombectomy at 30 days for patients with lower extremity acute limb ischemia by Dr. Maldonado and colleagues.

• An ultrasound-based femoral artery calcification score by Dr. Raul Guzman and colleagues.

Show Guests:

• Dr. Thomas Maldonado is the Schwartz - Buckley endowed professor of surgery in the Vascular Division at New York University Langone Medical Center in New York,  Co-Director of Center for Complex Aortic Disease

• Dr. Raul J. Guzman is the Donald Guthrie Professor of Vascular Surgery, Chief of Division of Vascular Surgery at Yale New Haven Hospital. He is also Surgeon-in-Chief of Vascular Surgery, Heart and Vascular Center for the Yale New Haven Health System. (raul.guzman@yale.edu)

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In today’s episode, Dr. Sharif Ellozy, Gowri Gowda, Ezra Schwartz, and Kundanika Lakkadi interview Dr. Premchand “PC” Gupta, a vascular surgeon in India. 

Dr. Gupta is the clinical director of vascular and endovascular surgery and vascular interventional radiology at the Care Hospitals in Hyderabad, India. He is President of the Vascular Society of India and Vice President of the World Federation of Vascular Societies. He is actively involved in research, sits on numerous editorial boards and has had many publications and awards. 

Dr. Gupta received his medical degree from the Armed Forces Medical College in Pune, India and completed his MS in Surgery at the Postgraduate Institute of Medical Education and Research in Chandigarh, India. He completed his vascular surgery fellowship at Nagoya University School of Medicine, Japan. Dr. Gupta pursued additional training in carotid surgery at the University of North Carolina at Chapel Hill as well as in complex aortic surgery at Houston Methodist Hospital.

Twitter:

• Dr. PC Gupta (@pcvasc)

• Dr Sharif Ellozy (@sharifellozy)

• Dr. Ezra Schwartz (@ezraschwartz10)

• Dr. Gowri Gowda (@gowrigowda11)

• Kundanika Lakkadi (@kundanikalakka1)

Articles, resources, and societies referenced in the episode:

• Indian healthcare system summary

• George R, Gupta PC. Vascular Surgery in India - the Challenge and the Promise. 

• Indian Journal of Vascular and Endovascular Surgery

• Vascular Society of Kerala

• Vascular Society of India and Vascular Society of India Annual Conference (VSICON)

• Aortic Rupture in the Indian Context

• Indian National Vascular Day and Amputation Free India and Walkathon

• Vascular Awareness In India: What More Needs to be Done

• CDC Disinfection & Sterilization Guide

Audible Bleeding editor Wen (@WenKawaji) is  joined by JVS-VS Associate Editor Dr. Jose Diaz, JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd) , and JVS Editor-in-Chief Dr. Thomas Forbes (@TL_Forbes) to discuss two great articles in the JVS family of journals.  They’re joined by Dr. Oliver Aalami and Dr. Terence Ryan, authors of each of the papers discussing SVS supervised exercise therapy and two proteins (S100A8 and S100A9) that play an integral role in the ischemic limb pathophysiology. 

“Use of an app-based exercise therapy program including cognitive behavioral techniques for the management of intermittent claudication” by Aalami et al.

“S100A8 and S100A9 are elevated in chronically threatened ischemic limb muscle and induce ischemic mitochondrial pathology in mice” by Ryan et al.

Show Guests:

• Dr. Oliver Aalami (@DrAalami) is a clinical professor of surgery at Stanford University. He is also the director of Stanford Byers Center for Biodesign since 2018. 
• Dr. Terence Ryan (@TerenceRyan_PhD) is an assistant professor on tenure track in the department of applied physiology and kinesiology at the University of Florida. Dr. Ryan’s work focuses on understanding the molecular pathways that regulate muscle and vascular responses to environmental and endogenous stressors. 

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Vascular Origin Stories (VOS) is a podcast series that explores the fun and engaging stories that shaped vascular surgery. Today we are kicking off a new origin stories series: the vascular offspring stories, where we interview practicing vascular surgeons about their vascular surgeon parents.

In this episode, we chat with Dr. Alan Dardik about his father, a pioneering vascular surgeon, Dr. Herbert Dardik.  Dr. Alan Dardik recollects many great stories of his father and how he ultimately followed in his footsteps.

Further reading and links:

• Herbert Dardik 1935-2020, Leaders in Vascular Surgery, Journal of Vascular Surgery
• Remembering Dr. Herbert Dardik, The JewishStandard
• Dr. Alan Dardik, Yale Profile

Host:  Marlene (@GarciaNeuer) is a first-year integrated vascular surgery resident at the Mayo Clinic in Scottsdale, AZ. 

Please share your feedback through our Listener Survey!

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This episode of Audible Bleeding features Drs. Adam Johnson and Jeniann Yi, members of the Society for Vascular Surgery Health Information Technology Committee, to discuss the application of large language models in vascular surgery with two experts in the field, Dr. Andrew Gonzalez and one of his collaborators, Shantanu Dev.  The episode promises a conversation exploring machine learning and large language models with insights from the guests' diverse expertise in vascular surgery, health informatics, and artificial intelligence.

Dr. Andrew Gonzalez, an assistant professor in vascular surgery at Indiana University School of Medicine and also an SVS HITC committee member, has clinical and research interests in peripheral arterial disease and artificial intelligence applications for amputation prevention.

Shantanu Dev, a computer science PhD student at Ohio State, focusing on multimodal modeling for clinical applications in AI. Shantanu worked at PWC for eight years in their AI R&D division and co-owns Satsang.ai (www.satsang.ai) Digital Health, an AI company addressing healthcare inequities and quality of care.

Relevant links:

• AI Revolution in Medince: GPT4 and Beyond by Peter Lee

• Artificial Intelligentce in Surgery: Understanding the Role of Ai in Surgical Practice by Dan Hashimoto

• Data Skeptic Podcast

• Deep Medicine: How Artificial Intelligence can make Helathcare Human Again by Eric Topel

Co-Hosts:

Dr. Jennian Yi is an Assistant Professor of Surgery at the University of Colorado.

Dr. Adam Johnson is an Assistant Professor of Surgery at Duke University, and editor at Audible Bleeding.

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Drs. Young Lee and Matthew Smeds review hemodialysis access.  Originally published March 28, 2020

Vascular Surgery Exam Prep eBook - Hemodialysis

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Mr. Andrew Nickinson, Mr. Aminder Singh, and Mr. Manj Gohel discuss the diagnosis and management of venous disease.  Miss. Leanna Erete oversaw content development.  Originally published on Nov 28, 2021.  Check out our ebook chapter for additional details on EHIT, coagulation factors, anticoagulants, PERT, SVC syndrome and lymphedema.

Vascular Surgery Exam Prep eBook - Venous Disease

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The Audible Bleeding team (Wen Kawaji and Anh Dang) is here at the annual EVS meeting in Charleston, SC. We wanted to highlight some of the research being presented at the conference by medical students and residents. 

Drs. Alex Forsyth and Sarah Carlson discuss acute limb ischemia.  Originally published on Oct 17, 2020.  Check out our ebook chapter for additional content on blue toe syndrome, popliteal entrapment syndrome, and cystic adventitial disease.

Vascular Surgery Exam Prep eBook - Lower Extremity: Acute Limb Ischemia

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The COVID pandemic has resulted in increased rates of burnout and mental illness among surgeons. The quiet epidemic of mental illness continues to leave both surgical trainees and staff at increased risk of self-harm or suicide. In this episode, we talk with Dr. Carrie Cunningham and Dr. Dawn Coleman about their efforts to change the narrative and provide data on the impacts of mental health on surgical training and practices. 

Disclaimer: Topics covered in this episode may be sensitive for some listeners. If you or someone you know is experiencing suicidal thoughts or a crisis, please get in touch with a trained professional or call 988 for the Suicide Prevention Lifeline.

Guests

• Dr. Carrie Cunningham (nee Lubitz) (@lubitz_carrie) is an Associate Professor of Surgery at Harvard Medical School, Section head of the Massachusetts General Hospital Endocrine Surgery Unit, and Associate Director at the Massachusetts General Hospital Institute for Technology Assessment.
• Dr. Dawn Coleman (@DawnDM_vasc) is the newly appointed Division Chief for the Division of Vascular and Endovascular Surgery at Duke University.

Additional Resources

• Vascular surgeon wellness and burnout: A report from the Society for Vascular Surgery Wellness Task Force
• If you need Mental Health Resources for Physicians or the National Suicide Prevention Lifeline.
• For more information on the Lorna Breen Foundation. 
• For more information about Jo Shapiro.

What other topics would you like to hear about? Let us know more about you and your thoughts about our podcast through our Listener Survey or email us at AudibleBleeding@vascularsociety.org.

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Audible Bleeding editors Matt (@chia_md) and Wen (@WenKawaji) are joined by JVS-CIT assistant editor Dr. Bernardo Mendes (@drbermendes) and JVS Editor-in-chief Dr. Thomas Forbes (@TL_Forbes) , to discuss two great articles in the JVS family of journals.  They’re joined by Dr. Powell, Dr. Corriere and Dr. Cooper, the authors of each of the papers discussing patient reported outcomes in claudication and gut microbiome in chronic mesenteric ischemia.  

Articles:

“Characterizing patient-reported claudication treatment goals to support patient-centered treatment selection and measurement strategies” by Powell et al.
“Chronic Mesenteric Ischemia Intestinal Dysbiosis Resolves after Revascularization” by Cooper et al.

Show Guests:

Dr. Chloe Powell: PGY-V vascular surgery resident at University of Michigan
Dr. Matthew Corriere (@MCorriereMD): Associate professor in the department of vascular surgery at University of Michigan. 
Dr. Michol Cooper (@CooperMichol): Assistant professor in the division of vascular surgery and endovascular therapy at the University of Florida College of Medicine. 

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Audible Bleeding editor Adam Johnson (@Adam_mdmph) is joined by MD/PhD student Rahul Ghosh (@ghoshrx), JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd) to discuss two great articles in the JVS family of journals.  Dr. Jasmine Bhinder joins them to discuss the following paper: 

“Understanding radiation exposure and improving safety for vascular surgery trainees” by Bhinder et al.

Show Guests:

• Dr. Jasmine Bhinder (@JasmineB_MD) is a PGY-4 General Surgery Resident at the University of Buffalo, applying to vascular surgery this year!

Link to the National survey of vascular surgery residents and fellows on radiation exposure and safety practices by Bhinder et al. mentioned in the podcast.

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Today, Gowri and our Holding Pressure team republish the Vascular and Endovascular Surgery Society (VESS) National Student-Run Vascular Surgery Interest Group (VSIG) Webinar on "Discover: Vascular Surgery."  This webinar originally occurred on November 10, 2022. 

Featured Physician Speakers: 

• Gabriela Velazquez MD, FACS, RPVI; Associate Professor, Program Director Vascular and Endovascular Surgery Fellowship, Director Vascular Surgery Clerkship; Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine
• Todd Berland, MD, FACS, RPVI; Associate Professor of Surgery, Division of Vascular Surgery at NYU Grossman School of Medicine; Director, Outpatient Vascular Interventions NYU Langone Health
• Ravi Rajani, MD, FACS, DFSVS; Professor of Vascular Surgery, Assistant Dean for Medical Education, Emory University School of Medicine; Chief, Vascular and Endovascular Surgery, Co-Director, Grady Heart and Vascular Center, Grady Memorial Hospital

VESS VSIG Team/Moderators

Audible Bleeding Resources:

• Episodes geared towards medical students: Audible Bleeding (Holding Pressure) 
• Exam Prep Book: https://adam-mdmph.quarto.pub/vascular-surgery-exam-prep/
  
  

VESS VSIG Resources for Medical Students interested in Vascular Surgery: 

• VESS membership link: https://vesurgery.org/my-vess/why-join-vess
• Website: https://vesurgery.org/vess-vsig/
• Email: vessvsig@gmail.com
• VESS VSIG Resources for Medical Students: publication date TBD; stay tuned for an updated link once published

Audible Bleeding editors Wen Kawaji (@WenKawaji), Yasong Yu (@YasongYuMD), and Imani McElroy (@IEMcElroy) are joined by Seth Sankary to discuss their experiences this past year going through the fellowship match process. They discuss the pearls and pitfalls of the interview trail and what influenced their final rank list decisions. 

Show Guests:

• Seth Sankary, MD - General Surgery Chief Resident at the University of Chicago

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Audible Bleeding editor Wen (@WenKawaji) is joined by 5th integrated vascular resident Yang (@YangYang_MD) and Moira 3rd year medical student discussing the International Society for Women Vascular Surgeons and Women’s Vascular Summit with Dr. Linda Harris. 

Show Guests:

• Dr. Linda Harris: Dr. Harris joined University of Buffalo in 1995 and currently sits as Professor of Surgery with tenure in the Department of Surgery. She is also the Program Director for the Vascular Fellowship and Vascular Residency Programs. She is the president of the international society for women vascular surgeons.

SVS Women's section episodes 

• SVS Women’s Section with Dr. Duncan and Dr. Shaw

• SVS Women's Section: Advice for Young Surgeons

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Drs. Mia Miller and Julie Duke review abdominal aortic aneurysms (AAA).  Originally published March 30, 2021.

Vascular Surgery Exam Prep eBook - AAA

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Audible Bleeding editor Wen Kawaji (@WenKawaji) is joined by MD/PhD student Rahul Ghosh (@ghoshrx), JVS editor-in-chief Dr. Thomas Forbes (@TL_Forbes) and JVS-VL Editor-in-chief Dr. Ruth Bush to discuss two great articles in the JVS family of journals. This episode hosts Dr. Siracuse and Dr. Chang, the authors of the following papers discussing mental health in CLTI patients and anticoagulation in venous treatments. 

Articles:

• Relationship between Wifi stage and quality of life at revascularization in the BEST-CLI trial by Siracuse et al.

• Direct oral anticoagulant agents might be safe for patients undergoing endovenous radiofrequency and laser ablation by Dr. Chang et al.

Show Guests:

• Dr. Chang is an assistant professor of surgery at New York Medical College and a vascular surgeon at Westchester medical center, completed his general surgery training at U mass and vascular fellowship at NYU. 

• Dr. Siracuse (@MDsiracuse) is a practicing surgeon in the division of vascular and endovascular surgery at Boston Medical Center and a professor of Surgery and Radiology at Chobanian and Avedisian School of Medicine. 

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Drs. Cullen McCarthy and Matthew Edwards discuss the diagnosis and management of renovascular disease.  Originally published on June 29, 2020.  Check out our ebook chapter for additional details on FMD, renal artery dissection, nutcracker syndrome, renal vein thrombosis and renal AV fistulas.

Vascular Surgery Exam Prep eBook - Renal

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Audible Bleeding contributor and 5th year general surgery resident Richa Kalsi (@KalsiMD) is joined by first-year vascular surgery fellow Zach Mattay (@ZMatthay), fifth-year general surgery resident Naveed Rahman (@naveedrahmanmd), JVS editor Dr. Thomas Forbes (@TL_Forbes), and JVS-CIT editor Dr. Matthew Smeds (@mattsmeds) to discuss two great articles in the JVS family of journals. The first article discusses national trends in surgeon-modified graft utilization for complex and thoracoabdominal aortic aneurysms. The second article discusses a novel technique, transcatheter electrosurgical aortic septotomy, to treat chronic dissecting aortoiliac aneurysms.  This episode hosts Dr. Thomas O’Donnell (@tfxod) and Dr. Carlos Timaran (@ch_timaran), the authors of these two papers.

Articles:

• Part 1:“National Trends in utilization of surgeon-modified grafts for complex and thoracoabdominal aortic aneurysms” by Dr. O’Donnell and colleagues.

  • Mentioned during the discussion:

• • •  “Application of Investigational Device Exemptions regulations to endograft modification” by Abel and Farb. 

• Part 2: “Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms” by Dr. Timaran and colleagues.

  • Mentioned during discussion:

    • “Transcatheter Electrosurgery: JACC State-of-the-Art Review” by Khan and colleagues.

    • “A Novel Way to Fenestrate a Type B Dissection Flap Using Endovascular Electrocautery” by Dr. Kabbani and colleagues. 

Show Guests 

• Dr. Thomas O’Donnell: Assistant professor of surgery in the aortic center at New York Presbyterian/Columbia University Irving Medical Center.

• Dr. Carlos Timaran: Professor and Chief of Endovascular Surgery at University of Texas Southwestern Medical Center’s Department of Surgery.

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The Audible Bleeding team is here at the annual EVS meeting in Charleston, SC. We wanted to share with you some of the attendees' experiences in their own words!

REGISTER HERE for the NEXT webinar 3-D, at 7 pm EST/4 pm PST on December 12, 2022. From 3-D printing to presurgical planning using 3-D modeling, this webinar will explore how 3-D technology is being utilized in vascular surgery today.

Today, we are republishing the Health Information Technology (HITC) Webinar from September 7, 2022, Hacking the EMR: Making the EMR work for you. 

A blessing and a curse, the EMR is an integral part of the modern practice of providing medical care. The Community Practice Section, Health Information Technology Committee, and Wellness Committee have collaborated to develop a webinar about making the EMR work for you. We review how to manage the EMR to benefit your daily practice needs; make the EMR work for small independent practices, including OBLs; how to manage EMR burnout; and a few hacks to make the EMR work for you.

Faculty & Topics:

• Mal Sheahan, MD - Stating the problem of whether the EMR works for us or the other way around. Vascular surgeons, burnout, and the EMR. Mitigation strategies and SVS’ role in resolving this issue.
• Daniel Bertges, MD - Strategies/updates on SVS discussions with EPIC/Powerchart on ways to integrate vascular-specific documentation requirements and streamline data entry (including VQI, etc.).
• London Guidry, MD, and James Craven, MD - How does the smaller independent group effectively use EMR in daily practice/OBL setting? Barriers/challenges/advantages. 
• Robert Beaulieu, MD, presenting for Jeniann Yi, MD - Challenges and opportunities of integrating different EMRs.

Moderator - Geetha Jeyabalan, MD; Vascular Surgeon, MedStar Heart & Vascular Institute.

Full Webinar Video

Relevant Links

• Epic dot phrase - .vasexam
• Weed. “Medical Records That Guide and Teach.” (1968) NEJM. 278(11): 593–600
• Longman. Best Care Anywhere: Why VA Healthcare is Better than Yours. (2012) Penguin Random House
• Chaiyachati et al. “Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations.”(2019)  JAMA IM 179(6):760–67.
• Chawla et al. “Settled Science: The Indisputable Link between EHR and Burnout.” (2021) Vascular Specialist 
• Corby et al.. “A Qualitative Study of Provider Burnout: Do Medical Scribes Hinder or Help?”(2021)  JAMIA Open 4(3)
• Sheahan. “An Open Letter to Epic Systems.” (2021) Vascular Specialist.
• IOM. To Err Is Human: Building a Safer Health System. Edited by Kohn et al.(2000) National Academies Press (US).
• Balasubramanian. “Physicians Would Need Almost 27 Hours A Day To Provide Optimal Patient Care, Per New Study.” (2022) Forbes.
• Morgenstern. “Of Clamps, Clips, and Computers.” (2006) Texas Heart Institute Journal. 33(3):279–80.
• Sinsky et al. “Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.”(2016)  Annals of Internal Medicine. 165(11):753.
• Stark. “H.R.6898 - 110th Congress (2007-2008): Health-e Information Technology Act of 2008.” (2008) Legislation,
• “VQI & Epic Electronic Health Record Integration.” Accessed November 23, 2022.
• Specialty Steering Boards Improve Quality on a Global Scale.  Epic Publication. 2016
• Suki.ai AI Voice Assistant for Healthcare.

SVS members can join the Community Practice Section by emailing svscps@vascularsociety.org.

What other topics would you like to hear about? Let us know more about you and your thoughts about our podcast through our Listener Survey or email us at AudibleBleeding@vascularsociety.org.

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Audible Bleeding editor Wen (@WenKawaji) and  Matt (@chia_md) are joined by MD/PhD student Rahul Ghosh (@ghoshrx), JVS editor-in-chief Dr. Thomas Forbes (@TL_Forbes), and JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd), to discuss two great articles in the JVS family of journals regarding renal stenting in the CORAL trial and metformin in AAA progression. This episode hosts Dr. Baohui Xu and Dr. Gregory Modrall, the authors of the following papers: 

Articles:

• Mechanisms and efficacy of metformin-mediated suppression of established experimental abdominal aortic aneurysms by Xu et al. 

• Retrieval of renal function after renal artery stenting improves event-free survival in a subgroup analysis of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions trial by Modrall et al. 

Show Guests:

• Dr. Gregory Modrall - Professor of Surgery, Division of Vascular and Endovascular Surgery at The University of Texas Southwestern Medical School

• Dr. Baohui Xu – Senior research scientist at Stanford University in collaboration with ShanDong First Medical University in Jinan.

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Audible Bleeding editor Wen (@WenKawaji) is joined by first-year vascular surgery fellow Zach (@ZMatthay), 5th year integrated vascular surgery resident Kaitlyn (@DunphyKaitlyn), JVS editor Dr. Forbes (@TL_Forbes) and JVS-VS associate editor Dr. Curci (@CurciAAA) to discuss two great articles in the JVS family of journals regarding machine learning in carotid endarterectomy and abdominal aortic aneurysm. This episode hosts Dr.Li (@ben_li123), Dr. De Mestral (@vasc_surg), Dr. Kiang (@sharon_Kiang_MD), and Dr. Tomihama (@roger_tomihama), the authors of the following papers:

Articles:

• Using Machine Learning to predict outcomes following carotid endarterectomy by Li et al.

• Machine learning analysis of confounding variables of a convolutional neural network specific for abdominal aortic aneurysms by Tomihama et al 

Show Guests:

• Dr. Li is a vascular surgery resident and PhD candidate at the University of Toronto

• Dr. De Mestral is an associate professor of vascular surgery at the University of Toronto who also has a PhD in health services research and focuses on clinical effectiveness, cost, and quality of surgical care.

• Dr. Sharon Kiang is the chief of vascular surgery at the Loma Linda Veteran’s affairs hospital as well as an associate professor and vice-chair of research of surgery at Loma Linda University. She is also the PI for the Center for Artificial Intelligence and Vascular Engineering.

• Dr. Roger Tomihama is an associate professor of interventional radiology with 18+ years of experience in clinical medicine, biomedical research, graduate medical education, and professional organizations. He was a former officer in the United States Navy and recipient of the Navy Commendation Medal. As a clinician scientist, he has procured $1.4 million dollars of extramural research grant funding, have 22 peer-reviewed publications, 4 invited publications, and 4 book chapters. His current research focus includes artificial intelligence in imaging for vascular disease.  Lastly, he is currently pursuing a Master's of Business Administration at the Wharton School of Business at the University of Pennsylvania.

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Drs. Anna Ohlsson and Sherene Shalhub review genetically inherited aortopathies.  Originally published May 18, 2020.

Vascular Surgery Exam Prep eBook - Aortopathies

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Welcome to the Transatlantic series, a co-production of Audible Bleeding (a publication of the SVS) and the ESVS podcast. In today’s episode, we explore the intersocietal guidelines on peripheral arterial disease in patients with diabetes and foot ulcers authored by the International Working Group on the Diabetic Foot (IWGDF), the European Society for Vascular Surgery (ESVS), and the Society for Vascular Surgery (SVS).

Dr. Robert Fitridge is a Professor of Vascular Surgery at University of Adelaide in Australia. He is a member of the IWGDF and is also a member of the steering committee for the Global Vascular Guideline on the management of Chronic Limb-threatening Ischaemia. 

Dr. Vivienne Chuter is a Professor in the Department of Podiatry at Western Sydney University and Honorary Professor in the School of Health Science at The University of NewCastle. She is a member of the IWGDF. She has published extensively on diabetic foot disease and leads a clinically based research program focusing on the prevention and management of diabetes-related foot disease for Aboriginal and Torres Strait Islander people and for non-Indigenous Australians.

Dr. Nicolaas Schaper is an emeritus professor of Endocrinology at Maastricht University Hospital in the Netherlands. Dr. Schaper was the coordinator of the European diabetic foot research consortium, Eurodiale. He is Chair of the 2023 Diabetic Foot Symposium (ISDF 2023) and is Chair of the IWGDF.

Dr. Joseph L. Mills is a Professor of Vascular Surgery at Baylor in Houston, Texas. He is a member of the IWGDF. Dr. Mills is a leader in the vascular surgery global community, has served as president of the Peripheral Vascular Surgery Society, and is currently a member of the Surgery Residency Review Committee of the ACGME.

Further reading and links:

• The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer.

• Global vascular guidelines for CLTI

• Best-CLI

• Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers

• A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers

• A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial

• Release of the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025; the impacts for podiatry in Australia: a commentary

• Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases

• Results of the CAPRIE trial: efficacy and safety of clopidogrel. Clopidogrel versus aspirin in patients at risk of ischaemic events

• Low-Dose Aspirin for the Primary Prevention of Cardiovascular Disease in Diabetic Individuals: A Meta-Analysis of Randomized Control Trials and Trial Sequential Analysis

• Diabetes, Lower-Extremity Amputation, and Death

• Outcomes in patients with chronic leg wounds in Denmark: A nationwide register‐based cohort study

• Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia

• Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. 

• Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review.

• Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review.

• The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI).

• Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia.

• A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial.

Mobile Applications:

• Society for Vascular Surgery Mobile App for Staging of Chronic Limb-Threatening Ischemia. 

• European Society for Vascular Surgery Clinical Practice Guidelines Mobile Edition.

Hosts: 

• Dr. Naveed A. Rahman is a chief surgery resident at SUNY Upstate in Syracuse, NY. He will pursue a vascular surgery fellowship at the University of Maryland starting in 2024. His Doximity profile is https://www.doximity.com/pub/naveed-rahman-md. Twitter: @naveedrahmanmd

• Dr. Suzanne Stokmans is a fifth-year vascular surgery resident at the Isala Hospital in Zwolle, the Netherlands.

Dr. Ezra Schwartz is a medical graduate from McGill University currently completing a Master of Medical Science in Medical Education at Harvard Medical School. He is an aspiring vascular surgeon and surgical education researcher. Twitter: @ezraschwartz10

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Adam and Ezra review the highlights of 2022 and what to look forward to in 2023!   This episode lists this year’s five most downloaded episodes and other recap topics.

Check out our team favorites:

• Uncomfortable Conversations - Mental Health Awareness in Surgery
• Role of the Modern Vascular Surgeon in Oncologic Surgery
• SVS Women’s Section with Dr. Duncan and Dr. Shaw
• Inside the Vascular Surgery Board - the Past, Present, and Future of Your Certification
• SAVS 2022 Recap

COVID-19 Publication

• Boreskie PE, Chan TM, Novak C, Johnson AP, Wolpaw J, Ong A, Priddis K, Buddhdev P, Jessica Adkins J, Silverman JA, Davis T, Siegler JE. Medical Education Blog and Podcast Utilization During the COVID-19 Pandemic. Cureus. Mar 2022. 14(3):e23361. PMID: 35475051

Follow us @audiblebleeding.  Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

Sound Effect from pixaby.com

Drs. Matt Smith and Nedal Katib review thoracic outlet syndrome.  Originally published November 27, 2019.

Vascular Surgery Exam Prep eBook - Thoracic Outlet Syndrome

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Nishi Vootukuru (@Nishi_Vootukuru) and Dr. Ezra Schwartz (@ezraschwartz10) interview Dr. William Shutze and Dr. Anahita Dua (@AnahitaDua) to discuss the Get a Pulse on PAD Campaign.

The Get a Pulse on PAD initiative (#PulseonPAD), launched in February, 2024, is a patient education and advocacy campaign designed to increase the understanding of peripheral artery disease's risk factors and potential symptoms.  

Dr. Shutze is a vascular surgeon with Texas Vascular Associates in Dallas, Texas and the Secretary of the SVS. Dr. Shutze completed his medical studies at Baylor University after completing general surgery residency at University of Alabama in Birmingham. Dr. Shutze returned to Baylor to complete his vascular fellowship. Dr. Shutze is one of the Get a Pulse on PAD initiative’s chairs and a leading expert in PAD. He has actively published in the field with over 100 abstracts and articles, with his most recent work focusing on prosthetics, and advocating for successful prosthetic referral after amputation. 

Dr. Dua is a vascular surgeon at Mass General Hospital and associate professor at Harvard Medical School. At Mass General, she is the director of the Vascular Lab, co-director of the Peripheral Artery Disease Center and Limb Evaluation and Amputation Program (LEAPP), associate director of the Wound Care Center, director of the Lymphedema Center and director of clinical research for the division of vascular surgery. She serves as the Editor-in-Chief of Journal of Vascular Surgery-Vascular Insights. Dr. Dua completed her undergraduate medical studies at the Aberdeen University School of Medicine in Aberdeen, Scotland. She then completed her general surgery residency at the Medical College of Wisconsin and vascular fellowship at Stanford University Hospital. She holds multiple master’s degrees including degrees in trauma sciences and business administration in healthcare management. She also completed certificate programs at the Massachusetts Institute of Technology in health economics and outcomes research as well as in drug and device development. Dr. Dua is a prolific researcher, researcher, and advocate, with much of her work centered on PAD. She furthers patient care not only through research but through her political work as Founder of the Healthcare for Action political action committee (PAC) and member of the SVS PAC Steering Committee. 

Special thank you to Jacob Soucey (@JacobWSoucy)

Resources:

• https://www.secondscount.org/get-a-pulse-pad

• https://evtoday.com/news/pad-pulse-alliance-survey-highlights-disconnect-in-public-knowledge-of-pad-risks

• Association of Black Cardiologists (ABC)

• Society for Cardiovascular Angiography & Interventions (SCAI)

• Society of Interventional Radiology (SIR)

• CardioVascular Coalition (CVC)

• Outpatient Endovascular and Interventional Society (OEIS)

• https://vascular.org/advocacy/political-action-committee

• https://evtoday.com/articles/2021-may/the-arc-act-fighting-amputation-via-legislation

• https://evtoday.com/articles/2006-may/EVT0506_10.html#:~:text=The%20Screening%20Abdominal%20Aortic%20Aneurysm,screening%20as%20a%20Medicare%20benefit

• CLariTI Study: Natural Progression of High-Risk Chronic Limb-Threatening Ischemia

• Socioeconomic and hospital-related predictors of amputation for critical limb ischemia

•  ARC Act of Congress

• Painkiller: TV Series 

• Congressman Payne 

• SAAAVE Act

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Audible Bleeding editor Matt Chia (@chia_md) is joined by Nishi Vootukuru (@Nishi_Vootukuru)  and Lili Sadri (@lilisadri) are joined by Drs. Joel Ramirez, James Iannuzzi, and James Pavel Kibrik to discuss their latest publications in the JVS family of journals.  Along with insight from JVS Assistant Editor Dr. Paul Dimuzio and JVS-VL Editor-in-Chief Dr. Ruth Bush (@RuthLBush), hear about the latest trends in AAA repair and the value of postoperative duplex after venous thermal ablation.  Don't miss it!

Articles:

Decreasing prevalence of centers meeting the Society for Vascular Surgery abdominal aortic aneurysm guidelines in the United States, by Ramirez et al.

Value and limitations of postoperative duplex scans after endovenous thermal ablation, by Kibrik et al.

Additional Links:

Factors associated with ablation-related thrombus extension following microfoam versus radiofrequency saphenous vein closure, by Chin et al.

Outcomes of a single-center experience in eliminating routine postoperative duplex ultrasound screening after endovenous ablation, by Woodhouse et al.

Show guests:

Joel Ramirez, MD - Integrated Vascular Surgery Resident at the University of California, San Francisco

James C. Iannuzzi, MD MPH - Assistant Professor, Division of Vascular and Endovascular Surgery at the University of California, San Francisco

Pavel Kibrik, DO - Graduate of New York Institute of Technology Osteopathic School of Medicine and current vascular surgery researcher at the NYU Langone School of Medicine 

Ruth Bush, MD JD MPH FACS - Professor of Vascular Surgery and Associate Dean of Educational Affairs at the University of Texas, Medical Branch and Editor-in-Chief of the Journal of Vascular Surgery Venous and Lymphatic Disorders

In today’s episode, Gowri Gowda, Ezra Schwartz and Morgan Gold, and Dr. Sharif Ellozy interview Dr. Daniel Silverberg about his experiences practicing and teaching vascular surgery in Israel.

Dr. Silverberg is the deputy director of the Department of Vascular Surgery and the Director of the endovascular service at the Chaim Sheba Medical Center in Ramat Gan in the municipality of Tel Aviv, Israel. He completed his undergraduate medical studies with honors at the Ben-Gurion University of the Negev in Beer-Sheva, Israel, and his clinical internship year at Meir Medical Center, Kfar-Saba, Israel. Dr. Silverberg performed his general surgery training at Meir Medical Center, Kfar-Saba, Israel, and later at Mount Sinai Medical Center, New York City. He then remained at Mount Sinai, where he completed his vascular surgery fellowship. Dr. Silverberg worked as an attending vascular surgeon at the James J. Peter VA Medical Center in New York for three years until returning to Israel in 2009. 

Contact Information for Dr. Daniel Silverberg

Email: daniel.silverberg@sheba.health.gov.il

Twitter:

Dr. Gowri Gowda (@GowriGowda11)

Dr. Ezra Schwartz (@ezraschwartz10)

Dr. Morgan Gold (@MorganSGold)

Articles, resources, and societies referenced in the episode:

• Israeli Society for Vascular and Endovascular Surgery:  https://israelivascular.ima.org.il/ViewEvent.aspx?EventId=3630

• https://www.commonwealthfund.org/international-health-policy-center/countries/israel

• Zhang LP, Silverberg D, Divino CM, Marin M. Building a Sustainable Global Surgical Program in an Academic Department of Surgery. Ann Glob Health. 2016 Jul-Aug;82(4):630-633. doi: 10.1016/j.aogh.2016.09.003. Epub 2016 Oct 1. PMID: 27986231.

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Drs. Kevin Kniery, Jason Bingham, and Todd Rasmussen discuss peripheral vascular trauma.  Originally published Sep 22, 2019, and was created in collaboration with Behind the Knife: The Premier Surgery Podcast.

Vascular Surgery Exam Prep eBook - Trauma: Peripheral

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As part of the Race & Representation (R&R) Series, we are doing spotlights on vascular trainees and faculty that identify as racial/ethnic minorities underrepresented in medicine (URiM), who have been historically excluded from the field. We hope to amplify these voices as examples of the unique challenges faced by URiMs within vascular surgery and as a source of inspiration and mentorship.

In this episode of Audible Bleeding, we sit down with Chloe Powell and discuss her research in physical resilience, understanding patient treatment goals, and pre-operative evaluation before undergoing major vascular intervention. We also delve into her motivations. 

Dr. Chloe Powell is an integrated vascular surgery resident at the University of Michigan. 

For more on Dr. Powell’s research.

What other topics would you like to hear about? Let us know more about you and what you think of our podcast through our Listener Survey or email us at AudibleBleeding@vascularsociety.org.

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Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

In this episode, we discuss the challenges of explanting aortic grafts, the diagnosis and management of infected aortic grafts, as well as tips and tricks for once we're in the operating room.

Interviewers/Editors:
Mark Basilious, MD Candidate (@markrbasilious)

Eva Urrechaga, MD (@urrechisme)
Sharif Ellozy, MD (@SharifEllozy)

Guests:

Dr. Francis Caputo (@FrankCaputoMD) is an Associate Professor of Surgery at the Cleveland Clinic Lerner College of Medicine, Vascular Surgery Director of the Aorta Center, and Program Director of the Vascular Surgery Training Programs. His clinical interests include complex open and endovascular repair of thoracic, thoracoabdominal, and abdominal aortic aneurysms, management of thoracic dissection, and endovascular and open repair of failed endograft. Dr. Caputo earned his medical degree from the University of Medicine and Dentistry New Jersey, Newark, NJ, where he also served his surgical residency and two years as a National Institutes of Health research fellow. He completed his fellowship in vascular surgery at Barnes-Jewish Hospital of Washington University, St. Louis, MO and joined the Cleveland Clinic medical staff in 2018.   

Dr. Peter Rossi (@peterjrossi) is a Professor of Surgery, Radiology, and Orthopedic Surgery, and Chief of the Division of Vascular and Endovascular Surgery at the Medical College of Wisconsin. His primary research and clinical interests are in complex  “re-do” and revision surgery, including for thoracoabdominal and abdominal aortic aneurysms, carotid artery surgery, and renal and mesenteric arterial disease, as well as vascular reconstruction for complicated soft tissue sarcomas. Dr. Rossi completed medical school at the University of Illinois College of Medicine before completing his general surgery training at the University of Chicago and his vascular surgery training at the Medical College of Wisconsin, where he has been a member of the faculty since 2009. 

Dr. Xavier Berard (@XavierBerardMD)  is a French vascular surgeon who has been a Consultant in the Department of Vascular Surgery and Professor of Vascular and Endovascular Surgery in Bordeaux University Hospital in Bordeaux, France since 2010 and a full Professor of Vascular Surgery at the University of Bordeaux since 2016. He has also completed a PhD in Vascular Biomaterials and in 2010 worked as a research fellow at Lausanne University Hospital in Switzerland. He has been board certified by the French College of Vascular and Endovascular Surgeons since 2008 and by the European Society for Vascular and Endovascular Surgery since 2010. He has served as an examiner for the FEBVS exam since 2014 and as a reviewer for the European Journal of Vascular and Endovascular Surgery since 2016. Additionally, he is a member of the ESVS guidelines writing group for vascular graft infection and AAA.  His personal surgical interests include open surgery of (thoraco)abdominal aneurysms, redo aortic surgery, infections in vascular surgery, EVAR explantation, and biomaterials. He works closely with Institut Bergonié Bordeaux Cancer Center for sarcomas. You can see educational videos and learn more about Dr. Xavier Berard here.

Helpful links and resources:

Video of explantation of infected chimney EVAR with duodenal fistula (courtesy of Dr. Berard)

Video of reimplanting the IMA after explanting an infected graft

Video of explantation of infected graft with suprarenal fixation

Videos of using the syringe technique to remove an aortic stent graft here and here (courtesy of Dr. Berard)

References

1. Kim YW. Aortic Endograft Infection: Diagnosis and Management. Vasc Specialist Int. 2023 Sep 21;39:26. doi: 10.5758/vsi.230071. PMID: 37732343; PMCID: PMC10512004.

2. Papas TT. Patient Selection Is Essential for Explantation of Infected Abdominal Aortic Endografts. Angiology. 2023 Nov 23:33197231218622. doi: 10.1177/00033197231218622. Epub ahead of print. PMID: 37995099.

3. Anagnostopoulos A, Mayer F, Ledergerber B, Bergadà-Pijuan J, Husmann L, Mestres CA, Rancic Z, Hasse B; VASGRA Cohort Study. Editor's Choice - Validation of the Management of Aortic Graft Infection Collaboration (MAGIC) Criteria for the Diagnosis of Vascular Graft/Endograft Infection: Results from the Prospective Vascular Graft Cohort Study. Eur J Vasc Endovasc Surg. 2021 Aug;62(2):251-257. doi: 10.1016/j.ejvs.2021.05.010. Epub 2021 Jun 14. PMID: 34140225.

4. Lumsden AB. Explant of the Aortic Endograft: Today's Solutions, Tomorrow's Problems. Methodist Debakey Cardiovasc J. 2023 Mar 7;19(2):38-48. doi: 10.14797/mdcvj.1176. PMID: 36936357; PMCID: PMC10022536.

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Audible Bleeding editor Wen (@WenKawaji) is joined by 5th year general surgery resident Richa Kalsi (@KalsiMD) from University of Maryland Medical Center, 4th year general surgery resident Nitin Jethmalani from New York Presbyterian Hospital-Weill Cornell, JVS (@JVascSurg) editor Dr. Forbes (@TL_Forbes) and JVS-VL (@jvsvl) editor Dr. Bush (@ruthlbush) to discuss two great articles in the JVS family of journals regarding chronic pain and resident burnout and SFJ reflux and its implication in C2 and C3 chronic venous insufficiency. This episode hosts Dr. Pillado (@drpillado), Dr. Coleman (@ColemanDM_vasc) and Dr. Lal. 

Articles:

• Reported pain at work is a risk factor for vascular surgery trainee burnout by Dr. Pillado and colleagues.

• Effect of junctional reflux on the Venous Clinical Severity Score in Patients with Insufficiency of the great saphenous vein (JURY study) by Dr. Lal and colleagues.

Show Guests:

• Dr. Coleman: Professor of Surgery at Duke University and Division Chief of Vascular and Endovascular Surgery at Duke University Medical Center.

• Dr. Pillado: vascular surgery resident at Northwestern Hospital in Chicago, IL 

• Dr. Lal: Professor of Surgery at the University of Maryland, Professor of neurology at Mayo clinic, and professor of biomedical engineering at George Mason University. and Director of Center for Vascular Research at University of Maryland Medical Center

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This three-episode mini-series republished a webinar that was recorded by the Eastern Vascular Society on important diversity issues in various settings including workplace, academia, training and education.

In this episode, Dr. Vincent Rowe will discuss diversity in academia. Dr. Rowe is a professor of surgery and division chief of vascular and endovascular surgery at UCLA. Dr. Rowe serves as the chair of diversity equity and inclusion committee in the society of vascular surgery.

Articles highlighted in episode 2:

1. Update on workforce diversity in vascular surgery by Dorsey et al. https://doi.org/10.1016/j.jvs.2020.12.063

2. National evaluation of racial/ethnic discrimination in US surgical residency programs by Yuce et al. https://doi.org/10.1001/jamasurg.2020.0260

3. Black vascular surgeons survey: who are they? Where are they? Who do they treat? by Kirksey et al. https://doi.org/10.1016/j.jvs.2021.06.414

Learn more about us at www.audiblebleeding.com and provide us with your feedback via our listener survey.

Join Audible Bleeding team Matthew Chia, Nitin Jethmalani, and Leana Dogbe and editors from the JVS family of publications Thomas Forbes and Gale Tang as we discuss two of the latest highlights in vascular research. First, we welcome Mary McDermott, MD to discuss the discordance between patient-reported outcomes and objective PAD measures in the latest episode of the JVS.  The episode finishes with a stimulating discussion with Alex Chan, PhD to discuss the effect of nicotine on angiogenesis in a murine model of PAD.

Articles:

Discordance of patient-reported outcome measures with objectively assessed walking decline in peripheral artery disease by McDermott et al. https://doi.org/10.1016/j.jvs.2023.12.027

Chronic nicotine impairs the angiogenic capacity of human induced pluripotent stem cell-derived endothelial cells in a murine model of peripheral arterial disease by Chan et al. https://doi.org/10.1016/j.jvssci.2023.100115

Related Articles:

Clinical characteristics and response to supervised exercise therapy of people with lower extremity peripheral artery disease by Patel et al. https://doi.org/10.1016/j.jvs.2020.04.498

Effects of supervised exercise therapy on blood pressure and heart rate during exercise, and associations with improved walking performance in peripheral artery disease: Results of a randomized clinical trial by Slysz et al. https://doi.org/10.1016/j.jvs.2021.05.033 

Show Guests:

Mary McDermott, MD is the Jeremiah Stamler Professor of Medicine and Preventive Medicine at the Feinberg School of Medicine at Northwestern Medicine.  Among her many accolades and titles, she serves as deputy editor of the Journal of the American Medical Society, and has an extensive career focused on improving our understanding of peripheral arterial disease.  

Alex Chan, PhD is a researcher who studied regenerative medicine and cell therapeutics as a postdoctoral fellow in the lab of Dr. Ngan Huang, PhD at the Stanford Cardiovascular Institute.

Audible Bleeding team Matt Chia (@chia_md) and Gowri Gowda (@GowriGowda11) are joined by the co-principle investigators of the BEST-CLI trial, Dr. Matthew Menard and Dr. Alik Farber.  We talk about the results of BEST-CLI, marking what is sure to be the next landmark trial in vascular surgery.  Drs. Menard and Farber give their insights on being clinical trialists and surgeons in the modern era, reflecting on challenges in conducting this work and its broad-reaching implications.

Links:

Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia

Comprehensive List of BEST-CLI Literature

Show Guests:

Dr. Matthew Menard (@MattMenard6) is the program director for the vascular and endovascular fellowship program and co-director of the Endovascular Surgery Program at Brigham and Women’s Hospital. He is a vascular and endovascular surgeon at BWH and an Associate Professor of Surgery at Harvard Medical School.

Dr. Alik Farber is the Chief of the Division of Vascular and Endovascular Surgery at Boston Medical Center and Professor of Surgery and Radiology at Boston University School of Medicine

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Drs. Nedal Katib and Danielle Bajakian discuss the medical management of peripheral arterial occlusive disease and claudication.  Originally published on Aug 24, 2020.

Vascular Surgery Exam Prep eBook - Lower Extremity: Medical Management and Claudication

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In this episode of Audible Bleeding, editor Dr. Adam Johnson is joined by General Surgery PGY-3 Sasank Kalipatnapu, MS2 Nishi Vootukuru, along with Dr. Anton Sidawy, MD, and Dr. William Schutze to discuss the nuances of the recently launched Society for Vascular Surgery (SVS) Outpatient Verification Program, in collaboration with the American College of Surgeons.

This episode brings out a conversation exploring the history behind the development of the program, the current state of the program, and the overwhelming importance of the program in the current day. The episode will also cover the broad steps that need to be taken by a facility looking to become verified and will also show the value added by being verified by this joint ACS/SVS Vascular Verification program.

Dr. Anton Sidawy, MD, MPH, FACS is the Lewis B. Saltz Chair and Professor of Surgery at George Washington School of Medicine, Washington DC. He is the chair of the Vascular Verification Program steering committee and oversees the development and implementation of inpatient and outpatient vascular verification programs.

Dr. William Patrick Shutze is a Vascular Surgeon from Texas Vascular Associates in Plano, TX, and Chair of the Outpatient Committee. He is also the secretary for the Society for Vascular Surgery and is also the chair of the Communications Committee. He has led the efforts with the implementation of the recently launched Outpatient Verification Program.

Relevant links:

• Official page of the Vascular Verification Program

Co-Hosts:

Dr. Adam Johnson is an Assistant Professor of Surgery at Duke University and editor at Audible Bleeding.

Dr. Sasank Kalipatnapu is a PGY-3 General Surgery resident at UMass Chan Medical School, Worcester, MA.

Nishi Vootukuru is a 2nd-year medical student at Rutgers NJMS University, Newark, NJ.

Vascular Team Talk is back with our second episode! This podcast mini-series is brought to you by the Society of Vascular Surgery Physician Assistant Section and Audible Bleeding. How does your Vascular team communicate or organize the day? Teams can consist of many people who have different responsibilities and due to the busy nature of vascular surgery services, it may be difficult to ensure urgent matters get passed on. In this episode, we focus on the importance of communication and relationships between vascular surgery students, residents, APPs, fellows and attendings. 

Jessica Fernandes, PA-C, a Vascular Surgery physician assistant at Boston Medical Center (BMC), interviews Dr. Katie Shean, a vascular surgeon at St. Elizabeth's Medical Center, regarding the importance of communication and the transition from a fellowship to an attending position. Both Jessica and Dr. Shean discuss how they worked together at BMC and compare how Dr. Shean runs her current vascular team at St. Elizabeth's Medical Center. 

Show Guests:

- Jess Fernandes, PA-C, is an inpatient physician assistant in the Division of Vascular and Endovascular Surgery at Boston Medical Center. She is also a member of the SVS PA committee and NESVS PA committee. She graduated with her bachelor degree and Master in Physician Assistant Studies from MCPHS University in 2016. 

- Katie Shean, MD is a vascular surgeon in the Division of Vascular and Endovascular Surgery at St. Elizabeth's Medical Center in Brighton, Massachusetts. She completed medical school at University of Vermont Medical School in 2013, followed by her general surgery residency at St. Elizabeth's Medical Center and vascular surgery fellowship at Boston Medical Center which she completed in 2022. 

Show Links:

SVS Physician Assistant Section

St. Elizabeth's Medical Center Vascular and Endovascular Division

Drs. Matthew Chia and Nick Mouawad discuss the diagnosis and management of mesenteric vascular disease.  Originally published on April 9, 2020.  

Vascular Surgery Exam Prep eBook - Mesenteric

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Authors: 

Sebouh Bazikian - PGY1 at Emory School of Medicine Integrated Vascular Surgery Program

Miguel F. Manzure - vascular surgery attending the University of Southern California Keck School of Medicine involved in complex limb preservation

Core Resources:

• Rutherford Chapters: 107, 108, 109 (Includes further information on anatomy), 112

Additional Resources:

• Relevant trials
• • BEST CLI: https://pubmed.ncbi.nlm.nih.gov/36342173/
  • BASIL 2: https://pubmed.ncbi.nlm.nih.gov/37116524/
• Relevant Audible Bleeding episodes
• • Audible Bleeding Endovascular Basics: https://open.spotify.com/episode/7jDpkhGMauBslk8SBklCyB?si=75f0931773d24b91
  • Audible Bleeding eBook, CLTI Chapter: https://adam-mdmph.quarto.pub/vascular-surgery-exam-prep/clti.html
• Anything else useful
• • WIFI: https://pubmed.ncbi.nlm.nih.gov/24126108/
  • GLASS: https://pubmed.ncbi.nlm.nih.gov/31159978/
  • Monophasic, Biphasic, Triphasic Waveforms: https://pubmed.ncbi.nlm.nih.gov/32667274/

Underlying disease featured in episode - peripheral arterial disease

1. Pathophysiology/etiology
   1. narrowing of peripheral arteries caused by atherosclerotic plaques causing arterial insufficiency distal to the point of occlusion. This reduces oxygen supply to the muscles.
   2. When oxygen demand increases but cannot be met, it leads to an imbalance such as pain and poor wound healing. 
   3. Risks: smoking, diabetes, hypertension, dyslipidemia, and older age
   4. Equal prevalence in men and women, peak incidence age 60-80
   5. Coexists with CAD, DM, stroke, Afib, and renal disease
2. Patient Presentation
   1. 20-50% asymptomatic, rest can be intermittent claudication, rest pain, or tissue loss
   2. claudication=pain or discomfort felt in the legs due to a lack of blood flow, especially during physical activity. 
   3. CLTI=chronic limb threatening ischemia: rest pain lasting greater than 2 weeks or nonhealing ulcers and gangrene
   4. Physical exam: 
      1. decreased skin temperature, less hair on the legs, brittle nails, atrophied muscles, shiny skin, livedo reticularis.
      2. Absent or diminished pulses
      3. Buerger sign
3. Diagnosis
   1. Ankle brachial index: <0.9=PAD. <0.4=multilevel disease associated with tissue loss. >1.3 can mean vessel calcification
   2. Toe pressures, toe brachial indexes, and transcutaneous oxygen measurement (TcPO2) if vessels calcified
   3. Duplex ultrasound: affordable and effective, can assess both anatomy and blood flow
      1. Can also assess degree of stenosis based on ratios of systolic and diastolic velocity
   4. Angiography: gold standard. Invasive and risks of infection, hematoma, pseudoaneurysms, and contrast nephropathy.
   5. Staging:
      1. WIFI - Wound, Ischemia, and Foot Infection (see additional resources)
      2. GLASS: Global Limb Anatomy Staging System (see additional resources)
4. Treatment (Medical/Surgical)
   1. Lifestyle modification, smoking cessation, high-intensity statins, antiplatelet therapy, and management of other medial comorbidities like HTN and DM.
   2. Structured exercise program: 3 times weekly for 12 weeks
   3. Cilostazol: phosphodiesterase III inhibitor
   4. Endovascular and surgical revascularization
      1. Endovascular offer superior perioperative outcomes but lacks durability
      2. Surgical revascularization offer durability and less reinterventions, but more invasive

Indications for surgery:

• CLTI and lifestyle limiting claudication

Relevant anatomy:

• Femoral triangle
• • inguinal ligament superior, the medial border of the sartorius muscle laterally, and the medial border of the adductor longus on the medially
  • Contains neurovascular bundle (NAVEL)
• Adductor canal: bordered anteriorly by the sartorius, posteriorly by the adductor magnus and longus, and to the lateral side by the vastus medialis
• common femoral artery bifurcates into the profunda and the superficial femoral artery  (SFA). SFA courses through adductor canal and turns into popliteal artery in the popliteal fossa
• GSV: originates at the ankle, tracts anterior to medial malleolus and then ascending the medial side of lower leg. Upon reaching the knee, it curves behind the medial condyles of the femur and tibia, continuing alongside the medial aspect of the thigh. Its journey culminates at the saphenofemoral junction

Preoperative preparation:

1. Identifying inflow and outflow vessels, both should be free of significant disease
   1. preop CTA or angiogram
2. Picking a conduit
   1. Best patency=autogenous: reversed GSV most common, others are small saphenous vein, cephalic vein, etc
   2. Prosthetic: polytetrafluoroethylene (PTFE)
   3. Cryopreserved vein

Surgical steps:

1. Harvesting GSV (if GSV adequate as conduit)
   1. Dissected along its length, branches ligated, removed and reversed
   2. Can also be left insitu, so only proximal and distal aspects are mobilized, and valves are removed using valvulotome
   3. Should be at least 3mm in diameter and no significant disease (scarring, thickening)
2. Arterial exposure
   1. Common femoral artery: lies in the medial third segment between the ASIS and the pubic symphysis. Longitudinal or oblique incision directly over the femoral artery pulse if present. ligate venous and lymphatic tributaries in the soft tissue. Open fascia along the medial margin of the sartorius muscle, retracting the sartorius muscle laterally exposes the underlying femoral sheath. CFA is located within the femoral sheath.
   2. Profunda and superficial femoral artery: trace the anterior surface of the CFA to where it bifurcates. The origin of the profunda is typically lateral

1. Popliteal artery: medial longitudinal incision 1 to 2 cm behind the tibia's posterior border. Carefully to avoid GSV, dissect down to fascia to enter the popliteal fossa. The medial head of the gastrocnemius is retracted posteriorly, giving us a clear view of the popliteal fossa. popliteal artery is surrounded by paired popliteal veins with smaller bridging veins

1. Tunneling and anastomosis
   1. Can be done anatomically or subcutaneously
   2. Must be careful not to twist the conduit
      1. Can do proximal anastomosis to pressurize vein prior to tunneling to minimize chance of twisting
   3. Clamp the vessels and heparinize
   4. Arteriotomy on femoral artery and anastomosis, same with popliteal artery distally
2. Closure and ensure patency
   1. Optional completion angiogram

Postoperative care:

• Anticoagulation and/or antiplatelet therapy
• Monitor graft patency once discharged with duplex/ABI

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Today, Dr. Ezra Schwartz and Dr. Nakia Sarad continue exploring how vascular surgeons and patients communicate. They discuss how we share stories and what may get lost in translation.

Dr. Rita Charon is a general internist, professor of medicine, and professor and founding chair of medical humanities at Columbia University. Dr. Charon originated the field of narrative medicine and is the founder and executive director of the Program in Narrative Medicine at Columbia. A literary scholar, Dr. Charon completed a Ph.D. in English at Columbia, concentrating on narratology and the works of American-British author Henry James. She is the author of Narrative Medicine: Honoring the Stories of Illness, co-author of Principles and Practice of Narrative Medicine, and co-editor of Stories Matter: The Role of Narrative in Medical Ethics and Psychoanalysis and Narrative Medicine.

Dr. Abraham Fuks is a clinical immunologist, a Professor in the Department of Medicine and Division of Experimental Medicine at McGill University, a Professor of Oncology at the Goodman Cancer Institute, and served as Dean of the McGill University Faculty of Medicine from 1995 to 2006.  Dr. Fuks’ has published on the metaphors of medicine and ethics in clinical research. In 2021, Dr. Fuks published a book, The Language of Medicine, in which he explores the ability of language to heal or harm and the potent metaphors prevalent in clinical care, especially military metaphors.

Dr. Anahita Dua is a vascular surgeon at the Massachusetts General Hospital, an associate professor of surgery at Harvard Medical School, and a frequent guest on Audible Bleeding. 

Resources:

• Dr. Charon’s related works:
  • Narrative Medicine: Honoring the Stories of Illness
  • The Principles and Practice of Narrative Medicine
  • Stories Matter: The Role of Narrative in Medical Ethics and Psychoanalysis and Narrative Medicine
  • TEDx Talk
• Dr. Fuks’ related works:
  • The Language of Medicine
  • The Mindful Medical Learner Podcast featuring Dr. Fuks
  • Arthur Frank, The Wounded Storyteller: Body, Illness, and Ethics 
• Dr. Dua’s related works: 
  • Epidemiology of Peripheral Arterial Disease and Critical Limb Ischemia
  • Peripheral Artery Disease: Where We Are and Where We Are Going
• Validated QOL surveys and Patient Reported Outcome Measures:
  • PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories): Overview of Design and Rationale of an International Prospective Peripheral Arterial Disease Study
  • Patient-Reported Outcomes for Peripheral Vascular Interventions for the Vascular Quality Initiative
  • Eric Cassell & Functionality
  • Vasc QOL Questionnaire 
  • PAD QOL Questionnaire
  • Vasc QL-6 Questionnaire
  • European QL 5D 5L Questionnaire

X Handles (previously known as Twitter):

• Dr. Anahita Dua (@AnahitaDua)
• Dr. Rita Charon (@RitaCharon)
• Dr. Abraham Fuks (@Abe_McGill)
• Dr. Ezra Schwartz (@ezraschwartz10)
• Dr. Nakia Sarad (@NakSaradDO)

Drs. Alaska Pendleton and Anahita Dua discuss what you need to know about vascular ultrasound for vascular surgery examinations.  Originally published Jan 06, 2022.

Vascular Surgery Exam Prep eBook - Vascular Lab

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In this episode of Audible Bleeding, Jamila, Anh, and Naveed discuss the LifeBTK Trial with Principal Investigator Dr. Brian DeRubertis, where we discuss the new Abbott Esprit everolimus-eluting resorbable scaffold for the below-knee popliteal space.

Guest:

Dr. DeRubertis, is the Principal Investigator of the LIFE-BTK trial. He is the Chief of the Division of Vascular & Endovascular Surgery at New York-Presbyterian and Weill Cornell Medicine in New York City.

Audible Bleeding Team

Dr. Jamila Hedhliis a general surgery resident at the University of Illinois.

Anh Dang, (@QuynhAnh_Dang), is a fourth year medical student at the University of Pennsylvania. 

Dr. Naveed A. Rahman, (@naveedrahmanmd), is a Vascular Surgery Fellow at the University of Maryland. 

References:

• Drug-Eluting Resorbable Scaffold versus Angioplasty for Infrapopliteal Artery Disease (LIFE-BTK).

• Advances in Endovascular Treatment of CLTI: Insights From the LIFE-BTK Trial.

• Diversity, Equity, and Inclusion in the LIFE-BTK Trial Evaluating the Esprit™ BTK Drug-Eluting Resorbable Scaffold for the Treatment of Infrapopliteal Lesions in Patients with Chronic Limb-Threatening Ischemia, VIVA 2024.

• Sirolimus-eluting stents vs. bare-metal stents for treatment of focal lesions in infrapopliteal arteries: a double-blind, multi-centre, randomized clinical trial (YUKON).

• Randomized comparison of everolimus-eluting versus bare-metal stents in patients with critical limb ischemia and infrapopliteal arterial occlusive disease (DESTINY). 

• A prospective randomized multicenter comparison of balloon angioplasty and infrapopliteal stenting with the sirolimus-eluting stent in patients with ischemic peripheral arterial disease (ACHILLES).

• Sex Differences in Outcomes Following Endovascular Treatment for Symptomatic Peripheral Artery Disease: An Analysis From the K- VIS ELLA Registry.

• Drug-Coated vs Uncoated Percutaneous Transluminal Angioplasty in Infrapopliteal Arteries: Six-Month Results of the Lutonix BTK Trial. 

• Paclitaxel-Coated Balloon in Infrapopliteal Arteries: 12-Month Results From the BIOLUX P-II Randomized Trial (BIOTRONIK'S-First in Man study of the Passeo-18 LUX drug releasing PTA Balloon Catheter vs. the uncoated Passeo-18 PTA balloon catheter in subjects requiring revascularization of infrapopliteal arteries). 

• The IN.PACT DEEP Clinical Drug-Coated Balloon Trial: 5-Year Outcomes.

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Audible Bleeding editor Wen (@WenKawaji) is joined by 3rd year medical student Nishi (@Nishi_Vootukuru), JVS editor Dr. Forbes (@TL_Forbes), and JVS-CIT associate editor Dr. Jimenez to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Trisha Roy (@trisharoymd), Dr. Judit Csore (@JuditCsore), and Dr. Maham Rahimi, the authors of the following papers. 

Articles:

• Employing magnetic resonance histology for precision chronic limb-threatening ischemia treatment plan
• Biodesign: Engineering an aortic endograft explantation tool

Show Guests 

• Dr. Trisha Roy- Assistant professor of cardiovascular surgery at the Houston Methodist Debakey Heart and Vascular Center. Background of Material engineering, vascular imaging, research interest in peripheral vascular disease.
• Dr. Judit Csore-Radiologist and assistant lecturer at the Heart and Vascular Center of Semmelweis University, Budapest, Hungary. Her primary focus is on cardiovascular imaging and vascular MRI. She recently spent two years in the United States at Houston Methodist Hospital, where she had been collaborating with Dr. Trisha Roy since 2022 as a postdoctoral fellow, specializing in peripheral arterial disease imaging.
• Dr. Maham Rahimi-Associate professor in the department of cardiovascular surgery at Houston Methodist Hospital, His research interests include nanotechnology and Biomedical Engineering

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