Vascular Specialist@VAM–Conference Edition 2

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In this issue: 03 A ortic valve Vascular surgeons key in multidisciplinary care team 06 V ein stenting Obesity not a barrier to treatment 13 A I and EVAR Model predicts risk of postop complications

FRIDAY JUNE 17 2022 | CONFERENCE EDITION 2

THE OFFICIAL NEWSPAPER OF THE

17 Photo gallery Snapshots from across day two of VAM

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TRANSALANTIC

DIVERSITY IN CARE: ‘FROM BEING EXCLUSIVE TO MORE INCLUSIVE’

F/BEVAR has high technical success and low mortality in chronic postdissection TAAA

indings from the study, which was co-authored by Emanuel R Tenorio, MD, and Gustavo Oderich, MD, both of The University of Texas Health Science Center at Houston, Houston, alongside senior author Bijan Modarai, PhD FRCS, Guy’s and St Thomas’ NHS Foundation Trust, London, England, were presented during Thursday’s Plenary Session taking place in Ballroom A/B. “F/BEVAR has been used widely in the treatment of thoracoabdominal aneurysms,” Abdelhalim told attendees of the morning session, adding that PD-TAAAs present a unique set of endovascular technical challenges.

The study aimed to analyze outcomes of F/BEVAR for treatment of

The role diversity played in the past, how it functions in the present and where it might take vascular surgery in the future will form one of the central themes running through the Presidential Address set to be delivered by Society for Vascular Surgery (SVS) President Ali AbuRahma, MD, during the 2022 Vascular Annual Meeting (VAM) this morning.

AbuRahma is the 16th SVS president to be born outside of the United States— an important backdrop to his opening remarks in “SVS past, present and future: From being exclusive to more inclusive.”

He will dip into the Society’s storied three-quarter-century history—pulling out and highlighting the 15 past presidents before him who were born outside of the United States—to settle on an important question posed to him by members: “Are we inclusive enough, or are we still as exclusive as we were 50 years ago?”

Those international names represent important figures in vascular surgery, important advances in the specialty as a whole, and many contributions to the development of the SVS, he will tell the VAM 2022 audience. The contingent includes two SVS charter members: Hungary-born Geza de Takats, MD, president in 1953; and Robert Linton, MD, a Scot who followed de Takats as president two years later. AbuRahma will spotlight the major contributions of all 15, including more recent predecessors such as Anton Sidawy, MD, who hails from Syria and was SVS president in 2010; Peter Gloviczki, MD, also born in Hungary; and the 2013 SVS president; and Michel Makaroun, MD, who was born in Lebanon and led

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Mohamed A. Abdelhalim

Fenestrated/branched endovascular aneurysm repair (F/BEVAR) is associated with high technical success and low mortality in patients with chronic post-dissection thoracoabdominal aortic aneurysm (PD-TAAA). This conclusion was presented by Mohamed A. Abdelhalim, MBChB, a PhD research fellow at St Thomas’ Hospital, London, England, who detailed multicenter, transatlantic experience with F/ BEVAR for chronic PD-TAAAs, writes Will Date

15 Women’s Section Talking about women surgeons’ lives and careers

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Join Medtronic at their in-booth presentations See page 5 for details 

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Vascular Specialist | Friday 17 June 2022

FROM THE COVER TRANSATLANTIC F/BEVAR: HIGH TECHNICAL SUCCESS AND LOW MORTALITY IN CHRONIC POST DISSECTION-TAAA chronic PD-TAAAs by reviewing clinical data of consecutive patients treated by F/BEVAR for Extent I-III PD-TAAAs in 16 centers from the United States and Europe from 2008‒2021. All patients received off-the-shelf or patient-specific manufactured fenestrated-branched stent grafts.

Endpoints for the study included any-cause mortality and major adverse events (MAEs) at 30 days, technical success, target artery (TA) patency, freedom from TA instability, minor (endovascular with <12Fr sheath) and major (open or >12Fr sheath) secondary interventions, and patient survival and freedom from aortic-related mortality (ARM).

Abdelhalim presented data from 246 patients (76% male; median age 67 years [interquartile range (IQR) 61‒73]), who were treated for Extent I (7%), Extent II (57%) and Extent III (36%) PD-TAAAs (Median aneurysm diameter, 65mm [IQR 59‒73]) by F/BEVAR. Of these, 18 patients (7%) were octogenarians, 212 (86%) were American Society of Anaesthesiologists (ASA) class ≥3, and 21 (9%) presented with contained ruptured or symptomatic aneurysms.

Abdelhalim reported that there were 917 renal-mesenteric vessels targeted by 581 fenestrations (63%) and 336 directional branches (37%), with a mean of 3.7 vessels per patient.

He noted that technical success of the procedure was 96%.

The author reported that the study investigators found “favorable” 30-day mortality among the patient cohort, with a rate of around 3%, whilst adding that MAEs occurred in 28%, including acute kidney injury in 8%, new-onset dialysis in 1%, major stroke in 1%, spinal cord injury in 7% and permanent paraplegia in 2%, he noted.

Mean follow-up was 24±23 months, wherein patient survival and freedom from ARM were 65±10% and 93±5% at five years, respectively. Secondary interventions were needed in 93 patients (38%), Abdelhalim noted, including minor procedures in 63 (26%) and major in 30 (12%). There was one conversion to open repair (<1%), while freedom from any secondary intervention was 44±9% at five years. The five-year freedom from target artery instability was 82±3% and instability was significantly more likely to affect branches than fenestrations. Major causes included endoleaks and stenosis, the presenter commented.

In his concluding remarks, Abdelhalim noted that F/BEVAR was associated with high technical success and low mortality (3%), new-onset dialysis (1%) and permanent

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L-r: Gustavo Oderich and Mohamed A. Abdelhalim

paraplegia rates (2%) in patients with chronic PD-TAAAs. Although the procedure is effective against ARM, he commented, overall patient survival at five years (65%) reflects the fact that patients treated have advanced age and significant comorbidities. Freedom from secondary interventions at five years was 44%, although most were minor procedures and conversion to open repair was needed in only one patient.

“Fenestrated and branched EVAR can be used in the treatment of chronic post-dissection aneurysms with low mortality and low morbidity,” Abdelhalim said. “However,” he cautioned, “this does carry a significant intervention rate, and because of this, a bespoke approach is required for each patient, and this includes close follow-up and monitoring of the long-term outcomes.”

The importance of long-term follow-up was a theme picked up in the discussion following the presentation, during which a number of audience members remarked on the significance of the data presented by Abdelhalim. Speaking from the floor, Ian Loftus of St George’s University Hospital NHS Foundation Trust, London, England, described these as

“really important data” and echoed the point that long-term outcomes are key.

“You have highlighted that these are very sick patients and it is very complex technology, and therefore is very expensive and time consuming,” remarked Loftus. “How do you think that we can prove that we are altering long-term outcomes for these patients, and how are we going to prove cost-effectiveness of these technologies?” he asked.

“The follow-up in this cohort is two years, so the only way to do that is for us to continue monitoring these patients and see where we are in a number of years from now,” Abdelhalim responded.

Study co-author Oderich, who joined Abdelhalim at the podium for the discussion, further remarked: “I think what this shows is that we selected a very high-risk population, and that reflects the fact that it is the beginning of the experience with fenestrated-branched grafting.

“As time goes by and we enrol patients that are intermediate or lower risk, I think we will be able to achieve a longer follow-up.”

SPOTLIGHT

Spotlight on Friday and Saturday@VAM

WE MIGHT HAVE REACHED THE halfway point at VAM but the education, exhibits and activities continue. There is still a lot for attendees to look forward to over the next couple of days, including the celebratory SVS Foundation Gala this evening in the Sheraton Grand. This year, the Gala will celebrate the 75th anniversary of the SVS. Tickets to the Gala are sold out but anyone, anywhere (with an internet connection) may bid on items in the Gala’s Silent Auction until 8:15 p.m. (Eastern Time). Visit vascular.org/ Gala22Tickets to view items and bid.

Before the celebrations kick off this evening, there are a range of sessions to choose from for attendees at all career stages. Are you a general surgery resident or medical student? Why not attend the mock interview

practice session from 6:30 to 8 a.m. in Room 311 at the Hynes Convention Center. Alternatively, there will be a World Federation of Vascular Societies session on global training and education during and post-pandemic taking place at the same time in Room 210.

For attendees who are interested in Concurrent Sessions, or who simply want the opportunity to re-watch certain presentations or sessions, don’t forget that you can access all content on-demand via the SVS website.

A highlight of today’s schedule will be the Presidential Introduction and Address, due to take place 11:00 a.m. to 12:15 p.m. in Ballroom A/B. This will follow two Plenary Sessions—5 and 6—scheduled for 8 to 9:30 a.m. and 10 to 11 a.m., respectively, in Ballroom A/B.

This afternoon, sessions include “Building Diversity and Equitable Systems in Vascular Surgery” from 1:30 p.m. to 3 p.m. and “The Failing and Failed EVAR” from 3:30 p.m. to 5 p.m., both in Ballroom A/B. Today’s exhibition will run from 9:30 a.m. to 5 p.m. in Hall C/D, so make sure to stop by exhibitors’ booths during coffee breaks and lunch. In addition, Advanced Oxygen Therapy, BD, Gore & Associates, and Silk Road Medical will host sponsored sessions throughout the day.

Education continues for another full day on Saturday. Stay tuned for the John Homans Lecture, scheduled for 10 a.m. to 10:30 a.m. in Ballroom A/B, which will be bookended

by Plenary Session 7 from 8 to 9 a.m. and Plenary Session 8 from 10:30 am to 12 p.m.,

both in Ballroom A/B. Other sessions on Saturday will include “Quality Improvement: Using a Data Driven Approach to Improve Care and the Bottom Line”, from 1:30 to 2:30 p.m. in Room 310, “Improving Vascular Care in Underserved Communities” from 1:30 to 3 p.m. in Room 309, and “Management of Vascular Trauma: Exploring Consensus in the Who and Where Amidst Subspecialized Training and Practice” from 1:30 to 4.30 p.m. in Room 312.

Sessions will end at 4:30 p.m. on Saturday, but make sure to check out the Poster Championship in Room 302 during the final hour slot of the day.

Registration will be open from 6 a.m. on both days, closing at 5:30 p.m. on Friday and 5 p.m. on Saturday.—Jocelyn Hudson

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FROM THE COVER DIVERSITY IN CARE ‘FROM BEING EXCLUSIVE TO MORE INCLUSIVE’ the SVS in 2019.

“At a time of unfortunate xenophobia in our culture, the SVS has always been an open international society, and this is no better reflected than in the backgrounds of so many of our past leaders,” he will tell attendees. The “unparalleled leadership of the SVS” in the field of vascular disease “reflects not only the wisdom of our past leaders,” but the organization’s commitment to evolution going forward, AbuRahma will say.

The chief of vascular and endovascular surgery at West Virginia University School of Medicine/Charleston Area Medical Center in Charleston, West Virginia, will spotlight how this evolution at the SVS has played out at the structural and committee levels.

“In the early SVS years, and during the first 50 years, there were very limited numbers of standing committees, including the membership, program, nominating [committees], and a committee on arrangements for VAM,” he plans to say.

AbuRahma will outline how the membership has expanded and become more inclusive, and how new dedicated membership sections for women, young surgeons and physician assistants, and for areas such as community practice and office-based labs, have broadened discussion and educational offerings.

He also will point out how changes at the SVS Nominating Committee level capture the essence of the Society’s evolution. “In the past, the SVS Nominating Committee consisted of three members appointed by the president one month before VAM, usually the three immediate past presidents, and its function was to compile a slate of officers to be presented to the Executive Council

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and members at the VAM,” AbuRahma will inform attendees. “Currently, it consists of seven members—the three most recent and surviving and available past presidents with the most senior as chair, one member that is elected annually from and by the 11 representatives of the regional and vascular societies serving on the Strategic Board, one member-at-large elected from the SVS membership who is not currently serving on the Executive Board, the vice-chair of the Community Practice Section, and the chair of Leadership and Diversity Committee.”

Looking ahead, AbuRahma will go on, the SVS must maintain focus on key areas, such as branding the specialty, continuing the fight for “fair and appropriate payment,” and continuing the support for those in community practice: “We must be united and have a common message across members and keep investing in embracing diversity and cultural change,” he will tell delegates.

“We should keep investing in our health and wellness and our early-career members which is critical for our future. We must continue to embrace quality in vascular patient care and finally we must work towards finding a common pathway in working with other non-vascular surgeon providers who practice endovascular therapy based on acceptable dedicated training in endovascular intervention.”

That harkens back to AbuRahma’s chosen topic for last year’s E. Stanley Crawford Critical Issues Forum in San Diego. The then incoming SVS president focused on the role of multispecialty care in vascular and endovascular surgery, hoping to get at least some answers to the question: Can the competing specialties of the vasculature work together?

AbuRahma assembled a panel of physi-

cians covering every specialty involved in the treatment of vascular disease for the VAM 2021 event. During the Forum, AbuRahma himself declared: “Vascular providers must have defined, dedicated vascular and endovascular training during their formal residency or fellowship. Multispecialty practice, if feasible, will enhance and improve vascular care.”

At VAM 2022, AbuRahma is set to return to the topic, and will pose such questions as what strategy vascular surgery should deploy in order to ensure vascular procedures are carried out by appropriately trained specialists. “Many specialties are attracted to performing vascular procedures in light of workforce shortage, and mal-distribution creates access issues to vascular surgeons,” he will say. “Advances in treatment and device technology make therapy for an increasing number of vascular conditions within the perceived scope of other specialists, some

“The conduit used, and whether or not the patient has undergone prior vascular interventions, are the key predictors of [lowerextremity bypass] failure” ALI ABURAHMA

of whom are without adequate training. The current policies and incentives are rewarding the wrong behavior with consequences of quality challenges, increased complications landing in vascular surgery practices, payment inefficiencies with overutilization and unnecessary procedures.”

He will once again raise the virtues of multispecialty practice, which traces its roots to his state—West Virginia—and the concept of a Vascular Center of Excellence model, such as the one developed at his institution: eight board-certified vascular surgeons, two board-certified cardiologists/vascular interventionists, one board-certified vascular medicine interventionist and one board-certified interventional radiologist.

AbuRahma conducted a survey of SVS members to assess the level of interest in multispecialty models of practice. Among the results, he found more than 50% of respondents saw cardiologists/interventional cardiologists and interventional radiologists as a threat among non-vascular surgeon providers performing procedures for vascular disease, while 58% said they did not form part of a multispecialty group that includes non-vascular surgeons.

What, then, should the strategy be?

AbuRahma will ask: “How can the SVS best position itself to take the lead in shaping the future of vascular surgery care delivery, and optimizing patient outcomes? Can demonstrated competence and quality metrics be established and agreed upon across specialties? Who are the critical partners to engage in the dialogue?” And, he will add, “are there highly successful multispecialty models to be demonstrated? All of us know politics are local. Can we or should we influence and or impact training guidelines?”—Bryan Kay

MULTIDISCIPLINARY CARE VASCULAR SURGEONS ‘HAVE A ROLE TO PLAY’ IN TRANSCATHETER AORTIC VALVE REPLACEMENT PROCEDURES VA S C U L A R S U RG E RY A S S I S TA N C E I N transcatheter aortic valve replacement (TAVR) can facilitate safe and effective device introduction through cases involving challenging femoral or iliac access. This was the conclusion delivered by Enrico Gallitto, MD, from the University of Bologna, Bologna, Italy in a presentation looking at the role of the vascular surgeon in transcatheter aortic valve implantation.

During Thursday’s Plenary Session 3, Gallitto delivered the findings of an analysis of TAVR procedures assisted by vascular surgeons between 2016 and 2020—in what Gallitto describes as a “high-volume tertiary hospital.” Gallitto noted that TAVR has become the standard treatment for severe aortic valve stenosis among patients at both high and intermediate operative risk for surgical valve replacement.

Percutaneous transfemoral access is the preferred route for the procedure, he added, due to its low invasiveness and lower perioperative morbidity and mortality compared to transapical, transaxillary or transaortic approaches. However, Gallitto added that vascular access complications occurring from the transfemoral access are associated with prolonged hospitalization and 30-day mortality, and the presence of severe peripheral arterial diseases as well as aortic aneurysm or cerebrovascular insufficiency may necessitate concomitant endovascular management.

“A multidisciplinary team with interventional cardiologists and vascular surgeons may minimize the rate of vascular access complications in patients with challenging femoral/ iliac access and significant disease of other vascular districts,” he added, noting that this may be important to optimize the outcome of transfemoral TAVR. The study sought to evaluate the role of vascular surgeons in transfemoral TAVR. Gallitto and colleagues looked at pre-, intra- and postoperative data for the given time period, which were clustered and retrospectively analyzed by a dedicated group of both interventional cardiologists and vascular surgeons.

Vascular access complications were defined according with the Valve Academic Research Consortium (VARC) 2 guidelines, and the outcomes of TAVR procedures with vascular surgeon involvement were assessed as the study’s endpoints.

Overall, Gallitto and colleagues assessed a total of 937 TAVR procedures performed with a transfemoral approach ranging between 78% (2016) and 98% (2020). Vascular surgeons were involved in 67 (7%) procedures.

Of these, three (4%) had indications for concomitant abdominal aortic aneurysm (endovascular aneurysm repair [EVAR]+TAVR), two (3%) with severe carotid stenosis (TAVR+CAS), and 62 (93%) had hostile femoral or iliac access or vascular access complications.

Balloon angioplasty of iliac artery pre-TAVR was per-

formed in 51 cases (conventional percutaneous transluminal angioplasty [PTA]: 38/51‒75%; conventional PTA+intravascular lithotripsy [IVL]: 13/51–25%).

The TAVR procedure was successfully completed via the percutaneous transfemoral approach in all 62 cases with challenging femoral/iliac access, Gallitto reported. Vascular access complications necessitating interventions occurred in 18 out of the 937 (2%) cases, localized to the common femoral or common/external iliac artery in 15/18 (83%) and 3/18 (17%) cases, respectively. They were managed by surgical or endovascular maneuvers in 3/18 (83%) and 15/18 (25%) cases, respectively. Fifteen/18 (83%) vascular access complications were treated during the index procedure, Gallitto reported, adding that there were no instances of procedure-related mortality or 30-day readmissions.

In his concluding remarks, Gallitto commented that the necessity of vascular surgeon assistance in TAVR procedures is “not infrequent”, and participation by vascular specialists allows safe and effective device introduction through challenging femoral/iliac access, for example.

“Similarly, the concomitant significant disease of other vascular districts can be safely addressed potentially reducing postoperative related mortality/morbidity,” he noted. “The organization of composite cardiological and vascular surgery teams should be encouraged wherever possible.”

Valiant™ Captivia™ Thoracic Stent Graft System Indications •

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The Valiant™ Thoracic Stent Graft with the Captivia™ Delivery System is indicated for the endovascular repair of all lesions of the descending thoracic aorta (DTA) in patients having appropriate anatomy, including:

iliac/femoral artery access vessel morphology that is compatible with vascular access techniques, devices, or accessories;

nonaneurysmal aortic diameter in the range of 18 mm to 42mm (fusiform and saccular aneurysms/ penetrating ulcers), 18 mm to 44 mm (blunt traumatic aortic injuries), or 20 mm to 44 mm (dissections); and

nonaneurysmal aortic proximal and distal neck lengths ≥ 20mm (fusiform and saccular aneurysms/ penetrating ulcers), landing zone ≥20 mm proximal to the primary entry tear (blunt traumatic aortic injuries, dissections). The proximal extent of the landing zone must not be dissected.

Contraindications

The Valiant Thoracic Stent Graft with the Captivia Delivery System is contraindicated in: •

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Patients who have a condition that threatens to infect the graft.

Patients with known sensitivities or allergies to the device materials.

MRI Safety and Compatibility

Warnings and Precautions

Non-clinical testing has demonstrated that the Valiant Thoracic Stent Graft is MR Conditional. It can be scanned safely in both 1.5T and 3.0T MR systems under specific conditions as described in the product Instructions for Use. For additional information regarding MRI please refer to the product Instructions for Use.

The long-term safety and effectiveness of the Valiant Thoracic Stent Graft with the Captivia Delivery System has not been established. All patients should be advised that endovascular treatment requires lifelong, regular follow-up to assess the integrity and performance of the implanted endovascular stent graft. Patients with specific clinical findings (for example, enlarging aneurysm (>5mm), endoleaks, migration, inadequate seal zone, or continued flow into the false lumen in the case of a dissection) should receive enhanced follow-up. Specific follow-up guidelines are described in the Instructions for Use. The Valiant Thoracic Stent Graft with the Captivia Delivery System is not recommended in patients who cannot undergo, or who will not be compliant with, the necessary preoperative and postoperative imaging and implantation procedures as described in the Instructions for Use. Strict adherence to the Valiant Thoracic Stent Graft sizing guidelines as described in the Instructions for Use is expected when selecting the device size. Sizing outside of this range can potentially result in endoleak, fracture, migration, infolding, or graft wear. As cautioned in the Instructions for Use, a balloon should never be used when treating a dissection.

The safety and effectiveness of the Valiant Thoracic Stent Graft with the Captivia Delivery System has not been evaluated in some patient populations. Please refer to the product Instructions for Use for details.

Adverse Events

Potential adverse events include, but are not limited to access failure, access site complications (e.g. spasm, trauma, bleeding, rupture, dissection), adynamic ileus, allergic reaction (to contrast, antiplatelet therapy, stent graft material), amputation, anaesthetic complications, aortic expansion (e.g. aneurysm, false lumen), aneurysm rupture, angina, arrhythmia, arterial stenosis, atelectasis, blindness, bowel ischemia/infarction, bowel necrosis, bowel obstruction, branch vessel occlusion, buttock claudication, cardiac tamponade, catheter breakage, cerebrovascular accident (CVA) / stroke, change in mental status, coagulopathy, congestive heart failure, contrast toxicity, conversion to surgical repair, death, deployment difficulties / failures, dissection / perforation / rupture of the aortic vessel and/or surrounding vasculature, embolism, endoleak(s), excessive or inappropriate radiation exposure, extrusion / erosion, failure to deliver stent graft, femoral neuropathy, fistula (including aortobronchial,

aortoenteric, aortoesophageal, arteriovenous, and lymph), gastrointestinal bleeding /complications, genitourinary complications, hematoma, hemorrhage / bleeding, hypotension / hypertension, infection or fever, insertion or removal difficulties, intercostal pain, intramural hematoma, leg /foot edema, lymphocele, myocardial infarction, neuropathy, occlusion – venous or arterial, pain / reaction at catheter insertion site, paralysis, paraparesis, paraplegia, paresthesia, perfusion of the false lumen, peripheral ischemia, peripheral nerve injury, pneumonia, post-implant syndrome, procedural / post-procedural bleeding, prosthesis dilatation / infection / rupture / thrombosis, pseudoaneurysm, pulmonary edema, pulmonary embolism, reaction to anaesthesia, renal failure, renal insufficiency, reoperation, respiratory depression / failure, sepsis, seroma, shock, spinal neurological deficit, stent graft material failure (including breakage of metal portion of device) / migration / misplacement / occlusion / twisting / kinking, transient ischemic attack (TIA), thrombosis, tissue necrosis, vascular ischemia, vascular trauma, wound dehiscence, wound healing complications, wound infection.

Please reference product Instructions for Use for more information regarding indications, warnings, precautions, contraindications and adverse events.

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

Heli-FX™ & Heli-FX™ Thoracic EndoAnchor™ Systems Indications for Use

The Heli-FX™ EndoAnchor™ system is intended to provide fixation and sealing between endovascular aortic grafts and the native artery. The Heli-FX™ EndoAnchor™ system is indicated for use in patients whose endovascular grafts have exhibited migration or endoleak, or are at risk of such complications, in whom augmented radial fixation and/or sealing is required to regain or maintain adequate aneurysm exclusion. The EndoAnchor™ implant may be implanted at the time of the initial endograft placement, or during a secondary (i.e. repair) procedure.

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Contraindications

Treatment with the Heli-FX™ EndoAnchor™ system is contraindicated for use in the following circumstances: •

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In patients with known allergies to the EndoAnchor™ implant material (MP35N-LT)

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In conjunction with the Endologix Powerlink™* endograft

Warnings •

The long-term performance of the EndoAnchor™ implant has not been established. All patients should be advised endovascular aneurysm treatment requires long-term, regular follow-up visits to assess the patient’s health status and endograft performance. The EndoAnchor™ implant does not reduce this requirement.

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MRI Safety and Compatibility

The EndoAnchor™ implant and the Heli-FX™ EndoAnchor™ system have been evaluated via in vitro testing and determined to be compatible with the Cook Zenith™*, Cook Zenith™* TX2™*, Gore Excluder™*, Gore TAG™*, Medtronic AneuRx™, Medtronic Endurant™, Medtronic Talent™ AAA, Medtronic Talent™ TAA, Medtronic Valiant Xcelerant™, Medtronic Valiant™ Captivia™, and Medtronic Valiant Navion™ endografts. Use with endografts other than those listed above has not been evaluated.

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The EndoAnchor™ implants have been determined to be MR Conditional at 3T or less when the scanner is in Normal Operating Mode with whole-body-averaged SAR of 2 W/kg, or in First Level Controlled Mode with a maximum whole-body-averaged SAR of 4 W/kg.

Please refer to documentation provided by the endograft system manufacturer for MR safety status of the endograft system with which the EndoAnchor™ implants are being used.

Potential Adverse Events

The performance of the EndoAnchor™ implant has not been evaluated for securing multiple endograft components together. Not securing EndoAnchor™ implants into aortic tissue could result in graft fabric damage, component separation, and resultant Type III endoleaks.

Possible adverse events that are associated with the Heli-FX™ EndoAnchor™ system, include, but are not limited to: • •

The performance of the EndoAnchor™ implant has not been evaluated in vessels other than the aorta. Use of the EndoAnchor™ implant to secure endografts to other vessels may result in adverse patient consequences such as vascular perforation, bleeding, or damage to adjacent structures.

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The performance of the EndoAnchor™ implant has not been evaluated for securing multiple anatomical structures together. Such use could result in adverse patient consequences such as vascular perforation, bleeding, or embolic events.

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Aneurysm rupture Death

EndoAnchor™ implant embolization Endoleaks (Type III) Enteric fistula

Failure to correct/prevent Type I endoleak Failure to prevent endograft migration Infection

Renal complications (renal artery occlusion/dissection or contrast-induced acute kidney injury) Stroke

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Vascular access complications, including infection, pain, hematoma, pseudoaneurysm, arteriovenous fistula Vessel damage, including dissection, perforation, and spasm

Please reference product Instructions for Use for more information regarding indications, warnings, precautions, contraindications and adverse events.

Additional potential adverse events may be associated with endovascular aneurysm repair in general. Refer to the Instructions for Use provided with the endograft for additional potential adverse events.

CAUTION: Federal (USA) law restricts these devices to sale by or on the order of a licensed healthcare practitioner. See package inserts for full product information.

CAUTION: EndoAnchor™ implant locations should be based upon a detailed examination of the preoperative CT imaging in cases involving irregular or eccentric plaque in the intended sealing zones. EndoAnchor™ implants should be implanted only into areas of aortic tissue free of calcified plaque or thrombus, or where such pathology is diffuse and less than 2mm in thickness. Attempting to place EndoAnchor™ implants into more severe plaque or thrombus may be associated with implantation difficulty and suboptimal endograft fixation and/or sealing.

Surgical conversion to open repair

Endurant™ II/Endurant™ IIs Stent Graft System Indications

The Endurant™ II/Endurant™ IIs bifurcated stent grafts are indicated for the endovascular treatment of infrarenal abdominal aortic or aortoiliac aneurysms. They may be utilized in conjunction with the Heli-FX™ EndoAnchor™ system when augmented radial fixation and/or sealing is required; in particular, in the treatment of abdominal aortic aneurysms with short (≥ 4 mm and < 10 mm) infrarenal necks (see Neck length definition below).

The Endurant II stent graft system aorto-uni-iliac (AUI) stent graft is indicated for the endovascular treatment of infrarenal abdominal aortic or aortoiliac aneurysms in patients whose anatomy does not allow the use of a bifurcated stent graft. The Endurant II/IIs stent graft system is indicated for use in patients with the following characteristics: •

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When used with the Heli-FX EndoAnchor system, the Endurant II/IIs stent graft system is also contraindicated in: •

Warnings and Precautions •

Proximal neck length of

○ ≥ 10 mm; or

○ ≥ 4 mm and < 10 mm when used in conjunction with the Heli-FX EndoAnchor system (bifurcated stent graft only)

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Infrarenal neck angulation of ≤ 60°

Aortic neck diameters with a range of 19 to 32 mm Distal fixation length(s) of ≥ 15 mm

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Iliac diameters with a range of 8 to 25 mm Morphology suitable for aneurysm repair

Contraindications

The Endurant II/Endurant IIs stent graft system is contraindicated in: •

patients who have a condition that threatens to infect the graft.

patients with known sensitivities to the EndoAnchor implant materials.

For contraindications regarding ancillary devices used with the Endurant II/Endurant IIs stent graft system, refer to the Instructions for Use provided with the device.

Adequate iliac or femoral access that is compatible with vascular access techniques, devices, or accessories

Note: Neck length is defined as the length over which the aortic diameter remains within 10% of the infrarenal diameter.

patients with known sensitivities or allergies to the device materials.

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The long-term safety and effectiveness of the Endurant II/Endurant IIs stent graft system has not been established. All patients should be advised that endovascular treatment requires lifelong, regular follow-up to assess the health and the performance of the implanted endovascular stent graft. Patients with specific clinical findings (e.g., endoleaks, enlarging aneurysms, changes in the structure or position of the endovascular graft, or less than the recommended number of EndoAnchor system when used in short (≥ 4 mm and < 10 mm) proximal necks) should receive enhanced follow-up. Specific follow-up guidelines are described in the Instructions for Use. Patients experiencing reduced blood flow through the graft limb, aneurysm expansion, and persistent endoleaks may be required to undergo secondary interventions or surgical procedures.

The Endurant II/Endurant IIs stent graft system is not recommended in patients unable to undergo or who will not be compliant with the necessary preoperative and postoperative imaging and implantation studies as described in the Instructions for Use. Renal complications may occur: 1) From an excess use of contrast agents. 2) As a result of emboli or a misplaced stent graft. The radiopaque marker along the edge of the stent graft should be aligned immediately below the lower-most renal arterial origin.

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Studies indicate that the danger of micro-embolization increases with increased duration of the procedure.

The safety and effectiveness of the Endurant II/Endurant IIs stent graft system has not been evaluated in some patient populations. Please refer to the product Instructions for Use for details.

MRI Safety and Compatibility: Non-clinical testing has demonstrated that the Endurant II/Endurant IIs stent graft is MR Conditional. It can be scanned safely in both 1.5T & 3.0T MR systems under certain conditions as described in the product Instructions for Use. For additional information regarding MRI please refer to the product Instructions for Use. Adverse Events

Potential adverse events include (arranged in alphabetical order): amputation; anesthetic complications and subsequent attendant problems (e.g., aspiration), aneurysm enlargement; aneurysm rupture and death; aortic damage, including perforation, dissection, bleeding, rupture and death; arterial or venous thrombosis and/or pseudoaneurysm; arteriovenous fistula; bleeding, hematoma or coagulopathy; bowel complications (e.g., ileus, transient ischemia, infarction, necrosis); cardiac complications and subsequent attendant problems (e.g., arrhythmia, myocardial infarction, congestive heart failure, hypotension, hypertension); claudication (e.g., buttock, lower limb); death; edema; EndoAnchor system (for infrarenal EVAR procedures using the Heli-FX EndoAnchor system): partial deployment, inaccurate deployment, fracture, dislodgement, embolization, stent graft damage, modelling balloon damage); embolization (micro and macro) with transient or permanent ischemia or infarction; endoleak; fever and localized inflammation; genitourinary complications and subsequent attendant problems (e.g., ischemia, erosion, femoral-femoral artery thrombosis, fistula, incontinence, hematuria, infection); hepatic failure; impotence; infection of the aneurysm, device access site, including abscess formation, transient

fever and pain; lymphatic complications and subsequent attendant problems (e.g., lymph fistula); neurologic local or systemic complications and subsequent attendant problems (e.g., confusion, stroke, transient ischemic attack, paraplegia, paraparesis, paralysis); occlusion of device or native vessel; pulmonary complications and subsequent attendant problems; renal complications and subsequent attendant problems (e.g., artery occlusion, contrast toxicity, insufficiency, failure); stent graft: improper component placement; incomplete component deployment; component migration; suture break; occlusion; infection; stent fracture; graft twisting and/or kinking; insertion and removal difficulties; graft material wear; dilatation; erosion; puncture and perigraft flow; surgical conversion to open repair; vascular access site complications, including infection, pain, hematoma, pseudoaneurysm, arteriovenous fistula, dissection; vascular spasm or vascular trauma (e.g., iliofemoral vessel dissection, bleeding, rupture, death); vessel damage; wound complications and subsequent attendant problems (e.g., dehiscence, infection, hematoma, seroma, cellulitis) Please reference product Instructions for Use for more information regarding indications, warnings, precautions, contraindications and adverse events.

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

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This seminar is restricted to physicians and teams trained in interventional vascular techniques treating patient populations described in the Instructions for Use for Medtronic endovascular therapies products. Medtronic product Instructions for Use and on-label product information can be found at http://manuals.medtronic.com/manuals/main/us/en_US/home.

As a medical device manufacturer, Medtronic does not provide credentials or certify your professional medical skills and/or your ability to provide appropriate medical care to patients for whom you intend to use a Medtronic medical device.

This content is not intended for attendees who practice in geographies where this product’s use has not been approved. Please see a Medtronic representative for additional information on product availability in your geography.

medtronic.com/aortic UC202300807 EN ©2022 Medtronic. All rights reserved. Medtronic and Medtronic logo are trademarks of Medtronic. All other brands are trademarks of a Medtronic company. 05/2022

6

Vascular Specialist | Friday 17 June 2022

VENOUS DISEASE Iliac vein stenting should remain a viable treatment option for higher BMI patients Despite greater comorbid conditions, patients with obesity benefited as much as patients with normal body mass index (BMI) from iliac vein stent placement for proximal venous outflow obstruction (PVOO) in a study from a research group in New York, writes Jocelyn Hudson

J

inseo Kim, BS, undergraduate research assistant to Windsor Ting at Icahn School of Medicine at Mount Sinai, New York, presented the study findings yesterday in Plenary Session 4.

Kim and colleagues outline in an abstract that it was their aim to determine the role of BMI in iliofemoral vein stent placement among patients who are normal weight, overweight, and those with obesity.

In order to achieve this, the research team retrospectively analyzed a clinical registry of 624 patients who underwent iliofemoral vein stenting for chronic PVOO from 2011 to 2021. The team divided patients into three groups based on their BMI: normal (n=250, 18.5≤BMI≤25), overweight (n=249, 25≤BMI≤30), and obese (n=125, BMI≥30).

Among patients with PVOO undergoing vein stent placement, Kim informed VAM attendees that the prevalence of obesity was 20% (n=125) and overweight was 39.9% (n=249) with mean BMIs of 35.3kg/m2 and 27kg/m2, respectively.

The presenter noted that diabetes (normal: 16% vs. overweight: 22.5% vs. obese: 40.8%; p<0.001), hypertension (40.8% vs. 75.2% vs. 52.6%; p<0.001), coronary artery disease (CAD; 7.6% vs. 26.2% vs. 9.3%; p<0.001), cancer history (10.4% vs. 19.2% vs. 9.6%; p=0.017), and mean Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) class (3.4 vs. 3.7 vs. 3.5; p=0.017) differed significantly across the three groups.

Univariate logistic regression, Kim revealed, showed that obesity was associated with increased risk of major reintervention (odds rato [OR], 1.88; 95% CI, 1.13–3.06; p=0.013).

The speaker added that, after controlling for age, gender, CAD, race/ethnicity, and diabetes status, the association

between obesity and major reintervention became no longer significant (OR, 1.06; 95% CI, 0.5–2.17; p=0.882).

Furthermore, he communicated that log-rank test similarly showed no difference in reintervention-free survival for major or minor reoperations among those Jinseo who were of normal, overweight, Kim or obese BMI (p=0.4).

Finally, the presenter noted that improvement in mean Venous Clinical Severity Score (VCSS) composites preoperatively to postoperatively (p=0.802), one-year follow-up (p=0.111), and five-year follow-up (p=0.44) showed no differences across the three groups.

He summarised that patients classified as being either overweight or obese were prevalent among vein stent patients. Kim added that, after controlling for the risk factors associated with greater comorbid conditions, patients with obesity benefited as much as patients with normal BMI from iliac vein stent placement for PVOO, as reflected in

“Providing a solid option of treatment for those patients who have a higher BMI is very important”

similar improvement in VCSS composite scores.

“Obesity does not impact iliofemoral stent outcomes,” Kim concluded, adding that the procedure “should remain as a viable treatment option for those who have higher BMI and those with obesity”.

Windsor In the discussion following Kim’s Ting presentation, moderator Misty Humphries, MD, MS, of University of California Davis Health in Sacramento, California, questioned how these findings might change practice. Kim responded: “I think obesity is very prevalent among the U.S. population, and providing a solid option of treatment for those patients who have a higher BMI is very important.”

One delegate commented from the floor that it is “very comforting” to know that patients with obesity can get the same benefit as that demonstrated in prior randomized controlled trials for this type of procedure.

Another delegate expressed some caution, however, stressing that “we need to be careful with reintervention” in this patient group, because obesity “cuts out the open option,” and multiple endovascular interventions “may compromise long-term outcomes.”

Speaking to Vascular Specialist@VAM, senior author Windsor Ting responded to this concern: “Reintervention we found to be an excellent option to extend the benefits and outcomes of vein stenting among these patients. Very few vascular surgeons resort to an open option in this disease.”

THORACIC AORTA

SYSTEMIC HEPARIN DURING TEVAR DEEMED SAFE FOR SELECTED TRAUMATIC BRAIN INJURY PATIENTS

Tomorrow’s program will see the presentation of a study indicating that the use of systemic heparin during thoracic endovascular aneurysm repair (TEVAR) for blunt thoracic aortic injuries (BTAI) appears to be safe in selected patients with traumatic brain injury (TBI). These findings are set to be delivered

by Rafael Lozano, MD, a general surgery resident at the University of California Davis Medical Center, Sacramento, California, in Plenary Session 8.

IN AN EFFORT TO COMPARE THE impact of intraoperative systemic heparinization on post-TEVAR outcomes for patients with TBI, researchers reviewed all patients admitted with BTAI from 2011 through 2021. Collected data included injury grading, demographics and concomitant traumatic injuries. The study’s primary outcome was progression of TBI after TEVAR.

The cohort comprised 174 patients (mean age=46 years; 68% men; median injury severity score [ISS]=34)—after excluding three who died upon arrival. Median doorto-repair time was 19 hours and 79% of the study population received systemic heparin.

In addition, BTAI treatment was aligned with guidelines for 87–89% of patients. Repair (all TEVAR) was required for 63% of patients and time to repair was delayed for TBI patients.

Heparin was used in the majority of TBI patients—but was used less frequently than for those without TBI. Overall mortality was 8% (12.5% with BTAI observed vs. 5.5% with BTAI treated) with no BTAI-related deaths.

Repair being delayed by more than 48 hours did not decrease mortality (5% vs. 5.6%).

Vascular complications occurred in 8.2% of those receiving TEVAR, with an overall reoperation rate of 4.5%.

Progression of TBI was not associated with severity of BTAI by either grading system, the study found. Progression of TBI after TEVAR was also not impacted by intraoperative systemic heparin use (4.6% with vs. 6.7% without). Mean follow-up after TEVAR was 7.9 months and 97% of repaired patients experienced resolution of their injury.

Based on these findings, the researchers conclude that the use of Matthew systemic heparin Mell during TEVAR for BTAI appears to be safe

in selected patients with concomitant TBI, without causing TBI progression. Finally, they note that clinical expertise remains key in determining optimal management of these patients.

Senior author Matthew Mell, MD, professor and chief of vascular surgery at UC Davis, outlined what he believes are the clinical implications of the findings in an interview with Vascular Specialist@VAM. “The main significance is we think it’s safe to heparanize trauma patients for TEVAR, even if they have a head injury,” he said “Our practice has been to wait 12–24 hours to make sure the head injury is stable, and it appears that when that practice is followed, giving heparin is safe.

“These injuries are complex and nuanced. It’s really important to make these decisions as a multidisciplinary team. This, we hope, will contribute the literature, that will allow people to be a little more comfortable to treat these with heparin.”

The presentation takes place from 11:17 to 11:24 a.m. in Ballroom A/B.— Bryan Kay

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Vascular Specialist | Friday 17 June 2022

LECTURE

AN ANTIDOTE FOR BURNOUT: VASCULAR SURGEONS AS HOSPITAL ADMINISTRATORS The much-maligned electronic health record (EHR)—sometimes referred to as electronic medical record, or EMR—is not among the causes of burnout, per se, but rather a symptom, VAM 2022 will hear during the John Homans Lecture on Saturday morning.

“BURNOUT IS ACCEPTED BY US AS AN epidemic problem in healthcare, and there are numerous proposed causes, most notably the electronic health record,” this year’s lecturer, the former SVS President Bruce Perler, MD, tells Vascular Specialist@VAM ahead of the talk. “My belief is that the EHR, and other professional irritants,” are not the cause of burnout, but rather the symptom of the problem, and the problem is physicians’ loss of control of our healthcare system.

One prescription that might help alleviate this burden is vascular surgeons—and other like physicians—taking on leadership positions at the hospital administration level, Perler proposes in a talk titled, “Surgeons as hospital administrators: An antidote to burnout and benefit for the healthcare system.”

Perler, who is currently vice president of the American Board of Surgery, is in a position to know how this might have impact. He was, until recently, the vice chair of clinical operations and finance at Johns Hopkins University School of Medicine and Johns Hopkins Hospital in Baltimore, Maryland.

“The message I hope to communicate is

not one that has received much attention at the SVS to date, but one that I believe is incredibly important for our practitioners moving forward,” Perler explains. “Today, an increasing number of physicians and surgeons have given up independent practice to become full-time hospital employees. Secondly, increasingly these hospitals are now being run by non-clinicians. For example, in 1935 one-third of hospital president/CEO positions in the United States were held by physicians and one-third by nurses. Today, no more than 2–5% of these leadership positions in the U.S. are held by physicians and about 2% by surgeons.”

More and more, this means vascular surgeons are working for administrative leaders with no connection to patient care, he goes on. “This structure in the U.S. is in contrast with much of the industrialized world where these CEO positions are filled by physicians—from 25% (England) to 75% (Germany) of institutions—in countries with far less expensive healthcare systems than in the U.S.” The move toward healthcare delivery being assessed in terms of quality rather than

LIFETIME ACHIEVEMENT Jonathan Towne honored with SVS Lifetime Achievement Award An “amazing clinician and leader.” Devoted to the specialty of vascular surgery.

Investigator and researcher. Champion of the in-situ technique for lower-extremity bypass. Former SVS secretary and president. And a leader in creating the Vascular Surgery Board.

FOR ALL THESE ACCOMPLISHMENTS, AND MORE, the Society for Vascular Surgery on Thursday bestowed upon Jonathan B. Towne, MD—to a standing ovation—one of its highest honors: the SVS Lifetime Achievement Award.

“The older you get the sweeter it is,” he told the crowd.

He had no speech prepared, but simply said, “I thank you.

volume presents an opening, instance; or a mid-career surPerler advises. geon can seek training in “I’ve always believed healthcare administration, which is now being prothat times of difficulty vided by organizations represent moments of enormous opportunity such as the ACS. “But for those with wisdom most importantly, we and leadership skills, and can provide opportuniI believe that the time is ties for medical students now for us to become and residents to become engaged in healthcare adtrained in the business of ministration and hospital leadmedicine and select this as a ership,” he says. “Healthcare outpart of their professional careers comes are increasingly being assessed moving forward.”

Bruce by quality and not volumes—i.e., paHe also has a more transcenPerler tient-centric care—and who better dent message amid the specter to lead in the delivery of patient-centric care of burnout. While the vascular-surthan physicians. geons-as-hospital-leaders prognosis “Further, I will show multiple published might live in a space best described as studies that affirm that hospitals that are cur- “a generational process of transformarently led by physicians in the U.S. and inter- tion,” he says, burnout can be tackled, at nationally, have the best outcomes in terms least in part, on an ongoing basis through of clinical and financial metrics. Healthcare daily mindfulness. administrative leadership organizations have “I firmly believe if each of us as vascular recognized this and increasingly are urging surgeons take just a couple of minutes each their administrators to engage clinicians to day to reflect on how blessed we are to do join the C-suite.” what we do, burnout won’t be such a probOptions to get involved in hospital lead- lem,” Perler adds. “Think about it, complete ership abound, Perler suggests. Senior sur- strangers come to us with their clinical probgeons can join a hospital committee, for lems and entrust their lives and limbs to our judgment and care. There is no other profession in which its members shoulder such responsibility, or engage in such meaningful work, or enjoy so much satisfaction for what we do for others. We are truly blessed to do what we do. I think if we reflect just a couple minutes a day on what we really do, the EHR and other minor annoyances won’t seem so significant.”

“I’ve always believed that times of difficulty represent moments of enormous opportunity for those with wisdom and leadership skills” BRUCE PERLER

“I had the very good fortune of being involved with vascular surgery relatively early on and in its early adolescence,” he said.

“Vascular surgery had a stormy, stormy young adulthood; it’s now matured and as I look around and follow what’s hapJonathan Towne pening, I like where you are,” he said. “Thanks to all of you who helped me do the things I was involved with that led to this. It is indeed an honor.’

His path to Thursday’s award was influenced by chance.

In medical school at the University of Rochester, Towne met vascular pioneer Charles Rob, MB, who was developing the concept of vein bypass grafting. That sparked an interest in surgery and what was evolving to become the specialty of vascular surgery.

Following medical school, general surgery residency and a two-year stint in the Air Force, Towne continued his training with a fellowship at Baylor University Medical Center in

Perler is scheduled to deliver the Homans Lecture in Ballroom A/B of the Hynes Convention Center on Saturday from 10–10:30 a.m.

Dallas. Victor Bernhard, MD, then recruited Towne to join the faculty at the Medical College of Wisconsin (MCW), where he would spend his entire professional career until his retirement in 2007.

There, Towne and Bernhard started one of the earliest vascular fellowships. Towne eventually trained 29 fellows plus countless general surgery residents and medical students. One of his mentees said, “Under his leadership, the Division of Vascular Surgery at the Medical College of Wisconsin became a major regional referral center, which it remains today.”

He established at MCW and at a Veterans Affairs center intensive follow-up protocols, maintained to this day.

Towne served as a principal investigator for a “seminal study” that established carotid endarterectomy as an effective treatment in preventing stroke in patients with asymptomatic carotid artery disease, a colleague said. Towne embraced endovascular therapy both early on and, as the technology evolved, participated in early studies evaluating endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms. He was an early adopter of the team strategy in vascular surgery and supported and promoted expertise in the vascular lab and vascular nursing.

A former colleague said, “We would not be where we are today as a specialty or a society if it had not been for Jon Towne leading the way during uncharted times.”

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Vascular Specialist | Friday 17 June 2022

FLOORPLAN MAP HYNES CONVENTION CENTER 900 Boylston Street, Boston, Massachuestts 02115 t: 877-393-3393 f: 617-954-3326 w: signatureboston.com

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SECOND LEVEL

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Moveable Airwall

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Entrance to Prudential Center (4,000 Person Seating Capacity)

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| Boston, Massachusetts 02115 17.954.3326 | SignatureBoston.com

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FRIDAY/SATURDAY SCHEDULE AT-A-GLANCE Friday, June 17, 2022

Sheraton Boston Hotel Connection

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6 a.m. to 5:30 p.m.

Registration

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6:30 to 8 a.m.

World Federation of Vascular Societies Session: Global Training and Education During and Post-Pandemic

210

6:30 to 8 a.m.

General Surgery Resident/Medical Student Program: Mock Interviews Practice Session

311

6:45 to 8 a.m.

Breakfast Sessions B4: Creation and Maintenance of a Comprehensive Dialysis Access Center: Lessons Learned from Vascular Leaders at all Levels

304

B5: Prevention and Management of Infection in Vascular Surgery

306

B6: Clinical Trials: What You Need to Know

312

8 to 9:30 a.m.

S5: Plenary Session 5

Ballroom A/B

9:30 to 10 a.m.

Coffee Break

Exhibit Hall C/D

9:30 a.m. to 5 p.m.

Exhibits

Exhibit Hall C/D

10 to 11 a.m.

S6: Plenary Session 6

Ballroom A/B

11 a.m. to 12:15 p.m.

Presidential Introduction & Address

Ballroom A/B

12:15 to 1:30 p.m.

Box Lunch in Exhibit Hall

Exhibit Hall C/D

1:30 to 2:30 p.m.

A3: My Worst Cases

310

1:30 to 3 p.m.

C5: Building Diversity and Equitable Systems in Vascular Surgery

Ballroom A/B

1:30 to 3 p.m.

Community Practice Section: Starting Your Own Independent Practice – What You Need to Know

210

1:30 to 4:30 p.m.

P2: Toe and Flow Rounds – Working Towards a Comprehensive Approach to the Management of Chronic Limb Threatening Ischemia

309

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Coffee Break

Exhibit Hall C/D

3:30 to 5 p.m.

C6: The Failing and Failed EVAR

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3:30 to 5 p.m.

Outpatient & Office Vascular Care Section: Providing Outpatient Vascular Care in the Office-based Lab (OBL) – Evaluating Trends, Quality and Value-based Care

210

3:30 to 5 p.m.

PC: Poster Competition

Hall D

5 to 6:30 p.m.

General Surgery Resident/Medical Student Program: Residency Fair

Hall A

6:30 to 11:30 p.m.

SVS Foundation Gala: 'Cheers to 75 Years'

Sheraton, Grant/ Ind/Liberty

6 a.m. to 5 p.m.

Registration

Outside Hall C

6:30 to 8 a.m.

IYSC: International Young Surgeons Competition

210

6:45 to 8 a.m.

Breakfast Sessions

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B8: Secrets to Choosing and Optimizing a Practice that will Support Your Wellness and Career Longevity

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B9: Physician-led Prosthetic Care Produces Improved Amputee Outcomes

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8 to 9:30 a.m.

S7: Plenary Session 7

Ballroom A/B

9:30 to 10 a.m.

Coffee Break

Foyer/Ballroom A/B

10 to 10:30 a.m.

E2: John Homans Lecture

Ballroom A/B

10:30 a.m. to 12 p.m.

S8: Plenary Session 8

Ballroom A/B

12 to 1:30 p.m.

Member Business Luncheon (Members Only)

Ballroom C

1:30 to 2:30 p.m.

A4: Quality Improvement: Using a Data Driven Approach to Improve Care and the Bottom Line

310

1:30 to 3 p.m.

C7: Improving Vascular Care in Underserved Communities

309

1:30 to 4:30 p.m.

P3: Management of Vascular Trauma: Exploring Consensus in the Who and Where Amidst Subspecialized Training and Practice

312

1:30 to 5 p.m.

Ultrasound Physics and Vascular Test Interpretation: Registered Physician Vascular Interpretation (RPVI) Examination Review

210

3 to 3:30 p.m.

Coffee Break

Foyer/302

3:30 to 4:30 p.m.

A5: Community Research Partnerships and Interventions

310

3:30 to 4:30 p.m.

Poster Championship

302

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B7: Surgical Approach to the Lumbar Spine

12

Vascular Specialist | Friday 17 June 2022

CAROTID REVASCULARIZATION

FEMALE SEX ‘SHOULD BE CONSIDERED AN INDEPENDENT RISK FACTOR’ FOR NEW STROKE OCCURRENCE AFTER CAROTID REVASCULARIZATION IN SYMPTOMATIC PATIENTS

differences were found at baseline between the two sexes,” Sirignano explained.

“Emergent patients treated within 24 hours of symptom onset have worse outcomes compared to patients treated in the urgent or elective setting. Looking at multivariate analysis, once again we found that female sex, and timing of surgery, were the only two independent risk factors for worse outcomes after both carotid endarterectomy and carotid artery stenting.”

Sirignano concluded: “Although this is another preliminary report on this rising topic, we have to admit that female sex should be considered as an independent risk factor for new stroke occurrence after carotid revascularization in A preliminary report lends evidence to support female sex being considered symptomatic patients.”

Session moderator Palma Shaw, MD, as an independent risk factor for new stroke occurrence after carotid noted how Sirignano and colleagues revascularization in symptomatic patients, according to a research team had mentioned timing of procedures from Italy who presented at the International Chapter Forum yesterday. impacted worse outcomes. “We have seen in prior presentations that intervening within 48 hours of an event has a worse outcome,” she said. “Are you PRESENTING AUTHOR PASQUALINO SIRIGNANO, within one month of symptom onset—pulled changing your approach to intervention MD, a vascular surgeon at the University of Rome in Rome, from the IRONGUARD 2 study—with CEA pain [the] acute [setting]?”

Italy, detailed how the team’s analysis was carried out amid tients collected by the University of Rome during He said that his practice had already been Pasqualino uncertainty in the Italian guidelines over specific recom- the same period. altered, explaining: “We try to treat patients Sirignano mendations for female patients undergoing revascularizaThe researchers were aiming to evaluate any new between three and seven days from symptom tion treatment for both symptomatic and asymptomatic stroke occurrence within the first 30 days of follow-up. onset whenever it’s possible. But for unstable pacarotid disease.

They included 265 patients, 72 of whom were women. Half tients, we really don’t know what to do—unstable meaning “We reviewed our experience to better review any pos- of the patient pool was treated in the urgent or emergent crescendo, transient ischemic attack, or recurrent stroke. sible gender-related difference [in outcomes] in patients setting, Sirignano said. Five out of nine new strokes were These were treated during the first 48 hours, and that was treated in Italy for a symptomatic carotid lesion—either by recorded among female patients, he continued. the reason for worse outcomes.” carotid endarterectomy [CEA] or carotid artery stenting “The most important thing we found was that, even Shaw suggested the data produced was being obscured [CAS],” he told the forum. though there were only 72 women in the cohort, the nine by the inclusion of such patients and that removing them The retrospective study matched CAS patients treated strokes were recorded within this female population, and no might elucidate a difference.

Thank You!

Quality Champions

Quality Associate

13

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MACHINE LEARNING

Artificial intelligence can predict risk of complications after endovascular aneurysm repair Will Date reports on research, due to be presented today, that is set to show how one newly-developed model did not require any expert-annotated data when compared to existing methods of assessing complications after endovascular repair

A

rtificial intelligence (AI) models can be developed to predict the risk of postoperative complications after endovascular aneurysm repair (EVAR) with “high accuracy,” research to be presented at today’s Plenary Session 5 will show.

“Complications after EVAR can be fatal,” Becky Long, MD, Central Michigan University, Saginaw, Michigan, will tell attendees, noting in her presentation that patient follow-up for surveillance imaging is becoming more challenging as fewer patients are seen, particularly after the first year.

The aim of Long’s study was to develop an AI model to predict the complication probability of individual patients to better identify those needing more intensive surveillance.

The research involved collecting preoperative computed tomography angiography (CTA) 3D reconstruction images of abdominal aortic aneurysm (AAA) from 273 patients who underwent EVAR from 2011‒2020.

Of these patients, 48 had postoperative complications including endoleak, AAA rupture, graft limb occlusion, renal artery occlusion, neck dilation, pelvic

ischemia, and graft migration.

Using a deep convolutional neural network model, the researchers utilized the 3D CT images to predict the risk of complications after EVAR. The model was built with Tensorflow software and run on the Google Colab Platform.

A training subset of 40 randomly selected patients with complications and 189 without were used to train the AI model. Eight positive and 36 negative cases tested its performance and prediction accuracy.

Data downsampling was used to alleviate data imbalance and data augmentation methodology to further boost the model’s performance.

Long’s presentation will report that successful training was completed on the 229 cases in the training set and then applied to predict the Becky complication probabilLong ity of each individual

SAVE THE DATE!

June 14-17, 2023 | National Harbor, MD

in the held-out performance testing cases.

The model provides a complication sensitivity of 100% and identified all the patients who later developed complications after EVAR. Of 36 patients without complications, 16 (44%) were falsely predicted to develop complications.

The results, therefore, demonstrated excellent sensitivity for identifying patients who would benefit from more stringent surveillance and also alleviate the need for surveillance in 56% of patients unlikely to develop complications, the presentation will show.

This, Long will conclude, demonstrates that AI models can be developed to predict the risk of postoperative complications with high accuracy.

“Compared to existing methods, the model devel-

oped in this study did not require any expert-annotated data but only the AAA CTA images as inputs,” Long’s presentation will show. “This model can play an assistive role in identifying all patients at high risk for postEVAR complications and the need for greater compliance in surveillance.”

Plenary Session 5 takes place from 8.00– 9:30 a.m. in Ballroom A/B. Long is slated to present her findings from 8–8:11 a.m.

“This model can play an assistive role in identifying all patients at high risk for postEVAR complications and the need for greater compliance in surveillance” BECKY LONG

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Vascular Specialist | Friday 17 June 2022

INDUSTRY@VAM A-Z EXHIBITOR LIST Exhibiting As

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T-114

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207

Watson Clinic LLP

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LifeLike BioTissue

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310

VS@VAM BRIEFS MEDICINE, NOT MUSIC, THE HIGHLIGHT OF THIS FAIR

Simon and Garfunkel asked if listeners were going to “Scarborough Fair.” In 1962, actor Pat Boone was a big fan of the “State Fair.” And in “Camelot,” Queen Guinevere toyed with one of the knights of the Round Table about taking her to the fair.

Future vascular surgeons, meanwhile, all are invited to a fair of a different kind, the Society for Vascular Surgery Residency Fair from 5 to 6:30 p.m. Friday in Hall A of the Hynes Convention Center.

Aimed at general surgery residents and medical students, the fair lets them explore different training programs from approximately 75 institutions, all of which will have booths and information to offer.

Trainees must consider a vascular fellowship (5+2) program or integrated vascular residency (0+5) program, as well as whether to follow an academic or community practice-based path. Vascular training programs that offer residencies, fellowships or both will all be present at the Fair.

A directory of all participating programs is available on the SVS website at vascular. org/FVSatVAM. Registration is not required.

BID ON AUCTION ITEMS UNTIL 8:15 PM

Party-goers will be in a festive mood tonight as they trip the light fantastic at the SVS “Cheers to 75 Years,” the finale in the yearlong celebration of the Society for Vascular Surgery’s 75th anniversary.

Gala tickets are already sold out, but anyone, anywhere (with an internet connection) may bid on items in the Gala’s Silent Auction through 8:15 p.m.

(Eastern Time).

Various items include vacations at destinations across the country, an 1870 copy of “Gray’s Anatomy,” gift baskets, Maui Jim sunglasses, golf packages, art, vintage wines, pet portraits and much more.

Visit vascular.org/Gala22Tickets.

MEMBERS, ATTEND ANNUAL BUSINESS MEETING

Members are encouraged to attend the important Society for Vascular Surgery Annual Business Meeting, where you will receive critical updates from President Ali AbuRahma, MD, officers, committee chairs and the SVS Foundation. You also will receive a report of the Nominating Committee announcing the 2022 election results for next SVS vice president and secretary.

The meeting includes the transition of the SVS presidency from AbuRahma to Presidentelect Michael C. Dalsing, MD. Only members in good standing may attend and tickets are required; they are available at registration.

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WOMEN’S SECTION Talking about women surgeons’ lives and career

By Beth Bales WOMEN—AND MORE THAN A FEW men—flocked to the inaugural education session of the Society for Vascular Surgery’s new Women’s Section.

The topics of “Supporting Women Vascular Surgeons—From Recruitment through Senior Leadership” reflected the name with sessions on the needs of the youngest generation of women vascular surgeons, radiation and women, pregnancy logistics and wellness, optimal partnerships for women, the role of mentorship in advancing in leadership, and how senior women surgeons can leave a legacy.

The membership section was established roughly six months ago and followed creation of four similar membership sections, including the also new Young Surgeon’s Section.

All are welcome, said moderator Audra Duncan, MD, co-leader with Palma Shaw,

MD, of the section steering committee.

She told women that to become involved in ongoing setting and communicating of goals, women should simply send her their names.

Many irons are in the fire. And a real priority is that everyone is seen, and everyone gets to do things they love and to talk about them, she said. “But our main goal is membership and making sure you are all engaged.”

Avianne Bunnell, MD, kicked off the session talking about the needs of the youngest women vascular surgeons and Ageliki G. Vouyouka, MD, discussed radiation and women. Other topics were optimal practice partnership for women (Patricia C. Furey, MD, MBA); the role of mentors and sponsors in advancing in leadership (Incoming President Michael C. Dalsing, MD); and how senior women surgeons can create a legacy ( Julie A. Freischlag, MD).

With pregnancy and raising children an important consideration during women surgeon’s child-bearing years, Meryl Logan, MD, an Air Force surgeon, discussed pregnancy, both before, during and after, a time she called “the fourth trimester.”

“There is no perfect time for anything,” she said of pregnancy. “There is only now.

You have to do what’s best for you and

Julie Freischlag

your family.”

The same is true for when to tell the news to whom is another personal decision. “There are no rules. Do what makes you comfortable.” She added wryly, “If you’re sick all day as I was it’s hard to hide.” Though women surgeons aren’t known for taking care of themselves, she urged pregnant surgeons to prioritize selfcare. “Don’t skip OB appointments. And go to the bathroom!”

To great laughter, she told the audience

that she gave herself an ultrasound during her pregnancy. Every. Single. Day. In the second trimester, tools of the trade include water and snacks. Bigger scrubs. Bigger lead aprons. And, “If you don’t wear compression socks, now is the time to start. Wear the socks!”

In the last three months, begin thinking about when you should adjust caseloads.

Sit when you can. Know the baby will get in the way.

Determine who will take care of patients and tell them the plan. Consider stopping patient appointments two weeks before the due date in case Jasper or Jane comes early.

In that “fourth trimester,” take as much leave as you can, she advised. “You’ll never get it back.” Simplify life through automatic home deliveries and a cleaning person. Oursource.

Prepare for any breastfeeding needs. “If that what you want to do, you can find a way to do it,” she said. Stock extra clothes and a second nursing bra for work. “You WILL leak,” she said.

Finally, showing a montage of pregnant women physicians, she said, “You are not alone!

“Pregnancy can suck. It did for me,” she said. “But it’s all worth it. You have these beautiful little babies at the end!”

A special thank you to

Our VAM VAM 2022 2022 Supporters!

Supporters!

Our Educational Grants Abbott Boston Scientific Corporation Cook Medical

Cordis® Gore & Associates Medtronic

VAM Sponsorships Abbott

Haemonetics Corp.

Boston Scientific Corporation

Medtronic

Getinge Group

Philips

Gore & Associates

Surmodics

The Society for Vascular Nursing thanks the following companies for their generous support of the 2022 SVN Annual Conference.

Gore & Associates Medtronic Hanger Clinic Silk Road Medical Smith & Nephew Osborn Health

SAVE the DATES

2022

WEST COAST VEIN FORUM AND FELLOWS COURSE IN VENOUS DISEASE for Physicians in Training & in Early Career

SEPTEMBER 22-24, 2022

2023

The Edgewater Hotel • Seattle, Washington

FEBRUARY 22-25, 2023 La Cantera Resort • San Antonio, Texas venousforum.org

VenousForum

2

r

3

VAM

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THROUGH THE LENS »

VAM22 picked up the pace on its second day with the opening of the Exhibit Hall and continued plenary and educational sessions. How to keep up with the news? Vascular Specialist@VAM, of course.

Less is less and more is more, Jan Brunkwall, MD, of Germany told those assembled at the Roy Greenberg Distinguished Lecture on Thursday. More people arrived at VAM, taking advantage of the chance to talk with exhibitors, attend informational, educational and scientific sessions, read about what happened on Opening Day. Events of that day included the Society for Vascular Nursing’s 40th anniversary Gala at the Fairmont Copley, the place where it all began decades ago

“We all know what we have, and when something new comes along, we normally hesitate a bit. We say, ‘Maybe this is not important; maybe we should do what we have done the last 20 or 50 years” JAN S. BRUNKWALL

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Vascular Specialist | Friday 17 June 2022

COMMENT&ANALYSIS CORNER STITCH

GETTING THE MOST OUT OF MEETINGS LIKE VAM Christopher Audu, MD, Vascular Specialist resident/fellow editor, dishes some tips for trainees on Meetingology 101

I

t’s Friday at VAM 2022 in Boston! Hopefully, many of us trainees are getting to mingle and meet leaders in the field in addition to other trainees outside of our usual orb. In his 2020 Vascular and Endovascular Surgical Society (VESS) presidential address, Matthew Corriere, MD, from the University of Michigan, spoke on the topic of “Meetingology” and shared his tips for conducting meetings within the context of COVID-19 social distancing practices.

Some of those lessons still apply today. While we are enjoying the privilege of an in-person VAM thanks to efficient COVID-19 vaccines, I imagine that the notion of making the most of this meeting weighs heavy on many a trainee’s mind.

And if you’re an introvert like me, you may feel intimidated to speak to surgeons you don’t know and whose names and faces you’ve only ever seen in print.

There’s no right way to engage a meeting but here’s a few things I’ve found to be helpful for me in navigating meetings like VAM.

The SVS would like to thank the following companies for their support in the SVS Industry Partnership Program.

Define your goals

If you’re here to present your work, do so with gusto…and then take a break and relax. If you’re here as part of the resident and trainee programming, engage with the program.

Ask questions. Get business cards. Go to the poster session when no one is there and peruse the posters. It may give you a feel for the meeting and your potential role in vascular surgery. Come to the Residency & Fellowship fair! Talk to all the programs you’re interested in.

Use your mentors and friends as resources

If you have an assigned mentor, find them and connect early.

Often, your mentor can also help introduce you to people you may have never met before. If you don’t have a mentor, say hello to a stranger. Introduce yourself. Make eye contact.

The cold introduction can be intimidating, and oftentimes, the well-known folks are surrounded or they have to run to other obligations, but if you have the chance to say hello, don’t let the opportunity go.

VAM student breakfast

Step outside the box

The presentations are incredible at VAM but exploring the city is fun too. Or going to dinners/gatherings. Or sports events. Or just hanging out with friends you haven’t seen in a long time. You’re building social capital and that is important too. Sometimes, the best thing about these meetings are the honest conversations you get to have outside the formal meeting and I hope you get to enjoy this experience.

Have fun and enjoy VAM2022!

CHRISTOPHER AUDU, MD, is a vascular surgery resident at the University of Michigan in Ann Arbor, Michigan, and the Vascular Specialist resident/fellow editor.

Y K O N U! A H Gold T Platinum Boston Scientific Gore & Associates

Abbott Medtronic

Silver BD

Bronze 3M Cook Medical Philips Janssen Pharmaceuticals

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Medical Editor Malachi Sheahan III, MD Associate Medical Editors Bernadette Aulivola, MD | O. William Brown, MD | Elliot L. Chaikof, MD, PhD | Carlo Dall’Olmo, MD | Alan M. Dietzek MD, RPVI, FACS | Professor HansHenning Eckstein, MD | John F. Eidt, MD | Robert Fitridge, MD | Dennis R. Gable, MD | Linda Harris, MD | Krishna Jain, MD | Larry Kraiss, MD | Joann Lohr, MD | James McKinsey, MD | Joseph Mills, MD | Erica L. Mitchell, MD, MEd, FACS | Leila Mureebe, MD | Frank Pomposelli, MD | David Rigberg, MD | Clifford Sales, MD | Bhagwan Satiani, MD | Larry Scher, MD | Marc Schermerhorn, MD | Murray L. Shames, MD | Niten Singh, MD | Frank J. Veith, MD | Robert Eugene Zierler, MD Resident/Fellow Editor Christopher Audu, MD Executive Director SVS Kenneth M. Slaw, PhD Director of Membership Marketing and Communications Tara J. Spiess, CAE Managing Editor SVS Beth Bales Marketing & Membership Specialist Amber Dunlop Assistant Marketing & Social Media Manager Kristin Crowe

Published by BIBA Publishing, which is a subsidiary of BIBA Medical Ltd. Publisher Roger Greenhalgh Content Director Urmila Kerslake Managing Editor Bryan Kay bryan@bibamedical.com Editorial contribution Jocelyn Hudson, Will Date, Jamie Bell and Anthony Strzalek Design Terry Hawes Advertising Nicole Schmitz nicole@bibamedical.com Letters to the editor vascularspecialist@vascularsociety.org BIBA Medical, Europe 526 Fulham Road, London SW6 5NR, United Kingdom BIBA Medical, North America 155 North Wacker Drive – Suite 4250, Chicago, IL 60606, USA

Vascular Specialist is the official newspaper of the Society for Vascular Surgery and provides the vascular specialist with timely and relevant news and commentary about clinical developments and about the impact of healthcare policy. Content for Vascular Specialist is provided by BIBA Publishing.

Content for the News From SVS is provided by the Society for Vascular Surgery. | The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher. The Society for Vascular Surgery and BIBA Publishing will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services, or the quality or endorsement of advertised products or services, mentioned herein. | The Society for Vascular Surgery headquarters is located at 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018. | POSTMASTER: Send changes of address (with old mailing label) to Vascular Specialist, Subscription Services, 9400 W. Higgins Road, Suite 315, Rosemont, IL 60018. | RECIPIENT: To change your address, e-mail subscriptions@bibamedical.com | For missing issue claims, e-mail subscriptions@bibamedical. com. | Vascular Specialist (ISSN 1558-0148) is published monthly for the Society for Vascular Surgery by BIBA Publishing. | Printed by Vomela Commercial Group | ©Copyright 2022 by the Society for Vascular Surgery

PAD First results from BEST-CLI poised to reveal ‘very low’ quality of life for patients entering the trial, especially women The analysis will be presented Saturday and shows patient-specific variables such as self-reported female gender, current smoking, impaired mobility and opioid use are associated with lower health-related quality of life (HR-QOL) as captured by multiple measurement tools, writes Urmila Kerslake RICHARD J. POWELL, SECTION CHIEF, Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, told Vascular Specialist@VAM this is a unique dataset that acquired information from three different patient-reported quality of life measures (VascQOL [Vascular Quality of Life Questionnaire], EQ-5D [EuroQoL 5D], and SF-12) and shed light on the baseline demographics of the 1,830 patients enrolled into the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) randomized controlled trial that is set to be presented in fall 2022. Data were obtained from the majority of patients (94.9%, 95.8%, and 95.8% of subjects completed the VascQOL, EQ5D, and SF-12 instruments at baseline). “I think that is the power of it. It is not just one quality of life measure, so if you see these factors reproducing themselves across instruments, it is probably real,” he said.

BEST-CLI is an ongoing, National Institutes of Health-sponsored, multicenter, randomized controlled trial comparing revascularization strategies in patients with chronic limb-threatening ischemia (CLTI).

Powell will outline that there is limited evidence regarding the role of health-related quality of life (HRQOL) measures in patients with CLTI. Speaking particularly on female gender being associated with lower quality of life in multiple QOL measurement tools, he quoted: “This bears looking into as it is present with other disease processes as well. Are women less able to receive social support to weather the storm? Are they not being looked after in the same way as men? Do they present with later-

or end-stage disease?

These remain questions to be researched.”

Powell is also categorical that while QOL scores assess perRichard J. ceptions of indepenPowell dence, mobility and mental sharpness and how “functional” patients are, they are not a direct indicator of happiness and that this is where is all gets “tricky”. “If the patient is a golfer who can no longer play golf, because they’ve got a sore on the bottom of their foot, they may be very functional but they’re likely to be miserable. But if it’s a person who gets up in the morning and watches TV all day, they could have lost their leg and still be perfectly happy because they’re doing everything they want to do. And it’s the doctor’s role to keep people happy for as long as possible.”

Vitally, this dataset allows physicians to look at the modifiable risk factors that cause patients to have low quality of life. “Smokers across the board have worse quality of life than non-smokers. So that’s a modifiable risk factor.

Another is independence. So, trying to do everything possible to keep the patient working,

“The FDA could actually use [this dataset] as a performance goal” RICHARD J. POWELL

and that might go along with things like making sure they have an orthotic or something to walk on and that they remain weight bearing [is really important]. But I think those sorts of patient modifiable factors have a direct impact on quality of life. And yet there are some non-modifiable risk factors like female gender and it is important for vascular specialists to be aware of this.”

The mean (standard deviation) SF-12 physical and mental health reads for all patients in the study will be revealed to be significantly lower than the national SF-12 scores for the U.S. population over 60 years of age. Indeed, Powell emphasized that these BEST-CLI SF12 baseline population scores are similar to a population of patients with cancer and three to four additional chronic conditions—typically characterized by impaired mobility and chronic pain. “Interestingly, these scores are a little bit better than those reported by the BASIL trial, and significantly better than three previous trials, so it might be that we are doing a better job of medically managing patients’ associated comorbidities,” he said.

Speaking to the wider interest that the dataset could garner, Powell stated that it could serve as a benchmark. “Other groups of people will find this useful if they are interested in planning a CLI trial, because they’ll be able to use this as a point of reference. The FDA could actually use it as a performance goal. So, if you know the average quality of life measure for CLI patients in these different scores, you could run a single-arm trial and use these data as a benchmark to simplify evidence generation,” he said.

NEW FINDINGS SUPPORT BENEFITS OF STRUCTURED DISCHARGE APPROACH FOR POST-DISCHARGE TRANSITION OF CARE RESEARCHERS HAVE FOUND THAT restructuring the discharge process of a vascular surgery service decreased escalation to clinical staff from an automated post-discharge phone call and improved early post-discharge visits. Thirty-day readmission rates remained unchanged despite these efforts, however, and was increased for patients requesting escalation. Cara G. Pozolo, MD, a resident at University of California Davis Medical Center in Sacramento, California, presented these findings in yesterday’s Plenary Session 4.

The investigators looked at all patients discharged from their vascular surgery service who underwent procedures from April 2021 through October 2021 with pre-discharge process improvement (PI) and compared these with a historical cohort discharged from May

2018 through July 2019.

For both cohorts, Polozo detailed, all patients received an automated phone call from a third-party vendor (CipherHealth, New York), with an option to escalate to a clinical nurse.

The investigators analyzed a total of 469 patients who received an automated call (1.4±1 days) after discharge, with 271 in the control group and 198 in the PI group. Polozo revealed that no significant change in overall 30-day readmission rates was observed (11.8% control vs. 10.6% PI; p=0.7). In addition, she communicated that request for escalation to the clinical nurse was significantly less frequent after intervention (28% control vs. 16.7% PI; p=0.004), and that escalation was associated with increased 30-day readmission (8.6% vs. 20.1%; p=0.001) for all patients. Direct

calls were made for patients considered high risk for readmission (2% control vs. 43% PI; p<0.001) regardless of escalation status, the presenter added.

On multivariate analysis, Polozo reported that escalation and direct calls were each independently associated with readmission.

Finally, the presenter detailed that the median interval from discharge to post-discharge visit was markedly improved with PI (24 days [IQR 14–33] compared to 16 days [IQR 11–32]; p=0.007). Compared with control, she added, median days from discharge to visit with escalation was not significantly improved.

“These findings support the benefits of a structured discharge approach for post-discharge transition of care,” she concluded.­— Jocelyn Hudson

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