Issuu

In this issue: 2 From the editor Malachi Sheahan III explains why he thinks Preference Signaling is well intended but wrong

11 VAM Ascher urges specialty to take active role in developing new technologies

4 VAM Can Tailored Thromboprophylaxis Reduce Amputation Risk?

JULY/AUGUST 2026 Volume 22 Number 6

THE OFFICIAL NEWSPAPER OF THE

19 Commentary Are AI surgeons the future? www.vascularspecialistonline.com

WHAT’S NEXT FOR CAROTID DISEASE MANAGEMENT? By Maria Gifford

‘Treat the water, not just the pipes’: Addressing prevention in vascular care Johnston highlighted different areas of opportunity, including aggressive lipid management, expanded use of antithrombotic therapies and greater attention to metabolic disease. She said that while statins remain foundational, many patients fail to reach current guideline-recommended LDL cholesterol targets without additional therapies. Emerging evidence also suggests that even lower LDL targets may provide additional benefit. The session also emphasized growing interest in therapies such as semaglutide, which have demonstrated cardiovascular benefits beyond weight loss alone. “These agents are fundamentally changing the vascular biology,” said Johnston, citing data showing reductions in major adverse cardiovascular events that appear independent of the amount of weight lost. Johnston noted that this shift toward cardiometabolic management is increasingly reflected in national guidelines and quality measures. Many of the latest performance metrics focus on risk-factor control rather than procedural outcomes alone. “All of the performance measures are about how we treat the water, not how we replace the pipes,” she said.

A LANDMARK TRIAL years in the making has left the vascular surgery community with more questions than clear answers and this year’s inaugural Wesley S. Moore Distinguished Lecture at VAM 2026 argued that figuring out what CREST-2 actually means may be the field’s most urgent task. The lectureship, newly established by the Society for Vascular Surgery (SVS) and SVS Foundation with support from more than 50 donors, honors Wesley Moore, MD, a former SVS president whose career includes founding the Western Vascular Society, training generations of vascular surgeons and participating in the earliest trials of endovascular aneurysm repair, transcarotid artery revascularization (TCAR) and CREST-2. The lecture was delivered by Peter Schneider, MD, professor of surgery at the University of California-San Francisco, who centered much of his talk on CREST-2’s central finding, that intensive medical management alone produced an annual stroke risk of roughly 1.3% to 1.7%, well above the sub-0.8% rate the trial had been statistically powered to detect. That gap matters because it means the study, despite its scale, was ultimately underpowered to answer the very question it was designed to resolve. “I think CREST-2 is a real reset for our field,” said Schneider.

See page 6

See page 8

By Killian Meara

“The artery is ours and it should be all of it,” said Lily Johnston, MD. “Trying to reroute the blood flow without changing what runs through it is like changing the pipes in a house without addressing the toxic wastewater that corroded those pipes in the first place.” During a session at VAM 2026, Johnston discussed several patients with peripheral artery disease (PAD) and other vascular conditions who did not currently require an operation but remained at high risk for future complications. These patients, she argued, represent some of the greatest opportunities for vascular surgeons to improve outcomes. “None of these patients need an operation today, but they desperately still need our help,” said Johnston, a vascular surgeon at Scripps Clinic in San Diego, California. “I would argue that the nonoperative patient is actually the best patient with the biggest window of opportunity for us to help them and prevent them from needing a morbid operation in the future.” According to Johnston, vascular surgeons have traditionally focused on procedural interventions while leaving risk-factor modification and metabolic management to primary care physicians, cardiologists and endocrinologists. That approach may no longer be sufficient as evidence increasingly demonstrates the impact of aggressive medical therapy on cardiovascular and limb-related outcomes.

CONSISTENT OUTPUT. MAXIMUM COVERAGE.1 1. Kereiakes, D, Virmani, R, Hokama, J. et al. Principles of Intravascular Lithotripsy for Calcific Plaque Modification. Figure 1E. J Am Coll Cardiol Intv. 2021 Jun, 14 (12) 1275–1292. https://doi.org/10.1016/j.jcin.2021.03.036

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Vascular Specialist | July/August 2026

Published by the Society for Vascular Surgery

This Signal Brings Noise By Malachi Sheahan III, MD Last month, my friend Nikhil Kansal detailed in Vascular Specialist why the Association for Program Directors in Vascular Surgery (APDVS) elected to implement Preference Signaling in the upcoming Integrated Vascular Surgery Match. Here I will explain why I think this decision was well intended, inevitable and wrong. Let’s break it down FAQ style.

What is Preference Signaling?

Preference signaling is a relatively new feature in the residency Match that lets applicants explicitly show interest in specific programs during the ERAS application process. Applicants get a limited number of “signals” they can send to the programs they are most interested in. Some specialties use a tiered system (gold, silver) to indicate levels of interest. Prior to sending interview invites, programs can see if an applicant signaled them, but cannot see where else that applicant sent signals.

Do all specialties participate in signaling?

No. Otolaryngology was an early adopter in 2021. Since then, it has become increasingly popular with over 25 specialties opting in for the 26-27 cycle.

What problems does signaling address?

1. Application inflation: In some specialties programs routinely receive over 1,000 applications per cycle. Holistic review becomes impossible and arbitrary numeric cutoffs are used to screen applicants (Step 2 score, class rank, AOA status, number of publications). Signaling creates a scarcity mechanism to combat this inflation. 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. The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society. The Society for Vascular Surgery 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 vascularspecialist@ vascularsociety.org | For missing issue claims, e-mail vascularspecialist@vascularsociety.org | Vascular Specialist (ISSN 1558-0148) is published by the Society for Vascular Surgery. | Printed by Ironmark | ©Copyright 2025 by the Society for Vascular Surgery

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2. Interview hoarding: Strong applicants accumulate disproportionate numbers of interviews while weaker applicants struggle to get enough. This unequal distribution of opportunities can lead to a downstream inefficiency in ranking/matching. This would manifest by programs going unfilled in the Match despite interviewing an appropriate number of applicants. Let’s say there were 200 applicants for 100 positions. If every program interviewed the same top 30 applicants there could be 70 unfilled positions and 170 unmatched applicants. 3. Randomness and inefficiency in the Match: Without signaling, Matches are influenced by timing, luck in getting interviews and arbitrary screening cutoffs. This can lead to less optimal applicant– program alignment which would manifest through high attrition numbers. (i.e. applicants are matching to programs where they are not happy).

Which of these problems is present in the current integrated vascular match?

None. But in life, the easiest problems to fix are ones that don’t exist. In 2025, the average vascular program received 140 applications. A manageable number for holistic review. If interview hoarding occurs, it is having no effect on the efficiency of the Match — 487 of 489 positions have filled over the past five years. Finally, the current Match process appears highly successful in generating applicantprogram concordance. The cumulative attrition rate in vascular residencies is only 4.1% over the past decade.

Wait, what? Then why are we doing this?

Insecurity. The Match is a near perfect system. The algorithm behind it won the Nobel Prize. When all parties follow the rules, the

system cannot be gamed. To play fair, however, requires a leap of faith. After the interview cycle, program directors must submit a rank list of applicants in the order of their preference without knowing how the applicants ranked them. To many of us this is untenable. What if I match someone and I was their tenth choice? The horror! We need to be wanted. Signaling is reminiscent of a middle school strategy to find a date for the dance. We slip the applicants a note — “Do you like me? Check Yes or No.” (There were no DMs to slide into back then kids).

Shouldn’t programs want to interview applicants who are genuinely interested in their program?

Studies on the effects of signaling have consistently shown one thing — when introduced, signaling becomes the predominant driver of interview offers. Interviews are obviously the main determinant of rank order lists and therefore the ultimate match. The signal would not be a big deal if program directors were mature enough to ignore it. But, unless vascular surgery is unique among all specialties, they are not. So, we have placed the most important decision in this process in the hands of the people who know little, at a point in time in which they know the least. What are they signaling based on? Mentor advice? Reputation? Program website? Reddit?? We are anchoring match outcomes to preferences formed at the least informed point in the process — before interviews, before fit assessment and often based on incomplete or secondhand impressions.

What’s the downside? Signaling seems harmless.

Prior to COVID, the integrated vascular matches were highly successful. Usually only one or two positions went unfilled. In my role at the APDVS, I would often reach out to these unmatched programs to debrief. One common theme stood out — the creation of artificial scarcity. Despite receiving enough applications to comfortably fill their spots, the program director had either interviewed or ranked too few applicants. An unforced error. Then, with COVID and the institution of virtual interviews, a peculiar thing happened. All vascular positions filled. For the first time ever, the match was now at 100% efficiency for both integrated residencies and fellowships. Virtual interviews had eliminated the key drivers of scarcity — applicant finances, applicant time and program resources. Despite the gradual reintroduction of in-person interviews and the annual increase in positions offered, the integrated vascular match has remained near perfect including a 100% fill rate in 2025. By introducing signaling we risk shrinking interview pools — reintroducing the same artificial scarcity that historically led to unfilled positions. We spent years trying to eliminate scarcity. It would be an impressive achievement to bring it back voluntarily.

How will the applicants really use signaling?

Now that we have placed the applicants in a high-stakes game of strategic resource allocation they will naturally develop their own tactics to achieve their desired outcome — a maximum number of interview invitations. Ideally, programs and applicants would engage in behavior that is mutually beneficial. Program directors should have the maturity to use signals as one small part of the holistic review process. Applicants should truly signal the programs they are most interested in and not use them to amass the highest possible number of interviews. Neither approach is enforceable. In game theory this is known as the Prisoner’s Dilemma. As a general rule of thumb, I try to avoid situations where the closest comp is incarceration. In the end, it is hard to blame the applicants if they approach

continued on page 4

Nothing beats Zilver® PTX®. Real-world REALDES study shows lower rate of instent occlusions with Zilver PTX than Eluvia®.1 There is no difference in primary patency or CD-TLR between Zilver PTX and Eluvia, despite the fact that longer lesions were treated in the Zilver PTX arm. Lower rate of in-stent occlusions for Zilver PTX

57.7% Eluvia

29.2%

Mean lesion length p=0.029

Primary patency* p=0.74

Zilver PTX 96 limbs (86 patients)

Eluvia 104 limbs (98 patients)

185.7 ± 92 mm

160.0 ± 98.5 mm

70.0%

65.2%

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In-stent occlusions (Tosaka class III2) p=0.041

Freedom from CD-TLR p=0.27

79.4%

76.3%

* Primary patency defined as a peak systolic velocity ratio of ≤2.4, without clinically driven target lesion revascularization (CD-TLR) or stenosis ≤50% based on angiographic findings. Eluvia is a registered trademark of Boston Scientific Scimed, Inc. 1. Shibata T, Iba Y, Shingaki M, et al. Comparative analysis of three year results of two paclitaxel related stents for the management of femoropopliteal disease in a real world setting. Eur J Vasc Endovasc Surg. 2025:S1078-5884(25)00238-2. doi: 10.1016/j. ejvs.2025.03.010. Online ahead of print. 2. Tosaka A, Soga Y, Iida O, et al. Classification and clinical impact of restenosis after femoropopliteal stenting. J Am Coll Cardiol. 2012;59(1):16–23.

READ MORE. See the 3-year REALDES results.

Vascular Specialist | July/August 2026

FROM THE EDITOR THIS SIGNAL BRINGS NOISE ➽

signaling with strategy rather than authenticity. The consequences are asymmetric. A poor signaling plan may cost an applicant interviews they would have otherwise received. Meanwhile, programs face minimum downside.

Why was signaling inevitable?

Program directors are running out of ways to evaluate student applications. Step 1 scores are hidden. Many schools are now pass/fail. Dean’s Letters obfuscate through implausible Likert scales — “Here at the Medical School of the Everglades we rank our students in five tiers from Exceptional to Outstanding.” Even once reliable letters of recommendation now often read like someone trying to send coordinates to a secret location through a random series of numbers (I have known Marie for 29 weeks. She is among the top 13.4% of medical students I have worked with).

continued from page 2

In the absence of other consistent metrics, program directors will naturally rely on signals for their interview invites. But if gauging an applicant’s interest pre-interview is deemed necessary, there are more reliable options for individual programs to employ. In person interviews and secondary applications both require extra time and effort from the applicant. Some programs even schedule their interview dates late in the cycle when many are tired of traveling and spending (Buyer beware: this tactic led to an unmatched program in at least one instance). As signaling is implemented, it should be treated as an experiment — not a solution. Track the outcomes that matter; diversity, geographic distribution, attrition and, of course, Match efficiency. Manufacturing scarcity for every program through signaling is likely folly. There is absolutely nothing to gain. We will soon discover what can be lost.

VAM

CAN TAILORED THROMBOPROPHYLAXIS REDUCE AMPUTATION RISK? By Maria Gifford One in five endovascular procedures fails within six months and for decades vascular surgeons have answered that statistic with the same blunt toolkit: aspirin, clopidogrel, or whatever combination a given surgeon prefers. This year’s Frank J. Veith Distinguished Lecture at VAM 2026 argued that guesswork is no longer good enough and that a simple blood test may finally tell clinicians which patients are headed for failure before it happens. This year’s lecture was given by Anahita Dua, MD, associate professor at Harvard Medical School and vascular surgeon at Massachusetts General Hospital, who argued for a more individualized approach to postrevascularization anticoagulation. Dua opened the lecture by describing the disconnect at the center of modern vascular practice: enormous technical investment during the procedure itself, followed by a return to decades-old, one-size-fits-all blood thinner regimens once the patient leaves the operating room. “We spend all of our time, all of our money and resources,” said Dua. “But the second you’re done with that six-hour procedure where you now have flow, you go to the PACU where you go right back to medieval times.” That gap, Dua explained, stems from a poor understanding of hypercoagulability in the months following revascularization, compounded by clinical trial data that fails to reflect real-world patients. Up to 25% of patients are resistant to clopidogrel and another 10% are resistant to aspirin, meaning uniform prescribing leaves a substantial share of patients undertreated without anyone realizing it. “At this point, a one-size-fits-all approach is not working,” said Dua. “We’re spending so much time and money revascularizing these patients and not knowing what to do next.” Dua’s lab turned to thromboelastography with platelet mapping, a test traditionally used in trauma and cardiac surgery to guide blood transfusion and applied it instead to predict clotting risk in PAD patients. Testing

patients at intervals after revascularization, her team found that results collected 30 days before a thrombotic event reliably predicted it, giving clinicians a window to intervene before failure occurred. Platelet aggregation emerged as the strongest predictor and further analysis identified a specific target: roughly 30% platelet inhibition, low enough to prevent clotting without raising bleeding risk. “We called it the Goldilocks solution because it’s just right,” said Dua. “Not too hot, not too cold.” Their research also revealed a significant sex-based difference in treatment response. Despite comparable medication adherence, postmenopausal women in the study were consistently more likely to thrombose, undergo amputation and experience delayed wound healing than men were. Platelet testing showed that women’s platelets simply did not respond to aspirin and clopidogrel the way men’s did, even at identical doses. “Women are not appropriately responding,” said Dua. “It’s not a genetic thing. It has to do with their particular platelets as females.” Building on those findings, Dua’s team developed an algorithm using thromboelastography results to adjust blood thinner therapy in real time, then tested it in a single-arm interventional study. Compared with standard treatment, patients managed under the guided protocol showed significantly lower rates of thrombosis and stenosis, improved amputation-free survival, fewer amputations and better overall survival, with no major bleeding events recorded in the guided-therapy group. “The intervention is not the blood thinner,” said Dua. “The intervention is the guidance.” The team’s work has since expanded into a multicenter randomized controlled trial spanning four institutions, with roughly 500 patients enrolled to date and early results continuing to favor the guided approach. Dua described the effort as an attempt to move vascular surgery away from reflexive prescribing and toward therapy tailored to each patient’s underlying biology.

PCSK9 inhibitors show promise as potential therapy for AAA By Killian Meara PCSK9 inhibitors may slow abdominal aortic aneurysm (AAA) growth and reduce the risk of rupture, according to data presented at VAM 2026. The study was this year’s James S.T. Yao Resident Research award recipient. “Despite surgical advances, aortic rupture carries a mortality rate over 80% and over 15,000 deaths occur due to rupture annually,” said Michael Fassler, MD, a general surgery resident at the University of Florida, who presented the data. “However, a salient fact remains that there has been no approved pharmacologic therapy to slow AAA formation, growth and prevent rupture.” Investigators first conducted a retrospective study of 166 patients with radiographically confirmed AAA, comparing outcomes among patients receiving PCSK9 inhibitors, statins or no lipid-lowering therapy. After propensity score matching, patients treated with PCSK9 inhibitors experienced significantly less aneurysm growth and lower mortality than comparison groups. The research team then analyzed human single-cell RNA sequencing data and multiple mouse models of AAA. Treatment with the PCSK9 inhibitors consistently reduced aneurysm growth, limited inflammatory macrophage infiltration, preserved smooth muscle cells and reduced degradation of the aortic wall. Further experiments suggested the drugs work by enhancing macrophage efferocytosis, the process by which immune cells clear apoptotic smooth muscle cells and help resolve inflammation. The investigators found this effect depended on the MERTK receptor, identifying a potential biological mechanism underlying the protective effect. “Our clinical results show significant association between decreased mortality rates and AAA growth in patients on PCSK9 inhibitor therapy,” said Fassler. “We believe these findings support the argument for multicenter prospective clinical trials to investigate repurposing PCSK9 inhibitors as a therapeutic modality for patients with AAA.”

“The second you’re done with that six-hour procedure where you now have flow, you go to the PACU where you go right back to medieval times.” ANAHITA DUA, MD

Vascular Specialist | July/August 2026

FROM THE COVER: ‘TREAT THE WATER, NOT JUST THE PIPES’: ADDRESSING PREVENTION IN VASCULAR CARE continued from page 1 Rather than expecting every vascular surgeon to become an expert in metabolic medicine, Johnston outlined practical strategies for integrating prevention into practice. These included standardized checklists addressing antiplatelet therapy, LDL cholesterol goals, blood pressure control, diabetes management, tobacco cessation and lipoprotein(a) testing. She also encouraged building multidisciplinary partnerships with endocrinologists, pharmacists, advanced practice providers and prevention specialists. Johnston argued that vascular surgeons are uniquely positioned to lead these efforts because they see firsthand the consequences of progressive vascular disease. “We are the ones with the most radical sense of responsibility for these patients,” said Johnston. “We are the ones who have to go in that groin a third or fourth

time to save the leg, or talk about amputation, dialysis or end of life. We get this in a way that the primary care doctor who has seen 100 patients that week just can’t.” Johnston described cardiometabolic medicine as a potential “new frontier” for vascular surgery and suggested that preventing disease progression may ultimately have a greater impact than any new device or procedural innovation. “If we do this right for our patients, it is going to revolutionize vascular surgery more than any new wire, stent or conduit because it is a disease-modifying treatment that is going to save lives and legs,” she said. “We know there are not enough vascular surgeons, but what if the solution to that were to reduce demand instead of trying to increase our supply? And would you as a surgeon find more joy in medicine if every operation you did were as durable as it deserves to be?”

VAM

Study finds low attrition rates in integrated vascular surgery training programs Integrated vascular surgery residency programs continue to demonstrate low attrition rates comparable to other competitive surgical specialties, according to research presented at VAM 2026. The integrated vascular surgery training pathway was approved in 2007 and has become an increasingly important route for training future vascular surgeons. While prior studies have shown strong board passage rates and high levels of readiness for independent practice among graduates, little data have been available on attrition within these programs. To better understand the issue, investigators analyzed data from the GME Track Resident database, examining all integrated vascular surgery, interventional radiology, thoracic surgery and plastic

“Future studies should investigate why vascular surgery has the lowest attrition rates during the first two years but sees an increase in year three” SARAH LAUVE, MD surgery residency programs from 2014 to 2025. Researchers evaluated factors including age at entry, gender, citizenship status, geographic training region and degree type. During the study period, approximately 4,200 residents entered one of the

VAM

Poor clopidogrel metabolizers face higher cardiac risk after PAD revascularization By Killian Meara Genetic variants that reduce the effectiveness of clopidogrel may increase the risk of heart attack and stroke in patients undergoing peripheral artery disease (PAD) interventions, according to research presented at VAM 2026. The study found that around one in five patients carried single nucleotide polymorphisms (SNPs) that impair the body’s ability to convert clopidogrel into its active form. While those patients did not experience higher rates of adverse limb outcomes after revascularization, they were significantly more likely to experience major adverse cardiovascular events over the following year. “Our purpose was really to look at whether patients who are poor metabolizers of clopidogrel, which is our standard antiplatelet regimen following peripheral interventions, would have poorer outcomes,” said Edith Tzeng, MD, senior author on the study. Investigators linked pharmacogenomic testing results with patients who underwent peripheral vascular interventions to evaluate whether carriers of the relevant SNPs experienced different outcomes than patients without the variants. The primary outcomes included both major adverse limb events, such as repeat

integrated training pathways. Across all specialties studied, investigators found no association between attrition and either gender or citizenship status. For vascular surgery specifically, residents older than 30 when entering training were more likely to leave before completion. No other demographic factors were associated with attrition. When researchers examined attrition patterns throughout residency, vascular surgery had the lowest cumulative incidence of attrition during the first two years of training. Attrition increased during the third year before stabilizing and following trends similar to those seen in integrated plastic surgery programs. Overall attrition rates at the completion of training were relatively low. Vascular

surgery, plastic surgery and interventional radiology reported attrition rates of around 4%. Thoracic surgery had the highest attrition rate at 8.7%. The authors concluded that integrated vascular surgery training remains a stable pathway with relatively low attrition. “Future studies should investigate why vascular surgery has the lowest attrition rates during the first two years but sees an increase in year three,” said presenting author Sarah Lauve, MD, an integrated vascular surgery resident at LSU Health New Orleans. “Further evaluation of residents who enter but do not complete vascular training, coupled with their alternate career path, could be beneficial to understanding the causes of attrition in our specialty.”

revascularization or major amputation, and major adverse cardiovascular events, including myocardial infarction and stroke. Although the genetic variants were not associated with increased limb complications, they were linked to a higher risk of cardiovascular events. “Patients with PAD have a four-times increased risk of coronary artery events than patients who are just diagnosed with coronary artery disease,” said senior author Katherine Reitz, MD. “It is a relevant finding despite it not being directly related to the intervention itself.” The findings add to growing interest in using pharmacogenomic information to personalize antiplatelet therapy. Alternative medications that do not require metabolic activation are already available, but they carry a greater bleeding risk and are not routinely prescribed for all patients. Rather than making an immediate practice recommendation, Tzeng and Reitz said the study highlights an important unanswered question. “These relevant genotypes that we’ve known about for at least 20 years are still relevant and we still have no answer,” said Reitz. “As genomic information becomes increasingly accessible, this is another thing we need to think about when we’re prescribing for patients.”

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FROM THE COVER: WHAT’S NEXT FOR CAROTID DISEASE MANAGEMENT? continued from page 1 “It’s a reminder that we need to double down on medical management. We need to optimize it not just for carotid patients, but for all of our patients.” Schneider also highlighted a detail often overlooked in early commentary on the trial: the point where outcome curves for repair and medical management diverge. In CREST-2, that crossover occurred at roughly one year for stenting and just over one year for carotid endarterectomy (CEA), meaning the benefit of intervention over medical management alone only becomes apparent after that window, a fact that Schneider said should inform how patient life expectancy factors into treatment decisions for asymptomatic disease. That nuance, Schneider argued, has been lost in some of the response to CREST-2, including recent editorial commentary suggesting that CEA should be reserved until patients become symptomatic. Schneider pointed instead to the trials that shaped that narrative — ECST-2 and SPACE-2 — both of which struggled to enroll patients and reported perioperative stroke risk exceeding 5%. “The predominant narrative about CEA comes from grossly underpowered trials,” said Schneider. “These are impossible trials.” Beyond the trial data itself, Schneider identified structural threats facing the specialty, particularly the rapid growth of stroke centers, an area in which vascular

surgeons remain largely absent despite the field’s expertise in carotid disease. Schneider also noted that carotid procedures will likely remain inpatient-based for the foreseeable future even as the broader specialty shifts toward outpatient care, making continued engagement in carotid treatment essential to the field’s relevance. On the technology side, Schneider offered a strong endorsement of TCAR, describing its emergence as a turning point for the specialty. “TCAR was a gift to vascular surgery because it capitalizes on all of our strengths,” he said. “It’s part open, part endo and it deals with the population we know best.” Registry data presented during the lecture showed TCAR performing competitively with CEA in standardrisk patients and outperforming both CEA and transfemoral stenting in high-risk patients, reinforcing its expanding role in contemporary carotid care. Schneider closed the lecture by reaffirming that despite the uncertainty introduced by CREST-2, CEA remains an essential option for many patients and that vascular surgeons are uniquely positioned to evaluate emerging technologies, refine patient selection using tools like CTbased plaque morphology assessment and train the next generation of specialists. “CEA is going to remain the best choice for a lot of patients,” said Schneider. “We have to be clear and firm about that.”

QUALITY IMPROVEMENT

INTRODUCING THE SVS QUALITY IMPROVEMENT CONSULTING SERVICE By Nikolaus Zacharias, MD

The Society for Vascular Surgery (SVS) Quality Improvement (QI) Committee is proud to announce the launch of a new QI Consulting Service designed to support vascular surgery practices, divisions and institutions across the country in conducting QI projects promoting patient care and clinical excellence. QI has become an essential component of modern vascular practice. From optimizing patient outcomes and improving operational efficiency to meeting institutional, programmatic and regulatory expectations, vascular specialists are increasingly called upon to implement meaningful and sustainable QI initiatives. Recognizing this growing need, the SVS QI Committee has developed a member-focused consulting service that provides direct access to experienced vascular surgeons and quality leaders with expertise in QI science, program development, outcomes assessment and systems-based practice enhancement. Through this new initiative, SVS members will have the opportunity to participate in a series of individualized consulting sessions tailored to their unique clinical and organizational needs. SVS QI Committee members are available to meet with and provide guidance to SVS or SVN members with all phases of local QI initiatives from getting started to publishing or disseminating results. Participants can request a single or multiple sessions. This longitudinal approach is intended to promote collaboration, accountability and meaningful progress throughout the development and implementation of each project. The consulting service is intended to supplement the SVS QI toolkit and is built around the well-established Plan-DoStudy-Act (PDSA) philosophy of continuous QI. Participants will be encouraged to define clear goals, implement targeted interventions, evaluate outcomes and refine processes through iterative learning cycles. By following the PDSA framework, participating teams can develop sustainable

strategies that lead to measurable improvements in patient care, institutional value and clinical performance. The QI Consulting Service has already successfully launched with pilot participants, generating enthusiastic feedback. “The input and perspective were invaluable,” said Falen Demsas, MD. “I was able to better organize my QI interventions and achieve meaningful impact in our hospital length of stay.” “I found very useful tools in understanding quality of life in patients with peripheral artery disease,” said Bianca Mulaney, MD, another pilot participant. These early experiences highlight the practical value of mentorship, structured feedback and collaborative problemsolving that the program aims to provide to vascular surgeons and trainees nationwide. Participating practices and institutions may seek guidance on a broad range of topics, including quality metrics, patient safety initiatives, quality data, multidisciplinary collaboration, perioperative optimization, workflow improvement, performance benchmarking and development of local QI projects. Whether a member is beginning a new quality initiative, seeking solutions to persistent challenges, or looking to strengthen existing programs, this service offers a valuable opportunity for mentorship and expert guidance from leaders within the vascular surgery community. Additional program information regarding scheduling and participation is available through the website. We encourage all SVS and SVN members, including trainees, interested in advancing QI efforts within their practices to take advantage of this exciting new resource. Please visit our site regularly for new resources for implementation of enhanced recovery after surgery (coming July 2026) and QI curricula for vascular trainees (launch TBD). Together, we can continue to improve the quality, safety and outcomes of vascular care for patients nationwide.

Study links additional vein segments to worse outcomes after infrainguinal bypass By Killian Meara Data presented at VAM 2026 suggest that while spliced vein bypass (SVB) remains an option for patients who don’t have adequate single segment great saphenous vein (GSV), outcomes worsen if more vein segments are needed for infrainguinal bypass. The study used data from the Vascular Quality Initiative (VQI) infrainguinal bypass module to compare outcomes between single segment GSV and SVB with two vein segments and three or more vein segments in patients with chronic limb-threatening ischemia (CLTI). “Single segment GSV is the gold standard for infrainguinal bypasses in patients with CLTI,” said Brandon Creisher, MD, an integrated vascular surgery resident at Yale New Haven Hospital, who presented the study. However, he noted that 20% of patients in the BEST-CLI trial did not have an adequate single segment vein available, making alternative conduit strategies necessary. Researchers analyzed nearly 47,000 infrainguinal bypass procedures. Among those, 51% utilized a single segment GSV, while 4% used two spliced vein segments and 0.4% required three or more segments. After propensity matching for patient characteristics, medical management and bypass configuration, investigators evaluated perioperative outcomes and major adverse limb event-free survival. Patients receiving two vein segments experienced higher rates of return to the operating room for thrombosis and graft revision compared with those receiving single segment GSV. Operative complexity was also greater, with significantly longer procedure times, increased blood loss and higher transfusion requirements. Those differences translated into worse long-term outcomes. Major adverse limb event-free survival was significantly lower in the group with two vein segments, driven primarily by higher rates of major amputation and reintervention. Outcomes were even less favorable among patients requiring three or more vein segments. At one year, the estimated rate of major adverse limb event or death was 40% for patients receiving single segment GSV, compared with 45% for two vein segment and 52% for three or more vein segments. “Once you’re starting to think about more than two pieces of vein, you really have to think hard and make sure you’re very selective in choosing your patients,” said Creisher.

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Vascular Specialist | July/August 2026

VAM

AI may help advance training and quality improvement in vascular surgery By Killian Meara Artificial intelligence (AI) could play a beneficial role in vascular surgery education, according to preliminary research demonstrating that AI can identify and analyze key steps of carotid endarterectomy procedures captured on video. Presented at VAM 2026 by Aarathi Minisandram, MD, a vascular surgeon at Lahey Hospital and Medical Center in Burlington, Massachusetts, the project explored whether commercially available AI software could be trained to review surgical videos and provide meaningful performance analytics that could eventually be used for training, education and quality improvement. Researchers began by creating a video library of carotid endarterectomy procedures recorded using high-definition cameras worn by surgeons in the operating room. The videos were uploaded to a secure cloud-based platform where AI software was trained to recognize and annotate key steps of the operation. The study included 17 videos performed between June 2024 and August 2025. After multiple rounds of supervised machine learning and manual feedback, the AI successfully identified many of the predefined procedural steps. Investigators then manually validated the software’s annotations to determine accuracy and evaluate variability between surgeons. The findings revealed both the promise and limitations

of the technology. The AI generally performed well when procedural steps were clearly visible, but accuracy declined when camera positioning obscured important moments during the operation. For example, the software frequently struggled to identify completion of portions of patch closure because the camera wearer occasionally looked away at critical moments. Researchers also found that surgeon-specific variations in technique could affect AI performance. In one example, a surgeon placed vascular clamps in a different sequence than expected, leading the software to incorrectly identify the timing of the maneuver. Despite these challenges, investigators observed encouraging signs that the system could adapt over time as additional cases and surgeons were incorporated into the training process. Beyond data collection, investigators reported an unexpected benefit. Real-time video displays in the operating room appeared to improve communication, engagement and education among members of the surgical team. The researchers acknowledged several barriers to broader adoption, including the costs associated with video capture equipment, cloud storage and AI analytics, as well as the institutional coordination required among different teams.

VAM

EVALUATING THE ROLE OF MEDICAL MANAGEMENT IN CREST-2 By Killian Meara

“Medical management worked in CREST-2. Let’s not walk away after reading the primary paper that medical management did not work.” That was the sentiment of Brajesh Lal, MD, professor of vascular surgery at the University of Maryland School of Medicine, who gave a presentation on the trial during a session at VAM 2026. Lal emphasized that CREST-2 was designed to evaluate revascularization in the context of contemporary, guideline-directed medical therapy rather than as an alternative to it. “When medical management was guideline driven, centrally assisted and supported with lifestyle coaching, stroke risks responded very well and were half those reported in asymptomatic carotid artery stenosis,” he said.

The medical management protocol included intensive control of vascular risk factors, including blood pressure targets below 130 mmHg, LDL cholesterol below 70 mg/ dL using statins or PCSK9 inhibitors, antiplatelet therapy, smoking cessation, weight management and structured lifestyle counseling. During the study, the proportion of patients meeting blood pressure and cholesterol goals increased from roughly 40% at enrollment to between 70% and 80% at follow-up. Lal noted that intensive medical therapy substantially lowered stroke risk compared with earlier studies, while carotid artery stenting and carotid endarterectomy each provided additional reductions in stroke risk when added to medical management. Lal concluded that current evidence supports combining intensive, guideline-directed medical therapy with careful selection of patients for carotid revascularization, while future analyses may help refine which patients are most likely to benefit from each treatment approach. “Medical management did contribute, in all likelihood, to the improved results of revascularization,” said Lal. “The revascularization results achieved in the trial cannot be looked at in isolation. They occurred in combination with intensive medical management.”

VAM

BROADER ADVOCACY EFFORTS ARE NEEDED TO ADDRESS WORKFORCE, PAYMENT CHALLENGES By Killian Meara Innovation in vascular surgery goes beyond new devices and procedures. It also requires new approaches to advocacy in a health care system increasingly shaped by consolidation, workforce shortages and shifting employment models. That was the central message from Margaret Tracci, MD, JD, during a session at VAM 2026, where she argued that vascular surgeons need to pursue coordinated advocacy and engage more aggressively at all levels. “There is cacophony in D.C.,” she said. “We talk constantly about disunity among physicians, a house divided. These result in disengagement and a general lack of leverage.” Tracci said the rapid growth of physician employment by large health systems has changed the advocacy landscape. As consolidation reduces the number of independent practices, more physicians become eligible for collective bargaining, creating opportunities to rethink how they advocate for resources. She highlighted efforts by organizations such as the American College of Surgeons to develop standards defining the institutional support vascular surgeons need. “This is innovation and advocacy in a way that’s intended to make us feel better where we live and work,” she said. She also pointed to recent state-level victories as evidence that coordinated physician advocacy can influence policy. In Virginia, lawmakers approved legislation restricting noncompete agreements after physicians turned out in large numbers to testify before legislators. “The legislators said, ‘We knew the hospitals would be here, but we’ve never had physicians lined up to testify,’” Tracci recalled. Tracci said addressing workforce shortages, payment challenges and physician autonomy will require a broader advocacy strategy that unites surgeons across specialties. “We need to broaden that fight on all fronts — federal, state and local,” she said. “We need to unite and engage and we need to find leverage everywhere we can and use novel approaches to bargaining power.”

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VAM

Finding common ground begins with shared experiences By Killian Meara During the keynote address at VAM 2026, author and political commentator Michael Smerconish argued that one of the greatest challenges facing the United States is not political disagreement itself, but the steady erosion of shared experiences that once connected communities.

Drawing on examples ranging from childhood school bus rides to volunteer organizations, Smerconish contended that Americans increasingly live, work and socialize in ways that reinforce existing beliefs instead of exposing them to different perspectives. “We lack common experience,” said Smerconish. “Fueled by technology, we’ve now self-sorted as a society. We’re spending more time alone and when we spend time in the company of others, they are people who are just like us.” He pointed to research showing Americans are increasingly clustering into politically homogeneous communities, while participation in civic organizations, local activities and face-to-face interactions has declined over recent decades. At the same time, he said technology has made it easier for people to build social networks based largely on shared viewpoints. Smerconish said that rebuilding civic life will require individuals to reconnect with their local communities. He encouraged greater participation in volunteer organizations,

community events, local journalism and other activities that bring together people with different backgrounds and perspectives. “Our real division isn’t between red and blue,” he said, quoting political commentator Bill Maher. “It’s between the people on both sides who aren’t willing to mingle.” Smerconish concluded by returning to the

story of the public school bus he rode as a child, describing it as a symbol of the shared experiences that once united people despite their differences. “The nation’s got problems, and if we want to fix them, we need to share more rides and get back on the same bus, headed in the same direction,” he said. “We need to mingle.”

VAM

ASCHER URGES SPECIALTY TO TAKE ACTIVE ROLE IN DEVELOPING NEW TECHNOLOGIES By Killian Meara

The E. Stanley Crawford Critical Issues Forum at VAM 2026 focused on innovations in vascular surgery and served as the setting for the launch of the Enrico Ascher Vascular Innovation Institute, a new entity under the Society for Vascular Surgery (SVS) Foundation’s research and innovation portfolio. The institute, named after Enrico Ascher, MD, clinical professor in the department of surgery at NYU Grossman School of Medicine, received generous support from the Ascher family and will be a platform for advancing innovative ideas, technologies and leadership in vascular surgery. During the Crawford session, Ascher called on vascular surgeons to embrace innovation as a defining priority for the specialty, arguing that the field must take an active role in shaping

VAM Subspecialty certification: Solution or added burden? By Killian Meara Should vascular surgeons receive additional certification in specific areas of practice? That question was explored at VAM 2026, where Kellie Brown, MD, professor of surgery at the Medical College of Wisconsin, discussed the potential benefits and challenges of formal subspecialty certification.

emerging technologies. “The best way to predict the future of medicine is to create it,” said Ascher, borrowing a phrase he attributed to management thinker Peter Drucker and computer scientist Alan Kay. Ascher traced the history of innovation from its origins as a concept often associated with disruption and skepticism to its modern role as a driver of scientific and technological prog ress. He highlighted landmark advances that transformed vascular surgery, including vascular grafts, angiography and endovascular aneurysm repair. “In this century, we have never had a greater opportunity to make meaningful scientific

Brown noted that vascular surgery itself emerged from general surgery after advances in the field outpaced traditional surgical training. While the establishment of a primary vascular surgery certificate helped standardize education and competency, the specialty has continued to evolve with increasingly complex procedures and greater involvement from other specialists. “The question really isn’t whether subspecialty standards have merit,” said Brown. “It’s whether the cumulative burden is sustainable and whether it’s the right instrument for the problem we’re trying to solve.” She said additional subspecialization could allow surgeons to develop deeper expertise in specific disease areas, align continuing medical education with their clinical practice and provide clearer signals

advances in vascular surgery,” said Ascher. “This is the year to start thinking about not just reviewing data but actually bringing something new that can analyze the data. Something new on the way we take care of patients, the way we use machinery and the way we even think about techniques.” He pointed to artificial intelligence, robotics and augmented reality as technologies already reshaping other specialties, particularly neurosurgery, and said vascular surgeons need to become more aggressive in exploring their potential applications. Ascher also reflected on past ideas that helped define vascular surgery, including workforce planning, outcomes assessment, reporting standards, the Vascular Quality Initiative and clinical practice guidelines. He suggested innovation should become the specialty’s next defining theme. “What I submit to you for this decade is maybe innovation should be the buzzword for vascular surgery,” said Ascher. “By doing so, we can play a meaningful role in shaping these disruptive technologies.”

of advanced competency for patients and referring physicians. At the same time, Brown cautioned that creating multiple certif ications could narrow the scope of practice for vascular surgeons and add to the growing number of training and credentialing requirements they already face. She also war ned against allowing outside organizations to define competency standards for vascular procedures. “Standards should be physician-controlled,” said Brown. “We need to be careful about who’s creating those standards.” Brown proposed a framework for evaluating future subspecialties,

including evidence that they improve patient outcomes, sufficient clinical volume to maintain competency and training pathways that preserve the broad skills needed to manage vascular emergencies. “Subspecialization is neither inherently good nor bad,” said Brown. “It’s a tool. Like all tools, its value depends entirely on whether it’s solving the right problem.”

Vascular Specialist | July/August 2026

ADVERTORIAL | SPONSORED BY PENUMBRA

Optimizing acute limb ischemia treatment with a percutaneous-first approach

cute limb ischemia (ALI) management is evolving as new thrombectomy technologies expand the role of endovascular intervention. Jayer Chung, MD, Professor and Medical Director in the Division of Vascular Surgery and Endovascular Therapy at Baylor College of Medicine, discusses why he favors a percutaneousfirst approach, the evidence behind it and where he sees ALI treatment heading next.

What is the state of ALI treatment and the current standard of care? Jayer Chung, MD: The current standard of care is in a bit of flux. Open surgical strategies remain the gold standard but have become somewhat historical. Open surgical strategies include open embolectomy and/or bypass. However, over the last two decades, we’ve witnessed a proliferation of newer devices, such as aspiration thrombectomy and basket thrombectomy devices. These have expanded the range of patient presentations that are now able to be treated successfully via percutaneous means, to the point where many centers have shifted towards a percutaneous first approach for all ALI presentations.

What is your preferred treatment strategy for ALI? Can you walk us through your decision-making process when choosing between different interventions? Chung: My preferred treatment strategy is to try a percutaneous first approach. The base of the pyramid is percutaneous aspiration thrombectomy, followed by other percutaneous modalities as needed after reestablishing at least some minimal amount of flow. I reserve open surgical revascularizations for isolated emboli that present with signs and symptoms of concurrent compartment syndrome. The best example of this is if patients have an embolus to their tibial perineal trunk, with very severe either Rutherford 2B or 3 ischemia, with concurrent compartment syndrome. Since I’m making the incisions anyway, there’s minimal additional morbidity to the dissection required for a thrombectomy. I reserve the other modalities of percutaneous revascularization, (such as thrombolysis), for when the initial percutaneous aspiration thrombectomy fails (very rare) or provides a suboptimal result. The percutaneous aspiration first technique has several benefits. One, it can immediately restore at least some flow to the foot and obviate the urgency of the danger of limb loss. Two, it provides better visualization of the anatomy, where

“We need larger, multicenter, prospectively maintained databases that track and compare outcomes between newer devices and therapeutics as they evolve.” blockages are and if there’s any underlying problems that can be corrected. It also reestablishes some antegrade flow which can alleviate the ischemia and also make other adjuncts like lysis work better. Finally, since most can be achieved with moderate sedation, it avoids the complications associated with general anesthesia.

You recently presented data at VAM 2026. Can you give an overview of the study and its key findings? Chung: We presented a two-center retrospective cohort analysis with our colleagues from the University of North Carolina at Chapel Hill (Drs. McGinigle and Pascarella). The gap that we were trying to address was the paucity of literature that directly compares large modern cohorts of endovascular first versus open first revascularizations. Until our paper, there were no recent large cohorts with sufficient follow up comparing open versus endovascular revascularization in ALI. Hence, we studied this over a nine-year period. We had 367 patients and 394 limbs. A little less than 30 were bilateral. Our median age was 65 and a little more than half were male. The key findings were that at 90 days, the endovascular first and open first strategies had very similar outcomes with respect to amputation-free survival, mortality and limb salvage. At last follow-up, the endovascular first cohort experienced some interesting advantages with respect to amputation-free survival, driven mostly by the improved overall survival of the cohort. It’s important to note that there were some baseline differences between the two cohorts. Embolic etiologies and more advanced ischemic presentations were more common in the open first cohort. However, the endovascular first cohort overall had a higher prevalence of atherosclerotic risk factors. This also captured the evolution of the learning curve using endovascular first approaches. Over time, even for more severely ischemic presentations, both of the centers transitioned towards an endovascular first approach. It’s important to note this because we didn’t have an overarching protocol that dictated how people were supposed to revascularize patients.

How does this data affect the treatment protocol for ALI patients? Chung: This helps to expand the application of percutaneous first

approaches towards a broader segment of the ALI population. There are some caveats to that. There’s a learning curve with percutaneous first approaches. Second of all, there are some center specific effects, like the availability of all the devices, balloons, drugs, nursing staff, imaging capabilities. But overall, in terms of the treatment algorithm, it shows that an endovascular first approach is at least as safe as and efficacious as an open first. It also requires emphasis that the prospective randomized control trials that provide a lot of the foundational elements of our guidelines are 30 years old, which means that the data collected for them are probably closer to 40 years old. There’s been significant device evolution, drug evolution and other critical care evolution that has ensued since. Moreover, the natural history of the disease and the etiologies have changed. It’s less frequently due to an embolic source and is now more frequently due to a thrombotic source and in situ thrombosis and is therefore perhaps more amenable to percutaneous first strategies. It’s time we have a new set of studies with larger, more comprehensive, prospectively gathered data to compare open first versus endovascular first strategies.

What is Lightning Bolt® and how does it differ from other mechanical thrombectomy systems? Chung: Lightning Bolt capitalizes on computer assisted vacuum thrombectomy (CAVT™). There are several main advantages of the Penumbra system versus other devices. The Lightning Bolt 7 catheter is different from other catheters as it’s constructed from stainless steel hypotube, with laser-cut etchings to provide both columnar strength while maintaining graduated flexibility. The Lightning Bolt Console incorporates proprietary algorithms that analyze material passing through the aspiration tubing in real time to differentiate thrombus from blood and adjust aspiration accordingly. The final thing is the modulated aspiration which occurs in the Lightning Bolt console with the infusion of saline. Lightning Bolt uses saline to vent between vacuum and ambient pressure to modulate aspiration and break down clot for faster removal. This is designed to minimize blood loss historically associated with vacuum thrombectomy. This alternating of saline and aspiration also helps to

dislodge any impacted thrombus at the tip, designed to reduce the potential for tip occlusion observed with earlier catheter designs. This makes the removal of thrombus more technically feasible while striving to keep blood loss to a minimum.

What are you hoping to see in the next three to five years for ALI treatment? Chung: This field is ripe for a lot of study. As I said before, the foundational randomized control trial data for this is at least 40 years old. It begs the question of how to best study a lot of the device and therapeutic evolution. I think there’s two ways to look at this. One is what new devices do we need? And two, what clinical trials do we need in the future to best answer the question of whether or not endovascular first versus open first is best? With regard to devices, I would love to see a marriage between aspiration thrombectomy and the basket retrieval systems. There’s always going to be some cases where one tool just doesn’t work and another one will. But if we can marry the advantages of both, we can capitalize on the advantages of both. With regards to clinical studies, at the very least, we need larger, multicenter, prospectively maintained databases that track and compare outcomes between newer devices and therapeutics as they evolve. The question of whether we need a prospective randomized control trial for this, I’m a little unclear about. Since prospective randomized control trials have become the standard teaching in most medical schools, this is what moves the needle most. I would also argue that since that time, there’s been rapid evolution in computer processing capabilities, AI, algorithms and therefore the ability to perform really advanced biostatistics on real time data that may obviate the need for an actual prospective randomized control trial. Interview sponsored by Penumbra, Inc. Procedural and operative techniques and considerations are illustrative examples from physician experience. Physicians’ treatment and technique decisions will vary based on their medical judgment. The clinical results presented herein are for informational purposes only and may not be predictive for all patients. Individual results may vary depending on patient-specific attributes and other factors. Caution: Federal (USA) law restrictions these devices to sale by or on the order of a physician. Prior to use, please refer to the Instructions for Use for complete product indications, contraindications, warnings, precautions, potential adverse events, and detailed instructions for use. Please visit https://www.penumbrainc.com/ pdf/brief-summaries-risk-statement/ for the complete IFU Summary Statements. Please contact your local Penumbra representative for more information.

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Vascular Specialist | July/August 2026

CLAUDICATION

ELECTIVE PVI FOR CLAUDICATION LINKED TO WORSE LIMB OUTCOMES AND HIGHER COSTS By Maria Gifford Vascular surgeons have long debated whether and when to intervene on claudication. A new study suggests the field may be intervening too often, too early and with consequences that compound over time. The findings, recently published in the Journal of Vascular Surgery, come from a propensity-matched analysis of more than 26,000 patients with peripheral arterial disease (PAD) and intermittent claudication (IC). Researchers found that elective peripheral vascular intervention (PVI) was associated with significantly higher rates of major adverse limb events (MALE), a markedly higher rate of repeat procedures and substantially greater costs of care compared with medical management alone. “We know that an increasing number of patients with PAD and IC are receiving elective PVI,” said lead study author Sanket Dhruva, MD, a cardiologist and assistant professor of medicine at the University of California in San Francisco. “However, medical management, including supervised exercise therapy (SET), is the standard of care,” said Dhruva. “Our study objective was to evaluate the association of elective PVI versus medical management with clinical and cost outcomes in a large, contemporary real-world cohort.” The investigators conducted a retrospective cohort analysis of commercially insured and Medicare Advantage patients in the OptumLabs Data Warehouse with incident PAD and IC diagnoses, yielding a matched sample of 26,716 patients with 13,358 in each group. Elective PVI was associated with more than double the incidence of MALE compared with no PVI, with all three component endpoints — new major amputations, new acute limb ischemia and progression to CLTI — significantly higher in the intervention group. One in four patients who underwent PVI received a repeat procedure within the following year, after excluding staged procedures in the first 30 days. “Elective PVI for patients with PAD and IC was associated with worse clinical outcomes and frequent reintervention compared to no intervention,” said Dhruva. “Rather than reducing downstream events, elective PVI was associated with increased rates of MALE.” The cost burden was substantial as well. Mean total cost of care over 12 months reached $44,934 among patients who underwent elective PVI, compared with $26,452 among those who did not — a cost ratio of 1.70. Both health plan-paid costs and out-of-pocket costs were significantly higher in the PVI group, as were rates of emergency department visits and acute inpatient hospitalizations. Additionally, patients who received atherectomy had higher MALE rates and

“These findings reinforce the need to ensure that patients are actually receiving important conservative therapies before surgical intervention is pursued.” SANKET DHRUVA, MD

were significantly more likely to undergo repeat procedures compared with those who received PVI without atherectomy. Patients who received infrapopliteal PVI fared worse still, with higher composite MALE and repeat PVI rates than those who underwent only femoropopliteal intervention, which is consistent with Society for Vascular Surgery guidelines that recommend against infrapopliteal revascularization for claudication. Equally significant was what the data revealed about the underuse of conservative care. SET — which carries a Class 1A guideline endorsement and has been shown to meaningfully improve walking distance — was used by only 0.2% of patients in either group at baseline and barely improved within the 12 months that followed. The authors note that while SET is covered by Medicare, utilization remains extremely low in practice. “These findings raise important questions about the effectiveness of elective PVI in this population and highlight that patients should be receiving guideline-directed medical management and SET before invasive treatment is considered,” said Dhruva. Beyond the utilization gap, Dhruva stressed the importance of how conversations about intervention happen at the individual patient level. If elective PVI is ultimately recommended, the downstream risks need to be part of the discussion. “If elective PVI is recommended to a patient in clinical practice, it’s very important that informed, shared decision-making occurs so that patients understand the potential risks later, including repeat procedures and adverse limb events,” said Dhruva. Dhruva and colleagues acknowledged the inherent constraints of a retrospective, claims-based design. Patients selected for elective PVI may have had more advanced or refractory disease than their matched counterparts and diagnosis codes alone cannot fully capture disease severity. However, matching on 17 variables substantially reduced baseline imbalances and negative control outcomes — including 12-month mortality and incident myocardial infarction or stroke — did not differ significantly between groups, lending support to the primary findings. Dhruva pointed to several questions

the study leaves open, including whether particular patient subgroups might benefit from revascularization while avoiding the subsequent harms seen in the broader population. But the more pressing near-term priority is structural, he said. “Future research should evaluate whether there are any subgroups of patients who derive meaningful clinical outcome benefit from revascularization while minimizing downstream harm,” said Dhruva. “More broadly, we need to evaluate how we can ensure patients with PAD and IC receive optimal guideline-directed medical management and we clearly need to double

down on improving the extremely low rates of SET, given that it carries the strongest clinical practice guideline recommendation and many additional benefits beyond improving outcomes in PAD,” he said. “Elective PVI for patients with PAD and IC was associated with worse limb outcomes, frequent repeat procedures and substantially higher costs compared with no PVI,” said Dhruva. “These findings reinforce the need to ensure that patients are actually receiving important conservative therapies before surgical intervention is pursued.”

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VAM

‘WE ARE ALL FAMILY’: CALLIGARO CALLS FOR UNITY AND INNOVATION DURING VAM PRESIDENTIAL ADDRESS By Killian Meara

“The biggest threat to our specialty is not cardiologists and it’s not low reimbursements, it’s divisiveness among ourselves. By speaking and acting with one voice, we can accomplish anything.” KEITH CALLIGARO, MD

During his presidential address at VAM 2026, Keith Calligaro, MD, called on vascular surgeons to think beyond today’s clinical challenges and outlined a vision for the specialty built around unity, innovation, education and patient advocacy. Speaking before a record-breaking attendance at the annual meeting, Calligaro framed his address around the theme of “family and future,” reflecting on the mentors, colleagues and trainees who shaped his career before turning his focus to what he described as 10 priorities for vascular surgery’s future. “The biggest threat to our specialty is not cardiologists and it’s not low reimbursements,” said Calligaro. “It’s divisiveness

among ourselves. By speaking and acting with one voice, we can accomplish anything.” Among his priorities was strengthening the identity of vascular surgeons as the experts in vascular disease. While multiple specialties perform vascular procedures, Calligaro argued that vascular surgeons remain uniquely qualified to offer the f ull spectr um of medical therapy, endovascular intervention and open surgery. “We are the only specialty to offer one-stop shopping,” he said. “No one else can do that and we need to make that known as best we can.” Calligaro also called for broader adoption of appropriate use criteria across specialties, saying vascular surgeons, cardiolog ists and interventional radiologists should work toward shared standards that ensure patients receive interventions only when appropriate. Innovation represented another major theme. He predicted advances in robotics, artificial intelligence and device technology will reshape vascular surgery, highlighting the newly established Enrico Ascher Vascular Innovation Institute as an important investment in the specialty’s future. Training also must continue to evolve, he said, noting declining exposure to complex open aortic surgery and

VAM

Peter Lawrence receives SVS Lifetime Achievement Award By Maria Gifford A career that nearly began on the football field instead of in the operating room culminated at VAM 2026 in the highest honor of the Society for Vascular Surgery (SVS), as Peter Lawrence, MD, received the SVS Lifetime Achievement Award for a body of work spanning more than four decades in vascular surgery, education and research. Lawrence’s career includes chief of vascular surgery posts at the University of Utah and UCLA, a term as dean for clinical affairs at UC Irvine, more than 500 published articles and book chapters and founding the Vascular Low Frequency Disease Consortium, an international research collaboration with more than 250 investigators. Lawrence’s surgical textbook is used in most U.S. medical school clerkships and he served as senior editor of the Journal of Vascular Surgery. Lawrence traced his path to the vascular surgery field back to a single moment during his surgical training at Harvard Medical School, when a planned career in orthopedic surgery gave way to something

else entirely. “When Chilton Crane clamped the aorta and opened it, I realized I wanted to become a vascular surgeon rather than an orthopedic surgeon,” said Lawrence. That decision led him through training at Columbia Presbyterian, a formative faculty post at the University of Utah and ultimately 23 years at UCLA, where he led the Gonda Vascular Center and helped train a new generation of vascular surgeons. Accepting the award, Lawrence returned to a lesson learned long before medicine, one drawn from his years as a college athlete at Dartmouth. “Surround yourself with great teammates if you want to play on a winning team,” said Lawrence. “It’s never only about you and awards like this are never given to those on losing teams.” Lawrence credited mentors, co-editors, research collaborators and colleagues at every stage of his career, along with his wife, Karen. “I’ve had great teammates who have helped me in so many ways throughout my career,” said Lawrence.

growing interest in focused practice areas such as venous disease. Rather than maintaining a one-size-fits-all model, Calligaro suggested future training pathways should provide greater flexibility while preserving comprehensive vascular expertise. He also emphasized the need to expand independent vascular centers, secure fair physician reimbursement, support diversity while maintaining merit-based leadership and improve work-life balance to sustain the specialty’s workforce. Calligaro proposed what he called a “Vascular Bill of Rights,” encompassing professional autonomy, fair reimbursement, innovation, modernized training and respectful collaboration. He concluded by reminding attendees that the strength of the specialty ultimately depends on the people within it. “You are my family,” said Calligaro. “We are all family. By working together as family, I am very optimistic that vascular surgeons have a very bright future.”

VAM SVS ELECTION RESULTS ANNOUNCED DURING ANNUAL BUSINESS MEETING During the Annual Business meeting at VAM 2026, the Society for Vascular Surgery (SVS) announced it elected William Shutze, MD, as the incoming vice president and Bernadette Aulivola, MD, as the new treasurer. As vice president, Shutze will help coordinate the activities of SVS councils and committees. His term as vice president will be followed by terms as president-elect and president, ensuring continuity of leadership. “I am honored by the confidence of SVS members and look forward to working collaboratively to strengthen our specialty, support our members and advance exceptional patient care,” said Shutze. Shutze, a board-certified vascular surgeon, is the co-founder of Texas Vascular Associates, a former fellowship program director at Baylor University Medical Center and author of more than 100 peer-reviewed publications. He has also spearheaded the SVS’ public awareness campaign Highway to Health since October 2024. As treasurer, Aulivola will serve a two-year term. Board-certified in surgery and vascular surgery, she is a professor of surgery at Loyola University Chicago Stritch School of Medicine and director of the Division of Vascular Surgery and Endovascular Therapy at Loyola University Health System. “I am grateful for the opportunity to serve SVS in this important leadership role,” said Aulivola. “As Treasurer, I look forward to supporting the Society’s long-term success through thoughtful stewardship and strategic investment.” During the meeting, the SVS also recognized several leadership transitions. Linda Harris, MD, DFSVS, assumes the role of president, succeeding Keith Calligaro, MD, DFSVS, who transitions to immediate past president. Andres Schanzer MD, DFSVS, formerly vice president, steps into the role of president-elect. “The strength of SVS lies in its dedicated volunteer leaders and their commitment to advancing vascular health,” said Harris. “We congratulate Dr. Shutze and Dr. Aulivola on their election and look forward to their contributions as SVS continues to support vascular surgeons, elevate the specialty and advance care for patients with vascular disease.”

Vascular Specialist | July/August 2026

THROUGH THE LENS

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THROUGH THE LENS

Vascular Specialist | July/August 2026

COMMENT&ANALYSIS THE OUTPATIENT

to their city as 40 or more patients per month were travel- effective, efficient, compassionate and cost effective than THE ROAD MORE TRAVELED: ing to our Flint location for the hemodialysis services we having these patients go to their local emergency departproviding in our OBL. Thus, MVC opened our second ment. Having to rely on very inefficient hospital services ADDRESSING VASCULAR DESERTS were location in 2013. This was an obvious benefit to those pa- not only increases the costs dramatically, but many of these

By Robert G. Molnar, MD

I have long been a proponent of Office Based Labs (OBLs) and Ambulatory Surgery Centers (ASCs) for the timely access to care offered to the communities they serve. The efficiencies, compared to the hospital systems, are tremendous and the easy access for patients and their families provides a wonderful service to those patients in need. My experience in providing this care spans 21 years, as I worked with my group, the Michigan Vascular Center (MVC), to establish one of the first OBLs in the country in 2005. At that time, our mission was to create a one stop opportunity to deliver the best hemodialysis care available. Prior to establishing our OBL, the care provided to the hemodialysis patient was fragmented, beset with delays and had lacked a standardized and consistent approach. Our OBL would provide all the necessary work up for new hemodialysis access creation as well as the maintenance and acute care intervention for established hemodialysis access or Perma catheter dysfunction. Our OBL became immensely popular, as hemodialysis units made one call for any access issue and our response was “Send them right over.” Patients would come in the same day and go right back to their hemodialysis session. In 2008, CMS approved payment for some peripheral vascular interventions to be performed in the OBL as the cost savings compared to the hospital setting were very significant. Thus, our very efficient access option extended not only the hemodialysis patients, but to those with chronic limb threatening ischemia (CLTI) and our ability to provide urgent and sometimes emergent access was established. In 2012, I began to receive calls from nephrologists in a city approximately 50 miles north of our Flint, Michigan based OBL. They requested that we establish an OBL close

LETTER TO THE EDITOR By O. William Brown, MD, JD, DFSVS and Mark A. Mattos, MD, DFSVS In a recent article, Benjamin Pearce, MD, used a line from a song by The Who to suggest that our training programs are adequately preparing our trainees to perform aortic procedures in practice. However, 10-year data from the Advanced Vascular Surgical Skills and Simulation Assessment Program (AVSSSAP) suggests that this is not the case. Having grown up in Detroit, I would paraphrase a song by The Temptations and suggest that clinical competency of our trainees in the treatment of aortic disease is “Just our imagination running away with us.” As vascular surgeons, we pride ourselves in relying upon data in making decisions regarding the care of our patients. So, too, must we rely on data

tients, whose transportation and access issues were significant. The services at both sites were identical and provided long term maintenance and acute care intervention for both established hemodialysis accesses, new access evaluation with timely access creation and catheter placement and maintenance. Over the past few years, I noticed that many patients at our newest OBL were traveling significant distances to receive the care we provide. It is important to recognize that there are still many “vascular deserts” where patients struggle to receive needed, life sustaining vascular care. Hemodialysis patients already have significant difficulties managing their transportation and many have multiple comorbidities requiring many doctor or testing appointments. This led me to do a paper and pencil study to see where our patients were coming from and the distances they were traveling. Of 1860 patients that are served by our northern OBL, 639 (34%) travel greater than 30 miles. I mapped out all their locations and identified some additional distances:

patients will be admitted, have numerous consults and often receive a temporary quinton catheter for hemodialysis until operating room or catheter lab access is obtained.

Establishing OBLs and ASCs can prevent unnecessary admissions, delays in care, unnecessary procedures, a waste of inpatient resources and tremendous costs. I believe we need to critically look at establishing an expanded OBL/ASC network to provide the needed, comprehensive, cost-effective, timely and patient centered vascular care. OBLs and ASCs need to be supported and expanded to provide care to those regions that are vascular deserts and to allow for a road less traveled by some of our vascular patients needing life and limb saving vascular care.

Travel distance to our OBL

Number of Patients

Percentage of patients

Greater than 30 miles

639

34.4

Greater than 50 miles

380

20.4

We often take for granted having expert and needed care close to us, but thisthan patient — already struggling178 Greater 75 population miles with a life on chronic hemodialysis with all its challenges — oftenGreater must travel significant distances to receive needed112 than 100 miles maintenance and urgent intervention. Traveling over three hours in any state is difficult, but our Michigan winters Greater than 150 miles 67 can be severe and this only exacerbates their difficulties to obtain needed services. 61

Greater than 200 miles

9.6 6.0 3.6 3.3

It is evident that the OBL/ASC model is much more

ARE THE KIDS REALLY ‘ALL RIGHT’ OR IS IT ‘JUST OUR IMAGINATION?’ to determine the technical competency of our trainees. We certainly agree that proficiency in the treatment of aortic disease takes years to develop and continues to develop throughout a surgeon’s career. However, when is it safe to allow the copilot to move to the pilot’s chair? In the reality of flight safety, a copilot must prove his/her technical proficiency on a simulator. We suggest that the same rigorous evaluation via simulation is necessary to establish the technical competency of a vascular surgeon. Ten years of unbiased testing of over three hundred graduating vascular trainees by the AVSSSAP on both open and endovascular simulators revealed that only 65% to 69% of the trainees were deemed to be “practice ready” to treat aortic disease six months prior to

completion of their formal training. The criteria to make this determination was based upon the evaluation and input of multiple vascular surgery program directors and vascular surgery section and department chairs. This data makes it incumbent upon all vascular surgeons who are involved in teaching programs to reexamine their training techniques and even more importantly, reevaluate how we assess the technical proficiency of vascular trainees. To continue to allow program faculty alone to determine the technical competency of its vascular trainees is to ignore extensive data which emphasizes the inherent bias in relying on this form of evaluation. Whereas there continues to be debate over the role of teaching vascular technique with the use of simulation, there can be no debate that

there should be an unbiased simulation assessment of technical skills prior to graduation. We suggest that similar to vascular laboratory competence, which has now become a component of board certification, demonstrating technical competence should also become a part of board certification. Clearly, the development of a technical skills certification exam, as with the other portions of the certification process, will require time to develop. However, at this time, as the AVSSSAP has shown, we do have simulators that can provide faculty members with unbiased data regarding the technical competence of their trainees. Only with data that supports technical competence can we be confident that patients are receiving the care that they expect and deserve.

www.vascularspecialistonline.com

COMMENT&ANALYSIS TO BE OR NOT TO BE: ARE AI SURGEONS THE FUTURE? By Andrea Fisher, MD

“Soon, AI will be able to perform surgery independently.”

As a PGY-4 vascular surgery resident conducting AI research, I encounter this prediction somewhat frequently. I have to wonder — do we (surgeons) want this? Autonomous surgery could potentially expand access to surgery; patients in certain areas of the United States and worldwide often struggle to access timely, high quality surgical care. Still, on a personal level, I would hesitate to relinquish the defining aspect of my profession to AI. For the past year, I have had the privilege of working in Stanford’s Center for Artificial Intelligence in Medical Imaging with talented computer scientists from every corner of the world. The lab has shown me how AI can provide unique patient benefit, from making tumor board recommendations personalized to a patient’s specific genetics and tumor distribution, to using imaging to predict which patients have a genetic connective tissue disorder (my project, stay tuned!). At the same time, AI coding tools have allowed tech companies to eliminate much of their workforce; software engineers who have been lucky enough to avoid layoffs have needed to make radical alterations to their skillsets to stay employed. The employment impact of this transformative technology is well known (and feared) in tech circles, but the impact of AI will certainly spread to every profession, including vascular surgery. As with any new technology, we face the choice to adapt

or be left behind. However, I contend that a secret third option is best for us and our patients: We must actively shape AI to fit our needs. AI solutions for healthcare are typically not built by doctors. And for good reason — physicians are usually busy treating patients. Although our lab has a variety of physician collaborators who offer valuable guidance on building clinically useful, safe models, many commercial healthcare-adjacent AI solutions seem to be built from the perspective of engineers who experience health care as patients. For instance, Doctronic, which performs fully autonomous medication refills (without a medical license), could plausibly have arisen from frustration with wait times for a PCP medication refill appointment. On our current trajectory, non-surgeons who imagine AI for surgery think of an autonomous AI surgeon. I am optimistic about the benefits of AI, but I do not think that this is a good goal — medicine (surgery in particular) will always be an art. Humans are not machines and the practice of alleviating suffering requires the care and trust that a human physician should provide. However, I think there are many opportunities for making vascular surgery safer, faster and more efficient using AI. Consider a model that takes in a patient’s CT and chart, simulates peripheral vascular interventions and shows predicted patency rates for each option. Or perhaps an AI companion that our patients bring home to help coordinate care

appointments, dispense medications and track changes in symptoms. We could develop an interactive AI cath lab that can anticipate steps of a procedure, ensures the right tools are in the room at the right time and learns our procedural preferences. Our unique perspectives as practicing surgeons allow us to imagine solutions that improve care without eliminating ourselves. Among medical specialties, vascular surgery is often at the forefront of innovation and several surgeon-led/ surgeon-advised companies are already bringing AI into vascular practice. As the AI revolution continues to pick up steam, it will be more important than ever for us to guide developers and engineers to make the right solutions. Even those who are not involved in software/device development should strive to cultivate a working familiarity with AI to prepare for the inevitable changes coming for clinical practice. I am hopeful we can continue to make AI work for us and not the other way around. ANDREA FISHER is a PGY-5 vascular surgery resident at Stanford, currently completing two years of research in Stanford’s Center for Artificial Intelligence in Medicine & Imaging and obtaining a master’s degree in biomedical data science.

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Vascular Specialist | July/August 2026

COMMENT&ANALYSIS

Adam Smith, Hippocrates, Pogo and the great American health care mess: Part two By Arthur E. Palamara, MD, FACS

In part one of this article, we discussed the intrusion of corporatization into a profession. The question was asked whether Adam Smith’s economic principles could be applied to health care. In this segment, physician responsibility will be examined. Hippocratic Oath and the Oath of Maimonides

Most physicians take the Hippocratic Oath or the Oath of Maimonides. Both call for the physician (Healer) to hold a high standard of ethics to benefit their patient. It calls for physicians to help the sick, abstain from causing harm, teach the art, keep confidentiality. Maimonides goes farther: appointing the physician and pharmacist “to watch over life and health of Thy creatures.” “May the love of my art actuate me at all times; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty ai of doing good to Thy children.” Predictive of the future, Maimonides asks the physician “to correct what I have acquired, extend its domain, for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can obtain a new light on what he thinks himself sure of today.” It concludes: “Oh God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.” Perhaps forgotten or intentionally ignored, these principles have served us well for millennia only to fall increasingly into desuetude as physicians have been drawn unwittingly and sometimes by force of circumstance into a system not of their choosing. In the nineteenth century, Rudolf Virchow wrote that “physicians are the natural attorneys of the poor.” The luster of our star has diminished. The conflict between the Federal Trade Commission (FTC) and the medical

profession has been painfully debated. Edmund Pellegrino, MD from the Kennedy Institute of Ethics and John Carroll, MD, from Georgetown University, debated this issue in 1982. Their monograph was titled What is a Profession? The Ethical Implications of the FTC order and Some Supreme Court Decisions. Their article responded to a1982 Supreme Court opinion overturning a writ of certiorari of the Court of Appeals March 23,1982. The Supreme Court opined that competition among providers is deemed to be paramount to ethical obligations. “This is a rather interesting subjugation of ethical norms to the service of competition,” wrote Pellegrino and Carroll. They cite earlier opinions of the Supreme Court in 1952 (U.S. vs. Oregon): “…there are ethical considerations where the historic direct relationship between patient and physician is involved which are re quite different from the usual considerations prevailing in ordinary commercial matter. This Court has recognized the forms of competition usual in the business world may be demoralizing to the ethical standards of a profession” (emphasis added). Obviously, the Supreme Court has strayed even further since 1982. Pellegrino and Carroll went on to write that the medical profession has not done a very good job policing itself. “We need to restore the ideal of a physician as a virtuous person who does not need philosophy, law, competition or even an ethical code to instruct (them) on what is (their) moral behavior in his relationship with those who are ill.” If anything, the intrusion of corporations and supportive antitrust laws make it even more difficult to resurrect “Medical Morality.”

Pogo

Walt Kelly’s Pogo was comic strip syndicated from 1948 until 1975 using animal characters to satirize social and political events of the era. Probably the most famous is a cartoon where Pogo (who resembles a cute porcupine) is walking through a pristine bayou with his son. The son says, “Ah Pogo, the beauty of the forest primeval gets me in the heart.” Pogo, who is tiptoeing, responds, “It gets me in the feet, Porkypine.” In the next frame, they are looking at a rubbish-filled forest with tires hanging from trees. Porkypine comments, “It is hard walkin’ on this stuff.” To which Pogo replies, “Yep, son. We have met the enemy, and it is us” (emphasis added). Organized medicine has stood on the ramparts of opposing the expansion of

nurse practitioners (NPs) for much of the last several decades. Articles have been written exposing their deficiencies in an independent setting. An article from the Journal of the Mississippi State Medical Organization published in January 2022 revealed independently practicing NPs at the Hattiesburg Clinic increased costs to patients by $28 million annually. This resulted from increased tests, referrals to specialists and emergency room visits. Trends reveal that nurse practitioners are leaving primary care into specialty areas

“We doctors have not been good stewards of our profession. Having succumbed to external pressures, there is little wonder that healthcare executives regard doctors and patients as a commodity.” where they are especially unprepared. While decrying the overuse of nurse pr actitioners, doctors themselves open free-standing clinics staffed by unsupervised NPs for their own monetary benefit. Likewise in hospitals, while nominally prohibited, initial consultations are done by nurse practitioners then signed off by neurosurgeons, vascular surgeons, cardiologists, etc. with only a cursory glance at the patient and a nominal conversation. Perhaps this is being done for expediency and to meet the time constraints of their employer. Similarly, Team Health is a national cor poration that hires doctors, primarily hospitalists and emergency department (ED) physicians. Doctors must meet efficiency goals. In some EDs they must also supervise more than four mid-levels in addition to their own more complicated cases. Given the limited amount of time, a conscientious physician will not know what they are missing. An admitted patient must be seen with a note written in 15’ and new patient

evaluated in 30’. While permissible for an 18-year-old coming in with appendicitis, it is certainly not for an 80-year-old with multiple admissions for heart failure, COPD, CKD stage V, and ischemic legs. This suggests that we have abandoned our responsibility to the patient. If we accept that a doctor must place the needs of the patient before their own, then what is the doctor’s responsibility when corporatized medicine has forced the physician into a compromising treatment paradigm? We doctors have not been good stewards of our profession. Having succumbed to external pressures, there is little wonder that healthcare executives regard doctors and patients as a commodity. We have not pushed back on those forces who regard doctors not as professionals but as skilled and highly paid workers. Insurance executives would be thrilled to eliminate us if they could. We are now valued for our economic productivity and no longer for knowledge or commitment. Those who control us serve a different master, their stockholders. They seek to expedite health care services to a dangerous extreme. The time allocated to brain surgery, a pancreatic resection, or a thoracoabdominal aneurysm can be hastened only with peril. Limiting time spent with a patient erodes the

ARTHUR E. PALAMARA, MD, FACS

www.vascularspecialistonline.com

COMMENT&ANALYSIS In 2024, America spent $13,676 per person, per year, or $4.22 trillion, 17.9% of the GDP. Of that, 32% XXXXXX XXXXX

was spent on hospital care, 20% on physician and clinical services (?) and 10% on prescription drugs. Where did the other 38% go?

physician-patient bond and ignores the integral nature of healing: that the patient enjoys the confidence that we can make them better. We don’t heal patients; we create pathways that allow them to heal themselves. We can speculate what will happen to practices with the advent of new drugs. GLP-1 agonists and PCSK-9s succeed in reducing the incidence of arteriosclerosis, aneurysms, and with it, the need for intervention. GLP-1s have already diminished the need for bariatric surgery. Pity the poor physician who has just completed their fellowship with more than $200,000 in debt. Married, with a young family as they struggle to begin a career. Most countries pay for or lavishly subsidize medical education and doctors are considered a public service. In this country, student loans become payable immediately relegating the new attending to that of an indentured servant. Once employed, they have no option but to follow their employers’ mandate or risk dismissal. This loss of authority is accompanied by the moral injury of ignoring the basic tenets of our profession. Regretfully, organized medicine has provided little protection for the employed physician. Which may be why so few of them join.

Where do we go from here?

Health care in our society is at an inflection point; we can no longer afford our health care system. Insurance premiums are unaffordable, as are deductibles and co-pays. In 2024, America spent $13,676 per person, per year, or $4.22 trillion, 17.9% of the GDP. Of that, 32% was spent on hospital care, 20% on physician and clinical services (?) and 10% on prescription drugs. Where did the other 38% go? In 2025, we spent $5.6 trillion, an increase of 7.1%. Despite spending this egregious amount, roughly twice that of any other developed country, America still has a problem with accessibility. Affordable Care Act (ACA) subsidies were discontinued leaving four million people uninsured because of increased premiums. Paraphrasing Adam Smith’s Wealth of Nations, “the butcher will not sell his meat out of the goodness of his heart but for his own benefit.” Doctors are different. We became doctors for altruistic reasons. We are entitled to earn a living compatible with years of training and complexity of service. But even Smith’s butcher will get sick and need care.

As we all will need medical care, our commitment renders health care a right and not a privilege. Because they depend on us, patients would become our natural allies, many of whom cannot afford insurance. Currently, their saving grace is EMTALA (Emergency Medical Treatment and Active Labor Act, passed in 1986.) EMTALA obligates hospitals to provide care to patients who come into their emergency departments and require treatment. The question is how to pay for it. Ewe Rinehart, the late eminent medical economist, wrote that “There are only two repositories for money in health care: private insurance or the government.” Some legislators have advocated creating Health Savings Account. They work fine if you’re not sick and have plenty of money. But if you don’t, they won’t solve the problem since hospital costs are enormous and lack consistency and transparency. A trip to the ED will run over $10,000 after several CT scans are factored in. Let alone exorbitant facility fees. Heaven forbid you

need chemotherapy which will render a wealthy person penniless. Capitalism — when applied to healthcare — clearly is not working. Health care insurance companies, private equity firms, for-profit hospital chains and organizations that place profit over patients have not demonstrated cost savings or improved outcomes. There is too much entropy (bureaucracy) in the system. Perhaps expanding Medicare and allowing patients to buy into it at a younger age is an alternative. At least taxpayers and voters maintain some control. Medicare works well, although CMS has tended to ignore physicians over the last 26 years while generously subsidizing Medicare Advantage Plans. (Medicare is attempting to recover overpayments to Medicare Advantage Plans “soon.”) At the Interim Meeting of the American Medical Association in November 2025, Mehmet Oz, Director of Medicare/ Medicaid Services, requested more physician involvement in the process

of solving this crisis. He proposed an alternative to insurance companies: the formation of Accountable Care Organizations, a collaboration between doctors and hospitals. Since we are the only two with direct patient contact and understanding of patients’ needs, we would be natural allies. To be successful, doctors will have to demonstrate the ability to regulate large institutions and assert leadership. We will have to be stewards of the profession and curb excessive care. Cognizant of medical necessity, doctors can exercise that function without harming patients. Physicians have become docile, often complacent, and reluctant to criticize harmful policies. It will be a painful transition, but doctors retain an attribute which corporatized medicine lacks: integrity. History appears to be providing physicians with an opportunity to reclaim our profession. The nation and the patients are waiting.

Vascular Specialist | July/August 2026

CLINICAL&DEVICENEWS Imperative Care releases findings from latest analysis of SYMPHONY-PE trial DATA FROM A POST-HOCK ANALYSIS OF of the SYMPHONY-PE trial have been released, according to a release from Imperative Care. The trial is evaluating the effect of early mechanical thrombectomy in patients with intermediate-risk pulmonary embolism (PE). Data from the analysis showed that treating patients within 12 hours of diagnosis may be associated with greater improvement in acute hemodynamic and right ventricle measures compared to treatment after 12 hours, with similar safety outcomes between groups.

Compiled by Killian Meara

“While thrombectomy can be beneficial for patients with intermediate-risk PE regardless of when it is performed after diagnosis, data from the SYMPHONY-PE trial add to the growing body of observational evidence suggesting that earlier catheter-based intervention may accelerate cardiac recovery, as reflected by greater reductions in right ventricleto-left ventricle ratio and mean pulmonary artery pressure,” said Sripal Bangalore, MD, lead author of the paper, in a release. “Randomized controlled trials are desirable to determine optimal treatment timing and to identify whether patients with certain risk factors are more likely to benefit from early intervention than others.” The SYMPHONY-PE trial was an IDE study conducted at 17 sites across the United States that formed the basis for Symphony’s FDA clearance to treat PE in August 2025. Results of were published in the November 2025 issue of Circulation: Cardiovascular Interventions. In the trial, mean pulmonary artery pressure decreased more in patients receiving early thrombectomy. These

“Randomized controlled trials are desirable to determine optimal treatment timing and to identify whether patients with certain risk factors are more likely to benefit from early intervention than others.” patients also experienced a larger reduction in right ventricleto-left ventricle ratio from baseline to 48 hours. Additionally, differences in efficacy outcomes were greatest in higher-risk patients as assessed by the Composite Pulmonary Embolism Shock (CPES) score. Imperative also announced in the release that over 500 PE patients in the U.S. have been treated with the Symphony Thrombectomy System, reflecting growing physician adoption since it became available in September 2025.

FDA CLEARS PENUMBRA’S THUNDERBOLT CAVT THE UNITED STATES FOOD AND DRUG Administration (FDA) has provided clearance to the Thunderbolt computer assisted vacuum thrombectomy (CAVT) technology for acute ischemic stroke, Penumbra announced in a release. Thunderbolt is powered by the Penumbra Engine and adds modulated aspiration to the company’s neuro thrombectomy portfolio. The system uses CAVT technology designed

to detect, fatigue and remove clot at the site of occlusion and is currently the only CAVT device cleared for stroke treatment in the US. The device will come pre-packaged with one of Penumbra’s catheters: Red 62, Red 68, Red 72 Silver Label or RED 72 Silver Label with SENDit technology. “Modulated aspiration may facilitate more consistent and complete clot removal when used in conjunction with standard aspira-

Cook’s steerable guiding sheath now available in US

FDA approves vascular closure device from CyndRx

THE VOLANTE STEERABLE GUIDING SHEATH now commercially available to physicians in the United States and other select global markets, Cook Medical announced in a release. The device aims to help clinicians reach challenging anatomy without the need for multiple sheath exchanges, making procedures easier and more predictable. Volante is a steerable sheath available in five lengths and six French sizes to accommodate different procedural approaches. It includes a radiopaque tip for fluoroscopic visibility, a selflocking knob to maintain the selected angle and braided Flexsteer shaft technology designed to provide greater precision and control during procedures. “Adding Volante to our portfolio adds to our goal of having every tool physicians need to complete these procedures,” said Mark Breedlove, senior vice president of Cook Medical’s Vascular division, in a release. “Paired with access essentials like our Coda Balloon Catheter and Indy Snare, Volante streamlines cases, helping reduce procedure time and improving the overall experience for clinicians and patients alike.”

THE UNITED STATES FOOD AND DRUG Administration (FDA) has approved the AbsorbaSeal vascular closure device for acute arterial access site closure following catheter-based procedures, CyndRx announced in a release. AbsorbaSeal is designed to reduce procedural complexity and provide a patient-friendly solution that avoids the use of permanent and collagen-based implants. The company said it is currently working with other stakeholders to support broader adoption for procedures requiring femoral arterial access. “As a clinical investigator in the SEAL TO HEAL trial, I saw AbsorbaSeal deliver on the priorities that matter most to interventionists regarding vascular access closure: reliable hemostasis, early ambulation, and no permanent implant left behind,” said Vishal Gupta, MD, MPH, professor of clinical medicine at Western Michigan University. “I believe AbsorbaSeal has the potential to set a new benchmark for femoral access closure, benefiting patients, operators, and health systems alike.”

tion thrombectomy catheters,” said David Fiorella, MD, PhD, director of the Cerebrovascular Center at Stony Brook University Hospital, in a release. “Our early experience with Thunderbolt within the context of the trial, suggests that this technology will meaningfully change how we approach stroke treatment and could substantively improve outcomes in patients with emergent large vessel occlusion.”

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IMPORTANT SAFETY INFORMATION Esprit™ BTK Everolimus Eluting Resorbable Scaffold System INDICATIONS The Esprit™ BTK Everolimus Eluting Resorbable Scaffold System is indicated for improving luminal diameter in infrapopliteal lesions in patients with chronic limb-threatening ischemia (CLTI) and total scaffolding length up to 170 mm with a reference vessel diameter of ≥ 2.5 mm and ≤ 4.00 mm. CONTRAINDICATIONS The Esprit™ BTK Everolimus Eluting Resorbable Scaffold System is contraindicated for use in: • Patients who cannot tolerate, including allergy or hypersensitivity to, procedural anticoagulation or the post-procedural antiplatelet regimen. • Patients with hypersensitivity or contraindication to everolimus or structurally related compounds or known hypersensitivity to scaffold components poly(L-lactide), poly(D, L-lactide), and platinum. WARNINGS • This device is intended for single use only. Do not reuse, reprocess, or re-sterilize. Note the product “Use-by” date on the package. Reuse, reprocessing, or re-sterilization may compromise the structural integrity of the device and / or delivery system and / or lead to device failure, which may result in patient injury, illness, or death. Reuse, reprocessing, or resterilization may also create a risk of contamination of the device and / or cause patient infection or cross-infection, including, but not limited to, the transmission of infectious disease(s) from one patient to another. Contamination of the device and / or delivery system may lead to injury, illness, or death of the patient. • The Esprit™ BTK System is intended to perform as a system. The scaffold should not be removed for use with other dilatation catheters. • The Esprit™ BTK System should not be used in conjunction with other non-everolimus drug eluting devices in the same vessel as the Esprit™ BTK Scaffold. • It is not recommended to use this scaffold to treat lesions located at any joint or other hinge points, such as the knee or ankle. The recommended region for below-the-knee (BTK) treatment with the Esprit™ BTK Scaffold is the infrapopliteal arteries at a location ≥ 10 cm above the proximal margin of the ankle mortise. The Esprit™ BTK Scaffold has not been tested for use outside the recommended implant locations. • This product should not be used in patients with aneurysms immediately adjacent to the scaffold implantation site. • Insertion of the Esprit™ BTK System and implantation of the scaffold should be performed only under fluoroscopic observation with radiographic equipment providing high resolution images. • Quantitative imaging is strongly recommended to accurately measure and confirm appropriate vessel sizing (reference vessel diameter ≥ 2.5 mm). If quantitative imaging determines a vessel size < 2.5 mm, do not implant the Esprit™ BTK Scaffold. • Adequate lesion preparation prior to scaffold implantation is required to ensure safe delivery of the scaffold across the target lesion. It is not recommended to treat patients having a lesion that prevents complete inflation of an angioplasty balloon. • Successful pre-dilatation with residual diameter stenosis of < 30% by visual estimation is required for treatment of the target lesion; < 20% by visual estimation is preferred. • Ensure the scaffold is not post-dilated beyond the allowable expansion limits. • Use of appropriate anticoagulant and / or antiplatelet therapy per standard of care is recommended for use of this scaffold system. • This product should not be used in patients who are not likely to comply with the recommended antiplatelet therapy. • Judicious selection of patients is necessary, since the use of this device carries the associated risk of scaffold thrombosis, vascular complications, and / or bleeding events.

PRECAUTIONS • Scaffold placement should not be performed in patients with known allergies to contrast agent that cannot be medically managed. • It is not recommended to treat patients having a lesion with excessive tortuosity proximal to or within the lesion. • When multiple scaffolds are required, only combinations of Esprit™ BTK Scaffolds must be used. Any potential interaction with other drugeluting or coated devices has not been evaluated. • The delivery system is intended for deployment of the scaffold only and should not be used to dilate other locations. • Implantation of the scaffold should be performed only by physicians who have received appropriate training. • As with all catheter-based procedures, scaffold placement should be performed at facilities where patient can be prepared for necessary intervention and / or surgical removal of the device and vessel repair as per facility protocol. • Pre-dilatation should be performed with an angioplasty balloon. Cutting or scoring balloons can be used per physician discretion, if the lesion appears to be mildly calcified. • Failure to pre-dilate the vessel may impair nominal / optimal scaffold delivery. • Implanting a scaffold may lead to dissection of the vessel distal and / or proximal to the scaffold, requiring additional intervention. Note: In cases of bailouts, bailout treatment of the target lesion can be done using the Esprit™ BTK Scaffold of the appropriate length. If an appropriate length Esprit™ BTK Scaffold is not available, physicians should use standard of care. • An unexpanded scaffold may be retracted into the introducer sheath one time only. An unexpanded scaffold should not be reintroduced into the artery once it has been pulled back into the introducer sheath. • Post-dilatation is strongly recommended for optimal scaffold apposition. When performed, post-dilatation should be performed at high pressure (> 16 atm) with a non-compliant balloon up to 0.5 mm larger than the nominal scaffold diameter. • Use an appropriately sized non-drug coated balloon to pre-dilate the lesion. When treating a long lesion, scaffold the distal portion of the lesion prior to scaffolding the proximal portion of the lesion. • Ensure that the scaffolded area covers the entire lesion / dissection site and that no gaps exist between scaffolds. • The extent of the patient’s exposure to drug and polymer is directly related to the number of scaffolds implanted. The safety of everolimus, polymer, and polymer breakdown products was evaluated in preclinical studies and the biocompatibility assessment of the Esprit™ BTK Scaffold. • The safety and effectiveness of the Esprit™ BTK Scaffold in patients with prior brachytherapy of the target lesion or the use of brachytherapy for treatedsite restenosis in the Esprit™ BTK Scaffold have not been established. Both vascular brachytherapy and the Esprit™ BTK Scaffold alter arterial modeling. The potential combined effect on arterial remodeling by these two treatments is not known. • The safety and effectiveness of the Esprit™ BTK System have not been established in clinical trials with the use of either mechanical atherectomy devices (directional atherectomy catheters, rotational atherectomy catheters) or laser atherectomy catheters. • Formal drug interaction studies have not been performed with the Esprit™ BTK Scaffold because of limited exposure to everolimus eluted from the scaffold. • Everolimus, the Esprit™ BTK Scaffold’s active pharmaceutical ingredient, is an immunosuppressive agent. Therefore, consideration should be given to patients taking other immunosuppressive agents or who are at risk for immune suppression. • Oral everolimus use in renal transplant and advanced renal cell carcinoma patients was associated with increased serum cholesterol and triglyceride levels, which in some cases required treatment.

• Non-clinical testing has demonstrated the Esprit™ BTK Scaffold is MR Conditional. A person with the Esprit™ BTK Scaffold may be safely scanned under the following conditions. Failure to follow these conditions may result in injury. • Static magnetic field strength of 7 Tesla or less • The Esprit™ BTK Scaffold should not migrate in this MRI environment. MRI at 7 Tesla or less may be performed immediately following the implantation of the Esprit™ BTK Scaffold. POTENTIAL ADVERSE EVENTS Potential adverse events include, but are not limited to: Allergic reaction or hypersensitivity to contrast agent, anesthesia, scaffold materials (poly[L-lactide] [PLLA], poly[D, L-lactide] [PDLLA], platinum, or everolimus), and drug reactions to anticoagulation or antiplatelet drugs • Vascular access complications which may require transfusion or vessel repair, including: • Catheter site reactions • Bleeding (ecchymosis, oozing, hematoma, hemorrhage, retroperitoneal hemorrhage) • Arteriovenous fistula, pseudoaneurysm, aneurysm, dissection, perforation / rupture, and laceration • Embolism (air, tissue, plaque, thrombotic material, or device) • Peripheral ischemia • Target artery complications which may require additional intervention, including: • Total occlusion or abrupt closure • Arteriovenous fistula, pseudoaneurysm, aneurysm, dissection, perforation / rupture • Embolism (air, tissue, plaque, thrombotic material, or device) • Artery or scaffold thrombosis • Stenosis or restenosis • Vasospasm • Tissue prolapse / plaque shift • Bleeding (non-access site) • Additional surgery such as peripheral artery bypass graft surgery or amputation • Peripheral nerve injury, neuropathy • Compartment syndrome • Tissue necrosis, gangrene, ulcer and acute limb ischemia • Reperfusion injury • New or worsening pain • Intervention due to • Damaged scaffolds • Partial scaffold deployment • Scaffold migration / unintentional placement of scaffold • Other general surgical risks, including: • Cardiac arrhythmias (including conduction disorders, atrial and ventricular arrhythmias, and blocks) • Stroke / cerebrovascular accident (CVA) and transient ischemic attack (TIA) • Venous thromboembolism (including pulmonary embolism) • Nausea and vomiting • Hypotension / hypertension • Infection – local and systemic (including postprocedural) • Fever • Blood cell disorders including heparininduced thrombocytopenia (HIT) and other coagulopathy • Death • System organ failures: • Cardiac Failure • Cardio-respiratory arrest (including pulmonary edema) • Respiratory failure • Renal failure • Shock

CAUTION: This material is intended for use with healthcare professionals. Product(s) included are intended for use by or under the direction of a physician. Prior to use, reference the Instructions for Use, inside the product carton (when available), at manuals.eifu.abbott for more detailed information on Indications, Contraindications, Warnings, Precautions and Adverse Events. Illustrations are artist’s representations only and should not be considered as engineering drawings or photographs. Information contained herein for DISTRIBUTION in the U.S. ONLY. Abbott 3200 Lakeside Dr., Santa Clara, CA 95054 USA, Tel: 1.800.227.9902 ™ Indicates a trademark of the Abbott Group of Companies. www.cardiovascular.abbott ©2026 Abbott. All rights reserved. MAT-2602109 v1.0

The risks described below include the anticipated adverse events referenced in the contraindications, warnings, and precautions sections of the everolimus labels / SmPCs and / or observed at incidences ≥ 10% in clinical trials with oral everolimus for different indications. Refer to the drug SmPCs and labels for more detailed information and less frequent adverse events. • Abdominal pain • Anemia • Angioedema (increased risk with concomitant angiotensin-converting enzyme [ACE] inhibitor use) • Arterial thrombotic events • Bleeding and coagulopathy (including hemolytic uremic syndrome [HUS], thrombotic thrombocytopenic purpura [TTP], and thrombotic microangiopathy; increased risk with concomitant cyclosporine use) • Constipation • Cough • Diabetes mellitus • Diarrhea • Dyspnea • Embryo-fetal toxicity • Erythema • Erythroderma • Headache • Hepatic artery thrombosis (HAT) • Hepatic disorders (including hepatitis and jaundice) • Hypersensitivity to everolimus active substance, or to other rapamycin derivates • Hypertension • Infections (bacterial, viral, fungal, or protozoan infections, including infections with opportunistic pathogens). Polyoma virus-associated nephropathy (PVAN), JC virus-associated progressive multiple leukoencephalopathy (PML), fatal infections and sepsis have been reported in patients treated with oral everolimus. • Kidney arterial and venous thrombosis • Laboratory test alterations (elevations of serum creatinine, proteinuria, hypokalemia, hyperkalemia; hyperglycemia, dyslipidemia including hypercholesterolemia and hypertriglyceridemia; abnormal liver function tests; decreases in hemoglobin, lymphocytes, neutrophils, and platelets) • Lymphoma and skin cancer • Male infertility • Menstrual irregularities • Nausea • Nephrotoxicity (in combination with cyclosporine) • Non-infectious pneumonitis (including interstitial lung disease) • Oral ulcerations • Pain • Pancreatitis • Pericardial effusion • Peripheral edema • Pleural effusion • Pneumonia • Pyrexia • Rash • Renal failure • Upper respiratory tract infection • Urinary tract infection • Venous thromboembolism • Vomiting • Wound healing complications (including wound infections and lymphocele) There may be other potential adverse events that are unforeseen at this time.

Now Proven With 3-year RCT Data

The scaffold is gone, but the benefit remains As the first-and-only FDA-approved drug-eluting resorbable scaffold for below the knee, the Esprit™ BTK System demonstrated sustained efficacy over balloon angioplasty through 3 years while maintaining its safety profile, as proven by the findings of the LIFE-BTK Study. 90% of Esprit™ BTK patients did not require reintervention through 3 years*1 Superior efficacy at 1 year, sustained benefits through 3 years1,2

Elevate your CLTI treatment strategy * Reintervention as defined by Clinically Driven Target Lesion Revascularization. 1. Parikh, S., et al. Long-Term Outcomes of the Esprit BTK Scaffold Versus Angioplasty in Infrapopliteal Chronic Limb-threatening Ischemia: 3-Year Results from the LIFE-BTK Trial; TCT 2025. 2. Varcoe, RL., et al. Drug-Eluting Resorbable Scaffold versus Angioplasty for Infrapopliteal Artery Disease. N Eng J Med 2024;390:9-19. INDICATIONS The Esprit™ BTK Everolimus Eluting Resorbable Scaffold System is indicated for improving luminal diameter in infrapopliteal lesions in patients with chronic limb-threatening ischemia (CLTI) and total scaffolding length up to 170 mm with a reference vessel diameter of ≥ 2.5 mm and ≤ 4.00 mm.