Audible Bleeding

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

Articles:

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

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

Show Guests:

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

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

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

Faculty Guest:

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

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

For more information on the CLariTI Study, click here.

Patient Guests: (Shared with consent)

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

Deep Venous Arterialization References:

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

Twitter:

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

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

 Articles:

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

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

Show Guests:

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

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

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

 Additional Notes:

• Vascular Low Frequency Disease Consortium Website 

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

• The VEDS Collaborative research study is still enrolling! Any patient interested in enrolling should reach out to [email protected] and follow @VEDSCollabo and @OHSUvascular on Twitter.

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

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

 Follow us @audiblebleeding

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

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

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

Contact Information for Dr. Daniel Silverberg

Email: [email protected]

Twitter:

Dr. Gowri Gowda (@GowriGowda11)

Dr. Ezra Schwartz (@ezraschwartz10)

Dr. Morgan Gold (@MorganSGold)

Articles, resources, and societies referenced in the episode:

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

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

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

Follow us @AudibleBleeding

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

Endovascular 101

Authors:

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

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

Editor: Yasong Yu

Reviewers: Matt Chia and Kirthi Bellamkonda

Core Resources:

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

Additional Resources:

• Relevant Audible Bleeding episodes

• • Holding Pressure Case Prep - AKA/BKA

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

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

• Closure devices: 

• • Angioseal

  • Mynx

  • Proglide

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

Endovascular procedures can be broken down into 4 key steps

1. Establishing arterial access

2. Navigating to target treatment zone or vessel

3. Treating the lesion

4. Closure

Basic definition of wire, sheaths, and catheters

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

• • A 0.018 wire is 0.018 inch in diameter

  • There are two categories of wires: Flexible and support

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

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

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

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

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

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

  • They are inserted inside the sheath 

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

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

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

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

Sheaths and catheters sizing

• Both are measured in French

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

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

  • Sheaths are defined by their inner diameter (ID)

  • Catheters are defined by their outer diameter (OD)

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

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

Step One: Establishing Arterial Access

• Preop preparation: 

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

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

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

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

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

• How do you choose arterial access, location?

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

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

  • The most common is retrograde femoral artery access

  • When would other access points be used?

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

• Arterial puncture

• • Femoral access:

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

    • Usually access

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

Links:

Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia

Comprehensive List of BEST-CLI Literature

Show Guests:

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

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

Follow us @AudibleBleeding

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

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

Articles:

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

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

Show Guests:

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

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

Follow us @audiblebleeding

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

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

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

Author + Host:

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

We are calling all medical students!

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

Include the following

• Your name, school, and year

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

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

Please share your feedback through our

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

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

Show Guests:

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

Show Links:

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

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

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

Show Guests:

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

Show Links:

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