Audible Bleeding

Audible Bleeding is a resource for trainees and practicing vascular surgeons, focusing on interviews with leaders in the field, board preparation, and dissemination of best clinical practices and high impact innovations in vascular surgery.

JVS Author Spotlight - Roy, Csore, and Rahimi 02/02/2025

JVS CIT Editorials and Abstracts - Dec 2024/Jan 2025 01/27/2025

JVS Author Spotlight - Schermerhorn, Sanders, Cox and Tsukagoshi 01/12/2025

Holding Pressure: AV Fistula/Graft Complications Part 1 01/06/2025

Holding Pressure: AV Fistula/Graft Complications Part 1 Guest: Dr. Christian de Virgilio is the Chair of the Department of Surgery at Harbor-UCLA Medical Center. He is also Co-Chair of the College of Applied Anatomy and a Professor of Surgery at UCLA's David Geffen School of Medicine. He completed his undergraduate degree in Biology at Loyola Marymount University and earned his medical degree from UCLA. He then completed his residency in General Surgery at UCLA-Harbor Medical Center followed by a fellowship in Vascular Surgery at the Mayo Clinic. Resources: Rutherford Chapters (10th ed.): 174, 175, 177, 178 Prior Holding Pressure episode on AV access creation: The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: Outline: Steal Syndrome Definition & Etiology Steal syndrome is an important complication of AV access creation, since access creation diverts arterial blood flow from the hand. Steal can be caused by multiple factors—arterial occlusive disease proximal or distal to the AV anastomosis, high flow through the fistula at the expense of distal arterial perfusion, and failure of the distal arterial networks to adapt to this decreased blood flow. Incidence and Risk Factors The frequency of steal syndrome is 1.6-9%1,2, depending on the vessels and conduit choice Steal syndrome is more common with brachial and axillary artery-based accesses and nonautogenous conduits. Other risk factors for steal syndrome are peripheral vascular disease, coronary artery disease, diabetes, advanced age, female sex, larger outflow conduit, multiple prior permanent access procedures, and prior episodes of steal.3,4 Long-standing insulin-dependent diabetes causes both medial calcinosis and peripheral neuropathy, which limits arteries’ ability to vasodilate and adjust to decreased blood flow. Patient Presentation, Symptoms, Grading Steal syndrome is diagnosed clinically. Symptoms after AVG creation occurs within the first few days, since flow in prosthetic grafts tend to reach a maximum value very early after creation. Native AVFs take time to mature and flow will slowly increase overtime, leading to more insidious onset of symptoms that can take months or years. The patient should have a unilateral complaint in the extremity with the AV access. Symptoms of steal syndrome, in order of increasing severity, include nail changes, occasional tingling, extremity coolness, numbness in fingertips and hands, muscle weakness, rest pain, sensory and motor deficits, fingertip ulcerations, and tissue loss. There could be a weakened radial pulse or weak Doppler signal on the affected side, and these will become stronger after compression of the AV outflow. Symptoms are graded on a scale specified by Society of Vascular Surgery (SVS) reporting standards:5 Workup Duplex ultrasound can be used to analyze flow volumes. A high flow volume (in autogenous accesses greater than 800 mL/min, in nonautogenous accesses greater than 1200 mL/min) signifies an outflow issue. The vein or graft is acting as a pressure sink and stealing blood from the distal artery. A low flow volume signifies an inflow issue, meaning that there is a proximal arterial lesion preventing blood from reaching the distal artery. Upper extremity angiogram can identify proximal arterial lesions. Prevention Create the AV access as distal as possible, in order to preserve arterial inflow to the hand and reduce the anastomosis size and outflow diameter. SVS guidelines recommend a 4-6mm arteriotomy diameter to balance the need for sufficient access flow with the risk of steal. If a graft is necessary, tapered prosthetic grafts are sometimes used in patients with steal risk factors, using the smaller end of the graft placed at the arterial anastomosis, although this has not yet been proven to reduce the incidence of steal. Indications for Treatment Intervention is recommended in lifestyle-limiting cases of Grade II and all Grade III steal cases. If left untreated, the natural history of steal syndrome can result in chronic limb ischemia, causing gangrene with loss of digits or limbs. Treatment Options Conservative management relies on observation and monitoring, as mild cases of steal syndrome may resolve spontaneously. Inflow stenosis can be treated with endovascular intervention (angioplasty with or without stent) Ligation is the simplest surgical treatment, and it results in loss of the AV access. This is preferred in patients with repetitive failed salvage attempts, venous hypertension, and poor prognoses. Flow limiting procedures can address high volumes through the AV access. Banding can be performed with surgical cutdown and placement of polypropylene sutures or a Dacron patch around the vein or graft. The Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) technique employs a percutaneous endoluminal balloon inflated at the AVF to ensure consistency in diameter while banding Plication is when a side-biting running stitch is used to narrow lumen of the vein near the anastomosis. A downside of flow-limiting procedures is that it is often difficult to determine how much to narrow the AV access, as these procedures carry a risk of outflow thrombosis. There are also surgical treatments focused on reroute arterial inflow. The distal revascularization and interval ligation (DRIL) procedure involves creation of a new bypass connecting arterial segments proximal and distal to the AV anastomosis, with ligation of the native artery between the AV anastomosis and the distal anastomosis of the bypass. Reversed saphenous vein with a diameter greater than 3mm is the preferred conduit. Arm vein or prosthetic grafts can be used if needed, but prosthetic material carries higher risk of thrombosis. The new arterial bypass creates a low resistance pathway that increases flow to distal arterial beds, and interval arterial ligation eliminates retrograde flow through the distal artery. The major risk of this procedure is bypass thrombosis, which results in loss of native arterial flow and hand ischemia. Other drawbacks of DRIL include procedural difficulty with smaller arterial anastomoses, sacrifice of saphenous or arm veins, and decreased fistula flow. Another possible revision surgery is revision using distal inflow (RUDI). This procedure involves ligation of the fistula at the anastomosis and use of a conduit to connect the outflow vein to a distal artery. The selected distal artery can be the proximal radial or ulnar artery, depending on the preoperative duplex. The more dominant vessel should be spared, allowing for distal arterial beds to have uninterrupted antegrade perfusion. The nondominant vessel is used as distal inflow for the AV access. RUDI increases access length and decreases access diameter, resulting in increased resistance and lower flow volume through the fistula. Unlike DRIL, RUDI preserves native arterial flow. Thrombosis of the conduit would put the fistula at risk, rather than the native artery. The last surgical revision procedure for steal is proximalization of arterial inflow (PAI). In this procedure, the vein is ligated distal to the original anastomosis site and flow is re-established through the fistula with a PTFE interposition graft anastomosed end-to-side with the more proximal axillary artery and end-to-end with the distal vein. Similar to RUDI, PAI increases the length and decreases the diameter of the outflow conduit. Since the axillary artery has a larger diameter than the brachial artery, there is a less significant pressure drop across the arterial anastomosis site and less steal. PAI allows for preservation of native artery’s continuity and does not require vein harvest. Difficulties with PAI arise when deciding the length of the interposition graft to balance AV flow with distal arterial flow. 2. Ischemic Monomelic Neuropathy Definition Ischemic monomelic neuropathy (IMN) is a rare but serious form of steal that involves nerve ischemia. Severe sensorimotor dysfunction is experienced immediately after AV access creation. Etiology IMN affects blood flow to the nerves, but not the skin or muscles because peripheral nerve fibers are more vulnerable to ischemia. Incidence and Risk Factors IMN is very rare; it has an estimated incidence of 0.1-0.5% of AV access creations.6 IMN has only been reported in brachial artery-based accesses, since the brachial artery is the sole arterial inflow for distal arteries feeding all forearm nerves. IMN is associated with diabetes, peripheral vascular disease, and preexisting peripheral neuropathy that is associated with either of the conditions. Patient Presentation Symptoms usually present rapidly, within minutes to hours after AV access creation. The most common presenting symptom is severe, constant, and deep burning pain of the distal forearm and hand. Patients also report impairment of all sensation, weakness, and hand paralysis. Diagnosis of IMN can be delayed due to misattribution of symptoms to anesthetic blockade, postoperative pain, preexisting neuropathy, a heavily bandaged arm precluding neurologic examination. Treatment Treatment is immediate ligation of the AV access. Delay in treatment will quickly result in permanent sensorimotor loss. 3. Perigraft Seroma Definition A perigraft seroma is a sterile fluid collection surrounding a vascular prosthesis and is enclosed within a pseudomembrane. Etiology and Incidence Possible etiologies include: transudative movement of fluid through the graft material, serous fluid collection from traumatized connective tissues (especially the from higher adipose tissue content in the upper arm), inhibition of fibroblast growth with associated failure of the tissue to incorporate the graft, graft “wetting” or kinking during initial operation, increased flow rates, decreased hematocrit causing oncotic pressure difference, or allergy to graft material. Seromas most commonly form at anastomosis sites in the early postoperative period. Overall seroma incidence rates after AV graft placement range from 1.7–4% and are more common in grafts placed in the upper arm (compared to the forearm) and Dacron grafts (compared to PTFE grafts).7-9 Patient Presentation and Workup Physical exam can show a subcutaneous raised palpable fluid mass Seromas can be seen with ultrasound, but it is difficult to differentiate between the types of fluid around the graft (seroma vs. hematoma vs. abscess) Indications for Treatment Seromas can lead to wound dehiscence, pressure necrosis and erosion through skin, and loss of available puncture area for hemodialysis Persistent seromas can also serve as a nidus for infection. The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines10 recommend a tailored approach to seroma management, with more aggressive surgical interventions being necessary for persistent, infected-appearing, or late-developing seromas. Treatment The majority of early postoperative seromas are self-limited and tend to resolve on their own Persistent seromas have been treated using a variety of methods-- incision and evacuation of seroma, complete excision and replacement of the entire graft, and primary bypass of the involved graft segment only. Graft replacement with new material and rerouting through a different tissue plane has a higher reported cure rate and lower rate of infection than aspiration alone.9 4. Infection Incidence and Etiology The reported incidence of infection ranges 4-20% in AVG, which is significantly higher than the rate of infection of 0.56-5% in AVF.11 Infection can occur at the time of access creation (earliest presentation), after cannulation for dialysis (later infection), or secondary to another infectious source. Infection can also further complicate a pre-existing access site issue such as infection of a hematoma, thrombosed pseudoaneurysm, or seroma. Skin flora from frequent dialysis cannulations result in common pathogens being Staphylococcus, Pseudomonas, or polymicrobial species. Staphylococcus and Pseudomonas are highly virulent and likely to cause anastomotic disruption. Patient Presentation and Workup Physical exam will reveal warmth, pain, swelling, erythema, induration, drainage, or pus. Occasionally, patients have nonspecific manifestations of fever or leukocytosis. Ultrasound can be used to screen for and determine the extent of graft involvement by the infection. Treatments In AV fistulas: Localized infection can usually be managed with broad spectrum antibiotics. If there are bleeding concerns or infection is seen near the anastomosis site, the fistula should be ligated and re-created in a clean field. In AV grafts: If infection is localized, partial graft excision is acceptable. Total graft excision is recommended if the infection is present throughout the entire graft, involves the anastomoses, occludes the access, or contains particularly virulent organisms Total graft excision may also be indicated if a patient develops recurrent bacteremia with no other infectious source identified. For graft excision, the venous end of the graft is removed and the vein is oversewn or ligated. If the arterial anastomosis is intact, a small cuff of the graft can be left behind and oversewn. If the arterial anastomosis is involved, the arterial wall must be debrided and ligation, reconstruction with autogenous patch angioplasty, or arterial bypass can be pursued. References 1. Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. Incidence and Characteristics of Patients with Hand Ischemia after a Hemodialysis Access Procedure. J Surg Res. 1998;74(1):8-10. doi:10.1006/jsre.1997.5206 2. Ballard JL, Bunt TJ, Malone JM. Major complications of angioaccess surgery. Am J Surg. 1992;164(3):229-232. doi:10.1016/S0002-9610(05)81076-1 3. Valentine RJ, Bouch CW, Scott DJ, et al. Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis. J Vasc Surg. 2002;36(2):351-356. doi:10.1067/mva.2002.125848 4. Malik J, Tuka V, Kasalova Z, et al. Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies. J Vasc Access. 2008;9(3):155-166. doi:10.1177/112972980800900301 5. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg. 2002;35(3):603-610. doi:10.1067/mva.2002.122025 6. Thermann F, Kornhuber M. Ischemic Monomelic Neuropathy: A Rare but Important Complication after Hemodialysis Access Placement - a Review. J Vasc Access. 2011;12(2):113-119. doi:10.5301/JVA.2011.6365 7. Dauria DM, Dyk P, Garvin P. Incidence and Management of Seroma after Arteriovenous Graft Placement. J Am Coll Surg. 2006;203(4):506-511. doi:10.1016/j.jamcollsurg.2006.06.002 8. Gargiulo NJ, Veith FJ, Scher LA, Lipsitz EC, Suggs WD, Benros RM. Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas. J Vasc Surg. 2008;48(1):216-217. doi:10.1016/j.jvs.2008.01.046 9. Blumenberg RM, Gelfand ML, Dale WA. Perigraft seromas complicating arterial grafts. Surgery. 1985;97(2):194-204. 10. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164. doi:10.1053/j.ajkd.2019.12.001 11. Padberg FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg. 2008;48(5):S55-S80. doi:10.1016/j.jvs.2008.08.067 /episode/index/show/audiblebleeding/id/34730655

The Art and Science of Leadership - An Introduction to the SVS Leadership Development Program 12/23/2024

The Art and Science of Leadership - An Introduction to the SVS Leadership Development Program In this special series, core faculty members of the , Dr. Manuel Garcia-Toca, Dr. Kenneth Slaw, and Steve Robischon, discuss the program origins, research regarding good leadership, and how to join. Manuel Garcia-Toca, MD completed his MD at the Universidad Anahuac in Mexico (1999) and MS in Health Policy at Stanford University (2020). Dr. Garcia-Toca completed his residency in General Surgery at Brown University (2008) and a fellowship in Vascular Surgery at Northwestern University (2010). He will serve within the Department of Surgery in the Division of Vascular Surgery and Endovascular Therapy and the Division of Emory Surgery at Grady based primarily at Grady Memorial Hospital. Kenneth Slaw, PhD is the executive director of the Society for Vascular Surgeons. Dr. Slaw received his master's and doctoral degrees in educational psychology from the University of Illinois. He has over 35 years of executive leadership experience in the medical society and philanthropic communities, having served in numerous previous roles, including as president of the American Association of Medical Society Executives, as chairman of the board of Make A Wish Illinois, and as senior staff member at the Academy of Pediatrics, where he assisted in efforts with the Pediatric Leadership Alliance Program, which has provided leadership skill building sessions for approximately 3, 000 physicians. Steve Robischon, PA-C is a Physician Assistant with the Division of Vascular and Endovascular Surgery at the Medical College of Wisconsin in Milwaukee, Wisconsin, and is also a member of the PA Section Steering Committee. More about the More about the Follow us Learn more about us at and provide us with your feedback with our . *Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device. /episode/index/show/audiblebleeding/id/34574960

JVS CIT Editorials and Abstracts - Oct/Nov 2024 12/15/2024

JVS Author Spotlight - Mota, Liang and Weinkauf 12/08/2024

Get a Pulse on PAD Campaign 11/24/2024

Get a Pulse on PAD Campaign Nishi Vootukuru () and Dr. Ezra Schwartz () interview Dr. and Dr. () to discuss the Get a Pulse on PAD Campaign. The initiative (#PulseonPAD), launched in February, 2024, is a patient education and advocacy campaign designed to increase the understanding of peripheral artery disease's risk factors and potential symptoms. Dr. Shutze is a vascular surgeon with Texas Vascular Associates in Dallas, Texas and the Secretary of the SVS. Dr. Shutze completed his medical studies at Baylor University after completing general surgery residency at University of Alabama in Birmingham. Dr. Shutze returned to Baylor to complete his vascular fellowship. Dr. Shutze is one of the Get a Pulse on PAD initiative’s chairs and a leading expert in PAD. He has actively published in the field with over 100 abstracts and articles, with his most recent work focusing on prosthetics, and advocating for successful prosthetic referral after amputation. Dr. Dua is a vascular surgeon at Mass General Hospital and associate professor at Harvard Medical School. At Mass General, she is the director of the Vascular Lab, co-director of the Peripheral Artery Disease Center and Limb Evaluation and Amputation Program (LEAPP), associate director of the Wound Care Center, director of the Lymphedema Center and director of clinical research for the division of vascular surgery. She serves as the Editor-in-Chief of Journal of Vascular Surgery-Vascular Insights. Dr. Dua completed her undergraduate medical studies at the Aberdeen University School of Medicine in Aberdeen, Scotland. She then completed her general surgery residency at the Medical College of Wisconsin and vascular fellowship at Stanford University Hospital. She holds multiple master’s degrees including degrees in trauma sciences and business administration in healthcare management. She also completed certificate programs at the Massachusetts Institute of Technology in health economics and outcomes research as well as in drug and device development. Dr. Dua is a prolific researcher, researcher, and advocate, with much of her work centered on PAD. She furthers patient care not only through research but through her political work as Founder of the and member of the Steering Committee. Special thank you to Jacob Soucey () Resources: Follow us Learn more about us at and provide us with your feedback with our vey. /episode/index/show/audiblebleeding/id/34128606

SCVS Rising Seniors / Incoming Fellows Program 11/18/2024

JVS Author Spotlight - Straus, Schermerhorn, and Etkin 11/12/2024

JVS Author Spotlight - Felsted, Scali, and Jayaraj 10/06/2024

JVS CIT Editorial and Abstracts - August 2024 10/01/2024

2024 EVS Research 09/27/2024

SVS Step Challenge 09/25/2024

2024 EVS Day 1 09/20/2024

Diagnosis and Management of Infected Aortic Endografts 09/08/2024

Diagnosis and Management of Infected Aortic Endografts In this episode, we discuss the challenges of explanting aortic grafts, the diagnosis and management of infected aortic grafts, as well as tips and tricks for once we're in the operating room. Interviewers/Editors: Mark Basilious, MD Candidate () Eva Urrechaga, MD () Sharif Ellozy, MD () Guests: Dr. Francis Caputo () is an Associate Professor of Surgery at the Cleveland Clinic Lerner College of Medicine, Vascular Surgery Director of the Aorta Center, and Program Director of the Vascular Surgery Training Programs. His clinical interests include complex open and endovascular repair of thoracic, thoracoabdominal, and abdominal aortic aneurysms, management of thoracic dissection, and endovascular and open repair of failed endograft. Dr. Caputo earned his medical degree from the University of Medicine and Dentistry New Jersey, Newark, NJ, where he also served his surgical residency and two years as a National Institutes of Health research fellow. He completed his fellowship in vascular surgery at Barnes-Jewish Hospital of Washington University, St. Louis, MO and joined the Cleveland Clinic medical staff in 2018. Dr. Peter Rossi () is a Professor of Surgery, Radiology, and Orthopedic Surgery, and Chief of the Division of Vascular and Endovascular Surgery at the Medical College of Wisconsin. His primary research and clinical interests are in complex “re-do” and revision surgery, including for thoracoabdominal and abdominal aortic aneurysms, carotid artery surgery, and renal and mesenteric arterial disease, as well as vascular reconstruction for complicated soft tissue sarcomas. Dr. Rossi completed medical school at the University of Illinois College of Medicine before completing his general surgery training at the University of Chicago and his vascular surgery training at the Medical College of Wisconsin, where he has been a member of the faculty since 2009. Dr. Xavier Berard () is a French vascular surgeon who has been a Consultant in the Department of Vascular Surgery and Professor of Vascular and Endovascular Surgery in Bordeaux University Hospital in Bordeaux, France since 2010 and a full Professor of Vascular Surgery at the University of Bordeaux since 2016. He has also completed a PhD in Vascular Biomaterials and in 2010 worked as a research fellow at Lausanne University Hospital in Switzerland. He has been board certified by the French College of Vascular and Endovascular Surgeons since 2008 and by the European Society for Vascular and Endovascular Surgery since 2010. He has served as an examiner for the FEBVS exam since 2014 and as a reviewer for the European Journal of Vascular and Endovascular Surgery since 2016. Additionally, he is a member of the ESVS guidelines writing group for vascular graft infection and AAA. His personal surgical interests include open surgery of (thoraco)abdominal aneurysms, redo aortic surgery, infections in vascular surgery, EVAR explantation, and biomaterials. He works closely with Institut Bergonié Bordeaux Cancer Center for sarcomas. You can see educational videos and learn more about Dr. Xavier Berard . Helpful links and resources: of explantation of infected chimney EVAR with duodenal fistula (courtesy of Dr. Berard) of reimplanting the IMA after explanting an infected graft of explantation of infected graft with suprarenal fixation Videos of using the syringe technique to remove an aortic stent graft and (courtesy of Dr. Berard) References Follow us Learn more about us at and provide us with your feedback with our . /episode/index/show/audiblebleeding/id/32964117

Robotic Vascular Surgery Part 2 08/18/2024

JVS Author Spotlight - Kempe and Navi 08/04/2024

Holding Pressure Case Prep - Fem Pop Bypass 07/28/2024

Holding Pressure Case Prep - Fem Pop Bypass Authors: Sebouh Bazikian - PGY1 at Emory School of Medicine Integrated Vascular Surgery Program Miguel F. Manzure - vascular surgery attending the University of Southern California Keck School of Medicine involved in complex limb preservation Core Resources: Rutherford Chapters: 107, 108, 109 (Includes further information on anatomy), 112 Additional Resources: Relevant trials BEST CLI: BASIL 2: Relevant Audible Bleeding episodes Audible Bleeding Endovascular Basics: Audible Bleeding eBook, CLTI Chapter: Anything else useful WIFI: GLASS: Monophasic, Biphasic, Triphasic Waveforms: Underlying disease featured in episode - peripheral arterial disease Pathophysiology/etiology narrowing of peripheral arteries caused by atherosclerotic plaques causing arterial insufficiency distal to the point of occlusion. This reduces oxygen supply to the muscles. When oxygen demand increases but cannot be met, it leads to an imbalance such as pain and poor wound healing. Risks: smoking, diabetes, hypertension, dyslipidemia, and older age Equal prevalence in men and women, peak incidence age 60-80 Coexists with CAD, DM, stroke, Afib, and renal disease Patient Presentation 20-50% asymptomatic, rest can be intermittent claudication, rest pain, or tissue loss claudication=pain or discomfort felt in the legs due to a lack of blood flow, especially during physical activity. CLTI=chronic limb threatening ischemia: rest pain lasting greater than 2 weeks or nonhealing ulcers and gangrene Physical exam: decreased skin temperature, less hair on the legs, brittle nails, atrophied muscles, shiny skin, livedo reticularis. Absent or diminished pulses Buerger sign Diagnosis Ankle brachial index: <0.9=PAD. <0.4=multilevel disease associated with tissue loss. >1.3 can mean vessel calcification Toe pressures, toe brachial indexes, and transcutaneous oxygen measurement (TcPO2) if vessels calcified Duplex ultrasound: affordable and effective, can assess both anatomy and blood flow Can also assess degree of stenosis based on ratios of systolic and diastolic velocity Angiography: gold standard. Invasive and risks of infection, hematoma, pseudoaneurysms, and contrast nephropathy. Staging: WIFI - Wound, Ischemia, and Foot Infection (see additional resources) GLASS: Global Limb Anatomy Staging System (see additional resources) Treatment (Medical/Surgical) Lifestyle modification, smoking cessation, high-intensity statins, antiplatelet therapy, and management of other medial comorbidities like HTN and DM. Structured exercise program: 3 times weekly for 12 weeks Cilostazol: phosphodiesterase III inhibitor Endovascular and surgical revascularization Endovascular offer superior perioperative outcomes but lacks durability Surgical revascularization offer durability and less reinterventions, but more invasive Indications for surgery: CLTI and lifestyle limiting claudication Relevant anatomy: Femoral triangle inguinal ligament superior, the medial border of the sartorius muscle laterally, and the medial border of the adductor longus on the medially Contains neurovascular bundle (NAVEL) Adductor canal: bordered anteriorly by the sartorius, posteriorly by the adductor magnus and longus, and to the lateral side by the vastus medialis common femoral artery bifurcates into the profunda and the superficial femoral artery (SFA). SFA courses through adductor canal and turns into popliteal artery in the popliteal fossa GSV: originates at the ankle, tracts anterior to medial malleolus and then ascending the medial side of lower leg. Upon reaching the knee, it curves behind the medial condyles of the femur and tibia, continuing alongside the medial aspect of the thigh. Its journey culminates at the saphenofemoral junction Preoperative preparation: Identifying inflow and outflow vessels, both should be free of significant disease preop CTA or angiogram Picking a conduit Best patency=autogenous: reversed GSV most common, others are small saphenous vein, cephalic vein, etc Prosthetic: polytetrafluoroethylene (PTFE) Cryopreserved vein Surgical steps: Harvesting GSV (if GSV adequate as conduit) Dissected along its length, branches ligated, removed and reversed Can also be left insitu, so only proximal and distal aspects are mobilized, and valves are removed using valvulotome Should be at least 3mm in diameter and no significant disease (scarring, thickening) Arterial exposure Common femoral artery: lies in the medial third segment between the ASIS and the pubic symphysis. Longitudinal or oblique incision directly over the femoral artery pulse if present. ligate venous and lymphatic tributaries in the soft tissue. Open fascia along the medial margin of the sartorius muscle, retracting the sartorius muscle laterally exposes the underlying femoral sheath. CFA is located within the femoral sheath. Profunda and superficial femoral artery: trace the anterior surface of the CFA to where it bifurcates. The origin of the profunda is typically lateral Popliteal artery: medial longitudinal incision 1 to 2 cm behind the tibia's posterior border. Carefully to avoid GSV, dissect down to fascia to enter the popliteal fossa. The medial head of the gastrocnemius is retracted posteriorly, giving us a clear view of the popliteal fossa. popliteal artery is surrounded by paired popliteal veins with smaller bridging veins Tunneling and anastomosis Can be done anatomically or subcutaneously Must be careful not to twist the conduit Can do proximal anastomosis to pressurize vein prior to tunneling to minimize chance of twisting Clamp the vessels and heparinize Arteriotomy on femoral artery and anastomosis, same with popliteal artery distally Closure and ensure patency Optional completion angiogram Postoperative care: Anticoagulation and/or antiplatelet therapy Monitor graft patency once discharged with duplex/ABI Follow us Learn more about us at and provide us with your feedback with our . /episode/index/show/audiblebleeding/id/32319782

JVS CIT Editorials and Abstracts - June 2024 07/24/2024

Meet the SVS Vice President Candidates 06/10/2024

JVS Author Spotlight - O'Donnell and Timaran 06/02/2024

ChatGPT/LLM in Vascular Surgery 05/20/2024

JVS Author Spotlight - Pillado, Coleman, and Lal 05/06/2024

JVS CIT Editorials and Abstracts - April 2024 04/30/2024

Social Deprivation in Vascular Surgery 04/25/2024

Social Deprivation in Vascular Surgery In this episode Abena Appah-Sampong () and Leana Dogbe () partner with Vaiva Dabravolskaite () from ESVS to host an episode discussing social deprivation in vascular surgery. Dr. Tara Mastracci and Dr. Olamide Alabi join us to offer insights into how social deprivation drives disparities in outcomes and steps to how we can shift practice paradigms to better address our patient needs. Dr. () is a vascular surgeon with over 15 years of experience treating and managing complex aortic pathologies. She is currently working at St. Bartholomew’s Hospital in London, UK, on the Cardiothoracic Team doing complex aortic surgery. On top of her clinical duties, Dr. Mastracci is dedicated to studying the social and non-clinical factors influencing vascular outcomes. Dr. Olamide Alabi () is an Associate Professor of Surgery in the Department of Surgery at Emory University School of Medicine. Her clinical effort focuses on the full scope of vascular disease for patients at Emory University Hospital and the Atlanta VA HealthCare System, however, her academic portfolio and funded research is focused primarily on the intersection of peripheral artery disease, quality, and health equity. References: Social Deprivation and the Association With Survival Following Fenestrated Endovascular Aneurysm Repair/2021 Is social deprivation an independent predictor of outcomes following cardiac surgery? An analysis of 240,221 patients from a national registry. BMJ/2015 Survival Disparity Following Abdominal Aortic Aneurysm Repair Highlights Inequality in Ethnic and Socio-economic Status/ Nash, D., McClure, G., Mastracci, T. M., & Anand, S. S. (2022). Social deprivation and peripheral artery disease. Canadian Journal of Cardiology, 38(5), 612-622. Vart, P., Coresh, J., Kwak, L., Ballew, S. H., Heiss, G., & Matsushita, K. (2017). Socioeconomic status and incidence of hospitalization with lower‐extremity peripheral artery disease: atherosclerosis risk in communities study. Journal of the American Heart Association, 6(8), e004995. Henry, A. J., Hevelone, N. D., Belkin, M., & Nguyen, L. L. (2011). Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. Journal of vascular surgery, 53(2), 330-339. Demsas, F., Joiner, M. M., Telma, K., Flores, A. M., Teklu, S., & Ross, E. G. (2022, June). Disparities in peripheral artery disease care: A review and call for action. In Seminars in vascular surgery (Vol. 35, No. 2, pp. 141-154). WB Saunders. Follow us Learn more about us at and provide us with your feedback with our . /episode/index/show/audiblebleeding/id/30984153

JVS Author Spotlight - McDermott and Chan 04/23/2024

How to Heal a Heel: Lessons From the Malvern Diabetic Foot Conference 04/21/2024

How to Heal a Heel: Lessons From the Malvern Diabetic Foot Conference In today’s episode, (@ROForsythe), consultant vascular surgeon at NHS Lothian, leads a fictional case-based discussion with leaders in managing diabetic foot ulcers. Joining the conversation are Professor Andrew Boulton, Mr. Patrick Coughlin, Dr. David Armstrong, Dr. Dane Wukich, and Dr. Edgar Peters. is a professor of medicine at Manchester University in England and is co-chair of the Malvern Diabetic Foot Conference meeting. He served as president of numerous distinguished societies, including the International Diabetes Federation. (@Coughlin_pa) is a consultant vascular surgeon in Leeds, England. He is a very active member of the Vascular Society of Great Britain and Ireland Council and has a special academic and clinical interest in peripheral artery disease. (@DGArmstrong) is a podiatric surgeon and professor of surgery at Keck School of Medicine of the University of California and director of the Southwestern Academic Limb Salvage Alliance. Dr. Armstrong is very well known for his work on amputation prevention, the diabetic foot and wound healing. (@DaneWukich) is a professor and chair of the Department of Orthopedics at the University of Texas, Southwestern and Medical Director of Orthopedic Surgery at UT Southwestern University Hospitals. Dr. Wich has an interest in foot and ankle surgery, including the management of diabetes-related complications. is an associate professor of internal medicine, infectious diseases, and acute medicine at Amsterdam University Medical Centers, Dr. Peter's main interest is infection of the musculoskeletal system, particularly in patients with diabetes and is the Scientific Secretary of the International Symposium on the Diabetic Foot. Malvern Diabetic Foot Conference info: If this episode was of interest to you, please take a listen to this where we speak with the authors of the SVS, ESVS, and IWGDFU joint guidelines on the management of peripheral arterial disease (PAD) in patients with diabetes. Articles, resources, and societies referenced in the episode: DF Blog. “Oral Is the New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review @bradspellberg @lacuscmedcenter @usc,” January 1, 2022. . Gariani, Karim, Truong-Thanh Pham, Benjamin Kressmann, François R Jornayvaz, Giacomo Gastaldi, Dimitrios Stafylakis, Jacques Philippe, Benjamin A Lipsky, and Lker Uçkay. “Three Weeks Versus Six Weeks of Antibiotic Therapy for Diabetic Foot Osteomyelitis: A Prospective, Randomized, Noninferiority Pilot Trial.” Clinical Infectious Diseases 73, no. 7 (October 5, 2021): e1539–45. . Li, Ho-Kwong, Ines Rombach, Rhea Zambellas, A. Sarah Walker, Martin A. McNally, Bridget L. Atkins, Benjamin A. Lipsky, et al. “Oral versus Intravenous Antibiotics for Bone and Joint Infection.” New England Journal of Medicine 380, no. 5 (January 31, 2019): 425–36. . Magliano, Dianna, and Edward J. Boyko. IDF Diabetes Atlas. 10th edition. Brussels: International Diabetes Federation, 2021. Østergaard, Lauge, Mia Marie Pries-Heje, Rasmus Bo Hasselbalch, Magnus Rasmussen, Per Åkesson, Robert Horvath, Jonas Povlsen, et al. “Accelerated Treatment of Endocarditis—The POET II Trial: Ration ale and Design of a Randomized Controlled Trial.” American Heart Journal 227 (September 2020): 40–46. . Price, Patricia. “The Diabetic Foot: Quality of Life.” Clinical Infectious Diseases 39 (2004): S129–31. Sharma, S., C. Kerry, H. Atkins, and G. Rayman. “The Ipswich Touch Test: A Simple and Novel Method to Screen Patients with Diabetes at Home for Increased Risk of Foot Ulceration.” Diabetic Medicine: A Journal of the British Diabetic Association 31, no. 9 (September 2014): 1100–1103. . Shin, Laura, Frank L. Bowling, David G. Armstrong, and Andrew J.M. Boulton. “Saving the Diabetic Foot During the COVID-19 Pandemic: A Tale of Two Cities.” Diabetes Care 43, no. 8 (August 1, 2020): 1704–9. . Tone, Alina, Sophie Nguyen, Fabrice Devemy, Hélène Topolinski, Michel Valette, Marie Cazaubiel, Armelle Fayard, Éric Beltrand, Christine Lemaire, and Éric Senneville. “Six-Week Versus Twelve-Week Antibiotic Therapy for Nonsurgically Treated Diabetic Foot Osteomyelitis: A Multicenter Open-Label Controlled Randomized Study.” Diabetes Care 38, no. 2 (February 1, 2015): 302–7. . Wukich, Dane K., Katherine M. Raspovic, and Natalie C. Suder. “Patients With Diabetic Foot Disease Fear Major Lower-Extremity Amputation More Than Death.” Foot & Ankle Specialist 11, no. 1 (February 2018): 17–21. . /episode/index/show/audiblebleeding/id/30918638

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