Audible Bleeding

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

Articles:

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

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

Show Guests:

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

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

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

Authors:

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

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

Core Resources:

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

Additional Resources:

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

Underlying disease featured in episode - peripheral arterial disease

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

Indications for surgery:

• CLTI and lifestyle limiting claudication

Relevant anatomy:

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

Preoperative preparation:

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

Surgical steps:

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

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

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

Postoperative care:

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

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

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

Readers:

Shourya Verma (@shourya__verma)

Nabeeha Khan (@Nabeeha_Khan_)

Miguel Fernandez (@MGfernandez21)

Amit Chaudhary (@VascularKGMU)

Dr. Jayer Chung (@Jayer_Chung)

Hosts:

Nishi Vootukuru (@Nishi_Vootukuru)

John Culhane (@Johnculhanemd)

Editorials (E) and Abstracts (A):

E- Arteries of fibromuscular dysplasia tell a sympathetic story

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

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

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

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

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

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

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

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

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In this episode, Sasank Kalipatnapu (@ksasank), John Culhane and Leana Dogbe (@ldogbe4) sit down along with Dr. Dalman (@RLDalmanMD) as chair of the SVS Nominating Committee for this year, along with the two vice presidential candidates Dr. Harris and Dr Shaw to learn more about them as part of the ongoing election process.

Show links:

SVS 2024 Meet the VP Candidates—Home Page—provides a comprehensive overview of all the candidates. Their professional biographies and answers to questions about their plans for the future are available in both text and video formats.

Show Guests:

• Dr. Linda Harris, Professor of Surgery at Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, NY

• Dr. Palma Shaw, Professor of Surgery at State University of New York, Syracuse, NY

• Dr. Ronald L. Dalman, Elsa R. and Walter C. Chidester Professor and Division Chief Emeritus of Vascular Surgery at Stanford University, CA, Associate Dean for Market Development and Outreach for Stanford Medicine and Vice Chair for Clinical Affairs in the Department of Surgery

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

Articles:

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

  • Mentioned during the discussion:

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

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

  • Mentioned during discussion:

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

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

Show Guests

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

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

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

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

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

Relevant links:

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

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

• Data Skeptic Podcast

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

Co-Hosts:

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

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

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

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

Articles:

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

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

Show Guests:

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

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

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

Follow us @audiblebleeding

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

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

Readers:

Matthew Smeds (@mattsmeds)

Christopher DeHaven (@ChrisDeHavenPSU)

Ethan Vieira

Litton Whittaker

Nicholas Schaper

Nishi Vootukuru (@Nishi_Vootukuru)

Editorials:

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

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

Abstracts:

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

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

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

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

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

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

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

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

Follow us @audiblebleeding

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

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

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

References:

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

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

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

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

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

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

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

Follow us @audiblebleeding

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

Articles:

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

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

Related Articles:

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

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

Show Guests:

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

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