Audible Bleeding

In today's episode, Dr. Rachael Forsythe (@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.

Professor Boulton 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.

Dr. Coughlin (@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.

Dr. Armstrong (@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.

Dr. Wukich (@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.

Dr. Edgar Peters 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:

https://www.facebook.com/MalvernDiabeticFootConference/

https://eu.eventscloud.com/website/8151/

If this episode was of interest to you, please take a listen to this Transatlantic Series episode 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. https://diabeticfootonline.com/2022/01/01/oral-is-the-new-iv-challenging-decades-of-blood-and-bone-infection-dogma-a-systematic-review-bradspellberg-lacuscmedcenter-usc/.

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. https://doi.org/10.1093/cid/ciaa1758.

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. https://doi.org/10.1056/NEJMoa1710926.

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. https://doi.org/10.1016/j.ahj.2020.05.012.

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. https://doi.org/10.1111/dme.12450.

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. https://doi.org/10.2337/dc20-1176.

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. https://doi.org/10.2337/dc14-1514.

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. https://doi.org/10.1177/1938640017694722.

Audible Bleeding editor Wen (@WenKawaji) is joined by 5th integrated vascular resident Yang (@YangYang_MD) and Moira 3rd year medical student discussing the International Society for Women Vascular Surgeons and Women's Vascular Summit with Dr. Linda Harris.

Show Guests:

• Dr. Linda Harris: Dr. Harris joined University of Buffalo in 1995 and currently sits as Professor of Surgery with tenure in the Department of Surgery. She is also the Program Director for the Vascular Fellowship and Vascular Residency Programs. She is the president of the international society for women vascular surgeons.

SVS Women's section episodes

• SVS Women's Section with Dr. Duncan and Dr. Shaw

• SVS Women's Section: Advice for Young Surgeons

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In this episode of Audible Bleeding, editor Dr. Adam Johnson is joined by General Surgery PGY-3 Sasank Kalipatnapu, MS2 Nishi Vootukuru, along with Dr. Anton Sidawy, MD, and Dr. William Schutze to discuss the nuances of the recently launched Society for Vascular Surgery (SVS) Outpatient Verification Program, in collaboration with the American College of Surgeons.

This episode brings out a conversation exploring the history behind the development of the program, the current state of the program, and the overwhelming importance of the program in the current day. The episode will also cover the broad steps that need to be taken by a facility looking to become verified and will also show the value added by being verified by this joint ACS/SVS Vascular Verification program.

Dr. Anton Sidawy, MD, MPH, FACS is the Lewis B. Saltz Chair and Professor of Surgery at George Washington School of Medicine, Washington DC. He is the chair of the Vascular Verification Program steering committee and oversees the development and implementation of inpatient and outpatient vascular verification programs.

Dr. William Patrick Shutze is a Vascular Surgeon from Texas Vascular Associates in Plano, TX, and Chair of the Outpatient Committee. He is also the secretary for the Society for Vascular Surgery and is also the chair of the Communications Committee. He has led the efforts with the implementation of the recently launched Outpatient Verification Program.

Relevant links:

• Official page of the Vascular Verification Program

Co-Hosts:

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

Dr. Sasank Kalipatnapu is a PGY-3 General Surgery resident at UMass Chan Medical School, Worcester, MA.

Nishi Vootukuru is a 2nd-year medical student at Rutgers NJMS University, Newark, NJ.

Audible Bleeding editor Wen (@WenKawaji) is joined by 3rd year general surgery resident Ryan Ellis discussing robotic vascular surgery with Dr. Judith Lin (@JudithLin4) and Dr. Petr Stadler. Dr. Lin and Dr. Stadler will share their personal journey in robotic vascular surgery, cases they have done, and what think the future looks like. This is part one of our robotic vascular series. Our next episode will feature Dr. Lumsden and Dr. Bavare from Houston Methodist.

Show Guests:

• Dr. Judith Lin: professor and chief of vascular surgery in the Department of Surgery at Michigan State University's College of Human Medicine

• Dr. Petr Stadler: Professor of Surgery, Head of Vascular Surgery Department, Na Homolce Hospital, Prague, Czech Republic

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Audible Bleeding editor Wen (@WenKawaji) is joined by second year medical student Nishi (@Nishi_Vootukuru), 3rd year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Forbes (@TL_Forbes) and JVS-CIT associate editor Dr. O'Banion (@limbsalvagedr) to discuss two great articles in the JVS family of journals regarding endovascular management of acute limb ischemia and ultrasound-based femoral artery calcification score. This episode hosts Dr. Thomas Maldonado (@TomMaldonadoMD) and Dr. Raul J. Guzman, the authors of the following papers:

Articles:

• Safety and efficacy of mechanical aspiration thrombectomy at 30 days for patients with lower extremity acute limb ischemia by Dr. Maldonado and colleagues.

• An ultrasound-based femoral artery calcification score by Dr. Raul Guzman and colleagues.

Show Guests:

• Dr. Thomas Maldonado is the Schwartz - Buckley endowed professor of surgery in the Vascular Division at New York University Langone Medical Center in New York, Co-Director of Center for Complex Aortic Disease

• Dr. Raul J. Guzman is the Donald Guthrie Professor of Vascular Surgery, Chief of Division of Vascular Surgery at Yale New Haven Hospital. He is also Surgeon-in-Chief of Vascular Surgery, Heart and Vascular Center for the Yale New Haven Health System. ([email protected])

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Authors:

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

Gowri Gowda - PGY1 at the University of California Davis Integrated Vascular Surgery Program

Steven Maximus- Vascular surgery attending at the University of California Davis, Director of the Aortic Center

Resources:

• Rutherford's 10th Edition Chapters: 88, 89, and 91

• The North American Symptomatic Carotid Endarterectomy

• Asymptomatic Carotid Atherosclerosis Study

• Audible Bleeding's eBook chapter on cerebrovascular disease

• Houston Methodist CEA Dissection Video:

Part 1: https://www.youtube.com/watch?v=wZ8PzhwmSXQ

Part 2: https://www.youtube.com/watch?v=E_wWpRKBy4w

Outline:

1. Etiology of Carotid Artery Stenosis

• Risk factors: advanced age, tobacco use, hypertension, diabetes.

• Atherosclerosis as the primary cause.

1. Development of Atherosclerotic Disease and Plaque Formation

   • LDL accumulation in arterial walls initiating plaque formation.

   • Inflammatory response, macrophage transformation, smooth muscle cell proliferation.

   • Role of turbulent blood flow at carotid bifurcation in plaque development.

1. Clinical Features of Carotid Artery Stenosis

   • Asymptomatic nature in many patients.

   • Symptomatic presentation: Transient ischemic attacks, amaurosis fugax, contralateral weakness/sensory deficit.

   • Carotid bruit as a physical finding, limitations in diagnosis.

1. Importance of Evaluating CAS

   • Assessing stenosis severity and stroke risk.

   • Revascularization benefits dependent on stenosis severity.

1. Classification of Stenosis Levels

   • Clinically significant stenosis: ≥ 50% narrowing.

   • Moderate stenosis: 50%–69% narrowing.

   • Severe stenosis: 70%–99% narrowing.

1. Stroke Risk Associated with Carotid Stenosis

   • Annual stroke rate: ~1% for 50-69% stenosis, 2-3% for 70-99% stenosis.

1. Diagnosis and Screening

   • No population-level screening recommendation.

   • Screening for high-risk individuals as per SVS guidelines.

   • Carotid Duplex Ultrasound as primary diagnostic tool.

   • Additional tools: CT angiography, Magnetic Resonance Angiography.

   • Handling of

1. Imaging Modalities

   • Ultrasound: Noninvasive, cost-effective, potential overestimation of stenosis.

   • CTA: Fast, high resolution, contrast exposure risks.

   • MRA: Contrast-free plaque analysis, possible overestimation of stenosis.

   • Angiography: Gold standard, expensive, stroke risk.

1. Assessing Degree of Stenosis via CDUS

   • Parameters for 50-69% stenosis: Peak Systolic Velocity (PSV) 125-229 cm/sec, End Diastolic Velocity (EDV) 40-100 cm/sec, Internal/Common Carotid peak systolic velocity Ratio 2-4.

   • Parameters for 70-99% stenosis: PSV ≥ 230 cm/sec, EDV > 100 cm/sec, Internal/Common Carotid peak systolic velocity Ratio > 4.

1. Revascularization Criteria

   • Symptomatic Patients: 50-69% or 70-99% stenosis, life expectancy at least three or two years, respectively.

   • Asymptomatic Patients: 70% stenosis, considering life expectancy.

1. Surgical Indications and Contraindications

   • Indications: symptomatic patients, life expectancy considerations.

   • Contraindications: Stenosis

1. Medical Management for All CAS Patients

   • Lifestyle changes, high-intensity statin therapy, antiplatelet therapy.

1. Decision Factors for Surgical Approaches

   • TCAR, stenting, endarterectomy: situational preferences.

1. Carotid Endarterectomy: Surgical Procedure

   • Incision along anterior border of sternocleidomastoid muscle.

   • Electrocautery through platysma muscle and subcutaneous tissues.

   • Protecting the great auricular nerve, dividing the external jugular vein.

   • Retracting sternocleidomastoid muscle, exposing carotid sheath.

   • Dissecting internal jugular vein, ligating facial vein.

   • Avoiding injury to the vagus nerve, dissecting the common carotid artery.

   • Identifying and mobilizing the hypoglossal nerve, addressing the external carotid artery.

   • Extending dissection from common carotid artery to beyond the internal and external carotid bifurcation.

   • Longitudinal arteriotomy, plaque removal using a Freer elevator.

   • Ensuring a smooth transition between endarterectomized artery and normal distal extent.

   • Patch angioplasty for arteriotomy closure, sequential clamp release for de-airing.

1. Neuromonitoring and Plaque Removal

   • Neuromonitoring methods: EEG, SSEPs, TCD, cerebral oximetry, awake patient monitoring.

1. Shunting and Vessel Closure

   • Shunting indications: neurological status changes, EEG alterations.

   • Carotid stump pressure measurement.

1. Postoperative Complications and Management

   • Common complications: stroke, hyperperfusion syndrome, myocardial infarction, cervical hematoma, nerve injuries, infection.

   • Managing hyperperfusion syndrome: blood pressure control, antiepileptic drugs.

   • Cranial nerve injuries:

   1. Hypoglossal Nerve (CN XII): Injury leads to tongue deviation towards the injured side.

   2. Glossopharyngeal Nerve (CN IX): Injury results in swallowing difficulties and aspiration risk.

   3. Vagus Nerve (CN X): Injury causes hoarseness due to laryngeal muscle involvement.

   4. Marginal Mandibular Branch of Facial Nerve: Injury leads to ipsilateral lip droop.

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Welcome to the Transatlantic series, a co-production of Audible Bleeding (a publication of the SVS) and the ESVS podcast. In today's episode, we explore the intersocietal guidelines on peripheral arterial disease in patients with diabetes and foot ulcers authored by the International Working Group on the Diabetic Foot (IWGDF), the European Society for Vascular Surgery (ESVS), and the Society for Vascular Surgery (SVS).

Dr. Robert Fitridge is a Professor of Vascular Surgery at University of Adelaide in Australia. He is a member of the IWGDF and is also a member of the steering committee for the Global Vascular Guideline on the management of Chronic Limb-threatening Ischaemia.

Dr. Vivienne Chuter is a Professor in the Department of Podiatry at Western Sydney University and Honorary Professor in the School of Health Science at The University of NewCastle. She is a member of the IWGDF. She has published extensively on diabetic foot disease and leads a clinically based research program focusing on the prevention and management of diabetes-related foot disease for Aboriginal and Torres Strait Islander people and for non-Indigenous Australians.

Dr. Nicolaas Schaper is an emeritus professor of Endocrinology at Maastricht University Hospital in the Netherlands. Dr. Schaper was the coordinator of the European diabetic foot research consortium, Eurodiale. He is Chair of the 2023 Diabetic Foot Symposium (ISDF 2023) and is Chair of the IWGDF.

Dr. Joseph L. Mills is a Professor of Vascular Surgery at Baylor in Houston, Texas. He is a member of the IWGDF. Dr. Mills is a leader in the vascular surgery global community, has served as president of the Peripheral Vascular Surgery Society, and is currently a member of the Surgery Residency Review Committee of the ACGME.

Further reading and links:

• The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer.

• Global vascular guidelines for CLTI

• Best-CLI

• Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers

• A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers

• A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial

• Release of the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025; the impacts for podiatry in Australia: a commentary

• Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases

• Results of the CAPRIE trial: efficacy and safety of clopidogrel. Clopidogrel versus aspirin in patients at risk of ischaemic events

• Low-Dose Aspirin for the Primary Prevention of Cardiovascular Disease in Diabetic Individuals: A Meta-Analysis of Randomized Control Trials and Trial Sequential Analysis

• Diabetes, Lower-Extremity Amputation, and Death

• Outcomes in patients with chronic leg wounds in Denmark: A nationwide register‐based cohort study

• Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia

• Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review.

• Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review.

• Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review.

• The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI).

• Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia.

• A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial.

Mobile Applications:

• Society for Vascular Surgery Mobile App for Staging of Chronic Limb-Threatening Ischemia.

• European Society for Vascular Surgery Clinical Practice Guidelines Mobile Edition.

Hosts:

• Dr. Naveed A. Rahman is a chief surgery resident at SUNY Upstate in Syracuse, NY. He will pursue a vascular surgery fellowship at the University of Maryland starting in 2024. His Doximity profile is https://www.doximity.com/pub/naveed-rahman-md. Twitter: @naveedrahmanmd

• Dr. Suzanne Stokmans is a fifth-year vascular surgery resident at the Isala Hospital in Zwolle, the Netherlands.

Dr. Ezra Schwartz is a medical graduate from McGill University currently completing a Master of Medical Science in Medical Education at Harvard Medical School. He is an aspiring vascular surgeon and surgical education researcher. Twitter: @ezraschwartz10

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In today's episode, Dr. Sharif Ellozy, Gowri Gowda, Ezra Schwartz, and Kundanika Lakkadi interview Dr. Premchand "PC" Gupta, a vascular surgeon in India.

Dr. Gupta is the clinical director of vascular and endovascular surgery and vascular interventional radiology at the Care Hospitals in Hyderabad, India. He is President of the Vascular Society of India and Vice President of the World Federation of Vascular Societies. He is actively involved in research, sits on numerous editorial boards and has had many publications and awards.

Dr. Gupta received his medical degree from the Armed Forces Medical College in Pune, India and completed his MS in Surgery at the Postgraduate Institute of Medical Education and Research in Chandigarh, India. He completed his vascular surgery fellowship at Nagoya University School of Medicine, Japan. Dr. Gupta pursued additional training in carotid surgery at the University of North Carolina at Chapel Hill as well as in complex aortic surgery at Houston Methodist Hospital.

Twitter:

• Dr. PC Gupta (@pcvasc)

• Dr Sharif Ellozy (@sharifellozy)

• Dr. Ezra Schwartz (@ezraschwartz10)

• Dr. Gowri Gowda (@gowrigowda11)

• Kundanika Lakkadi (@kundanikalakka1)

Articles, resources, and societies referenced in the episode:

• Indian healthcare system summary

• George R, Gupta PC. Vascular Surgery in India - the Challenge and the Promise.

• Indian Journal of Vascular and Endovascular Surgery

• Vascular Society of Kerala

• Vascular Society of India and Vascular Society of India Annual Conference (VSICON)

• Aortic Rupture in the Indian Context

• Indian National Vascular Day and Amputation Free India and Walkathon

• Vascular Awareness In India: What More Needs to be Done

• CDC Disinfection & Sterilization Guide

Audible Bleeding editor Matt Chia (@chia_md) is joined by Nishi Vootukuru (@Nishi_Vootukuru) and Lili Sadri (@lilisadri) are joined by Drs. Joel Ramirez, James Iannuzzi, and James Pavel Kibrik to discuss their latest publications in the JVS family of journals. Along with insight from JVS Assistant Editor Dr. Paul Dimuzio and JVS-VL Editor-in-Chief Dr. Ruth Bush (@RuthLBush), hear about the latest trends in AAA repair and the value of postoperative duplex after venous thermal ablation. Don't miss it!

Articles:

Decreasing prevalence of centers meeting the Society for Vascular Surgery abdominal aortic aneurysm guidelines in the United States, by Ramirez et al.

Value and limitations of postoperative duplex scans after endovenous thermal ablation, by Kibrik et al.

Additional Links:

Factors associated with ablation-related thrombus extension following microfoam versus radiofrequency saphenous vein closure, by Chin et al.

Outcomes of a single-center experience in eliminating routine postoperative duplex ultrasound screening after endovenous ablation, by Woodhouse et al.

Show guests:

Joel Ramirez, MD - Integrated Vascular Surgery Resident at the University of California, San Francisco

James C. Iannuzzi, MD MPH - Assistant Professor, Division of Vascular and Endovascular Surgery at the University of California, San Francisco

Pavel Kibrik, DO - Graduate of New York Institute of Technology Osteopathic School of Medicine and current vascular surgery researcher at the NYU Langone School of Medicine

Ruth Bush, MD JD MPH FACS - Professor of Vascular Surgery and Associate Dean of Educational Affairs at the University of Texas, Medical Branch and Editor-in-Chief of the Journal of Vascular Surgery Venous and Lymphatic Disorders

Audible Bleeding editor Wen (@WenKawaji) is joined by second year medical student Nishi (@Nishi_Vootukuru), third year medical student Leana Dodge (@ldogbe4), JVS editor Dr. Forbes (@TL_Forbes) and JVS-VS associate editor Dr. Curci (@CurciAAA) to discuss two great articles in the JVS family of journals regarding Medicare reimbursement for complex endovascular aortic aneurysm repair and novel drug delivery method involving tissue factor targeting peptides in reducing vascular injury response. This episode hosts Dr.Brinster, Dr. Conte, and Dr. Kim, the authors of the following papers:

Articles:

• Current Medicare reimbursement for complex endovascular aortic repair is inadequate based on results from a multi-institutional cost analysis by Brinster et al.

• Tissue factor targeting peptide enhances nanoparticle binding and delivery of a synthetic specialized pro-resolving lipid mediator to injured arteries by Dr. Levy et al.

Show Guests:

• Dr. Clayton Brinster: Associate Professor of Surgery at University of Chicago, and Co-Director of Center for Aortic Diseases, Department of Vascular Surgery and Endovascular Therapy

• Dr. Michael Conte: E.J. Wylie Chair, professor and chief of the division of Vascular and Endovascular Surgery at UCSF. Co-Directot of Heart and Vascular Center, Co-Director of UCSF Center for Limb Preservation and Diabetic Foot.

• Dr. Alexander Kim: Vascular surgery fellow and research fellow at UCSF

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