• Holding Pressure Case Prep - Fem Pop Bypass
    Jul 28 2024
    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 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 ...
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    29 mins
  • JVS CIT Editorials and Abstracts - June 2024
    Jul 24 2024

    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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    35 mins
  • JVS Author Spotlight - O'Donnell and Timaran
    Jun 2 2024

    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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    44 mins
  • ChatGPT/LLM in Vascular Surgery
    May 20 2024

    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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    46 mins
  • JVS Author Spotlight - Pillado, Coleman, and Lal
    May 6 2024

    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

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    38 mins
  • JVS CIT Editorials and Abstracts - April 2024
    Apr 30 2024

    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.

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    31 mins
  • Social Deprivation in Vascular Surgery
    Apr 25 2024

    In this episode Abena Appah-Sampong (@abenasamp) and Leana Dogbe (@leanadogbe) partner with Vaiva Dabravolskaite (vaivadabravolskaite@gmail.com) 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.

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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.

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    1 hr and 7 mins
  • JVS Author Spotlight - McDermott and Chan
    Apr 23 2024

    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.

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    39 mins