1. health and fitness
2. disease

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Page 1
®
THE OFFICIAL
NEWSPAPER
OF THE
VOL. 9
©J AN M IKA / I S TOCKPHOTO. COM
Fruits, but not
vegetables, shown
to lower AAA risk
Meta-analysis excluding discredited trial showed perioperative
beta-blockers increased mortality in noncardiac surgery.
Mortality up 27% with
periop beta-blockers
B Y M A R K S. L E S N E Y
IMNG Medical Ne ws
ore than one in four
patients who died
from all causes after
noncardiac surgery may have
survived if they had not been
treated with perioperative
beta-blockers as specified by
joint American College of
Cardiology Foundation/
American Heart Association
and separate European Society of Cardiology guidelines,
according to a recent report.
These guidelines recommend perioperative betablockers in all patients
undergoing vascular or intermediate-risk surgery with
coronary artery disease, or
with more than one risk factor for CAD, or with preex-
M
isting beta-blockade. These
are all iatrogenic deaths, according to a meta-analysis of
secure studies, which excluded data from the now discredited Dutch Echocardiographic Cardiac Risk
Evaluation Applying Stress
Echocardiography (DECREASE) family of trials.
“Refraining from this ESC
[European Society of Cardiology] guideline would
therefore be expected to prevent up to 10,000 iatrogenic
deaths each year in the U.K.,”
according to Dr. Sonia Bouri
and her coauthors at the National Heart and Lung Institute, Imperial College
London.
The researchers analyzed
See Mortality • page 4
•
NO. 5
•
SEPTEMBER 2013
I N S I D E
From the Editor
Sunshine, Sunset
Dr. Russell Samson gives his
view of the implications of
the new Sunshine Act.• 2
Same results seen for men and women.
B Y M A R K S. L E S N E Y
IMNG Medical Ne ws
he consumption of
fruits, but not vegetables, was associated
with a decreased risk of
abdominal aortic
aneurysm, especially the
risk of rupture, according
to results of a large database study of two prospective cohorts of Swedish
men and women.
“The risk of AAA decreased with increasing consumption of fruit (P =.003),
whereas no significant association was observed for
vegetable consumption,”
wrote Dr. Otto Stackelberg
and his colleagues at Upp-
T
sala (Sweden) University
(Circulation 2013;128:795802).
The study population in
the final analysis of the two
cohorts consisted of 36,109
women from the Swedish
Mammography Cohort (established between 1987 and
1990) and 44,317 men from
the Cohort of Swedish Men
(established in 1997).
Both cohorts responded
in 1997 to extensive questionnaires – identical except
for sex-specific questions –
that included 96 food-item
questions accompanied by
other lifestyle factors. Results were linked to the
See AAA • page 3
News From SVS
SVS Foundation
Annual Report
Dr. Peter Gloviczki
introduces the 2013
report. • 7
Tips and Tricks
Venous Ulcers
Dr. Albeir V. Mousa gives 10
tips his group uses to get
high success with healing
chronic venous ulcers. • 15
Vascular testing: Setting use criteria
BY SHARON
WORCESTER
IMNG Medical Ne ws
enous duplex ultrasound
is rarely appropriate as a
V
screening tool for upper or
lower extremity deep vein
thrombosis in the absence
of pain or swelling, according to new appropriate use
criteria for noninvasive vas-
cular laboratory testing issued by the American College of Cardiology.
The clinical scenarios involving venous duplex ultrasound for DVT screening
that were deemed rarely appropriate – such as screening
in those with a prolonged
ICU stay and those with
high DVT risk – represent
just a few of the 116 scenar-
ios included in the report,
which was developed in collaboration with 10 other
leading professional societies
to promote the most effective and most efficient use of
peripheral vascular ultrasound and physiological testing in clinical practice.
The report is the second
See Testing • page 5
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Page 2
EDITORIAL
2
SEPTEMBER 2013 • VASCULAR SPECIALIST
FROM THE EDITOR:
B Y R U S S E L L S A M S O N , M . D.
Medical Editor, Vascular Specialist
he Physician Payment Sunshine
Act is now in place, and I’m concerned that it may become the
“Sunset Act” since it may be another
reason for doctors to consider leaving
the profession. As of August, manufacturers of drugs, devices, biologicals, or medical supplies are obliged to
report annually to the Secretary of
Health and Human Services certain
payments or other transfers of value
to physicians and teaching hospitals.
According to the Centers for Medicare
and Medicaid Services (CMS) this bit
of regulatory burden is going to cost
industry $269 million the first year
and $180 million annually thereafter.
T
Let the ‘Sunset Act?’
What is the purpose of this “Sunshine Act”? Congress implied that this
process is not designed to stop, chill, or
call into question beneficial interactions
between physicians and industry,
but to ensure that
they are transparent. Although
CMS did not use
harsh or derogatory language,
what I think is
“transparent” is
the implication
DR. SAMSON
that making these
financial interactions public will prevent
industry from having undue influence
over physicians. In less euphemistic
terms I believe CMS thinks it will pre-
Visit our ‘Online Only’ content
f you missed the August onlineonly V
Iwww.vascularspecialistonline.com.
S
, visit
ASCULAR PECIALIST
Included is an editorial from our
Medical Editor, Dr. Russell Samson, titled “Keep RUC in mind.”
Excerpt: “In July, the Society for
Vascular Surgery sent requests to
its members to complete surveys
regarding the work involved with
creation, revision, and thrombectomy of hemodialysis access.
These surveys form the basis of
data used by the American Medical Association/Relative Value
Scale Update Committee (also
known as the RUC) to make recommendations to the Centers for
Medicare and Medicaid Services
(CMS) regarding the relative value
of these procedures.
“It is surprising, then, that some
members do not respond to these
requests nor fully comprehend the
importance of diligently completing the surveys. This could result
in vascular surgeons being reimbursed too little or too much (for
vascular surgery the latter is obviously very infrequent!).”
So be sure to routinely visit the
website, Facebook (Vascular Specialist), and Twitter (@VascularTweets) for the latest news for
vascular specialists from VASCULAR
SPECIALIST.
vent physicians from taking industry
bribes.
James Barrie once said, “Those that
bring sunshine into the lives of others
cannot keep it from themselves” – yet I
note that our politicians have not passed
similar legislation for themselves.
So what does this Sunshine Act
mean for vascular surgeons? In short,
any amount of money paid directly or
in kind (such as a free meal) in an
amount exceeding $10, or if less than
$10 amounting to more than $100
over a year, has to be reported by
these companies to a national database. This will be made public for all
our patients to see. I think it’s actually
quite comical that CMS set the level
of $10 for reporting. They clearly
think this amount is enough to influence us. That’s probably because they
realize that Medicare has reduced our
income so dramatically that we would
be willing to sell our mothers for $10!
Now, like every other law enacted
by the government, it took CMS 287
pages to describe how to interpret this
supposedly simple law. Despite the
length, I would urge everyone to read
the final rule – but a good dose of
Maalox should help. For in this extensive document CMS outlines rules
such as how companies will determine
how to report food a physician consumes at a national convention.
The final rule determines how research monies should be accounted for
and describes regulations for reporting
payment for talks given to groups of
referring physicians. I was especially
intrigued by the convoluted mathematics that CMS invented to determine the dollar amount a company
VASCULAR S PECIALIST
VASCULAR SPECIALIST Medical Editor Russell Samson, M.D.
ASSOCIATE EDITORS
Ali AbuRahma, M.D., Charles A. Andersen, M.D., Magruder Craighead
Donaldson, M.D., John F. Eidt, M.D., Ronald Fairman, M.D., Rob
Fitridge, M.D., Larry Kraiss, M.D., Joan Lohr, M.D., James McKinsey,
M.D., Mark Morasch, M.D., Frank Pomposelli, M.D., Brian Rubin, M.D.,
Russell H. Samson M.D., Cliff Shearman, M.D., Cynthia Shortell, M.D.,
Frank J. Veith, M.D., Robert Eugene Zierler, M.D.
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VASCULAR SPECIALIST (ISSN 1558-0148) is published bimonthly for the
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Subscription price is $230.00 per year.
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VASCULAR SPECIALIST is the official newspaper of the Society for Vascular
Surgery and provides the vascular specialist with timely and relevant
news and commentary about clinical developments and about the
impact of health care policy. Content for VASCULAR SPECIALIST is
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the Society is provided by the Society for Vascular Surgery.
The ideas and opinions expressed in VASCULAR SPECIALIST do not necessarily
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responsibility for damages, loss, or claims of any kind arising from or
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claims related to the products, drugs, or services mentioned herein.
needs to report for the food provided
by their representative for lunch for
physicians and their staff. It goes something like this: If the food cost $180
and two of the four partners and three
staff eat the food, then the per person
food cost would be $36. That then becomes the amount that would be reported for each of the two doctors
who got diarrhea from the bad food!
Now, just to prove that CMS is not
manned by a group of old fogies,
they have even created an app for our
smartphones so that we can track
what is being reported. But we are
obliged to enter the data ourselves,
and we can’t use this as proof that an
incorrect report was made. So, while
physicians will have a minimum of 45
days to challenge information before
it is public, and can dispute inaccurate
reports and seek corrections during a
2-year period, it is advisable to review
and correct all information before it is
published. To not do this would be
the same as asking the government to
do our taxes rather than having our
accountant do them!
It is certainly true that abuses have
occurred where unreasonable
amounts of money have been paid to
doctors to promote the use of drugs
and medical products, and where research may have been tainted by profit motives. Furthermore, travel
junkets thinly disguised as educational meetings have caused many to look
askance at the relationship between
industry and physicians. Improprieties
have occurred by physicians on hospital purchasing committees because of
undue influence from industry. And
Continued on page 15
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NEWS
S E P T E M B E R 2 0 1 3 • W W W. VA S C U L A R S P E C I A L I S T O N L I N E . C O M
VEITH'S VIEWS:
B Y F R A N K J. V E I T H , M . D.
stated goal of the United States is to support
and promote democracy
throughout the world. This
seems reasonable, because democracy has often worked well in our own
and other Western countries, and because no other form of government
has consistently been better. So is
democracy the best form of government? I submit that it is the best only
if certain conditions are met.
For democracy to work, the public DR. VEITH
must be well informed and willing to
consider, at least to some extent, the country’s interests in addition to their own self-interests. If a
major fraction of the public does not care about or
know what is good for the country or is totally
motivated by self-interest, the government and the
country will fail. Sadly this appears to be the case
in the U.S. today as evidenced by Jay Leno’s “JayWalking Segments” in which most young people
interviewed – even college graduates – have no
idea about issues important to our country. They
appear to be more interested in sports and their social life and more knowledgeable about TV sitcoms and reality shows.
How can such individuals be relied upon to pick
government leaders who will take care of our
country’s interests in the trying times it faces politically and economically? An ill-informed and noncaring public is more likely to pick leaders who are
the slickest talkers and who promise the most despite the impossibility or negative effects of keeping these promises. This know-nothing or
A
Democracy – best, but only if….
self-interested nature of our electorate contributes
importantly to the ever expanding entitlement culture in the U.S. and the resulting dangerous expansion of our national debt.
Another related requirement for democracy to be an effective form of government
is the need for an honest and objective media and press. A controlled or biased source
of information contributes hugely to an illinformed public. Whoever controls the
media and the press controls the minds of
the voters. For democracy to work effectively, the public must not only want to be
informed, they must also be given the necessary objective facts to make valid judgments. The press has a vital responsibility to
provide such facts with minimal bias. There is
considerable doubt about whether or not this is
occurring today in the U.S.
Of even greater importance to a successful
democracy is the ethical stature of its leaders and
their motivation – once elected – to act in the best
interests of the country. Many forces act upon our
leaders and are counter to these interests. These
include obligations to those who helped elect
them, ideology, personal gain, a desire to be reelected, and most importantly the corrupting requirement to solicit campaign financing. In the
U.S. currently, the need to finance expensive campaigns is a major flaw in our democracy, and is really a veiled form of bribery.
For a democratic leader to be successful in terms
of doing a good job of leading the country, all
these forces must be overridden by the desire to do
what is right and best for the whole country. This
means the leader must not serve solely special or
Fruits, not vegetables
from page 1
Swedish Inpatient Register and the
Swedish National Cause of Death
Register to follow outcomes of these
patients.
National health coverage in Sweden has been nearly 100% since
1987. All cases of AAA were identified by clinical events, not by general screening. AAA repair was
identified via the Nordic Classification of Surgical Procedures. To classify aneurysmal localization and
rupture status of AAA repairs, the
researchers linked the cohorts to the
Swedish Registry for Vascular
Surgery (founded in 1987, which accounted for 93.1% of all AAA repairs in Sweden).
Fruit and vegetable consumption
was summed from results of the 96
food item questionnaire and converted to daily consumption categories
ranging from never to greater than
or equal to 3 times daily.
Covariates assessed included edu-
©M ATTHEW K ENWRICK /F LICKR . COM
AAA
3
cation, alcohol consumption, diet,
physical activity, waist circumference, and smoking duration and
amount. The study population was
ethnically homogenous. History of
cardiovascular disease, diabetes, hypertension, and hypercholesterolemia was obtained from the
Swedish Inpatient Register, the
Swedish National Diabetes Register,
and the self-reported data from the
questionnaire.
During 13 years of follow-up
(1998-2010), the researchers found
that there were 1,086 primary cases
self-interests, and must have the courage and inner
strength to do what may at the moment be unpopular with his or her electoral base. He or she must
unite the country rather than divide it for shortterm political or parochial gain. Unfortunately
many of our recently elected U.S. leaders have not
met any of these requirements. If this trend continues, our democracy will serve the country’s interests poorly, and the U.S. will decline rather than
gain in stature and strength.
Efforts at democracy in the Middle East and elsewhere have failed because some or all of the requirements discussed here have not been met. A
similar decline awaits our U.S. democracy if the
current flaws in the underlying system cannot be
corrected.
So far this discussion has largely been related to
the U.S. federal government. However, the same
considerations apply to effective governments at
the county, state, and city levels, and to governing
bodies of other entities which purport to be managed in a democratic fashion. This even applies to
our vascular societies. The ethics and character of
the leaders and those choosing them are important
to effective governance and the success of the organization. If special interests, financial conflicts, and
self-interest prevail over the needs of the organization, the latter will fail and decline.
Dr. Veith is Professor of Surgery at New York University
Medical Center and the Cleveland Clinic. He is an
associate medical editor for VASCULAR SPECIALIST.
The ideas and opinions expressed in VASCULAR
SPECIALIST do not necessarily reflect those of the Society
or Publisher.
(899 in men; 83%) and 222 cases of
ruptured AAA (181 in men; 82%).
The mean age for nonruptured AAA
was 74 years in men and 76 years in
women. For ruptured AAA it was 76
and 78.5 years in men and women,
respectively. Cox proportional hazard analysis was used to estimate
hazard ratios.
Individuals in the highest quartile
of fruit consumption (greater than 2
servings per day) had a 25% lower
risk of AAA and a 43% lower risk of
ruptured AAA, compared with those
in the lowest quartiles of fruit consumption (less than 0.7 servings per
day). No association was observed
between vegetable consumption and
AAA risk. There was no impact of
smoking or sex of the individual on
the fruit consumption–related AAA
risk for both ruptured and nonruptured AAA.
Men and women with a high consumption of fruit and vegetables
were more educated; consumed
more fish, meat, and whole grains;
and were more likely to be leaner
and physically active, and less likely
to be smokers, according to the researchers. In addition, high consumers of fruit consumed less
alcohol, whereas the reverse was true
of high consumers of vegetables.
“A diet high in fruits may help to
prevent many vascular diseases, and
this study provides evidence that a
lower risk of AAA will be among the
benefits,” the researchers concluded.
The study was funded by grants
from the Swedish Research Council
and the Karolinska Institute. The authors reported they had no disclosures.
mlesney@frontlinemedcom.com
PERSPECTIVE
o I guess the old adage is correct … “An apple a day keeps
the doctor away,” or should I say
“An Apple A day keeps the AAA
Away?”
S
Dr. Russell Samson is the Medical
Editor of VASCULAR SPECIALIST.
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NEWS
4
SEPTEMBER 2013 • VASCULAR SPECIALIST
Perioperative beta-blockers
Mortality
from page 1
nine secure randomized trials totaling 10,529 patients who met the
guideline criteria, 291 of whom died.
They found that initiation of a
course of beta-blockers as per guideline recommendations before
surgery resulted in a 27% increase in
mortality.
In the secure trials, use of perioperative beta-blockers decreased nonfatal
myocardial infarction significantly
(RR, 0.73; P = .001), but increased
stroke (RR, 1.73; P =.05) and hypotension (RR, 1.51; P less than
.00001), according to the authors,
who presented their data in Heart
(2013 July 31 [doi: 10.1136/heartjnl2013-304262]).
Of the 291 deaths recorded in the
secure trials, 162 deaths (3.21%) occurred in 5,264 patients randomized
to beta-blockers, and 129 deaths
(2.45%) occurred in the 5,265 patients randomized to placebo.
Thus, the initiation of a course of
beta-blockers as per guideline recommendations before surgery resulted
in a 27% increase in all-cause mortality, Dr. Bouri and her coauthors stated. “Any remaining [perioperative
beta-blocker] enthusiasts might best
channel their energy into a further
randomized trial, which should be
designed carefully and honestly,” they
added.
The results from the DECREASE
family of trials substantially contradicted the meta-analysis of the secure
trials on the effect on mortality (P =
.05 for divergence).
“All studies investigated in the
DECREASE family for which data
had not been lost were found to be
insecure because of serious flaws.
In one case, it was clear that the entire study database had been fabricated. DECREASE I, published in
1999, escaped investigation as the
terms of the investigation only
reached back 10 years,” the researchers reported.
When the ESC and American College of Cardiology Foundation/
American Heart Association guidelines were formulated, “the inclusion
of insecure data caused them to
reach the conclusion that beta-blockade had a neutral effect on mortality
and allowed them to focus on the reduction of non-fatal MI as a surro-
gate endpoint,” the authors explained.
The DECREASE family of studies
was discredited almost 2 years ago
and subsequently underwent
lengthy internal investigation, the
results of which have been public
for some time, according to the authors. “Nevertheless, neither the European Society of Cardiology nor
the AHA guidelines have been retracted,” they said.
“Patient safety being paramount,
guidelines for perioperative betablockers should be retracted without further delay. Future
guidelines should be accompanied
by a commitment from named individuals to retract them immediately if the advice given is later
revealed to be harmful,” the authors concluded.
The authors reported that they had
no conflicts of interest.
mlesney@frontlinemedcom.com
Visit Vascular Specialist on
@VascularTweets and
Vascular Specialist
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on Changing News In the
Vascular World!
PERSPECTIVE
his article suggests that one in
four patients who die following
non-cardiac vascular surgery die because we prescribe beta-blockade
prior to major vascular surgery.
Could this finding be more devastating to those of us who have
changed our practice patterns to incorporate these medications into
our perioperative routine? Have we,
by following European Society of
Cardiology (ESC) and 2009 American College of Cardiology Foundation (ACCF)/American Heart
Association (AHA) guidelines, been
killing some of our patients? The
latter guidelines suggest that there is
at least a Class IIa indication for patients undergoing vascular surgery
to be prescribed beta blockers prior
to surgery, yet now we find that the
data they based these recommendations on may have been discredited.
At the outset I feel it is important
that the reader know that there has
been another recent publication
suggesting that there still may be
benefit from beta-blockade perioperatively in patients undergoing
noncardiac vascular surgery. (London MJ, Hur K, Schwartz GG, et al.
Association of perioperative-blockade with mortality and cardiovascu-
T
lar morbidity following major noncardiac surgery. JAMA 2013;
309:1704-1713). Still, those authors
agree that it is hypothesis-generating rather than definitive.
So what are we to do? Who are we
to believe? And how did this awful
dilemma arise? The most acceptable
answer is that there may be differences in the type and dosage of beta
blocker with some evidence that low
doses of atenolol rather than metoprolol are safer. This suggestion
comes from review of yet another
negative trial of beta blockade, the socalled POISE trial which also showed
an increase in death and stroke rate
(but with high doses of metoprolol
that most surgeons would not use).
However, the truly disquieting reason for this debate is that it appears
that questions have been raised concerning the validity of data provided
by Dr. Don Poldermans of Erasmus
Medical Center, may have falsified
data in his DECREASE trials. To
compound the problem Dr. Poldermans chaired the 2009 ESC guidelines for perioperative management
in noncardiac surgery until his recent resignation after being fired
from Erasmus Medical Center. Although he disputes the findings of
an in-house investigation, Erasmus
Medical Center concluded that there
were “serious shortcomings in the
procedure used to record informed
consent, the submission of publications based on unreliable data, and
scientifically inaccurate data collection. Erasmus press officer David
Drexhage found that data used in
several of Poldermans’s DECREASE
studies have not been able to be retrieved from hospital records. For example, in the pilot study
DECREASE-6, of 169 patients in the
database, only 5 could be found in
the hospital data system. “So 164 patients could not be accounted for,
and we do not know for sure if
these patients really existed,” according to Mr. Drexhage.
At this stage, I can offer the reader
no compelling reason to use or not
use these medications, and so I await
the new guidelines that hopefully
will be published early next year. For
now we will continue beta-blockers
in patients already on them or in patients with a strong cardiac history
since it does appear that cardiac risk
is reduced although overall stroke
mortality may be increased. We no
longer attempt to drastically lower
cardiac rate or blood pressure.
I am disappointed that once more
the medical community seems to be
affected by the hubris of individual
researchers whose academic aspirations transcend their moral obligations to tell the truth. We are
disillusioned but more importantly
our patients may be suffering strokes
or dying. Is a reprimand or firing
from a vaunted academic or hospital
position enough of a penalty or
should prison terms be given out? If
an individual were responsible for
thousands of deaths, would we ever
consider a simple slap on the wrist
as sufficient punishment? I think not.
Dr. Russell Samson is the medical
editor of Vascular Specialist. He is a
Clinical Associate Professor of Surgery,
Florida State University Medical
School and Attending Surgeon,
Sarasota Vascular Specialists. His
commentaries reflect his own opinions
and are not necessarily those of the
publisher or the Society for Vascular
Surgery. Information regarding Dr.
Poldermans and Erasmus Medical
Center was obtained from the Erasmus
Medical Center web site and reported
interviews. Visit the online version of
this article at our website:
www.vascularspecialist.org for links.
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VENOUS DISEASE
S E P T E M B E R 2 0 1 3 • W W W. VA S C U L A R S P E C I A L I S T O N L I N E . C O M
Appropriate use criteria
Testing
from page 1
in a two-part series evaluating noninvasive testing for peripheral vascular
disorders. Part I, published last year
( J. Am. Coll. Cardiol. 2012;60:24276), addressed peripheral arterial disorders, and Part II ( J. Am. Coll.
Cardiol. 2013 July 19[doi:10.1016/
j.jacc.2013.05.001]) addresses venous
disease and evaluation of hemodialysis access, according to Dr. Heather
Gornik, chair of the Part II writing
committee.
“Vascular laboratory tests really
play a central role in evaluating patients with peripheral vascular disorders. They are noninvasive, they have
good accuracy data, and they don’t
require radiation or dye. But we want
to make sure the right tests are being
ordered for the right reasons,” Dr.
Gornik, a cardiologist and vascular
tency and thrombosis; duplex evaluation for venous incompetency; venous physiological testing with
provocative maneuvers to assess for
patency and/or incompetency; du-
plex of the inferior vena cava and iliac veins for patency and thrombosis; duplex of the hepatoportal
system for patency, thrombosis, and
flow direction; duplex of the renal
vein for patency and thrombosis;
and preoperative planning and postoperative assessment of a vascular
access site.
5
Considering venous duplex ultrasound in a patient with acute unilateral limb swelling? Table 1 lists this
as an appropriate use. How about
duplex evaluation for venous incompetency in a patient with asymptomatic varicose veins? Table 3 says
this may be appropriate, but notes
Continued on following page
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Vascular lab tests
play a central
role in evaluating
patients with
peripheral
vascular
disorders.
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DR. GORNIK
medicine specialist at the Cleveland
Clinic, said in an interview.
Because these tests are low risk and
easily accessible, there is concern that
they are sometimes used excessively,
she explained – specifically mentioning the use of duplex ultrasound for
DVT screening as a commonly
overused procedure.
“There is very little evidence, if
any, to support broad screening for
blood clots in someone who has no
symptoms,” she said.
The goal of the ACC Foundation
Appropriate Use Criteria Task Force
responsible for developing the criteria
was to help clinicians minimize unnecessary testing, and maximize the
most effective and efficient testing,
she added.
Each of the clinical scenarios that
was developed by the writing committee were rated by a technical panel as to whether it represents an
“appropriate use,” or whether it is
“maybe appropriate” or “rarely appropriate.”
The various scenarios are listed,
along with their rating, in eight “ata-glance” tables that address the following more general categories:
venous duplex of the upper extremities for assessing patency and
thrombosis; venous duplex of the
lower extremities for assessing pa-
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01_3_5_6_13_14VS13_9.qxp
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VENOUS DISEASE
Continued from previous page
that it is rarely appropriate in a patient with spider veins.
The report also covers indications
for vascular testing prior to or after
placement of hemodialysis access,
because “evaluation of the superficial, deep, and central veins of the
upper extremity constitutes a large
component of these examinations,”
the report states.
In general, vascular studies were
deemed appropriate in the presence
of clinical signs and symptoms. The
report also shows that the vascular
laboratory plays a central role in the
evaluation of patients with chronic
venous insufficiency, and that preoperative vascular testing for preparing a dialysis access site is
appropriate within 3 months of the
procedure – but not for general surveillance of a functional dialysis fistula or graft in the absence of an
indication of a problem, such as a
palpable mass or swelling in the
arm.
The report is not intended to be
comprehensive, but rather is an attempt to address common and important clinical scenarios
encountered in the patient with manifestations of peripheral vascular disease, the authors noted.
SEPTEMBER 2013 • VASCULAR SPECIALIST
“The beauty of this report is that it
spans many disciplines,” Dr. Gornik
said, noting that numerous parties
have an interest in peripheral vascular disease, and that many specialties
order vascular laboratory tests.
A number of them were represented in the development of these
appropriate use criteria. Collaborating organizations included the Society for Vascular Surgery, the
American College of Radiology, the
American Institute of Ultrasound in
Medicine, the American Society of
Echocardiography, the American Society of Nephrology, the Intersocietal Accreditation Commission, the
Society for Cardiovascular Angiography and Interventions, the Society of
Cardiovascular Computed Tomography, the Society for Interventional
Radiology, and the Society for Vascular Medicine.
While other organizations have developed appropriate use criteria for
other modalities, such as cardiac testing, few have specifically addressed
vascular testing.
“I hope that these criteria will allow clinicians and vascular laboratories to really focus on doing the
highest quality work, and to evaluate
their use of vascular testing, maximize the use of the vascular lab, and
assure that the right test is done for
the right indication and that tests that
are not needed are not performed
just because they are readily available,” she said.
Dr. Gornik disclosed financial or
other relationships with Zin Medical,
Summit Doppler Systems Inc., the Fi-
bromuscular Dysplasia Society of
America, and the Intersocietal Accreditation Commission.
A detailed list of disclosures for all
Appropriate Use Criteria Task Force
Members is included with the full text
of the report.
PERSPECTIVE
ith the ever increasing pressures hospitals are under to
reduce costs, the elimination of unnecessary testing will be
critically important. Venous ultrasound carries
great potential for over
use and abuse due to its
safety, accuracy, availability, and low cost. It was
with this in mind that this
consensus group, which
also published criteria for
noninvasive diagnosis of peripheral
arterial disease, developed a set of
appropriate use criteria to guide
providers in the use of venous ultrasound in a large variety of clinical situations.
The rating scheme of “appropriate use,” “maybe appropriate” or
“rarely appropriate” is practical and
intuitive and all major venous studies were included. Moreover, the
W
multidisciplinary nature of the
work group and the well considered nature of their recommendations lend credibility to
the recommendations and
ensure that the scenarios
they cover are widely applicable. In one area,
however, the report disappoints somewhat. Given
the participation of the
Intersocietal Accreditation Commission, it is
surprising that there is less emphasis on the need for rigorous standards in our ultrasound labs so that
the quality of information generated is excellent.
Dr. Cynthia K. Shortell is Professor
and Chief, Division of Vascular
Surgery at Duke University Medical
Center, and an associate medical editor
for VASCULAR SPECIALIST.
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SEPTEMBER 2013 • WWW.VASCULARSPECIALISTONLINE.COM
NEWS
NEWSFROM
FRSVSSVS
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7
THE SVS® FOUNDATION ANNUAL REPORT 2013
A Message from the SVS Foundation Chair
Dear Colleagues:
Our specialty enjoys the prestige of
being known for quality care. One of
the reasons is the excellent research
we’ve conducted. We must continue
this good work both for our specialty
and our patients.
I am pleased to serve as the 2013 –
2014 Chair of the SVS® Foundation.
The Foundation is the Society for Vas-
cular Surgery’s® (SVS) philanthropic
arm that funds our mission to advance vascular research. The Foundation’s funds are dedicated specifically
for vascular surgery basic and clinical
research, and are awarded to many
younger surgeons to encourage their
research careers. During last fiscal
year SVS awarded $314,500.
Grants presented by SVS Foundation include:
1. E. J. Wylie Traveling Fellowship
2. SVS Foundation Resident Research
Prize
3. SVS Foundation Clinical Research
Seed Grants
My case was not an exception. Read
4. Multicenter Clinical Studies Planthe compelling stories on how SVS®
ning Grant
5. Mentored Clinical Scientist ReFoundation awards transformed the
search Career Developcareer of Luke Brewster
ment Award (K08)
from Emory, Michael Con6. Mentored Patient-Orite from UCSF, Peter Henke
ented Research Career Defrom the University of
velopment Award (K23)
Michigan, Melina Kibbe
7. Vascular Research Initiafrom Northwestern Univertives Conference Travel
sity and Keith Ozaki at the
Resident Scholarships
University of Florida. Sim8. SVS Foundation Student
ply click on the SVS FounResearch Fellowships
dation logo on the upper
9. Partnership Grant award- DR. GLOVICZKI
left-hand corner of the Vased jointly with the AmericularWeb.org home page.
can Geriatrics Society: The Jahnigen
Throughout the years there have
Scholars Program: A model for Faculbeen several very large contributions
ty Career Development
that served as the primary support
This is an ambitious undertaking
for these awards. While some of our
that is worth supporting. Being the
affiliated societies and industry genfirst E. J. Wiley Traveling Fellow in
erously assist in support, the Founda1987, I know how important this
tion needs individual SVS members
prestigious award was to my profesto donate and take responsibility.
sional career. I visited leading centers This 2013 SVS Foundation Annual Rein vascular surgery all around the
port highlights a few of the Foundaworld with the SVS brand on my
tion’s recent successes and awardees,
passport and a fellowship named afand the financial report. You will see
ter one of the greatest vascular surhow your funds are being spent and
geons ever, Dr. E. J. Wiley. I was
the care taken in choosing quality
traveling on the shoulder of a giant:
award winners.
no doors remained closed.
Our Annual Appeal Campaign,
conducted October through January,
is our primary fundraising program.
Your donation to each year’s Annual
Appeal accumulates toward the SVS
Foundation’s Legacy Program. New
this year, the Legacy Program tracks
your lifelong Foundation contributions with the total recognized and
published annually in SVS Foundation materials. The Legacy Program
levels begin at $10,000 and top at
$500,000. You will be honored in perpetuity for your personal commitment to your specialty.
I encourage you to make a donation to this year’s Annual Appeal to
keep feeding the pipeline of qualified
researchers. Join me in making your
SVS Foundation Annual Appeal donation at svsfoundationsite.org or using the donation form included in
this Annual Report. Donations to the
Foundation are tax deductible.
Thank you for your generosity. Your
contribution demonstrates your personal and professional commitment to
quality vascular care to your patients,
the public, and decision-makers.
Sincerely,
Peter Gloviczki, MD
Chair, SVS® Foundation
In 2012 Thomas S. Hatsukami, MD,
Professor of Surgery, Division of Vascular Surgery at the
University of
Washington in
Seattle, was presented the first
Multicenter Clinical Studies Planning Grant. This
$100,000 grant
was presented to
fund a high-imDR. HATSUKAMI
pact multicenter
clinical study in the treatment and/or
prevention of vascular disease. The following is an update on Dr.
Hatsukami’s clinical study.
ach year, more than 100,000 carotid
endarterectomy (CEA) and carotid
Estenting
(CAS) procedures are performed in the United States alone. Increasingly, the value of CEA and CAS
in patients with asymptomatic carotid
atherosclerosis is debated. Randomized trials comparing CEA to medical
therapy in patients with asymptomatic carotid stenosis have shown that
the absolute reduction in risk for
stroke provided by surgical intervention is relatively small. Given further
progress in the medical management
of atherosclerosis, some providers
now exclusively recommend non-surgical treatment to their patients with
asymptomatic carotid disease.
To deny carotid surgery or stenting
to all such patients, however, may
subject a subgroup of these individuals to the devastating consequences
of stroke – the leading cause of major long term disability and fourth
leading cause of death in the United
States. To improve the selection of
individuals for CEA and CAS, better
methods for identifying the high risk
carotid plaque are needed.
A number of studies have shown
that patients with intraplaque hemorrhage (IPH) or a disrupted luminal
surface (DLS), as identified by carotid
magnetic resonance imaging (MRI),
have a five to 17-fold higher risk for
SVS
Progress Report on SVS Foundation
Multicenter Clinical Studies Planning Grant
Figure 1: Simultaneous Non-contrast Angiography and intra-Plaque hemorrhage (SNAP)
image of the carotid artery. Panel (a) demonstrates a 3D maximal intensity projection (MIP)
image of the non-contrast enhanced angiography acquisition. There is a high-grade
stenosis in the proximal external carotid artery (arrowhead) and a minimally obstructive,
ulcerated plaque in the proximal internal carotid artery (arrow). The simultaneously
acquired IPH image shown in panel (b) is then color coded and fused with the angiographic
data in panel (c). Axial reformatted images (d) demonstrate the ulcer (arrows) and
surrounding high signal intensity consistent with intraplaque hemorrhage, confirmed by the
corresponding matched histology cross-sections (Mason’s trichrome).
future transient ischemic attack (TIA)
or stroke.
While results from these cohort
studies are promising, a randomized
controlled trial is needed to deter-
mine whether plaque characterization with MRI improves the selection of appropriate candidates for
carotid endarterectomy or stenting.
Continued on page 9
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NEWS FROM SVS
8
SEPTEMBER 2013 • VASCULAR SPECIALIST
THE SVS® FOUNDATION ANNUAL REPORT 2013
2013 SVS Foundation Award Recipients
At the 2013 Vascular Annual Meeting®, May 30–June 1 in San
Francisco, the SVS Foundation presented the following awards.
SVS Foundation Resident
Research Prize
E.J. Wylie Traveling Fellowship
Dr. Dardik, Research and Education
Committee Chair, and Dr. Cambria
presented the E.J. Wylie Traveling
Fellowship award to David H. Stone,
MD (center), of Dartmouth Hitchcock
Medical Center, Lebanon, NH. Dr.
Stone plans to visit three centers of
European excellence with
distinguished faculty and
accomplished EVAR track records in
order to investigate specific EVARassociated costs and operating
margins abroad.
Richard Cambria, MD (left), and
Alan Dardik, MD (right), presented
Nathan Airhart, MD, of Washington
University School of Medicine in
St. Louis, MO, with the SVS
Foundation Resident Research
Prize for his work titled: Smooth
muscle cells from abdominal aortic
aneurysms are unique and can
independently and synergistically
degrade insoluble elastin.
P HOTOS M ARTIN
ALLRED
Clinical Research Seed Grants
Left: Larry Kraiss, MD (right), Research Council Chair, and Dr. Cambria presented the Clinical Research Seed Grant to Guillermo A. Escobar, MD, of the University of
Michigan (Project Title: Urine mRNAs as a novel, early marker of acute kidney injury after contrast dye or surgery). Center: Dr. Gloviczki and Dr. Cambria presented
Mahmoud Malas, MD, of Johns Hopkins University with his Clinical Research Seed Grant (Project Title: Correlation of vasa-vasorum volume to carotid plaque
instability using contrast enhanced 3-dimensional carotid duplex ultrasound). Right: Dr. Cambria and Dr. Kraiss presented the Clinical Research Seed Grant to
Benjamin M. Jackson, MD, of the University of Pennsylvania (Project Title: Biomechanical modeling and biomarkers to predict thoracic aneurysm growth).
12 SVS Foundation Student Research Fellowships Named
he Student Research Fellowship, established by
T
the SVS Foundation, stimulates laboratory and clinical
vascular research by undergraduate college students
and medical school students
registered at universities in
the United States and Canada. Each award consists of a
$3,000 student stipend and a
two-year complimentary subscription to the Journal of
Vascular Surgery®.
Twelve college and medical school students were
named at the 2013 Vascular
Annual Meeting.
Elizabeth Chen
Yale School of Medicine
Sponsor: Alan Dardik, MD
Project title: Nanoparticles
Covalently Linked to Bovine
Pericardial Patches: A novel
implantable system for sustained in vivo drug delivery
Trit Garg
Stanford Medical School
Sponsor: Matthew Mell, MD
Project title: Adherence to PostOperative Surveillance Guidelines and Outcomes After Endovascular Aortic Aneurysm Repair
Among Medicare Beneficiaries
Project title: Role of p27Kip1838C>A SNP in Restenosis
Michael Harlander-Locke
University of California Los
Angeles
Sponsor: Peter Lawrence, MD
Project title: Low-Frequency
Disease Databases: A Necessary Alternative Method
Catherine Go
University of Pittsburgh
School of Medicine
Sponsor: Rabih Chaer, MD
Project title: Long-term Outcomes After Carotid Endarterectomy
Neil Huben
Omaha Veterans Affairs
Medical Center
Sponsor: Jason Michael Johanning, MD
Project title: Lower Extremity
Muscle Morphology and Gait
Function in Femoropopliteal
PAD Patients
Anthony Grieff
University of Washington
Sponsor: Alec Clowes, MD
Gregory Leya
Brigham and Women's Hospital, Harvard Medical School
Sponsor: Louis Nguyen, MD
Project title: Cost Effectiveness
Analysis of Silver Wound
Dressing in Lower Extremity
Wounds
Emily Nosova
UCSF/San Francisco Veterans’
Affairs Medical Center
Sponsor: Marlene Grenon, MD
Project title: Evaluating the
Severity of Peripheral Arterial
Disease and Associated Inflammatory Markers: What Role
Do n-3 Fatty Acids Play?
Scott Robinson
Emory University
Sponsor: Luke Brewster, MD
Project title: Enhancing the
Regenerative Potential of Mesenchymal Stem Cells for Targeted Therapy in Patients with
Critical Limb Ischemia
Grace Ruth Thompson
University of Florida
Sponsor: Scott Berceli, MD
Project title: Secondary Flow
Characteristics and Hemodialysis Fistula Maturation
Kaisen Yao
University of Iowa
Sponsor: William Sharp, MD
Project title: Pregnancy as a
Risk Factor for HyperglycemiaInduced Vasculopathy
Helen Lin Yuan
SUNY Upstate Medical
University
Sponsor: Vivian Gahtan, MD
Project title: The Pleiotropic
Effect of Short-term Statin
Administration on TSP-1
Induced Signaling in
VSMCs
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NEWS
NEWSFROM
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THE SVS® FOUNDATION ANNUAL REPORT 2013
Continued from page 7
In preparation for such a trial, there
are a number of barriers that must
first be addressed, including standardization of MR image acquisition protocols and assurance of
uniformity in image quality and reproducibility across imaging platforms and study centers.
There also is a need to reduce the
time for image acquisition, which
would decrease study costs and improve subjects’ tolerance of the scan.
Furthermore, protocols that avoid
the use of gadolinium contrast
would permit assessment of patients
with renal insufficiency. Finally, quantitative analysis tools that improve
the efficiency and reliability of interpretation of large volumes of imaging data are essential.
With funding from the SVS Foundation Multicenter Clinical Studies
Planning Grant, a network of imaging centers has been established
across North America.
Over the past year, investigators
from institutions in this network have
collaborated on the development and
testing of rapid, high-resolution 3-D
MR imaging protocols capable of identifying IPH, luminal surface disruption,
carotid arterial remodeling and luminal
stenosis without the need for intravenous contrast (Figure 1, on page 7).
This work provided critical preliminary background data for an application to the NIH for a multicenter study
of asymptomatic carotid disease using
these state-of-the art MRI techniques.
Furthermore, this work has set the
stage for additional multicenter grant
applications planned for the coming
year that will involve investigators in
North America, Europe, and Asia.
Clinical Relevance
The current paradigm for the management of carotid atherosclerosis is
guided by severity of stenosis. With
high-resolution carotid MRI, we now
have the opportunity to shift the focus from the flow channel to the diseased arterial wall itself.
Given the heterogeneity of carotid
plaque types, a method that can reliably characterize the carotid atheroma in vivo may lead to improved
risk stratification for new or recurrent stroke.
Better selection criteria will lead
to a reduction in overall health care
costs by reserving surgical procedures for individuals at greatest risk
for future stroke. Furthermore, a
better understanding of the nature
of the vulnerable plaque will serve
as a foundation for further research
into the mechanisms of initiation
and progression toward development of high-risk lesions of atherosclerosis, and perhaps lead to
development of novel pharmacological therapy.
The investigators wish to express
their sincere gratitude to the SVS
Foundation, whose support has significantly accelerated progress toward a better understanding of the
high-risk carotid plaque.
9
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NEWS FROM SVS
10
SEPTEMBER 2013 • VASCULAR SPECIALIST
THE SVS® FOUNDATION ANNUAL REPORT 2013
With Thanks to SVS Foundation Donors
The SVS Foundation thanks the following donors for their generous contributions during the Annual Appeal from April 1, 2012, through March 31, 2013.
Individual Contributors
Oliver O. Aalami, MD
Babak Abai, MD
Harry B. Abramowitz, MD
Ali F. Aburahma, MD
Donald L. Akers, MD
Tolulope K. Akinyemi, MD
Babatunde H. Almaroof, MD
Joseph M. Anain, MD
George Andros, MD
Alan J. Annenberg, MD
Enrico Ascher, MD
Marvin D. Atkins Jr., MD
Arthur I. Auer, MD
Bernadette Aulivola, MD
Mario H. Avila, MD
Martin R. Back, MD
J. Dennis Baker, MD
William H. Baker, MD
Jeffrey L. Ballard, MD
B. Timothy Baxter, MD
Carlos F. Bechara, MD
Michael Belkin, MD
Richard A. Berg, MD
Victor Bernhard, MD
Scott A. Berceli, MD, PhD
Edwin G. Beven, MD
James H. Black, MD
John Blebea, MD
Robert A. Brigham, MD
O. William Brown, MD
Phillip L. Cacioppo, MD
Keith D. Calligaro, MD
Richard P. Cambria, MD
James G. Chandler, MD
David P. Christenberry, MD
Paul L. Cisek, MD
Patrick G. Clagett, MD
Alexander W. Clowes, MD
Louis J. Cohen, MD
William B. Cohen, MD
John E. Connolly, MD
Michael S. Conte, MD
Jack L. Cronenwett, MD
David V. Cossman, MD
John A. Curci, MD
Ronald L. Dalman, MD
Michael C. Dalsing, MD
Stratton G. Danes, MD
Alan Dardik, MD, PhD
Herbert Dardik, MD
Mark G. Davies, MD, PhD
Joseph A. Davis, MD
David H. Deaton, MD
Devendra B. Dekiwadia, MD
Giacomo A. DeLaria, MD
Magruder C. Donaldson, MD
Peter S. Dovgan, M.D.
Maciej L. Dryjski, MD
Joseph R. Durham, MD
Matthew J. Eagleton, MD
Matthew S. Edwards, MD
John F. Eidt, MD
Ronald M. Fairman, MD
Rumi Faizer, MD
Mark Fillinger, MD
John J. Flanagan, MD
Thomas L. Forbes, MD
Randall W. Franz, MD
Julie Ann Freischlag, MD
Mark L. Friedell, MD
William R. Fry, MD
Dennis R. Gable, MD
Vivian Gahtan, MD
Nicholas D. Garcia, MD
Nitin Garg, MBBS
Stephen M. Gemmett, MD
Bruce L. Gewertz, MD
Gary Giangola, MD
Joseph S. Giglia, MD
Peter Gloviczki, MD
John F. Golan, MD
Jerry Goldstone, MD
Wayne S. Gradman, MD
Naren Gupta, MD
Prem C. Gupta, MD
Raul J. Guzman, MD
Vivienne J. Halpern, MD, FACS
Sachinder S. Hans, MD
Russell N. Harada, M.D.
Nancy L. Harthun, MD
Thomas S. Hatsukami, MD
G. Ken Hempel, MD
Peter K. Henke, MD
Anil P. Hingorani, MD
Mark D. Iafrati, MD
Karl A. Illig, MD
Daniel Ihnat, MD
Fernando L. Joglar, MD
K. Wayne Johnston, MD
William D. Jordan, Jr., MD
Peter E. Kagan, M.D.
Pierre B. Karam, MD
Vikram S. Kashyap, MD
Karthikeshwa Kasirajan, MD
Steven G. Katz, MD
Gregory J. Kechejian, MD
Melina R. Kibbe, MD
Lois A. Killewich, MD, PhD
Terry A. King, MD
Larry W. Kraiss, MD
Christopher J. Kwolek, MD
Gregory J. Landry, MD
Robert A. Larson, MD
George S. Lavenson, MD
Peter F. Lawrence, MD
Christopher J. Lecroy, MD
Cheong J. Lee, MD
Stephen E. Lee, MD
Rhoda F. Leichter, MD
Scott A. LeMaire, MD
Gary W. Lemmon, MD, FACS
Edward Li, MD
Michael P. Lilly, MD
Timothy K. Liem, MD
Frank W. LoGerfo, MD
Fedor Lurie, MD
Richard A. Lynn, MD, FACS, RPVI
Joseph G. Magnant, MD
Michel S. Makaroun, MD
M. Ashraf Mansour, MD
Rebecca M. Maron, CAE
Gordon H. Martin, MD
Kevin D. Martin, MD
Douglas W. Massop, MD
John H. Matsuura, MD
W. Burley McIntyre, MD
Robert B. McLafferty, MD
George H. Meier, MD
Donna M. Mendes, MD
Charles L. Mesh, MD
Joseph L. Mills, MD
Erica L. Mitchell, MD
Marc E. Mitchell, MD
Erin M. Moore, MD, FACS
Satish C. Muluk, MD
Richard F. Neville, MD
Patrick J. O’Hara, MD
Charles S. O’Mara, MD
William Oppat, MD
Robert W. Osborne Jr., MD
C. Keith Ozaki, MD
Frank T. Padberg, MD
Marcos Henrique Parisati, MD
Marc A. Passman, MD
Virendra I. Patel, MD
William H. Pearce, MD
Gregory J. Pearl, MD
Bruce A. Perler, MD
William C. Pevec, MD
Ralph B. Pfeiffer, MD
Giancarlo Piano, MD
Steve Powell, MD
Kevin Raftery, MD
Rajeev K. Rao, MD
Daniel J. Reddy, MD
Jeffrey M. Rhodes, MD
Norman M. Rich, MD, FACS
Thomas S. Riles, MD
Larry J. Robson, MD
L. Richard Roedersheimer, MD
Joel C. Rosenfeld, MD
David Rosenthal, MD
Charles B. Ross, MD
Matthew B. Rossi, MD
Fred W. Rushton, Jr., MD
Patrick C. Ryan, MD
Michael Joseph Sacca, MD
Farouq Ali Samhouri, MD
Russell H. Samson, MD
Bhagwan Satiani, MD
Sharon Saunders, FNP-C
Andres Schanzer, MD
Larry A. Scher, MD
Marc L. Schermerhorn, MD
Peter A. Schneider, MD
Darren B. Schneider, MD
Peter J. Schubart, MD
Gary R. Seabrook, MD
Piergiorgio G. Settembrini, MD
Raymond M. Shaheen, MD
Maureen K. Sheehan, MD
Paula Shireman, MD
Gregorio A. Sicard, MD
Anton N. Sidawy, MD, MPH
Alan E. Singer, DPM
Michael J. Singh, MD
Tej M. Singh, MD
Mahalingham Sivakumar, MD
Robert P. Smilanich, MD
Robert B Smith, MD
Wilson Oliveira Sousa Jr., MD
James C. Stanley, MD
W. Charles Sternbergh, MD
Ronald J. Stoney, MD
David S. Sumner, MD
Bauer Sumpio, MD
Anthony M. Sussman, MD, FACS
Robert B. Swersky, MD
Pinkus Szuchmacher, MD
Gale L. Tang, MD
Gary A. Tannenbaum, MD
Thomas T. Terramani, MD
Windsor Ting, MD
Dennis I. Toppin, MD, FRCSC
Jeffrey D. Trachtenberg, MD
James F. Tretter Jr., DO
Edith Tzeng, MD
Gilbert R. Upchurch Jr., MD
Jay Vasquez, MD
Gilford S. Vincent, MD
Uthan Vivek, MD
James S. Wagner, MD
Willis H. Wagner, MD
Dean H. Wasserman, MD
Daniel B. Walsh, MD
Thomas W. Wakefield, MD
Michael T. Watkins, MD
Fred A. Weaver, MD
Franklin W. West, RN
Alex Westerband, MD
John V. White, MD
Paul W. White, MD
Anthony Whittemore, MD
Edward Y. Woo, MD
Karen Woo, MD
Anson A. Yeager, MD
Elie J. Zayyat, MD
Jack Zeltzer, MD
Wei Zhou, MD
Robert M. Zwolak, MD, PhD
Surgery Department Contributors
• Division of Vascular and Endovascular
Surgery, Massachusetts General Hospital,
Richard P. Cambria, MD, Chief
• Division of Vascular Surgery, University
of Massachusetts Medical School, UMass
Memorial Health Care, Louis M.
Messina, MD, Vice Chair
Foundation and Association
Contributors
• American Podiatric Medical Association
• Edwards Vascular Foundation ( John D.
Edwards, MD)
• American College of Surgeons
•von Liebig Foundation
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SEPTEMBER 2013 • WWW.VASCULARSPECIALISTONLINE.COM
NEWS
NEWSFROM
FRSVSSVS
VQI REPORT
11
THE SVS® FOUNDATION ANNUAL REPORT 2013
Open the Pathway Recognition 2012-2013
The Open the Pathway campaign, conducted in 2009 and into early 2010, received strong support from SVS members, regional societies, and industry partners. The Foundation thanks those who supported the campaign and continue their pledge contributions.
SVS MEMBER CONTRIBUTORS
Platinum Level - $25,000-plus
George Andros, MD
Mark G. Davies, MD, PhD
Nicholas D. Garcia, MD
Vivienne J. Halpern, MD
William H. Pearce, MD
Gold Level - $10,000-plus
G. Patrick Clagett, MD
Michael C. Dalsing, MD
Rumi Faizer, MD, FRCS (C)
Dr. Bruce and Diane L. Gewertz
John F. Golan, MD
Joseph Magnant, MD
Dr. and Mrs. Joseph L. Mills Sr.
Gregory J. Pearl, MD
Dr. Bauer and Catherine Sumpio
Dr. Dan and Teri Walsh
Robert M. Zwolak, MD, PhD
Silver Level - $5,000-plus
Dr. Victor and Suzan Bernhard
Phillip L. Cacioppo, MD
Richard P. Cambria, MD
Alexander W. Clowes, MD
Michael S. Conte, MD
Jack L. Cronenwett, MD
Ronald L. Dalman, MD
Alan Dardik, MD, FACS
Herbert Dardik, MD
Matthew J. Eagleton, MD
Julie Ann Freischlag, MD
Dr. Peter and Monika Gloviczki
Nancy L. Harthun, MD
Peter K. Henke, MD
Mark D. Iafrati, MD
Karl A. Illig, MD
William D. Jordan Jr., MD
Dr. and Mrs. Larry W. Kraiss
Gary W. Lemmon, MD
Peter F. Lawrence, MD
Rebecca M. Maron, CAE
Kevin D. Martin, MD
Donna M. Mendes, MD, FACS
Charles S. O’Mara, MD
William Oppat, MD
Jeffrey M. Rhodes, MD
Gary R. Seabrook, MD
Dr. Thomas and Mary Wakefield
Dean H. Wasserman, MD, FACS
Fred A. Weaver, MD
Bronze Level - $1,000-plus
Harry B. Abramowitz, MD
Ali F. AbuRahma, MD
Enrico Ascher, MD
Martin R. Back, MD
J. Dennis Baker, MD
William H. Baker, MD
Dr. Tim and Barbara Baxter
Michael Belkin, MD
Richard A. Berg, MD
James H. Black III, MD
O. William Brown, MD, JD
Dr. Jim and Cindi Chandler
John A. Curci, MD
Magruder C. Donaldson, MD
Maciej L. Dryjski, MD, PhD
Drs. Matthew and Angela Edwards
Dr. John and Lacy Eidt
Ronald M. Fairman, MD
Drs. Mark and Mary Fillinger
Thomas L. Forbes, MD
Randall W. Franz, MD
Mark L. Friedell, MD
Dennis R. Gable, MD
Vivian Gahtan, MD
Stephen M. Gemmett, MD
Gary Giangola, MD
Joseph S. Giglia, MD, FACS
Jerry Goldstone, MD
Sachinder Singh Hans, MD
Anil P. Hingorani, MD
Daniel Ihnat, MD
K. Wayne Johnston, MD
Vik S. Kashyap, MD
Steven G. Katz, MD
Christopher J. Kwolek, MD
Gregory J. Landry, MD
George S. Lavenson Jr., MD
Stephen E. Lee, MD
Dr. and Mrs. Scott LeMaire
Timothy K. Liem, MD
Frank W. LoGerfo, MD
Dr. and Mrs. Richard A. Lynn
Michel S. Makaroun, MD
M. Ashraf Mansour, MD
Gordon H. Martin, MD
Douglas W. Massop, MD
Robert B. McLafferty, MD
George H. Meier, MD
Charles S. Mesh, MD
Louis M. Messina, MD
Erica L. Mitchell, MD
Marc E. Mitchell, MD
Satish C. Muluk, MD
Dr. and Mrs. Patrick O’Hara
Robert W. Osborne Jr., MD
Bruce A. Perler, MD
Rip B. Pfeiffer Jr., MD
Kevin B. Raftery, MD
Thomas S. Riles, MD
L. Richard Roedersheimer, MD
David Rosenthal, MD
Russell H. Samson, MD
Marc L. Schermerhorn, MD
Darren B. Schneider, MD
Maureen K. Sheehan, MD
Paula K. Shireman, MD
Gregorio A. Sicard, MD
Anton N. Sidawy, MD
James C. Stanley, MD
W. Charles Sternbergh, III, MD
Ronald J. Stoney, MD
Windsor Ting, MD
Jeffrey D. Trachtenberg, MD
Edith Tzeng, MD
Gib R. Upchurch, MD
Dr. and Mrs. Anthony Whittemore
Wei Zhou, MD
Foundation Friends
Jeffrey L. Ballard, MD
Keith D. Calligaro, MD
Paul Christenberry, MD
J. Louis Cohen, MD
William B. Cohen, MD
Jack E. Connolly, MD
David V. Cossman, MD
Wayne S. Gradman, MD
Raul J. Guzman, MD
Melina R. Kibbe, MD
Edward Li, MD
W. Burley McIntyre, MD
C. Keith Ozaki, MD
William C. Pevec, MD
Steve Powell, MD
Rajeev K. Rao, MD
Daniel J. Reddy, MD
Norman M. Rich, MD
Joel C. Rosenfeld, MD
Farouq Ali Samhouri, MD
Bhagwan Satiani, MD
Michael J. Singh, MD
Robert P. Smilanich, MD
Robert B. Smith, III, MD
Robert B. Swersky, MD
Jay Vasquez Jr., MD
Willis H. Wagner, MD
Edward Y. Woo, MD
VASCULAR SOCIETY CONTRIBUTORS
Eastern Vascular Society
Midwestern Vascular Surgical Society
New England Vascular Surgical Society
Western Vascular Society
CORPORATE CONTRIBUTORS
Premier Partners ($250,000 - plus)
Philips Healthcare
President’s Circle ($100,000 - plus)
Abbott Vascular
M2S
Atrium
Open the Pathway Contributors
Cook Medical
GE Healthcare
Invatec/Medtronic
Siemens
Spectranetics
ZymoGenetics
07_12VS13_9.qxp
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NEWS FROM SVS
12
SEPTEMBER 2013 • VASCULAR SPECIALIST
THE SVS® FOUNDATION ANNUAL REPORT 2013
SVS Foundation FY 2014
Budgeted Revenue and Expense
MARCH 2013
TOTAL ASSETS: 5.6 M*
SVS Foundation Total Income
SVS Foundation Total Expenses
Individual
contributions
19%
Fundraising
expenses
2%
89%
Awards
55%
Corporate
support
26%
9%
Society
contributions**
Total income
$367,000
Total expenses
$596,100
* includes cash, investments, and value of pledges of future support
** includes SVS, ACS, and regional society contributions
Source: Society for Vascular Surgery
Rabih Chaer, MD
Receives AGS Award
SVS Foundation Launches the
Roy Greenberg Distinguished Lecture at
2013 Vascular Annual Meeting
Greenberg has served as national
oy Greenberg, MD, was honprincipal investigator for several
ored during the Vascular Anendograft trials and holds four
nual Meeting held in San
personal IDEs related to endoFrancisco with the first of a segraft repair; most notable
ries of lectures in his name. Dr.
among these is his work with
Stephan Haulon, MD, PhD,
fenestrated and branched endoProfessor of Surgery, Université
grafting.
de Lille 2, Chief of Vascular
This first in the Greenburg seSurgery, Hôpital Cardiologique
ries of lectures was supported by
- CHRU Lille, Lille, France
DR. GREENBERG
a seed grant to the SVS Foundaspoke on “New Frontiers, New
Solutions? Lessons Learned from Training tion from Cook Medical.
with a Pioneer.”
Dr. Greenberg is currently Professor of
Surgery of the Cleveland
Clinic Foundation Lerner
College of Medicine. His
prestigious career is focused on development
and assessment of endovascular devices for
treating aortic diseases.
He holds more than 50
patents. He developed a
mathematical model for
processing and fusing
imaging modalities to facilitate complex aortic
Dr. Peter Gloviczki congratulates Dr. Stephan Haulon for giving
endograft repair. Dr.
the first Roy Greenberg Distinguished Lecture.
Administration
and governance
Vascular Surgeon Presented With a
Jointly-Funded Award by the American
Geriatrics Society (AGS) and the SVS
Foundation
R
related medical disciplines.
Working more closely together, JSP supports
highly qualified
Career Developyoung specialty facment Award ( JSP)
ulty members to iniin 2002. JSP fosters
tiate and ultimately
the development of
sustain a career in
scientists in the surresearch and educagical and related
tion in the geriatrics
medical disciplines.
aspects of their disSVS Foundation
cipline. Dr. Chear’s
collaborated with
award recognizes
AGS in funding the
DR. CHAER
the importance of
JSP award in 2009
collaboration between the vasand presented it to SVS
member Dr. Rabih Chaer. Dr. cular surgery specialty and
geriatrics.
Chaer’s research is titled
This unique award brings
“Effect of Aging and Aortic
Wall Behavior as Predictors of together the leaders from 10
specialty societies and geriatriAortic Aneurysm Growth.”
cians. Working together has
The JSP addresses the need
fostered an environment of
to create a structure of developing leaders in geriatrics, aca- sharing to improve the health
care of American seniors.
demic surgery, and other
M ARTIN A LLRED
he AGS launched the Jahnigen Scholars Program: A
T
Model for Faculty
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DEVICES, DRUGS, & TRIALS
S E P T E M B E R 2 0 1 3 • W W W. VA S C U L A R S P E C I A L I S T O N L I N E . C O M
13
Apixaban beats warfarin on safety in acute VTE
BY MITCHEL L. ZOLER
IMNG Medical Ne ws
AMSTERDAM – In patients with
acute venous thromboembolism, 6
months of treatment with the oralanticoagulant apixaban was as effective as was standard therapy with
subcutaneous enoxaparin for a week
followed by oral warfarin, and apixaban caused significantly fewer major
bleeding complications in a randomized, multicenter trial with more
than 5,000 patients.
But in addition to apixaban’s sterling individual performance in this
pivotal trial, which seems to clear the
way for the drug to eventually receive
a labeled indication for acute venous
thromboembolism, the results also appeared to further anoint the new, oral
anticoagulant roster of dabigatran
(Pradaxa), rivaroxaban (Xarelto), and
apixaban (Eliquis) as the thromboticdisease troika to be reckoned with,
the newcomers whose time has come.
Ever since rivaroxaban became the
first of the trio to gain acute VTE labeling, last November, physicians who
manage patients with acute VTE had
to wrestle with the question of how to
integrate this option into their prac-
tices. The new findings on apixaban
suggest that physicians will soon have
to think about deciding between rivaroxaban and apixaban for this indication. Since recent results from other
major trials also
established dabigatran as the
equal of warfarin
for efficacy when
treating acute
VTE and with superior safety,
dabigatran’s entry
into acute VTE
management
DR. ROSENDAAL
seems imminent
(N. Engl. J. Med. 2013;368:709-18).
Propelling this new anticoagulant
era are the indications of efficacy
that’s equivalent with heparin, but
safer, and with far easier drug delivery as the need for anticoagulation
clinics and regular measurement of
international normalized ratio (INR)
is eliminated by all three new drugs.
“An oral regimen without laboratory monitoring will simplify therapy,”
Dr. Giancarlo Agnelli noted when he
presented the new apixaban findings
at the congress of the International
Society on Thrombosis and
Haemostasis. Concurrently with his
report at the meeting, the results were
published online (N. Engl. J. Med.
2013;doi:10.1056/nejmoa1302507).
“I think the argument is overwhelming” to use one of the new
drugs instead of warfarin. “They are
oral drugs where you do not need a
blood draw every 2 or 3 weeks, they
are a lot easier to use, and they are at
least as good as warfarin and at least
as safe,” said Dr. Frits R. Rosendaal,
professor of clinical epidemiology in
hemostasis and thrombosis at Leiden
(The Netherlands) University.
The Apixaban for the Initial Management of Pulmonary Embolism
and Deep-Vein Thrombosis as FirstLine Therapy (AMPLIFY) trial
randomized 5,400 acute VTE patients at 358 centers in 28 countries.
Patients received either apixaban
starting with a 10-mg b.i.d. dosage
for 7 days, followed by a dosage of 5
mg b.i.d. for 6 months, or enoxaparin
at a dosage of 1 mg/kg every 12
hours for a median of 7 days followed by warfarin for 6 months with
a target INR of 2.0-3.0.
The study’s primary efficacy endpoint was the combined rate of recurrent, symptomatic VTE or death
related to VTE. This occurred in 59
of 2,609 patients (2.3%) who received
apixaban, and in 71 of 2,635 (2.7%)
patients who received enoxaparin followed by warfarin. These results met
the study’s prespecified criterion for
apixaban’s noninferiority to standard
treatment reported Dr. Agnelli, professor of medicine at the University
of Perugia, Italy.
Major bleeding events occurred in
15 of 2,676 (0.6%) patients on apixaban and in 49 of 2,689 (1.8%) patients
on enoxaparin and warfarin, a statistically significant difference. A composite safety outcome of major
bleeds plus clinically relevant nonmajor bleeds occurred in 4.3% of the
apixaban patients and in 9.7% of the
patients on standard therapy, a statistically significant difference. Aside
from bleeding events, the rates of all
other adverse events were similar in
the two treatment arms.
The trial was sponsored by Pfizer
and Bristol-Myers Squibb, which market apixaban. Dr. Agnelli disclosed ties
to Pfizerand other pharma companies.
Dr. Rosendaal had no disclosures.
100,000+
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
PROCEDURES COLLECTED &
READY FOR BENCHMARKING
Vascular Quality Initiative®
a collaboration between
®
GET STARTED NOW
www.vascularqualityinitiative.org/start
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14
SEPTEMBER 2013 • VASCULAR SPECIALIST
CLASSIFIEDS
A l s o a v a i l a b l e a t w w w. M e d J o b N e t w o r k . c o m
PROFESSIONAL OPPORTUNITIES
Vascular-Endovascular Surgeon
Harrisburg, PA
Pinnaclehealth Cardiovascular and Thoracic Surgery, in Harrisburg PA, is seeking a
full-time Vascular-Endovascular Surgeon to join their growing practice. Interested
candidates should be board-certified and vascular lab certified. Experience preferred
and must possess a willingness to work with a broad range of vascular sub-specialists
in a state-of-the-art facility. Benefits include: competitive compensation, atmosphere
of collegiality, impressive benefit package, professional allowance for CME, and
relocation allowance.
Nationally recognized, PinnacleHealth Cardiovascular Institute is a pioneer offering
the full continuum of cardiovascular services. We are passionate about providing
the highest quality care to our patients by incorporating leading edge technology and
landmark clinical trials. Our physicians are valued, as evidenced in their rise to many
of our leadership positions, standing with us as we are acknowledged for quality,
experience, and safety.
The Harrisburg, Pennsylvania, region and suburbs offer an abundance of arts and
entertainment, public and private schools, 10 colleges and universities, and affordable
homes. Listed among Forbes.com “America’s Most Livable Cities,” we are a day-trip away
from New York City, Philadelphia, Baltimore, and Washington, D.C.
Our advancing system is confirmed by the many awards, recognitions, and “firsts”
listed on our website and construction of another state-of-the-art hospital with a full
range of innovative cardiac services.
Our 140-year tradition of growth and excellence remains unabated; join us.
Qualified candidates please email CV to slauer@pinnaclehealth.org
For more information about PinnacleHealth please visit www.pinnaclehealth.org
The Ohio State
University
Heart and Vascular
Center
For deadlines and more information, contact Linda Wilson
Tel: (973) 290-8243, Email: lwilson@frontlinemedcom.com
Controversies in Vascular
Diseases and 6th Annual Vascular
Noninvasive Testing Symposium,
November 1-2, 2013 in
Columbus OH
Division of Vascular Diseases &
Surgery and the Peripheral Vascular lab
are sponsoring a two day event. The
Ohio State University Wexner Medical
Center, Center for Continuing Medical
Education is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to sponsor continuing medical education for physicians, nurses and sonographers this live
activity is designated for a maximum of
9 AMA PRA Category 1 Credits™ .
For more information please contact
Dawn Sagle at
Dawn.Sagle@osumc.edu
call 614-293-8536 or visit our website
for conference brochure information
http://surgery.osu.edu/vascular/
IMNG Medical Media, a division of
Frontline Medical Communications, Inc.
7 Century Drive, Suite 302
Parsippany, NJ 07054-4609
FIND YOUR NEXT JOB AT
MEDJOBNETWORK com
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The frst mobile job board for Physicians, NPs, and PAs
Disclaimer
VASCULAR SPECIALIST assumes the statements made in classified advertisements are accurate, but cannot investigate the
statements and assumes no responsibility or liability concerning their content. The Publisher reserves the right to decline, withdraw, or edit advertisements. Every effort will be made to avoid
mistakes, but responsibility cannot be accepted
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02_15VS13_9.qxp
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TIPS AND TRICKS
S E P T E M B E R 2 0 1 3 • W W W. VA S C U L A R S P E C I A L I S T O N L I N E . C O M
TIPS AND TRICKS:
B Y A L B E I R Y. M O U S A , M . D .
he underlying pathophysiology
of chronic venous insufficiency is
complex and involves many factors. Studies have shown that average
venous ulcers may need 6-12 months
for complete healing with an anticipated recurrence rate exceeding 2/3
cases in 5 years.
These numbers
reflect the magnitude of the problem and mandate
deploying all efforts to stop progression of the
disease. Our
group has found
the following 10
DR. MOUSA
tips have significantly improved our healing rates.
1. First, rule out any associated arterial, immunologic, endocrine, or
other systemic causes for leg/foot ulceration.
2. Be aggressive to stop progression of the disease (fight CEAP 6):
any local tenderness at the site of discolored skin at the gaiter area for venous ulcers should initiate a prompt
reflux study to evaluate for incompetent perforators.
3. Venous ulcers are associated
with an incompetent perforator within 2 cm of the ulcer area.
4. Recurrent venous ulcers at the
same location may be associated with
venous outflow obstruction, (MayThurner syndrome is an underestimated pathology) which affects
mainly the left leg.
5. When performing iliac vein
venograms, make liberal use of in-
T
Continued from page 2
yes, some doctors would sell their
mothers for 10 bucks. But, on the
whole, we remain one of the most
honest of professions. So was it really
necessary to add another impediment
to the doctor-patient relationship?
When our patients eventually look
at this database, will they really be able
to differentiate between monies for research or those used to provide lunch
to an office? Will they regard physicians as crooks just because they were
reimbursed for lecturing at a scientific
meeting? Maybe! Actually, I suspect
my patients won’t bother to look at
the database but those that do will just
be confused. Regardless, I suspect we
will now be spending time explaining
ourselves rather than explaining treatments. So much for Sunshine!
15
Ten tips for chronic venous ulcers
travascular ultrasound.
6. Exudative venous ulcers need multilayer compression dressings and appropriate antibiotics if infection exists.
7. Pentoxifylline (Trental) 800 mg,
3 times daily.
8. Frequent debridement and frequent objective evaluation for ulcer
area with each office visit.
9. Bi-layered living cell treatment
(Apligraf®) to promote healing.
10. Office/clinic visit every 3
months after complete healing (CEAP
5) and further testing as needed.
Dr. Mousa is an associate professor at the
Department of Surgery, West Virginia
University, Morgantown.
VAS_5
16.qxp
1/3/2013
10:31 AM
Page 1
HeRO (Hemodialysis Reliable OutFlow)
Graft is the ONLY fully subcutaneous
AV access solution clinically proven
to maintain long-term access for
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