Episodes

  • Holding Pressure: AV Fistula/Graft Complications Part 1

    Holding Pressure: AV Fistula/Graft Complications Part 1
    Jan 6 2025
    Guest: Dr. Christian de Virgilio is the Chair of the Department of Surgery at Harbor-UCLA Medical Center. He is also Co-Chair of the College of Applied Anatomy and a Professor of Surgery at UCLA's David Geffen School of Medicine. He completed his undergraduate degree in Biology at Loyola Marymount University and earned his medical degree from UCLA. He then completed his residency in General Surgery at UCLA-Harbor Medical Center followed by a fellowship in Vascular Surgery at the Mayo Clinic. Resources: Rutherford Chapters (10th ed.): 174, 175, 177, 178 Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/ The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/ Outline: Steal Syndrome Definition & Etiology Steal syndrome is an important complication of AV access creation, since access creation diverts arterial blood flow from the hand. Steal can be caused by multiple factors—arterial occlusive disease proximal or distal to the AV anastomosis, high flow through the fistula at the expense of distal arterial perfusion, and failure of the distal arterial networks to adapt to this decreased blood flow. Incidence and Risk Factors The frequency of steal syndrome is 1.6-9%1,2, depending on the vessels and conduit choice Steal syndrome is more common with brachial and axillary artery-based accesses and nonautogenous conduits. Other risk factors for steal syndrome are peripheral vascular disease, coronary artery disease, diabetes, advanced age, female sex, larger outflow conduit, multiple prior permanent access procedures, and prior episodes of steal.3,4 Long-standing insulin-dependent diabetes causes both medial calcinosis and peripheral neuropathy, which limits arteries’ ability to vasodilate and adjust to decreased blood flow. Patient Presentation, Symptoms, Grading Steal syndrome is diagnosed clinically. Symptoms after AVG creation occurs within the first few days, since flow in prosthetic grafts tend to reach a maximum value very early after creation. Native AVFs take time to mature and flow will slowly increase overtime, leading to more insidious onset of symptoms that can take months or years. The patient should have a unilateral complaint in the extremity with the AV access. Symptoms of steal syndrome, in order of increasing severity, include nail changes, occasional tingling, extremity coolness, numbness in fingertips and hands, muscle weakness, rest pain, sensory and motor deficits, fingertip ulcerations, and tissue loss. There could be a weakened radial pulse or weak Doppler signal on the affected side, and these will become stronger after compression of the AV outflow. Symptoms are graded on a scale specified by Society of Vascular Surgery (SVS) reporting standards:5 Workup Duplex ultrasound can be used to analyze flow volumes. A high flow volume (in autogenous accesses greater than 800 mL/min, in nonautogenous accesses greater than 1200 mL/min) signifies an outflow issue. The vein or graft is acting as a pressure sink and stealing blood from the distal artery. A low flow volume signifies an inflow issue, meaning that there is a proximal arterial lesion preventing blood from reaching the distal artery. Upper extremity angiogram can identify proximal arterial lesions. Prevention Create the AV access as distal as possible, in order to preserve arterial inflow to the hand and reduce the anastomosis size and outflow diameter. SVS guidelines recommend a 4-6mm arteriotomy diameter to balance the need for sufficient access flow with the risk of steal. If a graft is necessary, tapered prosthetic grafts are sometimes used in patients with steal risk factors, using the smaller end of the graft placed at the arterial anastomosis, although this has not yet been proven to reduce the incidence of steal. Indications for Treatment Intervention is recommended in lifestyle-limiting cases of Grade II and all Grade III steal cases. If left untreated, the natural history of steal syndrome can result in chronic limb ischemia, causing gangrene with loss of digits or limbs. Treatment Options Conservative management relies on observation and monitoring, as mild cases of steal syndrome may resolve spontaneously. Inflow stenosis can be treated with endovascular intervention (angioplasty with or without stent) Ligation is the simplest surgical treatment, and it results in loss of the AV access. This is preferred in patients with repetitive failed salvage attempts, venous hypertension, and poor prognoses. Flow limiting procedures can address high volumes through the AV access. Banding can be performed with surgical cutdown and placement of ...
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    39 mins
  • The Art and Science of Leadership - An Introduction to the SVS Leadership Development Program

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

    In this special series, core faculty members of the SVS Leadership Development Program, Dr. Manuel Garcia-Toca, Dr. Kenneth Slaw, and Steve Robischon, discuss the program origins, research regarding good leadership, and how to join.

    Manuel Garcia-Toca, MD completed his MD at the Universidad Anahuac in Mexico (1999) and MS in Health Policy at Stanford University (2020). Dr. Garcia-Toca completed his residency in General Surgery at Brown University (2008) and a fellowship in Vascular Surgery at Northwestern University (2010). He will serve within the Department of Surgery in the Division of Vascular Surgery and Endovascular Therapy and the Division of Emory Surgery at Grady based primarily at Grady Memorial Hospital.

    Kenneth Slaw, PhD is the executive director of the Society for Vascular Surgeons.  Dr. Slaw received his master's and doctoral degrees in educational psychology from the University of Illinois. He has over 35 years of executive leadership experience in the medical society and philanthropic communities, having served in numerous previous roles, including as president of the American Association of Medical Society Executives, as chairman of the board of Make A Wish Illinois, and as senior staff member at the Academy of Pediatrics, where he assisted in efforts with the Pediatric Leadership Alliance Program, which has provided leadership skill building sessions for approximately 3, 000 physicians.

    Steve Robischon, PA-C is a Physician Assistant with the Division of Vascular and Endovascular Surgery at the Medical College of Wisconsin in Milwaukee, Wisconsin, and is also a member of the PA Section Steering Committee.

    More about the SVS PA Section

    More about the SVS Leadership Program

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    32 mins
  • JVS CIT Editorials and Abstracts - Oct/Nov 2024

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

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

    Readers:

    Nick Schaper (@schapernj)

    Nabeeha Khan (@Nabeeha_Khan_)

    Hosts:

    John Culhane (@JohnCulhaneMD)

    Nishi Vootukuru (@Nishi_Vootukuru)

    Reference Articles:

    The Gore Iliac Branch Endoprosthesis as an alternate aortic main body: Promising results in select patients

    A classic article that has never been read in English

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    30 mins
  • JVS Author Spotlight - Mota, Liang and Weinkauf

    JVS Author Spotlight - Mota, Liang and Weinkauf
    Dec 8 2024

    Audible Bleeding editor Wen (@WenKawaji) is joined by 4th-year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Forbes (@TL_Forbes), JVS-VS associate editor Dr. John Curci (@CurciAAA) to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Mota, Dr. Liang and Dr. Weinkauf, authors of the following papers.

    Articles:

    1. The impact of travel distance in patient outcomes following revascularization for chronic limb-threatening ischemia

    2. Serum detection of blood brain barrier injury in subjects with a history of stroke and transient ischemic attack

    Show Guests:

    1. Dr. Lucas Mota- third-year general surgery resident at the Beth Israel Deaconess Medical Center

    2. Dr. Patrick Liang- assistant professor at Harvard medical school and a practicing vascular surgeon at the Beth Israel Deaconess medical center.

    3. Dr. Weinkauf - assistant professor with the Department of Surgery Division of Vascular and Endovascular Surgery at the University of Arizona College of Medicine

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    38 mins
  • Get a Pulse on PAD Campaign

    Get a Pulse on PAD Campaign
    Nov 24 2024
    Nishi Vootukuru (@Nishi_Vootukuru) and Dr. Ezra Schwartz (@ezraschwartz10) interview Dr. William Shutze and Dr. Anahita Dua (@AnahitaDua) to discuss the Get a Pulse on PAD Campaign. The Get a Pulse on PAD initiative (#PulseonPAD), launched in February, 2024, is a patient education and advocacy campaign designed to increase the understanding of peripheral artery disease's risk factors and potential symptoms. Dr. Shutze is a vascular surgeon with Texas Vascular Associates in Dallas, Texas and the Secretary of the SVS. Dr. Shutze completed his medical studies at Baylor University after completing general surgery residency at University of Alabama in Birmingham. Dr. Shutze returned to Baylor to complete his vascular fellowship. Dr. Shutze is one of the Get a Pulse on PAD initiative’s chairs and a leading expert in PAD. He has actively published in the field with over 100 abstracts and articles, with his most recent work focusing on prosthetics, and advocating for successful prosthetic referral after amputation. Dr. Dua is a vascular surgeon at Mass General Hospital and associate professor at Harvard Medical School. At Mass General, she is the director of the Vascular Lab, co-director of the Peripheral Artery Disease Center and Limb Evaluation and Amputation Program (LEAPP), associate director of the Wound Care Center, director of the Lymphedema Center and director of clinical research for the division of vascular surgery. She serves as the Editor-in-Chief of Journal of Vascular Surgery-Vascular Insights. Dr. Dua completed her undergraduate medical studies at the Aberdeen University School of Medicine in Aberdeen, Scotland. She then completed her general surgery residency at the Medical College of Wisconsin and vascular fellowship at Stanford University Hospital. She holds multiple master’s degrees including degrees in trauma sciences and business administration in healthcare management. She also completed certificate programs at the Massachusetts Institute of Technology in health economics and outcomes research as well as in drug and device development. Dr. Dua is a prolific researcher, researcher, and advocate, with much of her work centered on PAD. She furthers patient care not only through research but through her political work as Founder of the Healthcare for Action political action committee (PAC) and member of the SVS PAC Steering Committee. Special thank you to Jacob Soucey (@JacobWSoucy) Resources: https://www.secondscount.org/get-a-pulse-pad https://evtoday.com/news/pad-pulse-alliance-survey-highlights-disconnect-in-public-knowledge-of-pad-risks Association of Black Cardiologists (ABC) Society for Cardiovascular Angiography & Interventions (SCAI) Society of Interventional Radiology (SIR) CardioVascular Coalition (CVC) Outpatient Endovascular and Interventional Society (OEIS) https://vascular.org/advocacy/political-action-committee https://evtoday.com/articles/2021-may/the-arc-act-fighting-amputation-via-legislation https://evtoday.com/articles/2006-may/EVT0506_10.html#:~:text=The%20Screening%20Abdominal%20Aortic%20Aneurysm,screening%20as%20a%20Medicare%20benefit CLariTI Study: Natural Progression of High-Risk Chronic Limb-Threatening Ischemia Socioeconomic and hospital-related predictors of amputation for critical limb ischemia ARC Act of Congress Painkiller: TV Series Congressman Payne SAAAVE Act Follow us @audiblebleeding 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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    40 mins
  • SCVS Rising Seniors / Incoming Fellows Program

    SCVS Rising Seniors / Incoming Fellows Program
    Nov 18 2024

    In this episode of Audible Bleeding, editor Dr. Imani McElroy (@IEMcElroy) is joined by General Surgery PGY-4 Sasank Kalipatnapu(@ksasank) along with Dr.David Rigberg, MD (@drigberg), and Dr. Guillermo Escobar, MD (@GAEscobarMD) to discuss the Society for Clinical Vascular Surgery (SCVS) Rising Seniors / Incoming Fellows Program. 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 also provides a broad overview of the content presented in the program and the reasoning behind the talks.

    Guests:

    1. Dr. David Rigberg - Professor of Surgery, Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Program Director for the Vascular fellowship and integrated vascular surgery residency at the David Geffen School of Medicine, UCLA, Los Angeles, California

    2. Dr. Guillermo Escobar- Associate Professor, Division of Vascular Surgery and Endovascular Therapy, Program Director for the Vascular Surgery Fellowship and Residency at Emory University School of Medicine

    Relevant links:

    • Rising Seniors / Incoming Fellows Program - Program Details

    • SCVS - Fellows & Chief Residents Program

    • SCVS - Young Vascular Surgeons Program

    To apply for the Rising Seniors / Incoming Fellows Program, go to apply now!

    Audible Bleeding team:

    1. Dr. Imani McElroy is 1st year vascular surgery fellow at USC/LA and editor at Audible Bleeding

    2. Dr. Sasank Kalipatnapu, PGY-4 general surgery resident, Dept of Surgery, UMass Chan Medical School, Worcester, MA

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    35 mins
  • JVS Author Spotlight - Straus, Schermerhorn, and Etkin

    JVS Author Spotlight - Straus, Schermerhorn, and Etkin
    Nov 12 2024

    Audible Bleeding contributor and first year vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by vascular fellow Donna Bahroloomi (@DonnaBahroloomi), fourth year general surgery resident, Sasank Kalipatnapu (@ksasank), JVS editor-in-chief, Dr. Thomas Forbes (@TL_Forbes), and JVS-CIT editor Dr. Matt Smeds (@mattsmeds) to discuss two great articles in the JVS family of journals. The first article analyzes seven years worth of VQI data on TCAR, CEA, and TF-CAS to elucidate modern management of carotid disease. The second article provides a simple but powerful method of assessing adequacy of revascularization in the management of hemodialysis access-induced distal ischemia. This episode hosts Dr. Marc Schermerhorn (@MarcScherm), Sabrina Straus MS3 (LinkedIn), and Dr. Yana Etkin (@YanaEtkin), authors of these papers.

    Articles:

    Part 1: “Seven years of the transcarotid artery revascularization surveillance project, comparison to transfemoral stenting and endarterectomy” by Sabrina Straus, Dr. Schermerhorn, and colleagues.

    Part 2: “Proximalization of arterial inflow with adjunctive arterial pressure measurements for management of hemodialysis access-induced distal ischemia” by Dr. Etkin and colleagues.

    Show Guests:

    1. Sabrina Straus BS, 3rd year medical student at UCSD
    2. Dr. Marc Schermerhorn, George H.A. Clowes, Jr. Professor of Surgery, Harvard Medical School and Chief of Vascular and Endovascular Surgery, BIDMC
    3. Dr. Yana Etkin- Associate Professor of Surgery at the Zucker School of Medicine at Hofstra/ Northwell, Program Director for the Vascular Surgery Fellowship and Integrated Vascular Surgery Residency and Associate Chief of Vascular Surgery

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    Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.
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    42 mins
  • JVS Author Spotlight - Felsted, Scali, and Jayaraj

    JVS Author Spotlight - Felsted, Scali, and Jayaraj
    Oct 6 2024

    Audible Bleeding editor Wen (@WenKawaji) is joined by 1st year vascular surgery fellow Richa Kalsi (@KalsiMD), 3rd year medical student Nishi (@Nishi_Vootukuru), 4th-year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Forbes (@TL_Forbes), JVS-VLD associate editor Dr. Arjun Jayaraj and JVS social media liaison Dr. Haurani to discuss some of our favorite articles in the JVS family of journals.

    This episode hosts Dr. Amy Felsted, Dr. Salvatore Scali, and Dr. Arjun Jayaraj, the authors of the following papers. Dr. Arjun Jayaraj and Dr. Haurani will also spend time discussing a virtual special issue, centered around iliofemoral venous stenting published in the Journal of Vascular Surgery, Venous and Lymphatic Disorders that includes six articles published between August 2023 and May 2024.

    Articles:

    • Part 1: A patient-centered textbook outcome measure effectively discriminates contemporary elective open abdominal aortic aneurysm repair quality by Dr. Felsted, Dr. Scali and colleagues.

    • Part 2: Virtual special issues on contemporary role of iliofemoral venous stenting

    Show Guests

    • Dr. Amy Felsted (@aefelsted): Completed fellowship at Dartmouth-Hitchcock, Currently an assistant professor of surgery at Boston University School of Medicine and practicing vascular surgeon at the VA in Boston

    • Dr. Salvatore Scali: Professor of Surgery at University of Florida Division of Vascular Surgery and Endovascular Therapy, program director of the vascular fellowship at University of Florida.

    • Dr. Arjun Jayaraj: Vascular surgeon at the RANE Center in Jackson, Mississippi with a focus on the management of venous and lymphatic diseases, Associate Editor of JVS-VL.

    Follow us @audiblebleeding

    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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    53 mins