Audible Bleeding
HelseAudible Bleeding is a resource for trainees and practicing vascular surgeons, focusing on interviews with leaders in the field, board preparation, and dissemination of best clinical practices and high impact innovations in vascular surgery.
Siste episoder av Audible Bleeding podcast
- JVS Author Spotlight - Darling, Banks, and Beck (00:39:59)
Audible Bleeding editor Wen (@WenKawaji) is joined by 4th year medical student Nishi (@Nishi_Vootukuru), JVS editor Dr. Duncan (@ADuncanVasc), JVS-CIT associate editor Dr. Jimenez to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Darling, Dr. Banks and Dr. Beck. Articles: Outcomes following drug-coated balloons and drug-eluting stents in patients with peripheral arterial disease Fiber Optic RealShape (FORS) and three-dimensional overlay technology in preemptive segmental artery embolization to reduce the risk of spinal cord ischemia prior to fenestrated endovascular aortic aneurysm Show Guests Dr. Jeremy Darling- integrated vascular surgery resident at BIDMC Dr. Charles Banks - integrated vascular surgery resident at UAB Dr. Adam Beck- Director of the division of vascular surgery and endovascular therapy, professor of surgery, director of quality and associate chief medical quality officer at the University of Alabama. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- SVS Group Purchasing Organization (00:14:49)
SAVC (Section on Ambulatory Vascular Care) formed a GPO to help SVS members in private practice access competitive pricing on medical supplies, devices, pharmaceuticals, and services. The podcast episode explores the history of the collaboration, the benefits for SVS private practice members, and how they can become involved. Guest Info Dr. Anil Hingorani is a previous President of the Eastern Vascular Society. He is currently the Chair of the Section on Ambulatory Vascular Care (SAVC) of the Society for Vascular Surgery. Dr. Naveed A. Rahman, Editor, is a Vascular Surgery Fellow at the University of Maryland. Website Links SVS launches partnership to help private practice vascular surgeons cut costs Section on Ambulatory Vascular Care in SVS. How to Join the SVS - Group Purchasing Organization
- JVS Author Spotlight - Moussa-Pasha, Ebertz, Bishara and Gaweesh (00:39:02)
Audible Bleeding editor Wen (@WenKawaji) is joined by 5th-year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Duncan (@ADuncanVasc), JVS-VLD associate editor Dr. Hingorani (@hingorani_anil) to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Omar Moussa-Pasha, Dr. David Ebertz, Dr. Rashad Bishara, and Dr. Ahmed Gaweesh, the authors of the following papers. Articles: An audit of physical waste and fluoroscopy energy consumption in vascular surgery and suggestions for the future Impact of great saphenous vein ablation on healing and recurrence of venous leg ulcers in patients with post-thrombotic syndrome: A retrospective comparative study Show Guests Dr. Omar Moussa-Pasha: Medical student at St Louis University. Dr. David Ebertz (@EbertzDavid): second year vascular surgery fellow at St. Louis University Dr. Rashad Bishara (@agaweesh): Chairman of Vascular Surgery Organization for Teaching Hospitals of Egypt President, Egypt & Africa Vein and Lymph Association, Chair of the International Committee of the American Venous Forum Dr. Ahmed Gaweesh: Dr. Gaweesh is a Consultant Vascular Surgery in Egypt/UAE; Senior Lecturer in Alexandria University. Founder and Board Chairman of iVein Clinics – the first specialized chain of vein clinics in the Middle East since 2013. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- Holding Pressure: AV Fistula/Graft Complications Part 2 (00:37:06)
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/ Venous Hypertension Definition A functioning AV circuit delivers high volume arterial flow towards a stenotic venous segment, causing buildup in pressure and venous hypertension. If there are few or no branching veins between the access and stenosis, thrombosis could occur Etiology The most common etiology is venous stenosis caused by a history of vessel wall trauma by centrally-inserted venous devices such as tunneled and non-tunneled dialysis catheters, central lines, pacemakers, or defibrillator. In a study performed at a large academic medical center1, new hemodynamically significant central venous stenosis was associated with the duration of catheter dependence (26% in patients with CVCs for more than 6 months, versus 11% in patients with CVCs for less than 6 months). PICC lines can directly damage cephalic and basilic veins Venous stenosis can often go undetected until AV access creation occurs Patient Presentation Symptoms of venous insufficiency will be present– most commonly regional edema, in the area of venous stenosis. If there are patent venous branches between the AV anastomosis and the stenotic area, swelling can occur throughout the arm. Pigmentation, induration, dermatosclerosis, and ulceration may also be observed. An extensive collateral network of veins may be visible throughout anterior chest, shoulder, or flank SVC obstruction can result in swelling of the head, neck and shoulders, as well as a feeling of head and neck fullness, airway compromise, and visual problems Normal palpable thrill can be replaced by a strong pulse Dialysis can be complicated by difficulty with needle access, recirculation syndrome, and arm swelling after dialysis sessions. Workup Central vein thrombosis can be hard to detect on ultrasound because clavicle and sternum can block transmission Venography is essential to determine the presence and severity of venous stenosis or occlusion. Prevention The ideal scenario is to avoid central dialysis catheters completely, and this involves evaluating CKD patients and placing AVF or AVG before the need for dialysis arises. If a patient presents placement of an AVF/AVG, it is important to perform venography if a patient has a history of a central venous catheter or clinical signs of venous hypertension. A history of SVC obstruction from any cause can preclude permanent AV access creation in both upper extremities Treatment Endovascular approaches to venous outflow stenosis can be first-line treatment options, due to their minimal risk. They can also be performed at the same time as a diagnostic venogram. Angioplasty alone or with stenting are the endovascular options. In a study by Bakken et al2 that compared primary high-pressure balloon angioplasty versus stenting, primary patency was equivalent between groups, with 30-day rates of 76% for both groups and 12-month rates of 29% for angioplasty and 21% for stenting. Assisted primary patency was also equivalent with a 30-day patency rate of 81% and 12-month rate of 73% for the angioplasty group, 84% at 30 days, and 46% at 12 months for the stenting group. This study, along with others, shows that the major downside of endovascular interventions, whether angioplasty or stenting, often require repeat intervention and have poor long-term patency. For subclavian vein stenosis, angioplasty alone is appropriate due to its anatomical location that can put a stent at risk for extrinsic compression from the first rib and clavicle. Surgical bypass can be performed Possible bypasses include axillary-axillary, axillary-jugular, axillary-right atrial, and axillary-femoral. In these bypasses, the preferred conduits are autogenous saphenous or femoral veins. In cases where the proximal subclavian vein is obstructed, a jugular vein turndown can be performed. In this procedure the distal jugular vein is transected, sewed end-to-side at the distal subclavian vein, effectively acting as a bypass route for that obstructed segment. The Hemoaccess Reliable Outflow (HeRO) Vascular Access Device can be used as a hybrid approach, combining endovascular and open surgical techniques to bypass a central venous occlusion and provide a reliable outflow for dialysis. This device has a PTFE inflow limb that is sewn end-to-side onto the brachial artery. This limb is tunneled subcutaneously and connected to a silicone-coated nitinol outflow catheter that is inserted into a central vein and tracked directly into the right atrium. This effectively bypasses central venous stenoses. In the largest study to date on HeRO access grafts placed in 167 patients,3 HeRO primary and secondary patency was 48.8% and 90.8%, respectively, at 12 months. Interventions to maintain or re-establish patency were required in 71.3% of patients resulting in an intervention rate of 1.5/year. Access-related infections were reported in 4.3% patients. The authors concluded that HeRO device had performed comparably to standard AVGs and had proven superior to tunneled dialysis catheters in terms of patency, intervention, and infection rates. If no treatment options for venous hypertension or outflow obstruction are available, an alternate AV access site can be created, either in the contralateral arm if the SVC is uninvolved, or through placement of femoral AV access or a peritoneal dialysis catheter. Bleeding Access Site Etiology and Risk Factors Bleeding can be caused by high venous pressure after dialysis, pseudoaneurysm rupture, or trauma. Patients with end stage renal disease (ESRD) have a baseline elevated risk of bleeding due to uremia-induced platelet dysfunction and use of systemic anticoagulation within the hemodialysis circuit. Additional risk factors include dialysis through an AV graft, hypertension, longer duration of access use, and compromised integrity of the vascular access due to complications (clotting, infection) or invasive procedures. Dual antiplatelet therapy is also associated with overall bleeding events in ESRD patients. Dialysis patients could be on antiplatelet therapy for management of comorbid cardiovascular risk and/or patency of AV graft Patients with bleeding fistulas often present from their dialysis unit when standard digital pressure at the cannulation site fails to stop the bleeding. This is a very serious condition since most mature fistulas have high blood flow and the patients are at risk for hemorrhagic shock and death. Initial Management The first step of management is to obtain hemostasis. Elevate the limb above the level of the heart and apply firm and directed pressure at the site of bleeding using gauze for at least 30-40 minutes Milosevic et al4 reviewed non-operative management of bleeding fistulas and grafts and found that compared to standard dressings, the use of specialized hemostatic dressings decreased bleeding time at arterial and venous cannulation sites. These hemostatic materials included the IRIS compression bandage and cellulose-based, chitosan-based, poly-N-acetyl glucosamine-based, and thrombin-soaked dressings. There has been a "bottlecap method" described where the hollow side of a bottlecap is pressed on top of the puncture site. Maintaining pressure on the cap will cause the cap to fill with blood and clot, which tamponades the bleeding. The provider can also place a shallow figure-of-8 or purse string stitch just below the skin surface to aid in hemostasis. It is important to avoid placing the suture too deep as this can cause inadvertent fistula ligation. During this process, an assistant applies pressure just proximal and distal to the bleeding site to stop blood flow so the sutures can be placed. If these methods fail to achieve hemostasis, apply a tourniquet proximal to the fistula and tighten it until bleeding stops and the radial pulse is lost. This signifies complete occlusion of arterial inflow to the fistula. Tourniquet use should be limited to 3 hours or less, since limb ischemia beyond this timepoint is associated with permanent neuromuscular damage. Regardless of the method used for initial hemostasis, the patient is at risk for repeat hemorrhage, hematoma formation, vessel stenosis, and thrombosis. They should be evaluated by a vascular surgeon as soon as possible. Definitive Management Definitive management depends on etiology of each case, and there are a variety of interventions that can be pursued (i.e. aneurysmorrhaphy for aneurysmal bleeding) If skin erosion over the conduit is present, it should be assumed that the AV access is infected and emergency intervention should be pursued. A jump graft can be placed through with healthy tissue. A covered stent could be introduced through a separate percutaneous puncture site Finally, coagulopathy can be addressed by administering cryoprecipitate, DDAVP, erythropoietin, estrogen, tranexamic acid. Aneurysms and Pseudoaneurysms Definition and Etiology Aneurysms involve all three layers of the vessel wall and they develop due to hemodynamic changes causing remodeling of the vein wall in an AV fistula. This is necessary for vein maturation, but becomes problematic if the post-anastomotic vein continues to dilate and becomes aneurysmal. Aneurysms can also occur at anastomosis sites due to technical aspects of the surgery. Pseudoaneurysms only involve some layers of the vessel wall caused by repeated puncture for hemodialysis. Both aneurysms and pseudoaneurysms can enlarge due to venous outflow stenosis causing increased intraluminal pressures. Both true aneurysms and pseudoaneurysms can lead to overlying skin erosion and subsequent hemorrhage, pain, AV access dysfunction, and cannulation difficulties. Dialysis cannulation should be avoided at the aneurysmal sites to prevent bleeding complications. Diagnosis They can be diagnosed on ultrasound, which also provide information on flow rates, presence inflow/outflow/stenoses, and vessel diameters. Indications for Treatment Treatment is indicated for aneurysms that are rapidly expanding or ulcerating through the skin surface. These are at high risk for rupture and hemorrhage, which is life-threatening. Treatment is also indicated when the aneurysm occurs at the anastomotic site of the AV fistula, the patient has a cosmetic concern, cannulation becomes difficult, there is concern for infection, or the patient has high-output heart failure that could be exacerbated by high flow through the fistula. Treatment is not indicated in asymptomatic aneurysms, regardless of their size. True aneurysms and pseudoaneurysms are not prone to spontaneous rupture. Treatment Options Aneurysmorrhaphy is the most common treatment. It involves the resection of the aneurysmal vein wall to restore a normal diameter and removal of excess skin. Anastomosis is performed along the lateral wall to prevent issues with cannulation along the suture line. Aneurysm resection with interposition grafting is also possible. If multiple aneurysmal segments require treatment, staging their repairs can allow for continuation of dialysis without needing to place a temporary dialysis catheter. AV access ligation is an appropriate alternative to AV access salvage in certain situations but usually requires excision of the aneurysm/pseudoaneurysm due to the potential to develop thrombophlebitis and the cosmetic appearance of the thrombosed segment. If there is concern for an infected pseudoaneurysm or aneurysm, surgery should include removal of all infected material. References 1. Al-Balas A, Almehmi A, Varma R, Al-Balas H, Allon M. De Novo Central Vein Stenosis in Hemodialysis Patients Following Initial Tunneled Central Vein Catheter Placement. Kidney360. 2022;3(1):99-102. doi:10.34067/KID.0005202021 2. Bakken AM, Protack CD, Saad WE, Lee DE, Waldman DL, Davies MG. Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg. 2007;45(4):776-783. doi:10.1016/j.jvs.2006.12.046 3. Gage SM, Katzman HE, Ross JR, et al. Multi-center Experience of 164 Consecutive Hemodialysis Reliable Outflow [HeRO] Graft Implants for Hemodialysis Treatment. Eur J Vasc Endovasc Surg. 2012;44(1):93-99. doi:10.1016/j.ejvs.2012.04.011 4. Milosevic E, Forster A, Moist L, Rehman F, Thomson B. Non-surgical interventions to control bleeding from arteriovenous fistulas and grafts inside and outside the hemodialysis unit: a scoping review. Clin Kidney J. 2024;17(5):sfae089. doi:10.1093/ckj/sfae089
- JVS CIT Editorials and Abstracts - Aug 2025 (00:23:52)
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 Authors as well as members of the SVS Social Media Ambassadors. Guests: Juliet Blakeslee-Carter, MD (@AWBeckMD) The value and structure of writing a vascular surgery case report: A student's guide Neha Gupta (@nehaha00) We don't know what we don't know, until we do Colonic ischemia and the role of inferior mesenteric artery reimplantation after abdominal aortic aneurysm repair Abdominal aortic aneurysm classification based on dynamic intraluminal thrombus analysis during cardiac cycle Quantitative intra-arterial fluorescence angiography for direct monitoring of peripheral revascularization effects Ben Li, MD (@ben_li123) An introduction to the journal review and editorial process Hosts: John Culhane (@JohnCulhaneMD) Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *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.
- The Final Frontier: The Endo-Bentall Procedure (00:42:22)
Audible Bleeding Editor and vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by vascular surgery fellow Javaneh Jabbari (@JabbariMD) in hosting Dr. Gustavo Oderich (@GustavoOderich), Dr. Shahab Toursavadkohi (@Toursavadkohi ), and Dr. Mehrdad Ghoreishi (@dr_ghoreishi) to discuss the "final frontier" in the endovascular management of aortic pathology, or the Endo-Bentall Procedure. This episode highlights collaboration between vascular and cardiac surgery as we take a deep dive into physician modification of grafts to manage aortic root pathology. We will discuss the off-label use of endovascular devices and hear insights into the future of endovascular and open aortic surgery from these leaders and innovators in the field. For some background on the topic, see the resources below Articles: First-in-Human Endovascular Aortic Root Repair (Endo-Bentall) for Acute Type A Dissection Link to the Presentation on this by Dr. Ghoreishi at AATS for more procedural details Show Guests Dr. Shahab Toursavadkohi - Professor of Vascular surgery and Co-director of the Center for Aortic Disease at the University of Maryland Medical System Dr. Mehrdad Ghoreishi - Associate Professor of Cardiac Surgery and Co-director of aortic surgery and medical director of cardiac surgery research at Baptist Health Miami Cardiac & Vascular Institute Dr. Gustavo Oderich - Professor and Chief of the Division of Vascular Surgery and Endovascular Therapy at the Texas Heart Institute and director of the new Baylor Medicine Center for Aortic Surgery Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *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.
- JVS Author Spotlight – Alonso, Siracuse, Chaer, and Ali (00:38:40)
Audible Bleeding Editor and vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by 4th year general surgery resident Sasank Kalipatnapu (@ksasank), JVS editor Dr. Thomas Forbes (@TL_Forbes), and JVS-VS editor Dr. John Curci (@CurciAAA) to discuss two great articles in the JVS family of journals. The first article discusses disability from periprocedural stroke in patients undergoing carotid artery stenting. The second article discusses the application of contrast-enhanced ultrasound and plasma biomarkers to abdominal aortic aneurysm monitoring. This episode hosts Dr. Andrea Alonso, Dr. Jeffrey Siracuse(@MdSiracuse), Dr. Adham Ali (@AdhamAbouAli), and Dr. Rabih Chaer (@rchaer2) authors of these two papers. Articles: Part 1: Disability and associated outcomes among patients suffering periprocedural strokes after carotid artery stenting (Alonso, Siracuse) Referenced article - Postoperative disability and one-year outcomes for patients suffering a stroke after carotid endarterectomy (Levin, Siracuse) Audible Bleeding Episode - JVS Author Spotlight August 2023 Part 2: Contrast-enhanced ultrasound microbubble uptake and abnormal plasma biomarkers are seen in patients with abdominal aortic aneurysms (Ali, Chaer) Show Guests Dr. Alonso is a general surgery resident in her second year of research at Boston Medical Center on an AHRQ T32 grant. Dr. Siracuse is the Chief of vascular and endovascular surgery and the associate chair for quality and patient safety in the Department of Surgery at Boston Medical Center. He is also the program director for the vascular surgery fellowship and the medical director for the Vascular Study Group of New England. Dr. Ali is Assistant Professor of Vascular Surgery at Charleston Area Medical Center. Dr. Chaer is a Professor of Surgery and Division Chief of Vascular and Endovascular Surgery at Stony Brook University. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- JVS CIT Editorials and Abstracts: June 2025 (00:31:17)
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 Authors as well as members of the SVS Social Media Ambassadors. Guests: Juliet Blakeslee-Carter, MD (@AWBeckMD) The value and structure of writing a vascular surgery case report: A student's guide Neha Gupta (@nehaha00) We don't know what we don't know, until we do Colonic ischemia and the role of inferior mesenteric artery reimplantation after abdominal aortic aneurysm repair Abdominal aortic aneurysm classification based on dynamic intraluminal thrombus analysis during cardiac cycle Quantitative intra-arterial fluorescence angiography for direct monitoring of peripheral revascularization effects Ben Li, MD (@ben_li123) An introduction to the journal review and editorial process Hosts: John Culhane (@JohnCulhaneMD) Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *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.
- VESS 50th Anniversary (00:32:23)
Welcome to the VESS 50th Year Anniversary Episode, where we celebrate all the achievements and the future direction of the Vascular and Endovascular Surgery Society! We hope to see you all in person at the spring annual meeting on June 4, 2025 in New Orleans, and the Winter Annual Meeting at Everline Resort in Olympia, California on February 5-8, 2026. Guest Info Dr. Ravi Rajani is the current president of VESS. He is Executive Associate Dean for Emory at Grady Hospital and is the Leon L. Haley, Jr. Distinguished Professor within the Emory University School of Medicine. Dr. Matthew Smith is Assistant Professor at UW School of Medicine and on the Membership Development Committee of VESS. Dr. Erin Greenleaf is the Chair of the Membership Development Committee of VESS and Assistant Professor at Baylor. She is a surgeon in the US Army Reserves. Dr. Naveed A. Rahman (@naveedrahmanmd) is an Audible Bleeding Editor and currently a vascular surgery fellow at University of Maryland. Website Links VESS Spring Meeting 2025. VESS Winter Annual Meeting 2026. About VESS. Why Join VESS? Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *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.
- SVS Meet the Secretary Candidates (01:07:43)
In this episode, Audible Bleeding Editors Sasank Kalipatnapu (@ksasank), Falen Demsas sit down with Dr. Rabih Chaer (@rchaer2), Dr. Michael Conte(@MichaelSConteMD), Dr. Sherene Shalhub and Dr. Malachi Sheahan III, the four SVS secretary candidates for this year to learn more about them as part of the ongoing election process. Show links: SVS 2025 Meet the Secretary Candidates—Home Page—provides a comprehensive overview of all the candidates. Their professional biographies and answers to questions about their plans for the future are available in both text and video formats. Show Guests: Dr. Rabih Chaer, Professor of Surgery and Chief of the Division of Vascular Surgery at Stony Brook University Dr. Michael Conte, Professor and Chief of the Division of Vascular & Endovascular Surgery at the University of California, San Francisco. Dr. Sherene Shalhub, Professor and Chief of the Division Vascular and Endovascular Surgery at Oregon Health & Science University (OHSU). Dr. Malachi Sheahan, Professor and Chair of the Division of Vascular and Endovascular Surgery at Louisiana State University Health Sciences Center in New Orleans. Sasank Kalipatnapu - PGY4 general surgery resident, University of Massachusetts Falen Demsas- PGY 3 integrated vascular surgery resident, Massachusetts General Hospital Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- SVS 2025 Meet the VP Candidates (00:37:34)
In this episode, Audible Bleeding Editors Sasank Kalipatnapu (@ksasank), Richa Kalsi (@KalsiMD) sit down with Dr. Andres Schanzer and Dr. William Shutze, the two SVS vice presidential candidates for this year to learn more about them as part of the ongoing election process. Show links: SVS 2025 Meet the VP Candidates provides a comprehensive overview of all the candidates. Their professional biographies and answers to questions about their plans for the future are available in both text and video formats. Show Guests: Dr. Andres Schanzer, Professor and Chief in the Division of Vascular and Endovascular Surgery, UMass Medical School, Worcester, MA Dr. William P Shutze, Texas Vascular Associates, Plano TX Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- JVS Author Spotlight - Aridi, Motaganahalli, Nagarsheth, and Madabhushi (00:41:47)
Audible Bleeding editor Wen (@WenKawaji) is joined by 3rd year medical student Nishi (@Nishi_Vootukuru), 2nd year vascular fellow Donna, JVS editor Dr. Forbes (@TL_Forbes), and JVS-CIT editor Dr. Matt Smeds (@mattsmeds) to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Aridi, Dr. Motaganahalli, Dr. Nagarsheth, and Dr. Madabhushi, the authors of the following papers. Articles: Physicians preference for carotid revascularization impacts postoperative stroke and death outcomes Simultaneous percutaneous transmural arterial bypass and deep venous arterialization for treatment of critical limb ischemia Show Guests Dr. Hanaa Aridi (@aridi_hanaa)- PGY3 at Indiana University School of Medicine Dr. Raghu L. Motaganahalli (@Rmotaganahalli)- Professor of Surgery at the Indiana University School of Medicine and an attending Surgeon at the Indiana University Methodist Hospital. He is the Division Chief of Vascular Surgery and the Program Director of vascular surgery training program Dr. Nagarsheth (@KNagarshethMD) -Associate Professor of Surgery and Associate Program Director of Vascular Surgery Fellowship Program at the University of Maryland Medical Center in Baltimore. Program director of the integrated vascular surgery program. Dr. Madabhushi -Vascular Surgery Fellow at the University of Maryland Medical Center in Baltimore Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- The Improve AD Trial (00:40:15)
Dr. Ezra Schwartz (@ezraschwartz10) interviews Dr. Firas Mussa and Mr. Jake Howitt to discuss the IMPROVE-AD Trial, a landmark, multi-institutional study investigating treatment strategies for uncomplicated Type B Aortic Dissection (uTBAD). The IMPROVE-AD Trial is a multicenter randomized trial funded by the NIH/NHLBI that compares thoracic endovascular aortic repair (TEVAR) plus optimal medical therapy (OMT) vs. OMT and surveillance with selective TEVAR in patients with uncomplicated TBAD. The trial aims to address critical gaps in evidence left by prior studies (INSTEAD-XL, ADSORB), with a unique focus on quality of life, cost-effectiveness, and genetic data. Dr. Firas Mussa is a professor of Surgery at McGovern Medical School at UTHealth Houston. He previously served as the Director of the Vascular Surgery Residency and Fellowship programs at NYU Langone Health. Dr. Mussa earned his medical degree from the University of Baghdad, followed by general surgery training at Johns Hopkins University and a vascular surgery fellowship at Baylor College of Medicine. His research focuses on complex aortic pathology, and he serves as the principal investigator of the IMPROVE AD trial. Mr. Jake Howitt is the Community Engagement Co-Chair of the IMPROVE AD trial and a leading patient advocate within the PCORI-funded Aortic Dissection Collaborative. As a survivor of aortic dissection, he is passionate about improving patient-provider communication and raising awareness of hereditary aortic disease. His work emphasizes the importance of education, empathy, and community-building in clinical research and care delivery. Special thank you to Jacob Soucy (@JacobWSoucy). Resources: · Treatment of Uncomplicated Type B Aortic Dissection: Optimal Medical Therapy vs TEVAR + Optimal Medical Therapy- https://journals.sagepub.com/doi/10.1177/15385744231184671?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed · INSTEAD Trial - https://pubmed.ncbi.nlm.nih.gov/19996018/ · INSTEAD-XL 5-Year Follow-Up - https://pubmed.ncbi.nlm.nih.gov/23922146/ · ADSORB Trial - https://pubmed.ncbi.nlm.nih.gov/24962744/ · Feasibility of a proposed randomized trial in patients with uncomplicated descending thoracic aortic dissection: Results of worldwide survey - https://pubmed.ncbi.nlm.nih.gov/27823685/ · Treatment of AD: Meta-Analysis - https://pubmed.ncbi.nlm.nih.gov/29066151/ · TEVAR vs Medical Therapy- https://pubmed.ncbi.nlm.nih.gov/36334259/ · IMPROVE AD Trial website - https://improvead.org · John Ritter Foundation for Aortic Health - https://johnritterfoundation.org · Think Aorta US - https://thinkaorta.us Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *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.
- JVS CIT Editorials and Abstracts - April 2025 (00:23:17)
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 Authors as well as members of the SVS Social Media Ambassadors. Guests: Antonio L. Solano, MD (@solanotono) Rotational flap versus long plantar flap for transmetatarsal amputation closure following revascularization Lucerne milestone approach for benchmarking and education: Towards ultra-low dose endovascular aortic repair The use of stent grafts for management of junctional vascular injuries: Is this accepted practice? Hosts: John Culhane (@JohnCulhaneMD) Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- JVS Author Spotlight - Fereydooni and Satam (00:20:33)
Audible Bleeding editor Wen (@WenKawaji) is joined by first year vascular fellow Eva (@urrechisme), JVS editor Dr. Forbes (@TL_Forbes), to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Fereydooni and Dr. Satam, the authors of the following paper. Articles: Comparison of EndoSuture vs fenestrated aortic aneurysm repair in treatment of abdominal aortic aneurysms with unfavorable neck anatomy Show Guests Dr. Arash Fereydooni: PGY5 integrated vascular resident at Stanford Dr. Keyuree Satam: PGY2 integrated vascular resident at Stanford @StanfordVasc Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- Fellowship Series - 6 Months In (00:49:55)
In this episode we catch up with first-year fellows Imani, Yasong, Wen, and Seth as they recap the first 6 months of training and the transition from general surgery to vascular surgery. They recount learning their way around new hospitals, navigating new cities, and settling into life as vascular surgeons. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- JVS Author Spotlight - Gaffey, Hamouda, and Erben (00:48:54)
Audible Bleeding editor Wen (@WenKawaji) is joined by first year vascular fellow Eva (@urrechisme), second year vascular fellow Java (@JabbariMD), JVS editor Dr. Forbes (@TL_Forbes), and JVS-VS associate editor Dr. Hedin to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Ann Gaffey, Dr. Mohammed Hamouda, and Dr. Young Erben, the authors of the following papers. Articles: Outcomes of Prosthetic and Biological Grafts Compared to Arm Vein Grafts in Patients with Chronic Limb Threatening Ischemia Proteomic Analysis of Carotid Artery Plaques With and Without Vulnerable Features on MRI with Vessel Wall Imaging: A pilot study Show Guests Dr. Ann Gaffey (@Ann_Gaffey_MD): Assistant professor of surgery at UC San Diego School of Medicine in the Division of Vascular and Endovascular Surgery. Dr. Gaffey's clinical interests include examining new approaches to peripheral arterial disease and improving the patency of current bypass options. Dr. Mohammed Hamouda (@hamouda_mmz): Postdoctoral research fellow at UC San Diego, Division of Vascular & Endovascular Surgery Dr. Young Erben (@ErbenYoung): vascular surgeon from Mayo Clinic in Jacksonville Florida. She earned her medical degree from Goethe University in Frankfurt, Germany, and completed her general surgery as well as vascular surgery training at the Mayo Clinic in Rochester, Minnesota. Her clinical interests include cerebrovascular, aortic, and peripheral pathologies, as well as initiatives to eradicate disparities in care. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- JVS CIT Editorials and Abstracts - February 2025 (00:40:07)
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 Authors as well as members of the SVS Social Media Ambassadors. Guests: Kelsey Schmittling, Medical Student (@kelseyum2plus) "What can go wrong during thoracic endovascular aortic repair for type B aortic dissection" Development and feasibility testing of a new device for home-based leg heat therapy in patients with lower extremity peripheral artery disease Radiation-induced injury in endovascular surgery: How long is too long? Hosts: John Culhane (@JohnCulhaneMD) Nishi Vootukuru (@Nishi_Vootukuru) Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- LifeBTK Trial: Drug-Eluting Resorbable Scaffold versus Angioplasty for Infrapopliteal Artery Disease (00:47:12)
In this episode of Audible Bleeding, Jamila, Anh, and Naveed discuss the LifeBTK Trial with Principal Investigator Dr. Brian DeRubertis, where we discuss the new Abbott Esprit everolimus-eluting resorbable scaffold for the below-knee popliteal space. Guest: Dr. DeRubertis, is the Principal Investigator of the LIFE-BTK trial. He is the Chief of the Division of Vascular & Endovascular Surgery at New York-Presbyterian and Weill Cornell Medicine in New York City. Audible Bleeding Team Dr. Jamila Hedhliis a general surgery resident at the University of Illinois. Anh Dang, (@QuynhAnh_Dang), is a fourth year medical student at the University of Pennsylvania. Dr. Naveed A. Rahman, (@naveedrahmanmd), is a Vascular Surgery Fellow at the University of Maryland. References: Drug-Eluting Resorbable Scaffold versus Angioplasty for Infrapopliteal Artery Disease (LIFE-BTK). Advances in Endovascular Treatment of CLTI: Insights From the LIFE-BTK Trial. Diversity, Equity, and Inclusion in the LIFE-BTK Trial Evaluating the Esprit™ BTK Drug-Eluting Resorbable Scaffold for the Treatment of Infrapopliteal Lesions in Patients with Chronic Limb-Threatening Ischemia, VIVA 2024. Sirolimus-eluting stents vs. bare-metal stents for treatment of focal lesions in infrapopliteal arteries: a double-blind, multi-centre, randomized clinical trial (YUKON). Randomized comparison of everolimus-eluting versus bare-metal stents in patients with critical limb ischemia and infrapopliteal arterial occlusive disease (DESTINY). A prospective randomized multicenter comparison of balloon angioplasty and infrapopliteal stenting with the sirolimus-eluting stent in patients with ischemic peripheral arterial disease (ACHILLES). Sex Differences in Outcomes Following Endovascular Treatment for Symptomatic Peripheral Artery Disease: An Analysis From the K- VIS ELLA Registry. Drug-Coated vs Uncoated Percutaneous Transluminal Angioplasty in Infrapopliteal Arteries: Six-Month Results of the Lutonix BTK Trial. Paclitaxel-Coated Balloon in Infrapopliteal Arteries: 12-Month Results From the BIOLUX P-II Randomized Trial (BIOTRONIK'S-First in Man study of the Passeo-18 LUX drug releasing PTA Balloon Catheter vs. the uncoated Passeo-18 PTA balloon catheter in subjects requiring revascularization of infrapopliteal arteries). The IN.PACT DEEP Clinical Drug-Coated Balloon Trial: 5-Year Outcomes. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- JVS Author Spotlight - Roy, Csore, and Rahimi (00:33:43)
Audible Bleeding editor Wen (@WenKawaji) is joined by 3rd year medical student Nishi (@Nishi_Vootukuru), JVS editor Dr. Forbes (@TL_Forbes), and JVS-CIT associate editor Dr. Jimenez to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Trisha Roy (@trisharoymd), Dr. Judit Csore (@JuditCsore), and Dr. Maham Rahimi, the authors of the following papers. Articles: Employing magnetic resonance histology for precision chronic limb-threatening ischemia treatment plan Biodesign: Engineering an aortic endograft explantation tool Show Guests Dr. Trisha Roy- Assistant professor of cardiovascular surgery at the Houston Methodist Debakey Heart and Vascular Center. Background of Material engineering, vascular imaging, research interest in peripheral vascular disease. Dr. Judit Csore-Radiologist and assistant lecturer at the Heart and Vascular Center of Semmelweis University, Budapest, Hungary. Her primary focus is on cardiovascular imaging and vascular MRI. She recently spent two years in the United States at Houston Methodist Hospital, where she had been collaborating with Dr. Trisha Roy since 2022 as a postdoctoral fellow, specializing in peripheral arterial disease imaging. Dr. Maham Rahimi-Associate professor in the department of cardiovascular surgery at Houston Methodist Hospital, His research interests include nanotechnology and Biomedical Engineering Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- JVS CIT Editorials and Abstracts - Dec 2024/Jan 2025 (00:56:03)
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 the SVS Social Media Ambassadors. Guests: Dr. Gregory Magee, MD (@gregamagee) The past, present, and future of abdominal aortic aneurysm repair Dr. Eric Pillado, MD (@drpillado) The need for standardizing care for pediatric and geriatric vascular trauma patients Dr. Ben Li, MD (@ben_li123) Advanced chronic venous insufficiency and the role of the incompetent perforator vein: A 100-year quest for the right strategy Pediatric carotid body tumors: A case report and systematic review Early experience with baroreflex activation therapy from a vascular surgery perspective Dr. Donald Baril, MD (@DonaldBaril) Early graft failure following lower extremity bypass Dr. Michael Malinowski, MD Current challenges to vascular trauma training across levels and regions Hosts: John Culhane (@JohnCulhaneMD) Nishi Vootukuru (@Nishi_Vootukuru) Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *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.
- JVS Author Spotlight - Schermerhorn, Sanders, Cox and Tsukagoshi (00:37:58)
Audible Bleeding editor Wen (@WenKawaji) is joined by 3rd year medical student Nishi (@Nishi_Vootukuru), JVS editor Dr. Forbes (@TL_Forbes), and JVS social media liaison Dr. Haurani to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Marc Schermerhorn, Dr. Andrew Sanders, Dr. Mitchell Cox and Dr. Junji Tsukagoshi, the authors of the following papers. Articles: Ten Years of Physician Modified Endografts Peri-operative and intermediate outcomes of patients with pulmonary embolism undergoing catheter-directed thrombolysis vs. percutaneous mechanical thrombectomy Show Guests Dr. Marc Schermerhorn: Chief of vascular and endovascular surgery at Beth Israel Deaconess and professor of surgery, Harvard Medical School Dr. Andrew Sanders: PGY4 general surgery resident at Beth Israel Deaconess Dr. Mitchell Cox: Division chief of vascular surgery and endovascular therapy, program director of the vascular surgery residency program at the University of Texas Medical Branch. Dr. Junji Tsukagoshi: Fourth year vascular surgery resident at the University of Texas Medical Branch in Galveston Texas. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.
- Holding Pressure: AV Fistula/Graft Complications Part 1 (00:39:36)
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 polypropylene sutures or a Dacron patch around the vein or graft. The Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) technique employs a percutaneous endoluminal balloon inflated at the AVF to ensure consistency in diameter while banding Plication is when a side-biting running stitch is used to narrow lumen of the vein near the anastomosis. A downside of flow-limiting procedures is that it is often difficult to determine how much to narrow the AV access, as these procedures carry a risk of outflow thrombosis. There are also surgical treatments focused on reroute arterial inflow. The distal revascularization and interval ligation (DRIL) procedure involves creation of a new bypass connecting arterial segments proximal and distal to the AV anastomosis, with ligation of the native artery between the AV anastomosis and the distal anastomosis of the bypass. Reversed saphenous vein with a diameter greater than 3mm is the preferred conduit. Arm vein or prosthetic grafts can be used if needed, but prosthetic material carries higher risk of thrombosis. The new arterial bypass creates a low resistance pathway that increases flow to distal arterial beds, and interval arterial ligation eliminates retrograde flow through the distal artery. The major risk of this procedure is bypass thrombosis, which results in loss of native arterial flow and hand ischemia. Other drawbacks of DRIL include procedural difficulty with smaller arterial anastomoses, sacrifice of saphenous or arm veins, and decreased fistula flow. Another possible revision surgery is revision using distal inflow (RUDI). This procedure involves ligation of the fistula at the anastomosis and use of a conduit to connect the outflow vein to a distal artery. The selected distal artery can be the proximal radial or ulnar artery, depending on the preoperative duplex. The more dominant vessel should be spared, allowing for distal arterial beds to have uninterrupted antegrade perfusion. The nondominant vessel is used as distal inflow for the AV access. RUDI increases access length and decreases access diameter, resulting in increased resistance and lower flow volume through the fistula. Unlike DRIL, RUDI preserves native arterial flow. Thrombosis of the conduit would put the fistula at risk, rather than the native artery. The last surgical revision procedure for steal is proximalization of arterial inflow (PAI). In this procedure, the vein is ligated distal to the original anastomosis site and flow is re-established through the fistula with a PTFE interposition graft anastomosed end-to-side with the more proximal axillary artery and end-to-end with the distal vein. Similar to RUDI, PAI increases the length and decreases the diameter of the outflow conduit. Since the axillary artery has a larger diameter than the brachial artery, there is a less significant pressure drop across the arterial anastomosis site and less steal. PAI allows for preservation of native artery's continuity and does not require vein harvest. Difficulties with PAI arise when deciding the length of the interposition graft to balance AV flow with distal arterial flow. 2. Ischemic Monomelic Neuropathy Definition Ischemic monomelic neuropathy (IMN) is a rare but serious form of steal that involves nerve ischemia. Severe sensorimotor dysfunction is experienced immediately after AV access creation. Etiology IMN affects blood flow to the nerves, but not the skin or muscles because peripheral nerve fibers are more vulnerable to ischemia. Incidence and Risk Factors IMN is very rare; it has an estimated incidence of 0.1-0.5% of AV access creations.6 IMN has only been reported in brachial artery-based accesses, since the brachial artery is the sole arterial inflow for distal arteries feeding all forearm nerves. IMN is associated with diabetes, peripheral vascular disease, and preexisting peripheral neuropathy that is associated with either of the conditions. Patient Presentation Symptoms usually present rapidly, within minutes to hours after AV access creation. The most common presenting symptom is severe, constant, and deep burning pain of the distal forearm and hand. Patients also report impairment of all sensation, weakness, and hand paralysis. Diagnosis of IMN can be delayed due to misattribution of symptoms to anesthetic blockade, postoperative pain, preexisting neuropathy, a heavily bandaged arm precluding neurologic examination. Treatment Treatment is immediate ligation of the AV access. Delay in treatment will quickly result in permanent sensorimotor loss. 3. Perigraft Seroma Definition A perigraft seroma is a sterile fluid collection surrounding a vascular prosthesis and is enclosed within a pseudomembrane. Etiology and Incidence Possible etiologies include: transudative movement of fluid through the graft material, serous fluid collection from traumatized connective tissues (especially the from higher adipose tissue content in the upper arm), inhibition of fibroblast growth with associated failure of the tissue to incorporate the graft, graft "wetting" or kinking during initial operation, increased flow rates, decreased hematocrit causing oncotic pressure difference, or allergy to graft material. Seromas most commonly form at anastomosis sites in the early postoperative period. Overall seroma incidence rates after AV graft placement range from 1.7–4% and are more common in grafts placed in the upper arm (compared to the forearm) and Dacron grafts (compared to PTFE grafts).7-9 Patient Presentation and Workup Physical exam can show a subcutaneous raised palpable fluid mass Seromas can be seen with ultrasound, but it is difficult to differentiate between the types of fluid around the graft (seroma vs. hematoma vs. abscess) Indications for Treatment Seromas can lead to wound dehiscence, pressure necrosis and erosion through skin, and loss of available puncture area for hemodialysis Persistent seromas can also serve as a nidus for infection. The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines10 recommend a tailored approach to seroma management, with more aggressive surgical interventions being necessary for persistent, infected-appearing, or late-developing seromas. Treatment The majority of early postoperative seromas are self-limited and tend to resolve on their own Persistent seromas have been treated using a variety of methods-- incision and evacuation of seroma, complete excision and replacement of the entire graft, and primary bypass of the involved graft segment only. Graft replacement with new material and rerouting through a different tissue plane has a higher reported cure rate and lower rate of infection than aspiration alone.9 4. Infection Incidence and Etiology The reported incidence of infection ranges 4-20% in AVG, which is significantly higher than the rate of infection of 0.56-5% in AVF.11 Infection can occur at the time of access creation (earliest presentation), after cannulation for dialysis (later infection), or secondary to another infectious source. Infection can also further complicate a pre-existing access site issue such as infection of a hematoma, thrombosed pseudoaneurysm, or seroma. Skin flora from frequent dialysis cannulations result in common pathogens being Staphylococcus, Pseudomonas, or polymicrobial species. Staphylococcus and Pseudomonas are highly virulent and likely to cause anastomotic disruption. Patient Presentation and Workup Physical exam will reveal warmth, pain, swelling, erythema, induration, drainage, or pus. Occasionally, patients have nonspecific manifestations of fever or leukocytosis. Ultrasound can be used to screen for and determine the extent of graft involvement by the infection. Treatments In AV fistulas: Localized infection can usually be managed with broad spectrum antibiotics. If there are bleeding concerns or infection is seen near the anastomosis site, the fistula should be ligated and re-created in a clean field. In AV grafts: If infection is localized, partial graft excision is acceptable. Total graft excision is recommended if the infection is present throughout the entire graft, involves the anastomoses, occludes the access, or contains particularly virulent organisms Total graft excision may also be indicated if a patient develops recurrent bacteremia with no other infectious source identified. For graft excision, the venous end of the graft is removed and the vein is oversewn or ligated. If the arterial anastomosis is intact, a small cuff of the graft can be left behind and oversewn. If the arterial anastomosis is involved, the arterial wall must be debrided and ligation, reconstruction with autogenous patch angioplasty, or arterial bypass can be pursued. References 1. Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. Incidence and Characteristics of Patients with Hand Ischemia after a Hemodialysis Access Procedure. J Surg Res. 1998;74(1):8-10. doi:10.1006/jsre.1997.5206 2. Ballard JL, Bunt TJ, Malone JM. Major complications of angioaccess surgery. Am J Surg. 1992;164(3):229-232. doi:10.1016/S0002-9610(05)81076-1 3. Valentine RJ, Bouch CW, Scott DJ, et al. Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis. J Vasc Surg. 2002;36(2):351-356. doi:10.1067/mva.2002.125848 4. Malik J, Tuka V, Kasalova Z, et al. Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies. J Vasc Access. 2008;9(3):155-166. doi:10.1177/112972980800900301 5. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg. 2002;35(3):603-610. doi:10.1067/mva.2002.122025 6. Thermann F, Kornhuber M. Ischemic Monomelic Neuropathy: A Rare but Important Complication after Hemodialysis Access Placement - a Review. J Vasc Access. 2011;12(2):113-119. doi:10.5301/JVA.2011.6365 7. Dauria DM, Dyk P, Garvin P. Incidence and Management of Seroma after Arteriovenous Graft Placement. J Am Coll Surg. 2006;203(4):506-511. doi:10.1016/j.jamcollsurg.2006.06.002 8. Gargiulo NJ, Veith FJ, Scher LA, Lipsitz EC, Suggs WD, Benros RM. Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas. J Vasc Surg. 2008;48(1):216-217. doi:10.1016/j.jvs.2008.01.046 9. Blumenberg RM, Gelfand ML, Dale WA. Perigraft seromas complicating arterial grafts. Surgery. 1985;97(2):194-204. 10. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164. doi:10.1053/j.ajkd.2019.12.001 11. Padberg FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg. 2008;48(5):S55-S80. doi:10.1016/j.jvs.2008.08.067
- The Art and Science of Leadership - An Introduction to the SVS Leadership Development Program (00:32:28)
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 Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *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.
- JVS CIT Editorials and Abstracts - Oct/Nov 2024 (00:30:52)
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 Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *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.