Audible Bleeding

In this episode, we discuss the challenges of explanting aortic grafts, the diagnosis and management of infected aortic grafts, as well as tips and tricks for once we're in the operating room.   Interviewers/Editors: Mark Basilious, MD Candidate (@markrbasilious) Eva Urrechaga, MD (@urrechisme) Sharif Ellozy, MD (@SharifEllozy)   Guests: Dr. Francis Caputo (@FrankCaputoMD) is an Associate Professor of Surgery at the Cleveland Clinic Lerner College of Medicine, Vascular Surgery Director of the Aorta Center, and Program Director of the Vascular Surgery Training Programs. His clinical interests include complex open and endovascular repair of thoracic, thoracoabdominal, and abdominal aortic aneurysms, management of thoracic dissection, and endovascular and open repair of failed endograft. Dr. Caputo earned his medical degree from the University of Medicine and Dentistry New Jersey, Newark, NJ, where he also served his surgical residency and two years as a National Institutes of Health research fellow. He completed his fellowship in vascular surgery at Barnes-Jewish Hospital of Washington University, St. Louis, MO and joined the Cleveland Clinic medical staff in 2018.    Dr. Peter Rossi (@peterjrossi) is a Professor of Surgery, Radiology, and Orthopedic Surgery, and Chief of the Division of Vascular and Endovascular Surgery at the Medical College of Wisconsin. His primary research and clinical interests are in complex  “re-do” and revision surgery, including for thoracoabdominal and abdominal aortic aneurysms, carotid artery surgery, and renal and mesenteric arterial disease, as well as vascular reconstruction for complicated soft tissue sarcomas. Dr. Rossi completed medical school at the University of Illinois College of Medicine before completing his general surgery training at the University of Chicago and his vascular surgery training at the Medical College of Wisconsin, where he has been a member of the faculty since 2009.  Dr. Xavier Berard (@XavierBerardMD)  is a French vascular surgeon who has been a Consultant in the Department of Vascular Surgery and Professor of Vascular and Endovascular Surgery in Bordeaux University Hospital in Bordeaux, France since 2010 and a full Professor of Vascular Surgery at the University of Bordeaux since 2016. He has also completed a PhD in Vascular Biomaterials and in 2010 worked as a research fellow at Lausanne University Hospital in Switzerland. He has been board certified by the French College of Vascular and Endovascular Surgeons since 2008 and by the European Society for Vascular and Endovascular Surgery since 2010. He has served as an examiner for the FEBVS exam since 2014 and as a reviewer for the European Journal of Vascular and Endovascular Surgery since 2016. Additionally, he is a member of the ESVS guidelines writing group for vascular graft infection and AAA.  His personal surgical interests include open surgery of (thoraco)abdominal aneurysms, redo aortic surgery, infections in vascular surgery, EVAR explantation, and biomaterials. He works closely with Institut Bergonié Bordeaux Cancer Center for sarcomas. You can see educational videos and learn more about Dr. Xavier Berard here. Helpful links and resources: Video of explantation of infected chimney EVAR with duodenal fistula (courtesy of Dr. Berard) Video of reimplanting the IMA after explanting an infected graft Video of explantation of infected graft with suprarenal fixation Videos of using the syringe technique to remove an aortic stent graft here and here (courtesy of Dr. Berard) References Kim YW. Aortic Endograft Infection: Diagnosis and Management. Vasc Specialist Int. 2023 Sep 21;39:26. doi: 10.5758/vsi.230071. PMID: 37732343; PMCID: PMC10512004. Papas TT. Patient Selection Is Essential for Explantation of Infected Abdominal Aortic Endografts. Angiology. 2023 Nov 23:33197231218622. doi: 10.1177/00033197231218622. Epub ahead of print. PMID: 37995099. Anagnostopoulos A, Mayer F, Ledergerber B, Bergadà-Pijuan J, Husmann L, Mestres CA, Rancic Z, Hasse B; VASGRA Cohort Study. Editor's Choice - Validation of the Management of Aortic Graft Infection Collaboration (MAGIC) Criteria for the Diagnosis of Vascular Graft/Endograft Infection: Results from the Prospective Vascular Graft Cohort Study. Eur J Vasc Endovasc Surg. 2021 Aug;62(2):251-257. doi: 10.1016/j.ejvs.2021.05.010. Epub 2021 Jun 14. PMID: 34140225. Lumsden AB. Explant of the Aortic Endograft: Today's Solutions, Tomorrow's Problems. Methodist Debakey Cardiovasc J. 2023 Mar 7;19(2):38-48. doi: 10.14797/mdcvj.1176. PMID: 36936357; PMCID: PMC10022536. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.  

Audible Bleeding contributor and vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by vascular fellow Eva Urrechaga (@urrechisme),  fourth year medical student Leona Dogbe (@ldogbe4), JVS Editor-in-Chief, 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 analyzes amputation trends over 12 years in Oklahoma, and identifies risk factors that can be used to target intervention strategies. The second article explores the role of toll-like receptor 4 in skeletal muscle damage caused by chronic limb-threatening ischemia.  This episode hosts Dr. Kelly Kempe (@KellyKempe) and Dr. Ali Navi (@VascularChap), authors of these two papers. Articles: Part 1: “Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions” by Drs. Kempe, Nelson, and colleagues. Part 2: “Role of toll-like receptor 4 in skeletal muscle damage in chronic limb-threatening ischemia” by Drs. Navi, Tsui, and colleagues. Show Guests: Dr. Kelly Kempe: Associate Professor and Vascular Surgery Program Director at the University of Oklahoma in Tulsa, Oklahoma. Dr. Ali Navi: Consultant Vascular Surgeon at Cambridge University Hospitals, UK. 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.

We are excited to bring back part two of our discussion on Robotic Vascular Surgery. Yasong (@yasongyumd) and Eva (@urrechisme) are joined by Dr. Lumsden and Dr. Bavare from Houston Methodist Hospital Show Guests: Alan Lumsden: Chair of Cardiovascular Surgery at Houston Methodist and DeBakey Heart and Vascular Center Charu Bavare: Vascular Surgeon at Houston Methodist and Debakey Heart and Vascular Center Hosts: Eva Urrechaga - Vascular fellow at University of Pennsylvania Yasong Yu - Vascular fellow at University of Chicago Robotic Vascular Surgery Episode 1 with Dr. Judith Lin and Dr. Petr Stadler Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

Authors:  Sebouh Bazikian - PGY1 at Emory School of Medicine Integrated Vascular Surgery Program   Miguel F. Manzure - vascular surgery attending the University of Southern California Keck School of Medicine involved in complex limb preservation Core Resources: Rutherford Chapters: 107, 108, 109 (Includes further information on anatomy), 112 Additional Resources: Relevant trials BEST CLI: https://pubmed.ncbi.nlm.nih.gov/36342173/ BASIL 2: https://pubmed.ncbi.nlm.nih.gov/37116524/ Relevant Audible Bleeding episodes Audible Bleeding Endovascular Basics: https://open.spotify.com/episode/7jDpkhGMauBslk8SBklCyB?si=75f0931773d24b91 Audible Bleeding eBook, CLTI Chapter: https://adam-mdmph.quarto.pub/vascular-surgery-exam-prep/clti.html Anything else useful WIFI: https://pubmed.ncbi.nlm.nih.gov/24126108/ GLASS: https://pubmed.ncbi.nlm.nih.gov/31159978/ Monophasic, Biphasic, Triphasic Waveforms: https://pubmed.ncbi.nlm.nih.gov/32667274/ Underlying disease featured in episode - peripheral arterial disease Pathophysiology/etiology narrowing of peripheral arteries caused by atherosclerotic plaques causing arterial insufficiency distal to the point of occlusion. This reduces oxygen supply to the muscles. When oxygen demand increases but cannot be met, it leads to an imbalance such as pain and poor wound healing.  Risks: smoking, diabetes, hypertension, dyslipidemia, and older age Equal prevalence in men and women, peak incidence age 60-80 Coexists with CAD, DM, stroke, Afib, and renal disease Patient Presentation 20-50% asymptomatic, rest can be intermittent claudication, rest pain, or tissue loss claudication=pain or discomfort felt in the legs due to a lack of blood flow, especially during physical activity.  CLTI=chronic limb threatening ischemia: rest pain lasting greater than 2 weeks or nonhealing ulcers and gangrene Physical exam:  decreased skin temperature, less hair on the legs, brittle nails, atrophied muscles, shiny skin, livedo reticularis. Absent or diminished pulses Buerger sign Diagnosis Ankle brachial index: <0.9=PAD. <0.4=multilevel disease associated with tissue loss. >1.3 can mean vessel calcification Toe pressures, toe brachial indexes, and transcutaneous oxygen measurement (TcPO2) if vessels calcified Duplex ultrasound: affordable and effective, can assess both anatomy and blood flow Can also assess degree of stenosis based on ratios of systolic and diastolic velocity Angiography: gold standard. Invasive and risks of infection, hematoma, pseudoaneurysms, and contrast nephropathy. Staging: WIFI - Wound, Ischemia, and Foot Infection (see additional resources) GLASS: Global Limb Anatomy Staging System (see additional resources) Treatment (Medical/Surgical) Lifestyle modification, smoking cessation, high-intensity statins, antiplatelet therapy, and management of other medial comorbidities like HTN and DM. Structured exercise program: 3 times weekly for 12 weeks Cilostazol: phosphodiesterase III inhibitor Endovascular and surgical revascularization Endovascular offer superior perioperative outcomes but lacks durability Surgical revascularization offer durability and less reinterventions, but more invasive   Indications for surgery: CLTI and lifestyle limiting claudication   Relevant anatomy: Femoral triangle inguinal ligament superior, the medial border of the sartorius muscle laterally, and the medial border of the adductor longus on the medially Contains neurovascular bundle (NAVEL) Adductor canal: bordered anteriorly by the sartorius, posteriorly by the adductor magnus and longus, and to the lateral side by the vastus medialis common femoral artery bifurcates into the profunda and the superficial femoral artery  (SFA). SFA courses through adductor canal and turns into popliteal artery in the popliteal fossa GSV: originates at the ankle, tracts anterior to medial malleolus and then ascending the medial side of lower leg. Upon reaching the knee, it curves behind the medial condyles of the femur and tibia, continuing alongside the medial aspect of the thigh. Its journey culminates at the saphenofemoral junction Preoperative preparation: Identifying inflow and outflow vessels, both should be free of significant disease preop CTA or angiogram Picking a conduit Best patency=autogenous: reversed GSV most common, others are small saphenous vein, cephalic vein, etc Prosthetic: polytetrafluoroethylene (PTFE) Cryopreserved vein   Surgical steps: Harvesting GSV (if GSV adequate as conduit) Dissected along its length, branches ligated, removed and reversed Can also be left insitu, so only proximal and distal aspects are mobilized, and valves are removed using valvulotome Should be at least 3mm in diameter and no significant disease (scarring, thickening) Arterial exposure Common femoral artery: lies in the medial third segment between the ASIS and the pubic symphysis. Longitudinal or oblique incision directly over the femoral artery pulse if present. ligate venous and lymphatic tributaries in the soft tissue. Open fascia along the medial margin of the sartorius muscle, retracting the sartorius muscle laterally exposes the underlying femoral sheath. CFA is located within the femoral sheath. Profunda and superficial femoral artery: trace the anterior surface of the CFA to where it bifurcates. The origin of the profunda is typically lateral Popliteal artery: medial longitudinal incision 1 to 2 cm behind the tibia's posterior border. Carefully to avoid GSV, dissect down to fascia to enter the popliteal fossa. The medial head of the gastrocnemius is retracted posteriorly, giving us a clear view of the popliteal fossa. popliteal artery is surrounded by paired popliteal veins with smaller bridging veins Tunneling and anastomosis Can be done anatomically or subcutaneously Must be careful not to twist the conduit Can do proximal anastomosis to pressurize vein prior to tunneling to minimize chance of twisting Clamp the vessels and heparinize Arteriotomy on femoral artery and anastomosis, same with popliteal artery distally Closure and ensure patency Optional completion angiogram Postoperative care: Anticoagulation and/or antiplatelet therapy Monitor graft patency once discharged with duplex/ABI Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovations, and Techniques (JVS-CIT). Editorials and Abstracts are read by members of our SVS Social Media Ambassadors and authors.   Readers: Shourya Verma (@shourya__verma) Nabeeha Khan (@Nabeeha_Khan_) Miguel Fernandez (@MGfernandez21) Amit Chaudhary (@VascularKGMU) Dr. Jayer Chung (@Jayer_Chung)   Hosts: Nishi Vootukuru (@Nishi_Vootukuru) John Culhane (@Johnculhanemd)   Editorials (E) and Abstracts (A):   E- Arteries of fibromuscular dysplasia tell a sympathetic story A- Transcarotid arterial revascularization is feasible and safe with concomitant inferior vena cava occlusion A- Surgical anteriorization of the left common iliac vein results in improved venous outflow and quality of life for May-Thurner syndrome E- Longer is better, discussing length of coverage and timing of intervention in type B aortic dissection A-Endovascular repair of ascending aortic pathologies in patients unfit for open surgery: Case series and literature review A-Improved gait parameters following surgical revascularization in patients with intermittent claudication A- Totally percutaneous endovascular renal allograft salvage for common iliac artery pseudoaneurysm A- Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms E- Impact of the infrapopliteal bypass with distal arteriovenous fistula and distal cuffs in the management of small arterial disease     Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

In this episode, Sasank Kalipatnapu (@ksasank), John Culhane and Leana Dogbe (@ldogbe4) sit down along with Dr. Dalman (@RLDalmanMD) as chair of the SVS Nominating Committee for this year, along with the two vice presidential candidates Dr. Harris and Dr Shaw to learn more about them as part of the ongoing election process.    Show links: SVS 2024 Meet the VP 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. Linda Harris, Professor of Surgery at Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, NY Dr. Palma Shaw, Professor of Surgery at State University of New York, Syracuse, NY Dr. Ronald L. Dalman, Elsa R. and Walter C. Chidester Professor and Division Chief Emeritus of Vascular Surgery at Stanford University, CA, Associate Dean for Market Development and Outreach for Stanford Medicine and Vice Chair for Clinical Affairs in the Department of 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.

Audible Bleeding contributor and 5th year general surgery resident Richa Kalsi (@KalsiMD) is joined by first-year vascular surgery fellow Zach Mattay (@ZMatthay), fifth-year general surgery resident Naveed Rahman (@naveedrahmanmd), JVS editor Dr. Thomas Forbes (@TL_Forbes), and JVS-CIT editor Dr. Matthew Smeds (@mattsmeds) to discuss two great articles in the JVS family of journals. The first article discusses national trends in surgeon-modified graft utilization for complex and thoracoabdominal aortic aneurysms. The second article discusses a novel technique, transcatheter electrosurgical aortic septotomy, to treat chronic dissecting aortoiliac aneurysms.  This episode hosts Dr. Thomas O’Donnell (@tfxod) and Dr. Carlos Timaran (@ch_timaran), the authors of these two papers. Articles: Part 1:“National Trends in utilization of surgeon-modified grafts for complex and thoracoabdominal aortic aneurysms” by Dr. O’Donnell and colleagues. Mentioned during the discussion:  “Application of Investigational Device Exemptions regulations to endograft modification” by Abel and Farb.  Part 2: “Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms” by Dr. Timaran and colleagues. Mentioned during discussion: “Transcatheter Electrosurgery: JACC State-of-the-Art Review” by Khan and colleagues. “A Novel Way to Fenestrate a Type B Dissection Flap Using Endovascular Electrocautery” by Dr. Kabbani and colleagues.  Show Guests  Dr. Thomas O’Donnell: Assistant professor of surgery in the aortic center at New York Presbyterian/Columbia University Irving Medical Center. Dr. Carlos Timaran: Professor and Chief of Endovascular Surgery at University of Texas Southwestern Medical Center’s Department of Surgery.   Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

This episode of Audible Bleeding features Drs. Adam Johnson and Jeniann Yi, members of the Society for Vascular Surgery Health Information Technology Committee, to discuss the application of large language models in vascular surgery with two experts in the field, Dr. Andrew Gonzalez and one of his collaborators, Shantanu Dev.  The episode promises a conversation exploring machine learning and large language models with insights from the guests' diverse expertise in vascular surgery, health informatics, and artificial intelligence.   Dr. Andrew Gonzalez, an assistant professor in vascular surgery at Indiana University School of Medicine and also an SVS HITC committee member, has clinical and research interests in peripheral arterial disease and artificial intelligence applications for amputation prevention.   Shantanu Dev, a computer science PhD student at Ohio State, focusing on multimodal modeling for clinical applications in AI. Shantanu worked at PWC for eight years in their AI R&D division and co-owns Satsang.ai (www.satsang.ai) Digital Health, an AI company addressing healthcare inequities and quality of care.   Relevant links: AI Revolution in Medince: GPT4 and Beyond by Peter Lee Artificial Intelligentce in Surgery: Understanding the Role of Ai in Surgical Practice by Dan Hashimoto Data Skeptic Podcast Deep Medicine: How Artificial Intelligence can make Helathcare Human Again by Eric Topel   Co-Hosts:   Dr. Jennian Yi is an Assistant Professor of Surgery at the University of Colorado. Dr. Adam Johnson is an Assistant Professor of Surgery at Duke University, and editor at Audible Bleeding. Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovations, and Techniques (JVS-CIT). Editorials and Abstracts are read by members of our SVS Social Media Ambassadors and Editor in Chief of JVS CIT, Dr. Matthew Smeds.   Readers: Matthew Smeds (@mattsmeds) Christopher DeHaven (@ChrisDeHavenPSU) Ethan Vieira Litton Whittaker Nicholas Schaper Nishi Vootukuru (@Nishi_Vootukuru)   Editorials: Accomplishments and goals: Review of 2023 and previous of 2024 for the Journal of Vascular Surgery Cases, Innovations, and Techniques.   The enduring success of the DRIL technique and new advances in dialysis access.   Abstracts: Intraprocedural application of a peripheral blood flow monitoring system during endovascular treatment for femoropopliteal disease.   Thoracic outlet syndrome: single-center experience on the transaxillary approach with the aid of the TRIMANO Arthrex arm.   Inferior vena cava hemangioma resected using a novel Toumai robotic surgical platform.   Surgical release of anterior tibial artery entrapment with associated popliteal artery entrapment.   Revisiting Heinz-Lippman disease as a complication of chronic venous insufficiency.   Utilization of coronary computed tomography angiography and computed tomography-derived fractional flow reserve in a critical limb-threatening ischemia cohort.   A rare case of Bannayan-Riley-Ruvalcaba syndrome with concurrent arteriovenous malformation.   Autologous and synthetic pediatric iliofemoral reconstruction: A novel technique for pediatric iliofemoral artery reconstruction.   Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.    

In this episode Abena Appah-Sampong (@abenasamp) and Leana Dogbe (@leanadogbe) partner with Vaiva Dabravolskaite (vaivadabravolskaite@gmail.com) from ESVS to host an episode discussing social deprivation in vascular surgery. Dr. Tara Mastracci and Dr. Olamide Alabi join us to offer insights into how social deprivation drives disparities in outcomes and steps to how we can shift practice paradigms to better address our patient needs.   Dr. Tara Mastracci (@aorticsurgeon) is a vascular surgeon with over 15 years of experience treating and managing complex aortic pathologies. She is currently working at St. Bartholomew’s Hospital in London, UK, on the Cardiothoracic Team doing complex aortic surgery. On top of her clinical duties, Dr. Mastracci is dedicated to studying the social and non-clinical factors influencing vascular outcomes.    Dr. Olamide Alabi (@OAlabiMD) is an Associate Professor of Surgery in the Department of Surgery at Emory University School of Medicine. Her clinical effort focuses on the full scope of vascular disease for patients at Emory University Hospital and the Atlanta VA HealthCare System, however, her academic portfolio and funded research is focused primarily on the intersection of peripheral artery disease, quality, and health equity.    References: Social Deprivation and the Association With Survival Following Fenestrated Endovascular Aneurysm Repair/2021 https://www.annalsofvascularsurgery.com/article/S0890-5096(21)00872-4/fulltext Is social deprivation an independent predictor of outcomes following cardiac surgery? An analysis of 240,221 patients from a national registry. BMJ/2015 https://bmjopen.bmj.com/content/5/6/e008287.long   Survival Disparity Following Abdominal Aortic Aneurysm Repair Highlights Inequality in Ethnic and Socio-economic Status/ https://www.ejves.com/article/S1078-5884(17)30521-X/fulltext Nash, D., McClure, G., Mastracci, T. M., & Anand, S. S. (2022). Social deprivation and peripheral artery disease. Canadian Journal of Cardiology, 38(5), 612-622. Vart, P., Coresh, J., Kwak, L., Ballew, S. H., Heiss, G., & Matsushita, K. (2017). Socioeconomic status and incidence of hospitalization with lower‐extremity peripheral artery disease: atherosclerosis risk in communities study. Journal of the American Heart Association, 6(8), e004995. Henry, A. J., Hevelone, N. D., Belkin, M., & Nguyen, L. L. (2011). Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. Journal of vascular surgery, 53(2), 330-339. Demsas, F., Joiner, M. M., Telma, K., Flores, A. M., Teklu, S., & Ross, E. G. (2022, June). Disparities in peripheral artery disease care: A review and call for action. In Seminars in vascular surgery (Vol. 35, No. 2, pp. 141-154). WB Saunders.   Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

In today’s episode, Dr. Rachael Forsythe (@ROForsythe), consultant vascular surgeon at NHS Lothian, leads a fictional case-based discussion with leaders in managing diabetic foot ulcers. Joining the conversation are Professor Andrew Boulton, Mr. Patrick Coughlin, Dr. David Armstrong, Dr. Dane Wukich, and Dr. Edgar Peters. Professor Boulton is a professor of medicine at Manchester University in England and is co-chair of the Malvern  Diabetic Foot Conference meeting. He served as president of numerous distinguished societies, including the International Diabetes Federation. Dr.  Coughlin (@Coughlin_pa) is a consultant vascular surgeon in Leeds, England. He is a very active member of the Vascular Society of Great Britain and Ireland Council and has a special academic and clinical interest in peripheral artery disease. Dr. Armstrong (@DGArmstrong) is a podiatric surgeon and professor of surgery at Keck School of Medicine of the University of California and director of the Southwestern Academic Limb Salvage Alliance. Dr. Armstrong is very well known for his work on amputation prevention, the diabetic foot and wound healing. Dr. Wukich (@DaneWukich) is a professor and chair of the Department of Orthopedics at the University of Texas, Southwestern and Medical Director of Orthopedic Surgery at UT Southwestern University Hospitals. Dr. Wich has an interest in foot and ankle surgery, including the management of diabetes-related complications. Dr. Edgar Peters is an associate professor of internal medicine, infectious diseases, and acute medicine at Amsterdam University Medical Centers, Dr. Peter's main interest is infection of the musculoskeletal system, particularly in patients with diabetes and is the Scientific Secretary of the International Symposium on the Diabetic Foot.    Malvern Diabetic Foot Conference info: https://www.facebook.com/MalvernDiabeticFootConference/ https://eu.eventscloud.com/website/8151/   If this episode was of interest to you, please take a listen to this Transatlantic Series episode where we speak with the authors of the SVS, ESVS, and IWGDFU joint guidelines on the management of peripheral arterial disease (PAD) in patients with diabetes.    Articles, resources, and societies referenced in the episode: DF Blog. “Oral Is the New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review @bradspellberg @lacuscmedcenter @usc,” January 1, 2022. https://diabeticfootonline.com/2022/01/01/oral-is-the-new-iv-challenging-decades-of-blood-and-bone-infection-dogma-a-systematic-review-bradspellberg-lacuscmedcenter-usc/. Gariani, Karim, Truong-Thanh Pham, Benjamin Kressmann, François R Jornayvaz, Giacomo Gastaldi, Dimitrios Stafylakis, Jacques Philippe, Benjamin A Lipsky, and Lker Uçkay. “Three Weeks Versus Six Weeks of Antibiotic Therapy for Diabetic Foot Osteomyelitis: A Prospective, Randomized, Noninferiority Pilot Trial.” Clinical Infectious Diseases 73, no. 7 (October 5, 2021): e1539–45. https://doi.org/10.1093/cid/ciaa1758. Li, Ho-Kwong, Ines Rombach, Rhea Zambellas, A. Sarah Walker, Martin A. McNally, Bridget L. Atkins, Benjamin A. Lipsky, et al. “Oral versus Intravenous Antibiotics for Bone and Joint Infection.” New England Journal of Medicine 380, no. 5 (January 31, 2019): 425–36. https://doi.org/10.1056/NEJMoa1710926. Magliano, Dianna, and Edward J. Boyko. IDF Diabetes Atlas. 10th edition. Brussels: International Diabetes Federation, 2021. Østergaard, Lauge, Mia Marie Pries-Heje, Rasmus Bo Hasselbalch, Magnus Rasmussen, Per Åkesson, Robert Horvath, Jonas Povlsen, et al. “Accelerated Treatment of Endocarditis—The POET II Trial: Ration ale and Design of a Randomized Controlled Trial.” American Heart Journal 227 (September 2020): 40–46. https://doi.org/10.1016/j.ahj.2020.05.012. Price, Patricia. “The Diabetic Foot: Quality of Life.” Clinical Infectious Diseases 39 (2004): S129–31. Sharma, S., C. Kerry, H. Atkins, and G. Rayman. “The Ipswich Touch Test: A Simple and Novel Method to Screen Patients with Diabetes at Home for Increased Risk of Foot Ulceration.” Diabetic Medicine: A Journal of the British Diabetic Association 31, no. 9 (September 2014): 1100–1103. https://doi.org/10.1111/dme.12450. Shin, Laura, Frank L. Bowling, David G. Armstrong, and Andrew J.M. Boulton. “Saving the Diabetic Foot During the COVID-19 Pandemic: A Tale of Two Cities.” Diabetes Care 43, no. 8 (August 1, 2020): 1704–9. https://doi.org/10.2337/dc20-1176. Tone, Alina, Sophie Nguyen, Fabrice Devemy, Hélène Topolinski, Michel Valette, Marie Cazaubiel, Armelle Fayard, Éric Beltrand, Christine Lemaire, and Éric Senneville. “Six-Week Versus Twelve-Week Antibiotic Therapy for Nonsurgically Treated Diabetic Foot Osteomyelitis: A Multicenter Open-Label Controlled Randomized Study.” Diabetes Care 38, no. 2 (February 1, 2015): 302–7. https://doi.org/10.2337/dc14-1514. Wukich, Dane K., Katherine M. Raspovic, and Natalie C. Suder. “Patients With Diabetic Foot Disease Fear Major Lower-Extremity Amputation More Than Death.” Foot & Ankle Specialist 11, no. 1 (February 2018): 17–21. https://doi.org/10.1177/1938640017694722.

Audible Bleeding editor Wen (@WenKawaji) is joined by 5th integrated vascular resident Yang (@YangYang_MD) and Moira 3rd year medical student discussing the International Society for Women Vascular Surgeons and Women’s Vascular Summit with Dr. Linda Harris.  Show Guests: Dr. Linda Harris: Dr. Harris joined University of Buffalo in 1995 and currently sits as Professor of Surgery with tenure in the Department of Surgery. She is also the Program Director for the Vascular Fellowship and Vascular Residency Programs. She is the president of the international society for women vascular surgeons.   SVS Women's section episodes  SVS Women’s Section with Dr. Duncan and Dr. Shaw SVS Women's Section: Advice for Young Surgeons   Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

In this episode of Audible Bleeding, editor Dr. Adam Johnson is joined by General Surgery PGY-3 Sasank Kalipatnapu, MS2 Nishi Vootukuru, along with Dr. Anton Sidawy, MD, and Dr. William Schutze to discuss the nuances of the recently launched Society for Vascular Surgery (SVS) Outpatient Verification Program, in collaboration with the American College of Surgeons. This episode brings out a conversation exploring the history behind the development of the program, the current state of the program, and the overwhelming importance of the program in the current day. The episode will also cover the broad steps that need to be taken by a facility looking to become verified and will also show the value added by being verified by this joint ACS/SVS Vascular Verification program.   Dr. Anton Sidawy, MD, MPH, FACS is the Lewis B. Saltz Chair and Professor of Surgery at George Washington School of Medicine, Washington DC. He is the chair of the Vascular Verification Program steering committee and oversees the development and implementation of inpatient and outpatient vascular verification programs.   Dr. William Patrick Shutze is a Vascular Surgeon from Texas Vascular Associates in Plano, TX, and Chair of the Outpatient Committee. He is also the secretary for the Society for Vascular Surgery and is also the chair of the Communications Committee. He has led the efforts with the implementation of the recently launched Outpatient Verification Program.   Relevant links: Official page of the Vascular Verification Program   Co-Hosts: Dr. Adam Johnson is an Assistant Professor of Surgery at Duke University and editor at Audible Bleeding. Dr. Sasank Kalipatnapu is a PGY-3 General Surgery resident at UMass Chan Medical School, Worcester, MA. Nishi Vootukuru is a 2nd-year medical student at Rutgers NJMS University, Newark, NJ.  

Authors:  Sebouh Bazikian - MS4 at Keck School of Medicine of University of Southern California Gowri Gowda - PGY1 at the University of California Davis Integrated Vascular Surgery Program Steven Maximus- Vascular surgery attending at the University of California Davis, Director of the Aortic Center   Resources:  Rutherford’s 10th Edition Chapters: 88, 89, and 91 The North American Symptomatic Carotid Endarterectomy Asymptomatic Carotid Atherosclerosis Study Audible Bleeding’s eBook chapter on cerebrovascular disease Houston Methodist CEA Dissection Video: Part 1: https://www.youtube.com/watch?v=wZ8PzhwmSXQ Part 2: https://www.youtube.com/watch?v=E_wWpRKBy4w   Outline:  1. Etiology of Carotid Artery Stenosis Risk factors: advanced age, tobacco use, hypertension, diabetes. Atherosclerosis as the primary cause. Development of Atherosclerotic Disease and Plaque Formation LDL accumulation in arterial walls initiating plaque formation. Inflammatory response, macrophage transformation, smooth muscle cell proliferation. Role of turbulent blood flow at carotid bifurcation in plaque development. Clinical Features of Carotid Artery Stenosis Asymptomatic nature in many patients. Symptomatic presentation: Transient ischemic attacks, amaurosis fugax, contralateral weakness/sensory deficit. Carotid bruit as a physical finding, limitations in diagnosis. Importance of Evaluating CAS Assessing stenosis severity and stroke risk. Revascularization benefits dependent on stenosis severity. Classification of Stenosis Levels Clinically significant stenosis: ≥ 50% narrowing. Moderate stenosis: 50%–69% narrowing. Severe stenosis: 70%–99% narrowing. Stroke Risk Associated with Carotid Stenosis Annual stroke rate: ~1% for 50-69% stenosis, 2-3% for 70-99% stenosis. Diagnosis and Screening No population-level screening recommendation. Screening for high-risk individuals as per SVS guidelines. Carotid Duplex Ultrasound as primary diagnostic tool. Additional tools: CT angiography, Magnetic Resonance Angiography. Handling of <50% stenosis cases. Imaging Modalities Ultrasound: Noninvasive, cost-effective, potential overestimation of stenosis. CTA: Fast, high resolution, contrast exposure risks. MRA: Contrast-free plaque analysis, possible overestimation of stenosis. Angiography: Gold standard, expensive, stroke risk. Assessing Degree of Stenosis via CDUS Parameters for 50-69% stenosis: Peak Systolic Velocity (PSV) 125-229 cm/sec, End Diastolic Velocity (EDV) 40-100 cm/sec, Internal/Common Carotid peak systolic velocity Ratio 2-4. Parameters for 70-99% stenosis: PSV ≥ 230 cm/sec, EDV > 100 cm/sec, Internal/Common Carotid peak systolic velocity Ratio > 4. Revascularization Criteria Symptomatic Patients: 50-69% or 70-99% stenosis, life expectancy at least three or two years, respectively. Asymptomatic Patients: <50% stenosis, no revascularization; 50-69% stenosis, follow-up and surveillance; >70% stenosis, considering life expectancy. Surgical Indications and Contraindications Indications: symptomatic patients, life expectancy considerations. Contraindications: Stenosis <50%, severe comorbidities, 100% occlusion. Medical Management for All CAS Patients Lifestyle changes, high-intensity statin therapy, antiplatelet therapy. Decision Factors for Surgical Approaches TCAR, stenting, endarterectomy: situational preferences. Carotid Endarterectomy: Surgical Procedure Incision along anterior border of sternocleidomastoid muscle. Electrocautery through platysma muscle and subcutaneous tissues. Protecting the great auricular nerve, dividing the external jugular vein. Retracting sternocleidomastoid muscle, exposing carotid sheath. Dissecting internal jugular vein, ligating facial vein. Avoiding injury to the vagus nerve, dissecting the common carotid artery. Identifying and mobilizing the hypoglossal nerve, addressing the external carotid artery. Extending dissection from common carotid artery to beyond the internal and external carotid bifurcation. Longitudinal arteriotomy, plaque removal using a Freer elevator. Ensuring a smooth transition between endarterectomized artery and normal distal extent. Patch angioplasty for arteriotomy closure, sequential clamp release for de-airing. Neuromonitoring and Plaque Removal Neuromonitoring methods: EEG, SSEPs, TCD, cerebral oximetry, awake patient monitoring. Shunting and Vessel Closure Shunting indications: neurological status changes, EEG alterations. Carotid stump pressure measurement. Postoperative Complications and Management Common complications: stroke, hyperperfusion syndrome, myocardial infarction, cervical hematoma, nerve injuries, infection. Managing hyperperfusion syndrome: blood pressure control, antiepileptic drugs. Cranial nerve injuries:  Hypoglossal Nerve (CN XII): Injury leads to tongue deviation towards the injured side. Glossopharyngeal Nerve (CN IX): Injury results in swallowing difficulties and aspiration risk. Vagus Nerve (CN X): Injury causes hoarseness due to laryngeal muscle involvement. Marginal Mandibular Branch of Facial Nerve: Injury leads to ipsilateral lip droop.   Follow us @audiblebleeding   Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

Welcome to the Transatlantic series, a co-production of Audible Bleeding (a publication of the SVS) and the ESVS podcast. In today’s episode, we explore the intersocietal guidelines on peripheral arterial disease in patients with diabetes and foot ulcers authored by the International Working Group on the Diabetic Foot (IWGDF), the European Society for Vascular Surgery (ESVS), and the Society for Vascular Surgery (SVS).   Dr. Robert Fitridge is a Professor of Vascular Surgery at University of Adelaide in Australia. He is a member of the IWGDF and is also a member of the steering committee for the Global Vascular Guideline on the management of Chronic Limb-threatening Ischaemia.    Dr. Vivienne Chuter is a Professor in the Department of Podiatry at Western Sydney University and Honorary Professor in the School of Health Science at The University of NewCastle. She is a member of the IWGDF. She has published extensively on diabetic foot disease and leads a clinically based research program focusing on the prevention and management of diabetes-related foot disease for Aboriginal and Torres Strait Islander people and for non-Indigenous Australians.   Dr. Nicolaas Schaper is an emeritus professor of Endocrinology at Maastricht University Hospital in the Netherlands. Dr. Schaper was the coordinator of the European diabetic foot research consortium, Eurodiale. He is Chair of the 2023 Diabetic Foot Symposium (ISDF 2023) and is Chair of the IWGDF.   Dr. Joseph L. Mills is a Professor of Vascular Surgery at Baylor in Houston, Texas. He is a member of the IWGDF. Dr. Mills is a leader in the vascular surgery global community, has served as president of the Peripheral Vascular Surgery Society, and is currently a member of the Surgery Residency Review Committee of the ACGME.   Further reading and links:   The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. Global vascular guidelines for CLTI Best-CLI Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial Release of the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025; the impacts for podiatry in Australia: a commentary Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases Results of the CAPRIE trial: efficacy and safety of clopidogrel. Clopidogrel versus aspirin in patients at risk of ischaemic events Low-Dose Aspirin for the Primary Prevention of Cardiovascular Disease in Diabetic Individuals: A Meta-Analysis of Randomized Control Trials and Trial Sequential Analysis Diabetes, Lower-Extremity Amputation, and Death Outcomes in patients with chronic leg wounds in Denmark: A nationwide register‐based cohort study Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review.  Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review. Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI). Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial.   Mobile Applications:   Society for Vascular Surgery Mobile App for Staging of Chronic Limb-Threatening Ischemia.  European Society for Vascular Surgery Clinical Practice Guidelines Mobile Edition.   Hosts:    Dr. Naveed A. Rahman is a chief surgery resident at SUNY Upstate in Syracuse, NY. He will pursue a vascular surgery fellowship at the University of Maryland starting in 2024. His Doximity profile is https://www.doximity.com/pub/naveed-rahman-md. Twitter: @naveedrahmanmd Dr. Suzanne Stokmans is a fifth-year vascular surgery resident at the Isala Hospital in Zwolle, the Netherlands. Dr. Ezra Schwartz is a medical graduate from McGill University currently completing a Master of Medical Science in Medical Education at Harvard Medical School. He is an aspiring vascular surgeon and surgical education researcher. Twitter: @ezraschwartz10   Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.