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• W4321463962 abstract "I would like to thank you very much for the incredible honor of serving as the president of this great society. The New England Society for Vascular Surgery (NESVS) has always been extremely special to me, ever since I first attended and presented as a first year fellow back in 2005. Having the opportunity to serve as president has certainly and unequivocally been a highlight of my career. When I began my journey into medicine, this is what I thought career development looked like (Fig 1, A). You start somewhere and then, in a very linear process, you advance to somewhere else. College, followed by medical school, followed by residency, followed by fellowship, followed by getting a job… What I have learned is that this journey is really about connecting dots (Fig 1, B). Meeting different people. Seeing opportunities when faced with challenges. Seeking out inflection points. And, in my opinion, most important, having a relentless curiosity and thirst for knowledge and education. And it is by connecting those dots, that ideally you get from some point A to some more desired distant point B. I would like to tell you a bit about the dots I have connected and why it makes me so incredibly optimistic for our future as a specialty. Today, I will talk about five key dots that I believe are the essence of what makes vascular surgery special. I will try to do this through a few themes, or specific dots. As vascular surgeons, we collaborate. We do this every day. Within our specialty and with all the other specialties that need what we bring to the table. And I think the extent to which we collaborate is unique to vascular surgery. And for collaboration, I will give two examples. First, I’ll give an example of collaboration in the time of crisis and second, I’ll give an example of collaboration to advance the field. I had the opportunity to work with past president, Dr Rick Powell, on this document evaluating the value of a vascular surgeon to a health care system.1Powell R. Brown K. Davies M. Hart J. Hsu J. Johnson B. et al.The value of the modern vascular surgeon to the health care system: a report from the Society for Vascular Surgery Valuation Work Group.J Vasc Surg. 2021; 73: 359-371.e3Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar I believe it is an important document filled with extremely useful data. But actually, one of my favorite things that came out of this effort was this graphic that was generated by SG2, with whom we partnered (Fig 2). Because it really is so true. When things are going poorly in the operating room, who does the hospital look to: vascular surgery. And this, I believe to be an incredible privilege. As Dr Belkin so articulately described during his presidential address in 2013, we are the firewomen and firemen of the operating romm.2Belkin M. The training of firemen.J Vasc Surg. 2014; 59: 1144-1151Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar If we cannot fix it, it likely cannot be fixed. No doubt, this is a significant weight to shoulder, but what could be more professionally satisfying than being the final line of defense for our patients? We are called on to help everyone and we rise to the challenge. The importance of collaboration in the time of crisis, and the value of synergy to achieve greater things became crystal clear to me during the coronavirus disease 2019 (COVID) pandemic. Remember the dark days in March, April, and May of 2020, when visitors were not allowed, when pumps were extended into hallways to minimize care team exposures, and when cafeterias were closed? But when we were also able to see silver linings, many of them in the way of gratitude and in the way of unprecedented teamwork. Almost immediately when COVID started having a major impact, a text stream with many vascular surgeon chiefs from the northeast developed with the goal of trying to help each other. Dr Vi Patel, working at Columbia Presbyterian, in the New York City epicenter, was hit particularly hard by COVID, and took the time to share his experience. Other division chiefs related their staffing challenges and strategies on how best to contribute. These insights led directly to our response at the University of Massachusetts and informed a rational approach, as opposed to the initial irrational approach, asked of us by our hospital. Trust me when I say, you do not want me managing the vent settings on a critically ill patient. Through these lessons learned from other centers in the region and some others we spoke with from around the world, we wanted to answer the following questions and get them as right as we could in a world that was changing quicker than anything we had every experienced.•How can we best leverage the skillset of the vascular surgery division? I told the intensive care doctors, in no uncertain terms, you did not want me or my team providing primary management for critically ill patients. That was not an area in which we could meaningfully contribute.•How can we provide the best service to the hospital system and our medical colleagues addressing the current needs? We wanted to do our part.•Finally, how can we accomplish this while maintaining control of our own workforce? In answer to those questions, we proposed, designed, initiated and executed a surgical workforce access team (SWAT).3Sheth P.D. Simons J.P. Robichaud D.I. Ciaranello A.L. Schanzer A. Development of a surgical workforce access team in the battle against COVID-19.J Vasc Surg. 2020; 72: 414-417Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The scope was the formation of Surgical SWAT teams responsible, 24/7, for responding to all requests for arterial or venous access with page to puncture initiated within 60 minutes of pager activation of the SWAT team. Each SWAT team consisted of a vascular surgery SWAT lead and SWAT member, with vascular attending back up. In 24 hours, we gathered the resources necessary and created a centralized inventory management system to replace all equipment twice a day across two large hospital campuses. We had standardized mobile line carts made with all necessary materials to place arterial lines, triple lumen central venous lines, cordis large-bore central lines, and temporary dialysis lines. We appropriated two duplex machines. Personal protective equipment was provided and restocked. Pagers were programmed and distributed. In a pre- or post-COVID setting, this would have taken months to develop and many committees to endure. We set this up in 24 hours. Meaningful change can come from collaboration in times of crisis. We answered the call, placing more than 500 lines in just the first month that we provided this service. And we did it well and we did it safely; with a complication rate of less than 1%. Everyone stepped up in a way that we could all be extremely proud of. We worked together to change our scope of work completely but to do so in a way that leveraged our skillset. Another unique collaboration that I have had the opportunity to observe has been the formation of the US Aortic Research Consortium. I see this as an example of how powerful collaboration can be in moving our field forward. This collaboration consists of 10 institutions, all running physician-sponsored investigational device exemption studies evaluating the safety and efficacy of fenestrated branched endovascular aortic repair. All sites are monitored independently and audited by the US Food and Drug Administration. All sites use similar device designs with selective use of fenestrations and branches. Although I am proud of the contributions we have made as a single center reporting on our experience with complex aortic repair, I believe that the single-center reporting model is the past. Larger collaborative efforts can advance the technology and science so much faster. Collaborations like the US Aortic Research Consortium are the best way to study, test, validate, and roll out new technologies. I believe this model is the future. Functioning as a high-performing collaborative team, we can achieve so much more with such greater efficiency and efficacy. We now have enrolled more than 3000 consecutive fenestrated branched endovascular aortic repair patients, with this dataset growing every day, with real-time prospective data entry. This effort already represents the largest database in the world, by several orders of magnitude, ever assembled evaluating these technologies. We have already started to see some of the tangible benefits from this effort with multiple studies presented and published from this experience.4Aucoin V.J. Eagleton M.J. Farber M.A. Oderich G.S. Schanzer A. Timaran C.H. et al.Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium.J Vasc Surg. 2021; 73: 323-330Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 5Chamseddin K. Timaran C.H. Oderich G.S. Tenorio E.R. Farber M.A. Parodi F.E. et al.Comparison of upper extremity and transfemoral access for fenestrated-branched endovascular aortic repair.J Vasc Surg. 2022; Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 6Edman N.I. Schanzer A. Crawford A. Oderich G.S. Farber M.A. Schneider D.B. et al.Sex-related outcomes after fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms in the U.S. Fenestrated and Branched Aortic Research Consortium.J Vasc Surg. 2021; 74: 861-870Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 7Motta F. Oderich G.S. Tenorio E.R. Schanzer A. Timaran C.H. Schneider D. et al.Fenestrated-branched endovascular aortic repair is a safe and effective option for octogenarians in treating complex aortic aneurysm compared to non-octogenarians.J Vasc Surg. 2021; 74: 353-362.e1Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 8Parodi F.E. Schanzer A. Oderich G.S. Timaran C.H. Schneider D. Sweet M.P. et al.The development and potential implications of the US Fenestrated and Branched Aortic Research Consortium.Semin Vasc Surg. 2022; 35: 380-384Crossref PubMed Scopus (2) Google Scholar, 9Schanzer A. Beck A.W. Eagleton M. Farber M.A. Oderich G. Schneider D. et al.Results of fenestrated and branched endovascular aortic aneurysm repair after failed infrarenal endovascular aortic aneurysm repair.J Vasc Surg. 2020; 72: 849-858Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 10Tenorio E.R. Oderich G.S. Farber M.A. Schneider D.B. Timaran C.H. Schanzer A. et al.Outcomes of endovascular repair of chronic postdissection compared with degenerative thoracoabdominal aortic aneurysms using fenestrated-branched stent grafts.J Vasc Surg. 2020; 72: 822-836.e9Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 11Timaran C.H. Oderich G.S. Tenorio E.R. Farber M.A. Schneider D.B. Schanzer A. et al.Expanded use of preloaded branched and fenestrated endografts for endovascular repair of complex aortic aneurysms.Eur J Vasc Endovasc Surg. 2021; 61: 219-226Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 12Zettervall S.L. Tenorio E.R. Schanzer A. Oderich G.S. Timaran C.H. Schneider D.B. et al.Secondary interventions after fenestrated/branched aneurysm repairs are common and nondetrimental to long-term survival.J Vasc Surg. 2022; 75: 1530-1538.e4Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar These publications have focused on a diverse array of topics critically important to evolving these technologies. The second dot or theme I would like to discuss is innovation. As vascular surgeons, innovation is part of our DNA. This goes all the way back to the early days. Innovation is the foundation of our specialty and it is important to understand how the history of innovation in our specialty defines it and has kept vascular surgery at the forefront. We started in vascular surgery by using cautery to stop bleeding. “Sir, I’m just going to heat up this Iron rod in the fire and apply it to your site of bleeding, You’re going to feel a little pressure sir.” Then Ambrose Pare came along and lived between 1510 and 1590. He was the first to challenge cautery and use ligatures for bleeding arteries. John Hunter, who lived between 1728 and 1793, described collateral artery enlargement and was the first to propose Hunterian repair of aneurysms with popliteal artery aneurysm proximal ligation. This was followed by a number of theoretical breakthroughs that came in the 1800s with the knowledge that gangrene is due to obstruction of the arteries and that claudication was the result of a postmortem discovery of a thrombosed terminal aorta; detailed descriptions of intermittent claudication and cold ischemic extremities were put forward. In the 1800s, we understood peripheral artery disease, but there was no practical way to treat it because we still could not connect blood vessels. Alexis Carrel, who lived between 1873 and 1948, provided the next transformative contribution by pioneering the suturing of blood vessels using techniques like suture triangulation, a key innovation for which he was awarded the Nobel prize in 1912. From this point forward, innovation took off with the development of radiographs, an achievement for which Konrad Roentgen received the Nobel prize. Dr Brooks performed the first angiogram by injecting sodium iodide in 1923 and, for the first time, the femoropopliteal system was imaged. In 1929, Dr Santos performed the first translumbar aortogram. The next series of transformative innovations revolved around conduit. In the early twentieth century, various reports were published using vein to replace damaged arteries, culminating in 1948 with Kunlin’s description of the first vein bypass.13Kunlin J. [Long vein transplantation in treatment of ischemia caused by arteritis].Rev Chir. 1951; 70: 206-235PubMed Google Scholar In World War I, unsuccessful attempts were made to replace arteries with tubes of metal and glass, but paved the way for the 1940s, when arterial homografts began being used for aortic replacement. In the 1950s, we started the phase of prosthetic graft development with Vinyon-n artificial grafts described in 1952 by Dr Vooorhees14Blakemore A.H. Voorhees Jr., A.B. The use of tubes constructed from Vinyon N cloth in bridging arterial defects; experimental and clinical.Ann Surg. 1954; 140: 324-334Crossref PubMed Scopus (96) Google Scholar and Dacron grafts, first described by surgical giants Debakey, Cooley, and Crawford, in 1958.15De Bakey M.E. Cooley D.A. Crawford E.S. Morris Jr., G.C. Clinical application of a new flexible knitted Dacron arterial substitute.AMA Arch Surg. 1958; 77: 713-724Crossref PubMed Scopus (48) Google Scholar Aortic therapy had its own evolution in the early 1900s, with a host of different attempts to arrest aneurysm growth ranging from external clamp devices, fascial compression, wall irritants to induce scarring, rubber tube constriction, and probably the best known because this is the failed treatment that Albert Einstein had for his aneurysm: cellophane wrapping with the hopes of inducing scar to stop growth. So, by the late 1950s, we understood the concept: arterial occlusion causes ischemia. We had the necessary techniques: blood vessels can be sutured together. We could image blood vessels with angiography. And we had the necessary conduits to bring blood flow from point A to point B using vein, homograft, or synthetic.16Cohen J.R. Graver L.M. The ruptured abdominal aortic aneurysm of Albert Einstein.Surg Gynecol Obstet. 1990; 170: 455-458PubMed Google Scholar Look how far we have come from there. We can image arteries from outside the skin using noninvasive ultrasound examination. We can do this with wireless, portable probes that fit in our pockets and connect wirelessly, directly to our smart phones. We can also image the inside of arteries using intravascular ultrasound examination with amazing resolution. We can see the origin of branch arteries as they arise from truncal arteries. And these two vascular surgery pioneers, Dr Volodos and Dr Parodi, have completely transformed the way we think about aneurysm treatment.17Volodos N.L. Karpovich I.P. Troyan V.I. Kalashnikova Yu V. Shekhanin V.E. Ternyuk N.E. et al.Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction.Vasa Suppl. 1991; 33: 93-95PubMed Google Scholar,18Parodi J.C. Palmaz J.C. Barone H.D. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.Ann Vasc Surg. 1991; 5: 491-499Abstract Full Text PDF PubMed Scopus (2999) Google Scholar Changing the paradigm developed in the 1950s from open surgery, with direct exposure to the aorta, to endovascular repair using catheter and wire manipulation through needle holes. We have come so far, using three-dimensional fusion imaging to create three-dimensional maps that can be adjusted to match up with a patient’s position on the table (Fig 3), thereby enabling complex repairs that could not even be imagined 20 years ago. Repairs like this three-vessel retrograde arch repair that leverages new designs and device configurations to perform this repair with a single femoral artery access for deployment of all devices and all bridging branch stent grafts (Fig 4). No upper extremity access or supra-aortic cutdowns for delivery of devices.Fig 4Three-vessel retrograde arch repair leveraging new designs and device configurations to perform this repair with a single femoral artery access for deployment of all devices and all bridging branch stent grafts.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We are slowly starting to break our dependence on radiation. We are definitely not there yet, but there are new technologies on the horizon that will allow us to decrease the amount of radiation we are all exposed to while doing these procedures. Fiber Optic RealShape technology is one example of several.19Finnesgard E.J. Simons J.P. Marecki H. Ofori I. Kolbel T. Schurink G.W.H. et al.Fiber Optic RealShape technology in endovascular surgery.Semin Vasc Surg. 2021; 34: 241-246Crossref PubMed Scopus (4) Google Scholar This technology leverages fiberoptic cables embedded in wires and catheters to reconstruct, in real time with amazing precision, the three-dimensional position of a wire and catheter. With no radiograph use at all, we are able to track a wire and catheter in three-dimensional space in multiple projections, some of which could not be obtained with conventional x-ray equipment. Right now, we are using this routinely for the most radiation intense navigational steps of complex aortic repair. It works well for wire and catheter navigation steps (Fig 5). What is next? I will not answer that. But I will implore this group to keep asking that question. Keep pushing. Because I believe that innovation is part of our vascular surgery DNA. It is what makes us who we are and we need to double down on a commitment to innovate. Some of it will not work. But if we keep the patient at the center we will get better and better. There is a great book written by Walter Isaacson describing Jennifer Doudna’s discovery of CRISPR technology. In it, one of Dr Doudna’s collaborators is quoted to say, “At the end of the day, the discoveries are what endure. We are just passing on this planet for a short time. We do our job, and then we leave and others pick up the work.” So during our time, let’s do our job and make the world a better place, and continue to make vascular surgery the best job in the world. The third dot or theme I would like to discuss relates to our trainees. Just as innovation will define our future, so will our trainees. We are incredibly well-positioned and incredibly fortunate to be attracting the best students and residents to our specialty. Our match has become the second most competitive match of all specialties. This last year, there were 1.7 applicants for each of the positions available. And plastic surgery at number 1, watch out; we’re coming for you! Mentorship has been so critically important to my development professionally and personally. Lean into mentorship. We all have something to offer. I am frequently reminded how little it can take to inspire a student. And I believe we need to start earlier. One of our trainees, Emily Fan who is a PGY5 and presenting at this meeting, received grant funding to increase diversity in surgery. She will promote awareness of careers in vascular surgery for high school and college students in Worcester and host local students for summer immersion experiences with our division. The time horizon to see results for innovative programs like this is long but the payoff for such activities has the potential to be huge. For the students and trainees in the room, seek out mentorship. Bring enthusiasm and passion to the table. Thank you for the energy and promise you bring to our field. Enthusiasm and passion will take you much farther than you think. The fourth dot or theme I would like to discuss is diversity, equity, and inclusion (DEI). As we evolve, DEI is a key to that evolution. We need to look like the patients we serve. We need to have people with different perspectives and lived experiences to get new ideas that we did not even know we needed. The science is clear that teams that bring together different perspectives and experiences have greater productivity and innovation. In our current integrated vascular surgery residency program, 6 of 10 trainees are women and several are under-represented minorities in medicine. This is what the future of vascular surgery looks like. This is not what vascular surgery looked like to me when I was a trainee. Change is happening, never fast enough, but it is happening. We need to double down on DEI efforts. We need to embrace it. We need to be intentional. The recruitment of our trainees is intentional. This NESVS postgraduate course put together 2 years ago by our current Secretary, Dr Keith Ozaki, where every speaker was a woman, is intentional. Ensuring that every single session across the entire Society for Vascular Surgery Vascular Annual Meeting program, first session to last session, has at least one moderator who is a woman or an under-represented minority in medicine is intentional. And we are doing this for all NESVS programming as well. The makeup up the NESVS executive council is intentional. I have said it now a few times, but I will say it again: this is not what the NESVS leadership looked like to me when I first attended this meeting in 2005. This makeup brings with it a palpable energy and, as this year’s president, I have benefitted from and ridden this wave of energy. Having a vascular surgery faculty at UMass that is outstanding in every regard and is 60% women is intentional. We have made progress, but we clearly have so much farther to go. As providers, we need to build a work force that looks more like our patients so we can better care for our patients. This is not about committees and statements and tweets. It is about hiring, promoting, paying, and acknowledging the indisputable fact that diversity makes us better. If you are not bringing under-represented groups to the table, in whatever leadership capacity you have, you are the problem. We need to do this not for ourselves, but for our patients, our trainees, and our society. I would like to acknowledge Past President, Dr Marc Schermerhorn, who addressed our society on this very topic 2 years ago and, in doing so, delivered one of the best presidential addresses I have ever heard from any society.20Schermerhorn M.L. 2020 Rise to the challenge.J Vasc Surg. 2021; 74: 687-693Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar I will use his very own words: “Be an advocate for change...that time is now. We have another challenge ahead of us, and I truly believe we are up to the task.” We are up to the task; we have to be, and we will be. The fifth and final dot or theme I would like to discuss is our patients. Finally, and most important, why am I optimistic about our future as a specialty? Because of our amazing patients. They are the ones that make all this work worthwhile. They are the ones that inspire us to get up each morning, deal with the challenges that we all encounter every single day—electronic medical records, elearning, coding/billing, litigation, preauthorizations, meetings, and yes, I know the list goes on. Our patients are the magic. It is an incredible privilege to see patients better able to enjoy their lives, hopefully, because of the care we provide them. What is the cure for burnout? I do not know; it is different for everyone. For me, it is rounding on my patients once in the morning and once before I head home in the evening. That is what keeps me going. And I believe these rich long-term relationships with our patients, unique to vascular surgery, are what will keep us thriving as a field. I would like to close a bit more lighthearted and invite you into my office at work (Fig 6). Like most, I have a lot of knickknacks and memories. I will share one of the most important. Early in my career, I wrote a paper that got a lot of criticism. Since then, the message has been embraced; when it came out, however, it was rough with a lot of leaders in the field very upset with what it said. Some past presidents from this great society said, in no uncertain terms, your research is garbage. This is for the trainees and young faculty in the room who will undoubtedly face challenges throughout your careers. When you do, remember this and try to take yourself a little less seriously. I know that I need to do this often. This letter I was copied on to the editors of Circulation helps me to keep things in perspective. We all need to be reminded sometimes about what really matters most. Here is a letter that my niece, Shayla Goldberg, wrote when in fifth grade. She is now on her way to medical school and I would like to read it to you, “Please leave my Uncle Andy alone. He may not know a lot about arteries and veins, and his research may be terrible, but he is a great uncle! My Uncle Andy takes me camping, he buys me ice cream, he’s a great soccer player, and he even sat through my four-hour dance recital—two years in a row! Now say you’re sorry.” In summary, collaborate, innovate, mentor, champion DEI, and relish the opportunity to form deep connections with our amazing patients. And always, always, keep the patients at the center. If we do this, I believe the rest will take care of itself in amazing ways. Because this line I have showed you throughout this talk, is not about any one person or any one career. It certainly is not about mine. It’s about our field and advancing it by sticking to and leveraging these key anchor values that make vascular surgery so special (Fig 7). As I bring this address to a close, I would like to share one more quote from one of my favorite books that I have recently read, Multipliers, by Liz Wiseman. I ask these questions today to everyone in this room because we all lead in one way or another, “How do you want to be remembered as a leader? Someone with a big personality? or someone around whom other people grew?” If we all commit to grow the people around us, our field will continue to advance in incredible ways. I hope that taking a look at some of the dots I have experienced and observed that make me so optimistic help to make you optimistic. We can create a bold new future for vascular surgery: it’s go time. Thank you very much for the incredible honor to serve as your president. The society and our specialty are healthy and strong." @default.
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• W4321463962 title "Creating a bold new future for vascular surgery: It’s go time" @default.
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