2022 Fall Newsletter
President’s Message
Hello everyone,
I am honored to serve as the President of the Florida Vascular Society. The Society provides a wonderful opportunity for vascular surgeons to connect, bond, and learn with fellow like-minded and trained individuals. To me, this organizations is one of the best, and I am so thankful to steer FVS for the next year.
Another incredible Scientific Sessions was held this past April under the excellent guided leadership of our immediate past president, Thomas Huber, MD, FACS. The Executive Council and our management team are committed to the mission of the Society, and I am very fortunate to be the president at a time in which growth and education are at the forefront. We are in the planning stages of the 36th Annual Scientific Session which will be held April 27-30, 2023, at the beautiful Four Seasons Hotel in Orlando. Registration is open, so be sure to register here. You will not want to miss our visiting professors, Dawn M. Coleman, MD, FACS, C. Keith Ozaki, MD, and Sherene Shalhub, MD, MPH, the FVF golf tournament, or the splash bash. The conference will have rigorous Scientific Sessions with our visiting professors, a student, resident, fellow forum, and a social program designed to advance the mission of
the society and promote the camaraderie of the membership. The abstract window recently closed, and we had over 30 submissions! I hope you plan to attend the conference and celebrate the cutting-edge science our members and peers are producing.
We are also planning several regional outreach meetings
to engage membership and identify new members in various regions throughout the state. Those programs and dates will be announced soon as they are finalized.
We added 23 new members to the organization during the 2021-2022 year. Thank you to everyone who helped. This year, my goal is to add at least another 20 dues paying members to the organization. Please be sure to recruit your partners and colleagues to join our growing organization. Please reach out to me or any of the Executive Council with any concerns or opportunities regarding the Society. We are committed to the Florida Vascular Society being one of the best societies and I thank you for your continued support.
2023 Scientific Sessions Visiting Professors
Dr. Dawn M. Coleman is a Professor of Surgery, who recently transitioned from her post as Program Director of the Vascular Surgery training programs at the University of Michigan to Division Chief of Vascular Surgery at Duke University. She graduated with honors from the University of Cincinnati in 1999 and earned her medical degree from the University of Cincinnati’s College of Medicine in 2003. She completed her general surgery residency at the University of Mich-igan in 2010 and then went on to complete a two-year vascular surgery fellow-ship at the same institution in 2012. She is the current President-Elect for the Association of Program Directors in Vascular Surgery, co-leading the VASCU-LAR arm the SECOND trial. She also serves as a Lieutenant Colonel in the Army Reserve assigned to a Forward Resuscitative Surgical Team, having deployed on three occasions to support forward operations in the Middle East.
Dr. C. Keith Ozaki serves as the John A. Mannick Chair of Surgery and the Executive Vice-Chair for the Department of Surgery, Brigham and Women’s Hospital, and as a Professor of Surgery at Harvard Medical School. Dr. Ozaki earned his undergraduate and medical degrees from Duke University, trained at the Deaconess/Harvard Surgical Service, and went on to complete a fellowship in vascular surgery at the University of Michigan. At the University of Florida
(1997-2008), he served as Professor and Chief of the North Florida/South Geor-gia Veterans Health System. Dr. Ozaki, an academic surgeon, performs approx-imately 350 vascular cases annually, including open operations for visceral and lower extremity arterial occlusive disease, and complex hemodialysis access. He co-edited a two-volume comprehensive vascular surgery textbook/atlas Master Techniques in Surgery: Vascular Surgery.
Dr. Sherene Shalhub has been recently transitioned from the University of Washington and is now the division head of vascular surgery at the Oregon Health and Science University. Since joining UW Medicine in 2013, she has received a PRAISE Award and was named a rising star by the Institute of Trans-lational Health Sciences. Dr. Shalhub provides personalized care to patients suffering from rare vascular conditions. She believes in creating active part-nerships with her patients to achieve the best possible outcomes. Dr. Shalhub is also a member of the Multidisciplinary Thoracic Aortic Program “MTAP” to support patients with complex thoracic aortic conditions as a Vascular Surgeon. Dr. Shalhub earned her M.D. and M.P.H. at the University of South Florida. Her clinical interests include treating aortic and peripheral arterial aneurysms and dissections in patients with genetically triggered vascular diseases
Foundation Report
President, Florida Vascular Foundation
The 35th Annual Meeting of the Florida Vascular Society this past April was fantastic – it was great to see so many of you after a long and stressful two years. The Florida Vascular Foundation (FVF) provides scholarships to ease the burden of attending the scientific sessions to all trainees in vascular surgery. The Foundation supported six medical students and five surgical residents to attend the 2022 meeting, and we are looking forward to seeing them expand their interests in vascular surgery. I am also pleased to announce the following competitive abstract award winners for the 2022 meeting: (1) The Jose “Pepe” Alvarez, Jr., MD Resident Award, for the best overall presentation for clinical or experimental work performed by residents of fellows in training, was awarded to Morgan Cox, MD of Gainesville. (2) The Dr. JJ Karmacharya Award, for the best presentation in aortic aneurysmal disease reconstruction and treatments, was awarded to Antione Ribieras, MD, of Miami. (3) The Mark L. Friedell, MD Award, for the best medical student presentation, was awarded to Coulter Small, MS3, of Gainesville. Congratulations to these impressive individuals! The foundation looks forward to presenting these awards again at the 2023 meeting. The abstract window has recently closed, and the judging will begin soon.
The Foundation provides a mechanism to promote excellence in the treatment of vascular diseases through educational programs directed at physicians, physician assistants, nurses, and vascular technologists involved in the care of patients with these disorders. The Foundation provides scholarship support to medical students and residents who desire to pursue careers as vascular specialists. Since the inception of the FVF,
the members of the Florida Vascular Society (FVS), along with our industry partners have donated over $300,000 to the Foundation. Now, more than ever, the foundational support provided by you is essential to ensure that future patients will have access to care by highly qualified vascular professionals. I would like to personally thank those who donated to our effort in 2022, amounting to over $14,000:
• Juan Pereda, MD, FACS
• Lyle Breeding, MD, FACS
• James Dennis, MD, FACS
• Paul Citrin, MD, FACS
• Russell Samson, MD, FACS, DFSVS, RVT
• Jon Wesley, MD, FACS
• Grady Morrell
• Scott Tapper, MD, FACS, RPVI
• Libby Watch, MD, FACS
• Arthur Palamara, MD, FACS
• Vincent Rowe, MD
• Ignacio Rua, MD, FACS • Murray Shames, MD, FACS
• Jack Zeltzer, MD, FACS
• John Rechtenwald, MD
• Deepak Nair, MD, FACS, MS, MHA, RVT
• Paul Armstrong, DO, FACS
• Xavier Cannella, MD, FACS
• Thomas Huber, MD, PhD, FACS
• Robert Feezor, MD, FACS
• Charles Thompson, MD, FACS
• Jim and Cathy Seiler
I look forward to seeing all of you at the Four Seasons in Orlando, April 27-30, 2023. The Foundation looks forward to hosting another golf tournament to raise funds for our efforts, and much more. Coming to the meeting not only supports the mission of the Florida Vascular Society, but also gives lifeblood to its very important foundation. By contributing to the Florida Vascular Foundation, you can help reach these lofty goals that are so critical to the health and well-being of our fellow Floridians. Please join us in our efforts by contributing to this most worthy cause.
2022 Scientific Sessions Abstract Winners
The Impact of Clostridium difficile Infection in Contemporary Vascular Surgery
Salvatore Scali, MD, Jesse Columbo, MD, MS, Thomas Huber, MD, PhD, Dan Neal, M.S., David Stone, M.D.
Morgan Cox, MD, Gainesville, FL, winner of the Jose “Pepe” Alvarez, Jr., MD Resident Award
Funding: None.
Synopsis: The eradication and prevention of Clostridium difficile (CDiff) infection has been identified as an urgent problem by the CDC. Accordingly, institutional infection rates have become proxies for healthcare quality, and efforts to limit organizational CDiff have emerged as a healthcare system priority. However, the sequelae of CDiff infection after contemporary vascular surgery remains undefined. The purpose of this analysis was to quantify the impact of CDiff infection among patients undergoing major vascular operations in the United States.
Methods: All patients (n=38,378) undergoing open AAA repair (OAAA; n= 5,504), suprainguinal bypass (SUPRA; n=8,489), and infrainguinal bypass (INFRA; n=24,385) in the VIZIENT Clinical Database Resource Manager (CDB/RM) were queried between 2015-2019. The primary exposure was postoperative CDiff infection. The primary outcomes were postoperative length of stay (LOS), total hospitalization cost, and in-hospital mortality. Mixed-effects linear and logistic regression models were used for risk-adjustment.
Results: The incidence of CDiff infection for the entire cohort was 1.2% (n= 452; OAAA: 1.6%, n=86, 1.4
cases/1000 patient days; SUPRA: 1.8%, n= 149, 1.6 cases/1000 patient days; INFRA: n=217, 0.9%, 0.9 cases/1000 patient days). Compared to non-CDiff patients, those with CDiff were significantly older, more likely to have
a non-elective presentation, and have multiple cardiovascular and GI-related (e.g., peptic ulcer and/or liver disease) comorbidities. The risk-adjusted median LOS was 50-71% higher among patients with CDiff (OAAA: 50% higher; 12 [IQR: 11-14] vs. 8 [6,12] days, p<.0001; SUPRA: 71% higher; 12 [11-14] vs. 7 [5,12] days, p<.0001; INFRA: 70% higher; 8.5 [8-9] vs. 5 [3,8] days, p<.0001). Similarly, CDiff infection was associated with a 38-56% increase in the median cost of the index hospitalization (OAAA: 38% increase; $50,000, [IQR: $45,000-$56,000] vs. $37,000, [$25,000-$63,000], p<.0001; SUPRA: 43% increase; $50,000, [$46,000-$54,000] vs. $35,000,
[$23,000-$58,000], p<.0001; INFRA: 56% increase; $39,000 [$36,000-$42,000] vs. $25,000 [$16,000-
$42,000], p<.0001) (Figure). CDiff was associated with increased mortality after INFRA (OR 2.7, [95%CI 1.7-4.5]; p<.0001), but not after OAAA or SUPRA.
Conclusion: Postoperative CDiff infection after major vascular surgery was associated with more than a 50% increase in both median LOS and total cost. These findings were consistent across procedure types. Accordingly, hospital-led efforts to mitigate the impact of CDiff infection is a justifiable priority given the significant impact on healthcare resource utilization. This data may serve to inform stakeholders seeking to decrease hospital LOS and cost.
2022 Scientific Sessions Abstract Winners
Effect of Weight Status on Outcomes following Endovascular Abdominal Aortic Aneurysm Repair
Arash Bornak, MD
Antoine Ribieras, MD, Miami, FL, winner of the Dr. JJ Karmarcharya Award
Funding: None.
Synopsis: An obesity paradox exists across several surgical fields, where patients with overweight or mild obesity often fare better than normal weight patients. In vascular surgery, both under- and overnutrition as measured by body mass index (BMI) are associated with worse outcomes. However, the influence of BMI on endovascular aortic aneurysm repair (EVAR) outcomes are not well-known. Our aim was to compare the presentation, management, and outcomes for patients of various weight statuses undergoing EVAR.
Methods: We queried the 2016-2019 National Surgical Quality Improvement Program database for patients undergoing EVAR and for whom complete vascular procedure-targeted data was available. We then categorized patients by BMI weight status (underweight: <18.5, normal weight: 18.5-24.9, overweight: 25-29.9, Obese I: 30-34.9, Obese II: 35-39.9, Obese III: >40) and compared preoperative characteristics and anatomic and technical parameters of aneurysm repair across weight classes. Primary outcome was 30-day mortality. Secondary outcomes were total hospital length of stay, 30-day readmission rate, and 30-day incidences of various postoperative complications. Chi-square and nonparametric Kruskal-Wallis tests were used for categorical and continuous variables, respectively, with Bonferroni corrections applied for multiple comparisons.
Results: We identified 7304 EVAR cases, of whom 5.0% were underweight, 24.3% normal weight, 37.4% overweight, and 21.7% with class I obesity, 8.1% class II obesity, and 3.5% class III obesity. The proportion of female patients was highest in underweight (30.4%) and morbidly obese (28.1%) categories. Patients with obesity were significantly younger than under- and normal weight patients. The incidence of hypertension, diabetes, and dyspnea increased with obesity class. Underweight patients presented with significantly larger (6.0 [5.3-7.5] cm) and more frequently ruptured (33.3%) aneurysms compared to normal weight patients (5.5 [5.1-6.2] cm and 6.1%, respectively) (p<.001). Consistently, underweight patients required more postoperative transfusion (27.4%) and longer intensive care unit length of stay (1 [0-2] day) compared to normal weight patients (13.6% and 0 [0-1] days, respectively) (p<.001). Thirty-day mortality was significantly worse in underweight patients (13.6%) compared to all other weight classes (3.5% for normal weight class) (p<.001). While morbid obesity was associated with prolonged operative time, surgical site infection, and pneumonia, patients who were overweight or with class I obesity status fared similarly than normal weight patients with regards to incidence of stroke and renal failure, and significantly better in terms of myocardial infarction, postoperative transfusion requirement, and total hospital length of stay.
Conclusion: In this study of BMI influence on outcomes following EVAR, underweight patients presented more frequently with ruptured aneurysms and subsequently suffered additional morbidity and mortality compared with normal weight patients, suggesting that higher vigilance and earlier repair may be required in this population. Additionally, overweight and mild obesity status conferred protection against certain outcomes following EVAR, confirming prior reports of an obesity paradox in aortic vascular surgery.
2022 Scientific Sessions Abstract Winners
Comparison of Operative Characteristics and Outcomes after Infected Endovascular and Open-Surgical Abdominal Aortic Graft Excision
Scott Berceli, MD, PhD, Michol Cooper, MD, PhD, Martin Back, MD, MS, Gilbert Upchurch, MD, Thomas Huber, MD, PhD, Salvatore Scali, MD, Samir Shah, MD, MPH
Coulter Small, MS3, Gainesville, FL, winner of the Mark L. Friedell, MD Award
Funding: None.
Synopsis: National rates of open aortic repair (OAR) are declining due to endovascular procedures (EVAR); however, both strategies can present with aortic graft infection (AGI). AGI is a devastating complication associated with significant morbidity and mortality but technical elements of infected EVAR management can further complicate surgical extirpation. To date, no studies compare infected EVAR to OAR graft removal. Therefore, we sought to analyze our experience with AGI and assess differences in patient characteristics, operative strategies, and short-term outcomes between infected EVAR and OAR graft excision.
Methods: A single-center, retrospective review of all AGI procedures was performed (2004-2020). EVAR and OAR infected graft removal operations were subsequently compared. The primary endpoint was 30-day mortality. Secondary endpoints included complications, re-infection, aorta-related death, and survival.
Results: A total of 142 AGI explants were examined: infected EVAR-27% (n=38), OAR-73% (n=104). Demographics and comorbidities were similar between groups, but tobacco exposure (p=.032) and peripheral artery disease (p<.001) were more prevalent among OAR patients. Gram-negative infection was significantly more common with infected EVAR (50% vs. OAR-22%; p=.002). Infected EVAR removal was more likely to employ an aorto-biiliac reconstruction configuration (EVAR-68% vs. OAR-9%; p<.001). There was no difference in the frequency of single vs. multi-stage or in-situ vs. extra-anatomic repair strategies. In contrast, conduit selection was significantly different with rifampin-soaked Dacron being used most frequently with infected EVAR (42% vs. OAR-13%; p<.001) while autogenous/non-autogenous biologic allograft use was more common with infected OAR (68% vs. EVAR-31%; p<.001). No other differences in operative details were present. The overall 30-day mortality rate was 20% and was not different between cohorts (EVAR-21% vs. OAR-20%; p=1). Similarly, there were no differences in overall complication incidence, but infected EVAR patients had a higher rate of gastrointestinal complications (34% vs. OAR-17%; p=.040). Freedom from major adverse limb events was lower after infected EVAR management (1-year: 85±7% vs. EVAR-63±6%; log-rank p-value=.06). Life-long suppressive antibiotic therapy was prescribed more commonly after infected EVAR operations (24% vs. 10%; p=.048). However, one-year freedom from re-infection was similar (OAR 76±6% vs. 88±6%; log-rank p=.6). Correspondingly, there were no differences in aorta-related death or survival.
Conclusion: Infected EVAR is now a common cause of AGI and is associated with more virulent microbiology and increased postoperative gastrointestinal morbidity compared to infected OAR graft excision. Despite significant differences the in technical conduct of the operations, similar short-term outcomes can be anticipated for both infected EVAR and OAR graft removal operations. Differential use of suppressive life-long antimicrobial prophylaxis and incidence of adverse limb events in follow-up support utilization of different surveillance strategies.
Membership Report
Chair, Membership
The Membership Committee has met to discuss initiatives to increase membership
and expand upon member categories.
We are looking forward to our annual meeting. In 2022, we added 22 new members and we are eager to add more for 2023. In an effort to drive membership goals, we have been pushing the FVS Membership Challenge. The member who recruits the most applicants/members will have a waived registration fee for this year’s annual meeting.
We currently have 132 members within FVS with paid dues. We have members with unpaid dues for which we will continue outreach. Membership can now pay dues through the website. Non-members can now join through the website directly, at https://fvs.org/apply/. In addition, we recently added autopay as an option for dues payments to simplify it for our members. Fellows, residents, and medical students have no membership/application fees.
As a goal for continued growth in FVS we have developed
a tool for outreach and have assigned regions to each committee member based on their current practice location. Through this, we are asking our local industry partners to help recruit regional Vascular Surgeons. This list will be used to track current members as well as to help recruit new members. Further outreach will FMA, ACS, and other lists of Vascular Surgeons. This will be an ongoing initiative.
Please welcome FVS’s newest members:
Kyle Diamond, MD
Estela Abich, MD
K. Dean Arnaoutakis, MD Turan Badali, PA-C
Dariam Cardentey-Oliva, MD Michol Cooper, MD
Jeffrey Edwards, MD, RPVI Sherali Gowani, MD, FACC Edgar Guzman, MD
Kevin Treto, MD
Benjamin Jacobs, MD
Mark Lytle, MD
Issa Mirmehdi, MD, RPVI Matthew Sanders, MD, RPVI Salvatore Scali, MD
Jai Shahani, medical student Tony Shao, MD
Benjamin Szpila, MD
Chun Yang, MD
Rare Case Presentation
The patient is a middle-aged man who presented with a thoracoabdominal gunshot wound. He was explored by trauma surgery and was found to have multiple abdominal injuries; including stomach, pancreas, kidney, spleen. The patient was eventually diagnosed with a pseudoaneurysm of aorta at the level of the celiac and superior mesenteric arteries. He underwent an urgent repair of the aortic injury. The approach was retroperitoneal. The injured aorta was replaced with an interposition bypass graft and the celiac and superior mesenteric arteries were re-implanted.
This case is rare because many patients do not survive the initial injury. Most do not live long enough to be operated on, so the procedure is rarely performed.
Thank you to Tony Shao, MD, for submitting!
Committee Volunteer Opportunities
The Florida Vascular Society was established to promote the science and art of the diagnosis and management of vascular disease and encourge research and education in the field. We are looking for volunteers to join the following FVS committees to meet our goals:
Advocacy Committee: The FVS Advocacy Committee works to make sure our voices are heard in Florida Legislature through collaboration on surgical advocacy days programming, at the Florida Medical Association House of Delegates, the Florida Board of Medicine, and First Coast Service Options – Florida’s current Medicare Administrative Contract. By joining this committee, you can ensure the voice of FVS is heard in the state.
Communications Committee: The FVS Communications Committee leads the outreach efforts to our membership and beyond through social media, our website, and a newly-developed and member-exclusive electronic newsletter. Volunteer today to help FVS promote the awareness, collaboration, and opportunities to engage in Florida’s vascular community.
Membership Committee: The FVS Membership Committee seeks to identify who we are to the Florida medical community, increase membership and awareness of the FVS in Florida, and develop value for the membership through tangible and intangible membership benefits.
Email membership@fvs.org to volunteer for one of these important and engaging FVS committees. Get involved today!