From the Vascular Community

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SAAVS meeting a success

The Sixth Annual meeting of the South Asian American Vascular Society (SAVVS), an affiliate of the Society for Vascular Surgery, was held on May 31 during the Vascular Annual Meeting.

The Society was formed to provide a forum for scientific, clinical, cultural, charitable and social interaction among American physicians and healthcare providers of South Asian origin involved in the management of vascular disease. SAAVS also works as a forum to collaborate with Vascular Societies across South Asia .

Member benefits include being able to support vascular surgery in our countries of origin; sharing business knowledge and experience with members related to vendors, office practices, and opening centers for access/veins; mentoring of younger surgeons and medical students; assisting with new techniques and endovascular training; guiding job placement, contracts, and privileging issues; networking with friends and colleagues all over the world; taking a greater role in national societies; and taking advantage of the network for assistance in locating/obtaining training positions for family members.

The first annual meeting of the SAAVS was held in 2010. Past Presidents have included Drs. Krishna Jain, Bhagwan Satiani, Brajesh Lal, Anil Hingorani, Dipankar Mukherjee, and Ravi Veeraswamy. During VAM 2017, the current president, Faisal Aziz, MD, of Penn State gave his annual report and the society then inducted its future president Raghu Motaganahalli, MD, from Indiana University into office. Dr. Motaganahalli was also recently appointed as Director of the Division of Vascular Surgery at Indiana University. Peter Lawrence, MD, provided a keynote address highlighting opportunities for conducting research to improve patient care.

Other officers for 2017-2018 include President Elect Sachinder Hans, MD; Secretary Raj Sarkar, MD; Treasurer Krish Soundararajan, MD; Membership Committee: Kapil Gopal, MD, and Syed Alam, MD; Bylaws: Bhagwan Satiani, MD; Industry Relations: Krishna Jain, MD.

A regular feature of the meeting is an abstract/presentation contest for medical students and fellows interested in Vascular Surgery. First place winners from each category are offered cash prizes. In the future, SAAVS plans to have traveling fellowship programs for physicians from South Asia, as well as the United States, for collaborative clinical and educational exchange. Two members have already visited India and Pakistan for collaboration and assistance with endovascular procedures.

The website is www.saavsociety.org

Bhagwan Satiani, MD, The Ohio State University College of Medicine, Columbus.

Study established for “precision” surveillance for PAD

During the Vascular Annual Meeting (VAM) in San Diego, the Centers for Medicaid and Medicaid Services (CMS) announced its decision to reimburse supervised exercise therapy (SET) for beneficiaries with PAD. This decision was based on evidence which concluded that SET improves health outcomes for Medicare beneficiaries with intermittent claudication due to PAD. Up to this point physician-prescribed supervised exercise therapy was only covered exclusively for Cardiac Rehabilitation.

SET for PAD covers up to 36 sessions over a 12 week period if sessions 1) last 30-60 minutes; 2) are conducted in a hospital outpatient setting or physician’s office; and 3) are delivered by qualified auxiliary personnel to ensure benefits exceed harm and if 4) beneficiaries are under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques. Face-to-face visits with the physician responsible for PAD treatment is required for a SET referral. At this visit, the beneficiary must receive information regarding CV and PAD risk factor reduction, which could include education, counseling, behavior interventions and outcome assessments.

The widespread implementation of SET programs will require the adoption of a functional outcome assessment for PAD.

Here at the Division of Vascular Surgery at Stanford University, we are evaluating the use of a patient’s own smartphone to track and monitor walking activity. The research study called, VascTrac, was developed to provide a more “personalized” approach to surveillance for patients with intermittent claudication in line with precision medicine. We hypothesize that there is a direct correlation between a patient’s walking ability (functional status) and their disease burden.

Vascular surgeons today are finding themselves faced with an increasingly common problem: the “returning patient.” All too often, patients with peripheral artery disease are returning to clinic just months after treatment, frustrated by resurfacing symptoms. What was seemingly a straightforward femoral artery occlusion with an easy stent fix has somehow degraded into disabling claudication (Rutherford Class II/III) in a very short period of time. A staggering number of these patients have perfect-appearing completion angiograms, yet they return to clinic with complete re-occlusions. The tale of mild symptom return, typically beginning several months prior to the current visit, is becoming unsettlingly familiar. Inevitably, the story raises the question: “Why didn’t you come in sooner?”

This frustrating scenario calls for a new paradigm for surveillance of PAD – a more personalized approach in line with precision medicine.

Over the past decade, the prevalence of smartphones and other personal mobile devices has increased at a blistering pace. Today, over 700 million iPhones alone exist worldwide. These devices have an enormous potential to revolutionize the way we deliver care.

In 2014, Apple launched a secure personal mobile health repository called HealthKit, which now comes pre-loaded on every iPhone that is sold. This repository stores data ranging from step counts to blood glucose levels in a secure and structured way. As a bonus, every phone contains accelerometers which passively track a user’s daily activity. On the heels of HealthKit came the Apple ResearchKit framework, launched in 2015 as a means to standardize study enrollment, data collection, storage and transmission on the iPhone. The advent of this new study tool opened the door for remote patient monitoring and “siteless” clinical trials at scale.

These two new platforms have significant implications for health monitoring and diagnosis. While activity is the functional outcome that physicians aim to improve for disabling claudicants, the field currently lacks a means of objectively measuring patient activity and functional outcomes.

Traditional PAD monitoring focuses primarily on vessel patency and ankle brachial indices (ABIs) at 1-, 3-, 6- and 12-month intervals. The problem is that stents don’t fail at 1-, 3-, 6- and 12-month intervals, but ultrasounds and ABI’s require technicians and it’s challenging to perform those more often. There are too many gaps in knowledge, too many black holes, and a more granular approach is required. [NB: Seems to me just adding a 1 month reading would have solved the problem. The rest of the data points are perfect representations of the trend for which VascTrac provides no added benefit. The graph is not needed and would add even more “advertising flair.”

Using activity data as a surrogate for traditional measures of ABIs and vessel patency, we have designed algorithms to passively monitor patients’ daily activity using their personal smartphones. We have implemented these algorithms into an app and have now launched the VascTrac PAD Research Study.

VascTrac is an app available for download from the Apple App Store. Participants need an iPhone 5s (released in 2013) or a newer model. Enrollment, including consent, is all done on the phone. There are three short surveys focused on medical history, surgical history and PAD-specific history (including ABIs). Every two weeks, the app asks patients to perform a 6-minute walk test, and every quarter they are asked to complete the medical, surgical and PAD surveys. However, the majority of activity data is collected passively. Specifically, the app collects total steps per day, distance walked per day, and flights climbed per day and uses an algorithm developed by the team to gather data on a new unique metric, “Max Steps Without Stopping” (MSWS).

A motivated patient can walk 5 miles a day, but he or she may have to stop multiple times along the way. We believe MSWS will help catch the stopping due to the claudication. Patients are provided with a dashboard of their average activity for the week, month and year. They are also provided with links to PAD educational resources.

The VascTrac study is open to all, even non-PAD participants. The inclusion criteria are that a participant must be at least 18 years of age, live in the United States, speak English and have an iPhone 5s or newer model. The ideal patient, however, would be someone who is scheduled for an intervention. This way, the team can obtain a few weeks of baseline activity before evaluating the intervention’s effect on the patient’s functional activity.

Some of the questions our team hopes to answer are, What are the actual effects of our interventions (open vs. bypass) on a patient’s functional capacity? How stable are our interventions relative to a patient’s functional activity? What are the failure modes – is there a gradual decline in activity before failure or an abrupt decline? Can we predict failure of an intervention by doing a regression analysis of a patient’s functional activity trends?

We welcome the participation of any interested providers. More information can be found at www.vasctrac.stanford.edu, where providers can also request recruitment materials. Alternatively, the team can be contacted directly at contact@vasctrac.com.

This is an IRB-approved study and neither the researchers nor the university have any financial disclosures.

Oliver Aalami, MD, Stanford University School of Medicine/Palo Alto.

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