The 10 Things That They Don’t Teach You in Vascular Surgery Fellowship


  1. Unless you are going out and setting up shop on your own, which is very unlikely, you will be signing a contract. The contract shapes your work life and forms the foundation of your business model. Not understanding this will set you up for headaches. It is worthwhile not only to have a lawyer review it, but also a business savvy physician.
  2. Every medical community has a Jabba the Hut, who is obvious, but there is usually a hidden Sith Lord as well.
  3. People generally will behave in ways that reinforce their worldviews. Add to that the fact that most people stop picking up new ideas or techniques after training, and you have people who practice as much on belief over evidence. This becomes dangerous in hospital privileging committees which are often a tool for killing off young competitors before they pose a threat. The Torquemadas and vascular Taliban are out there, young one, waiting to pounce on your first complication with that new-fangled whatchamacallit.
  4. The easy way to grade the livability and economic level of a town or a burg is looking at what car dealerships are there. Similar metric –is there sushi made by an actual Japanese sushi chef?
  5. Technically, you may press the EMTALA based federal law that you only need to be on call every third day to get paid for any extra days of call.
  6. Veins and dialysis access are far more complex and common than what you may think working for the chairman at Humanity’s Best Hospital. So are limb salvage and wound care.
  7. You are only as good as your team. As nice as you are, patients will hate you if you have an uncaring office staff or hospital rounding crew. As good as you are, your results will be poor without excellent anesthesia, critical care, and floor nursing. Take good care of your partners.
  8. Be careful about high paying jobs in tiny hospitals with no other vascular surgeons. The reasons for this are legion, and frankly, no matter how good you are, you need to be aged like good steak, and that means partners who have been out for a while seasoning you. Also, being solo means it is impossible to find coverage for vacation, unless you put it in your contract that the hospital or employer will pay for locums coverage during your vacation or fly you back first class if you need to come back from vacation and then return you to vacation with offsets for extra days –I have seen all of this and it can happen as long as you negotiate it.
  9. Strive to get better, and that means keeping track of metrics like OR times, contrast volume, fluoroscopy time, blood loss, length of stay, and complications, for standard cases like: Elective Open AAA Repair, EVAR, carotid endarterectomy, infrageniculate bypass with vein. You should get better every year.
  10. Open surgical skills are going to be far more valuable than you think, and it’s not the anastomosis. If all you want to do is the anastomosis and you think you “did the case” if that is all you got to do, you have been fooled by the oldest staff trick in the book. The value is in figuring out first why an operation is chosen, how it is performed, and how it is healed, and having plans B, C, D, and E. Even when an endovascular approach is planned, you have to have in mind the open alternative.

Big Data


The NYT reports the increasing use of hospital EMRs and registries to help make clinical decisions based on experience not yet published. Of course we must use all the tools available within our databases which is an extension of our knowledge. But I also get the other side of the argument.

link to NYT article

Journal Club

Paper reading 101


The reading of papers can be just that -a passive run through received wisdom, or a critical exercise that can mean life or death when it comes to the medical literature. Dr. Mastracci last year did a wonderful thing by offering a few papers on how to judge the evidence. What the critical reader does is akin to what a pawn broker does when a purchase is considered. There are objective criteria, qualitative criteria, and the gut feeling of value. Do not discount the last, but apply the first because not all that shines is gold.

BMJ -how to read papers

Medscape link

OSU link

article cohort studies

cohort studies 2

stats article link


Order your el aneurismo shirts


Link Here

The graphic is a painting I did several years ago meant to be a market sign for a vascular surgeon in some faraway place. I get no proceeds from their sale, but if I do, they will be turned over to a vascular related charity or foundation.


SFA Stent Removal -Taking off those full metal jackets


When conduit is limited, or PTFE or cadaver vein is being considered, in the setting of occluded SFA stents, I have found that it is possible and perhaps preferable to attempt removal of these stents using remote endarterectomy.

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The CTA, particularly with 3D reconstruction, is helpful in planning these cases.

The additional material needed is fluoroscopy and endovascular skills. Directing a subintimal Glidewire helps free the stent and aid passage of the Moll ring dissector.

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Adding cold saline seems to help shrink the stents. A plaque free distal end point allow the stents to be removed with a gentle tug.

Completion distal end point
Stent removal
Specimen -4 occluded nitinol stents placed into TASC D lesion

I put these patients on coumadin anticoagulation. Surveillance is needed for recurrent stenoses -typically these occur randomly as focal TASC A stenoses, and likely represent remnant medial tissues that have caused intimal hyperplasia. This may be particularly amenable to treatment with drug eluting balloons. Failure as thrombosis typically is limited to the treated vessel without the embolism seen when PTFE grafts fail. Failure tends to occur in smokers. Inability to pass the dissector is usually seen in patients with heavy calcification -diabetics, renal failure, and I would avoid attempting remote endarterectomy in these patients. When the dissectors fail to pass, cutting down and directly endarterectomizing the vessel and resuming remote endarterectomy is feasible. The common femoral artery is repaired with a patch. I try to avoid having to place a distal stent and when a tapered end point, as in a successful carotid endarterectomy, is achieved, usually unnecessary.

Parts of this was presented at Midwest Vascular in 2008.


Top Ten Daily Gift Suggestions for Your Favorite Staff Surgeon


1. Beef Jerky, organic, traditional flavor

2. Tall Blonde Roast, two fingers of half and half

3. Honest, hard work

4. 12 inch Subway Club, with mozzarella, toasted, lettuce, tomato, olives, onions, sweet onion relish, and Sriracha, liter of water

5. Hygiene and grooming

6. An updated list with good news

7. Articulate, thoughtful, organized speech

8. Coordination

9. Good Halloween candy

10. Dark chocolate from DGC office


A case report in the quarterly Cardiac Consult of a difficult EVAR


Here is a link to the current issue of Cardiac Consult where I have a case report of a difficult EVAR. In it also is a feature on our vice chair, Dr. Timur Sarac, and his bioabsorbable stent, and Dr. Eric Roselli of the Cardiovascular Surgery on stent grafting of ascending thoracic aortic dissections, for which he received special recognition at todays State of the Clinic address by Dr. Cosgrove.