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  • Distal microembolization occurs spontaneously in acute coronary syndromes. When the fibrous cap of a vulnerable plaque ruptures a portion of the large lipid core is released as atheroemboli. The remaining plaque core contains tissue factor, which is highly thrombogenic, leading to thrombus formation overlying the lesion. Platelets and thrombus may also embolize. This process is likely to be ongoing, whereby a plaque ruptures and then heals and ruptures again, leading to a progression of CAD and unstable angina, or if the emboli are occlusive – acute MI.

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  • Vascular Disease and the Hispanic Population: Major disparity in the US Heron E. Rodriguez MD
  • Hispanics in the US Population 15%
  • Hispanics in the US Population 15% 30%
    • Diabetes
    • Renal failure
    • Risk of death from prostate cancer and liver disease.
    Health Disparities among Hispanics
  • 1) Carotid artery / Stroke 2) Abdominal Aortic Aneurysm 3) Lower Extremity Occlusive Disease
  • Carotid Artery Disease
    • 795,000 strokes each year in the US
      • One stroke every 40 seconds
      • 3rd leading cause of death
    • Leading cause of disability
      • over 3 million survivors - many disabled
    • Cost of Stroke: $68.9 billion
      • Lifetime cost $140,048
  • Embolization Ruptured Fibrous Cap Athero- and Thromboemboli Large Lipid Core Stroke or CVA Carotid Artery Disease
  • Carotid Artery Disease
  •  
    • Smoking cessation
    • Antiplatelet Therapy
      • Aspirin
      • Clopidogrel (Plavix)
    • Blood Pressure Control
    • Statins
    Carotid Artery Disease: Prevention
  • Carotid Endarterectomy
  • Carotid Endarterectomy
  • CAS
  • Carotid Artery Disease Devastating consequences Preventable Easily detected Treated by very effective interventions
  • Carotid Artery Disease Morrissey et al JVS 2007 2000 2001 2002 2003 2004 White Hispanic More frequently presented with symptomatic disease Higher perioperative stroke rate
  • Carotid Artery Disease
    • Hispanics present at more advanced stages
    • Underutilize carotid revascularization
    • Have worse perioperative outcomes
  • Abdominal Aortic Aneurysm Affects 5% white elderly males If untreated, 90% mortality
  • Abdominal Aortic Aneurysm 2007 SAAAVE Act: allows for US screening in elderly smokers and family history
  • Abdominal Aortic Aneurysm 2007 SAAAVE Act: allows for US screening in elderly smokers and family history
  • Abdominal Aortic Aneurysm 2007 SAAAVE Act: allows for US screening in elderly smokers and family history
  • Abdominal Aortic Aneurysm
  • Abdominal Aortic Aneurysm Devastating, fatal consequences Easily detected Treated by very effective interventions
  • Abdominal Aortic Aneurysm Prevalence in Hispanics is unknown 2000 2001 2002 2003 2004 White Hispanic More frequently presented with rupture Almost double the perioperative mortality rate Morrissey et al JVS 2007
  • Weighted national estimates from HCUP Nationwide Inpatient Sample (NIS), Agency for Healthcare Research and Quality (AHRQ), based on data collected by individual States and provided to AHRQ by the States.
  • Abdominal Aortic Aneurysm Vogel et al. Vascular and Endovascular Surgery 2009 6227 patients hospitalized in new Jersey from 2001-2006 for AAA treatment.
  • Abdominal Aortic Aneurysm Vogel et al. Vascular and Endovascular Surgery 2009 6227 patients hospitalized in new Jersey from 2001-2006 for AAA treatment. EVAR 256 cases in 2001 (24%) 775 cases in 2006 (73%)
  • Abdominal Aortic Aneurysm Vogel et al, Vascular and Endovascular Surgery 2009
  • Abdominal Aortic Aneurysm
    • Prevalence in Hispanics is not known
    • Present more frequently with rupture
    • Underutilize open and endovascular repair
    • Have worse perioperative outcomes
  • Lower Extremity Occlusive Disease
  • Lower Extremity Occlusive Disease
  • Morrissey et al JVS 2007 Lower Extremity Occlusive Disease
  • Morrissey et al JVS 2007 Lower Extremity Occlusive Disease
  • Robinson et al JVS 2009 Lower Extremity Occlusive Disease
  • Lower Extremity Occlusive Disease Rowe et al, Vascular and Endovascular Surgery 2007
  • Lower Extremity Occlusive Disease Rowe et al, Vascular and Endovascular Surgery 2007
  • Vascular Diseases in Hispanics
    • Increased prevalence
    • Presents at more advanced stages
    • Patients have worse outcomes
    Why? Different genetic makeup? Increased frequency of risk factors?
    • 28128 patients undergoing bypass surgery in CA
    • Follow-up 61.5 months
    Vascular Diseases in Hispanics
    • Higher prevalence of gangrene at initial surgery
      • 36.7% vs 19.3% in whites
    • Higher comorbidity index
      • 22.1% vs 14.8% in whites
    • Limb salvage rate at 3 yrs
      • 75% vs 90% in whites
    Vascular Diseases in Hispanics
  • Lower Extremity Occlusive Disease Feinglass et al JVS 2010
  • Vascular Surgery Disparity
    • Controlling for age and baseline factors (gangrene, comorbidities)
    • BETTER PERIOPERATIVE AND ESSENTIALLY IDENTICAL AMPUTATION FREE SURVIVAL OUTCOMES
  • Vascular Surgery Disparity
    • Different genetic makeup
    • A strong reason for the observed disparity is the fact that Hispanic patients present at later stages with worse comorbidities
  • Risk Factors
    • Diabetes
    • Renal Failure
    • HTN
    • ETOH use
    • Smoking
    • Hyper-lipidemia
    • Obesity
  • Vascular Surgery Disparity
    • Access to care
    • Health literacy
    • Cultural isolation
    • Language issues
  • Vascular Surgery Disparity
    • Access to care
    • Health literacy
    • Cultural isolation
    • Language issues
    • Shortage of Vascular Surgeons
    • Shortage of Hispanic Vascular Surgeons
  • Vascular Surgery Disparity
    • Overall, there is a lack of Vascular Surgeons
      • 2610 Vascular Surgeons
      • 1 per 121,600 people
  • Practicing physicians in the US
  • Hispanic physicians in the US
  • Hispanic physicians in the US Only 3% of SVS members
  • Hispanic trainees in the US
  • KANE et al JVS 2009
  • Conclusions
    • Significant disparities affect the Hispanic population of the US regarding vascular disease
    • The causes are multifactorial
    • Access to care and other consequences of poverty appears to be a major determinant
  • Conclusions
    • Urgent need to increase resources
      • The study of disparity
      • Recruitment of individuals of Hispanic origin into medical schools, surgical programs and Vascular surgery training
      • Recruitment of practicioners of Hispanic origin
  •  
  •  
  • Training Opportunities
    • ACGME approved new training paradigms that lead to certification.
      • 5+2: Currently, most fellowships consist of two years of vascular training after completing an ACGME-approved GS residency (two Boards).
      • 4+2: Also available is the fast track, which is a total of six years (two Boards).
      • 0+5: Integrated program of which 3 years are devoted to vascular surgery and 2 years to core surgical training (one Board in VS).
      • 3+3: Consists of 3 years vascular surgery training following 3 initial years of preliminary general surgery training in the same institution (one Board in VS).
  • Student Networking Section
    • Join the SVS Student Networking Section to receive direct access to valuable career resources, as well as network with similarly interested students.
    • Benefits include items such as various SVS e-communications and e-newsletters, access to the online edition of Vascular Specialist and monthly podcasts on vascular surgery topics.
  • Podcasts on iTunes
    • The Educational Topics on Vascular Surgery for Medical Students and Residents Podcasts address a broad scope of vascular surgery topics, as well as career opportunities.
    • New podcasts are posted monthly on iTunes. Subscribe through iTunes (Medical Podcasts) or VascularWeb.org.
    • Student and resident e-newsletter, On the Cutting Edge, reports on new training programs, research and award opportunities, and breaking vascular research.
    • Sign-up by sending email to studentresident@vascularsociety.org
    Student and Resident E-newsletter
  • Find A Mentor
    • Search the online SVS Mentor Match-up for a mentor. SVS members are happy to discuss your career and serve as a mentor.
    • You can search for mentors based on location and gender at www.VascularWeb.org.
  • 2010 Vascular Annual Meeting
    • Attend the 2010 Vascular Annual Meeting, June 10-14 in Boston to learn more about a career in vascular surgery. There is no registration fee for students.
    • Ask a SVS member at your institution to nominate you for a student travel scholarship. Nomination forms are online at VascularWeb.org.
    • www.VascularWeb.org provides information for students on training programs, vascular surgery images and information for papers, and breaking vascular research.
    Additional Online Resources
  • Need More Information? Society for Vascular Surgery 633 N. St. Clair, 24 th Floor Chicago, IL 60611 Phone: 800-258-7188 or 312-334-2300 Fax: 312-334-232- Email: studentresident@vascularsociety.org www.VascularWeb.org [email_address]
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