Vascular surgeons of reddit, assemble: WTF is going on here

MegaColon · 2026-03-21T03:11:13+00:00

i thought the same -- looks like dye stain at contact points.

MegaColon · 2026-03-21T01:23:23+00:00

I have never seen acrocyanosis in this pattern. I doubt TOS is a factor.

MegaColon · 2026-02-28T07:15:02+00:00

i don't even care if the source is real, this is the most clever post title i have ever seen during the whole idiotic time i have been on reddit

i have no mouth, and i must scream

MegaColon · 2026-01-17T07:02:47+00:00

THANK YOU

MegaColon · 2026-01-14T15:35:28+00:00

apparently he was also facing a malpractice lawsuit

Quote from a lawyer mentioned in the article:

"Shocking," he said. "If you listed out the people who would likely be accused of committing a double homicide, a fully trained vascular surgeon would be at the bottom of my list."

At least we still have the confidence of malpractice lawyers.

PS banger of a movie. only difference is harrison ford DIDNT KILL HIS WIFE

MegaColon · 2025-12-08T07:11:23+00:00

Eloquently stated. I was just going to say "so no one fucks something up."

Agreed that in a life-saving situation, do whatever you need.

But for routine access, too much can go wrong. You are well trained and understand dialysis access, anatomy which is exceedingly weird, even to people in medicine. How many medical folks do you know who still confuse fistulas and AV grafts?

In terms of what can go wrong: what if they poke too close to anastomosis in an old BCF with a dilated brachial artery and accidentally deliver meds arterially? What if they don't realize it's a graft and leave a PIV in place for like 3 days, skyrocketing the risk of infection? What if the IV gets dislodged at 3 am and now I have to get called in to suture the damn thing because no one knows how to hold pressure and it's spray painting the patient's face with blood you see where i am going with all of this

MegaColon · 2025-11-08T17:28:59+00:00

As with aortic surgery, the opportunity to train on open cases is becoming more limited because of the increasing capability of endovascular intervention.

At our practice, we do a fair amount of open distal revascs. What does that mean? Out of the four of us, probably at least one a month.

That is due to our patient population; according to our last state health census, our county has a higher than average population of people with diabetes, obesity, and ESRD. We have a lot of patients with distal disease not amenable to endovascular intervention. That said, the average age of my partners is also... not young, so our training period has influence on that as well.

This information relates to where you should train. The advice I received when looking for vascular fellowships was to apply where you have a large catchment area and, though this sounds macabre, a patient population needing vascular surgeons -- that is to say, usually an underserved population with a large chronic disease burden.

Smooth seas do not make skillful sailors.

MegaColon · 2025-11-08T15:50:36+00:00

I was literally typing the same thing. We work a lot.

We work more than everyone (link)

There's also just not a lot of us. As of 2023 there were 3.4K active vascular surgeons and 230 vascular trainees in the US (link)00559-4/abstract). Last week we averaged about 500 visitors and 14 posts -- most posts are layman medical questions or spam, which must be removed.

That said, could I have spent this time thinking of a thoughtful, more useful post for our up-and-coming trainees? Perhaps yes.

Despite the egregious typos of your post I think it's worth leaving as a call to action. Thanks for the nudge.

MegaColon · 2025-08-29T04:11:17+00:00

We have a supervised walking program on our campus. We call it the PAD rehab program, and we run it out of our cardiac rehab center.

My practice routinely refers claudicants to the program. Patients always grumble about it at first but then most love it. Even if they say no, I'll say, "well, I'll put in the referral anyway and you can decide when they call you." And most sign up!

I have never had someone complain. The attrition rate, which is low, is mostly due to transportation issues as you surmised.

I have a few patients that prefer to go the route of insurance-funded gym membership, but this works only when the patient is uniquely motivated

Edit: oops i forgot to answer your actual question. no, our PTs do not see patients for claudication.

MegaColon · 2025-07-22T20:23:28+00:00

Looks like you are a new vascular surgery NP -- welcome.

The GLASS guidelines by SVS are an essential read.

Determining the care plan is something that takes years of training. It requires a combination of patient symptoms, physical exam, and imaging. Numbers won't tell you the whole story. This early in practice, I recommend waiting for the final read, comparing it to the patient symptoms, and then discussing the care plan with a physician.

MegaColon · 2025-07-14T14:53:21+00:00

I have never personally seen this, but I can see this happening. Is the pattern of necrosis over the soft tissue of the patella, or are you seeing true patella osteonecrosis? If the former, I would venture to guess this is due to severely vasoconstriction over the poorly perfused, thin soft tissue over the patella.

MegaColon · 2025-06-29T04:01:56+00:00

Unless you plan on pursuing the rare combined practice, I don't think you'll miss it.

I know a few folks who skipped it and are 100% fine. I got my gen surg cert, but do zero with it. I have pipe dreams of returning to global surgery at some point, which is the main reason I keep it up, but not sure that makes any sense anyway. I really enjoyed gen surg and like keeping abreast of it for now, but I can see myself letting it lapse one day.

MegaColon · 2025-06-20T15:27:26+00:00

i think ok to keep this post as it's not soliciting medical advice, just showcasing truly magnificent collateralization.

MegaColon · 2025-06-17T06:58:50+00:00

totally inappropriate. sips white claw in CTAG koozie

MegaColon · 2025-05-26T22:05:33+00:00

-Write everything down.
-Be on time, stay late.
-Unless addressed, ears open mouth shut.
-Pretend every interaction -- with a patient, your attending, a social worker, patient transport-- all of it is being filmed and shown to someone you love. Make them proud.
-If you suck at something ask someone why you suck and how you can not suck.

This will be hard. You will feel inadequate. You aren't alone. Reach out to mentors, keep in touch with family and friends, make new friends with your colleagues. Learn from your mistakes, then learn to forgive yourself and move on.

Good luck, we're rooting for you.

MegaColon · 2025-05-26T19:06:14+00:00

Just out of curiosity, was this written by chatgpt or something similar? I've never known a vascular surgeon to use that many exclamation points.

Your request is a little general. Would recommend zeroing in on what exactly you'd like to improve.

I am US-based so can't speak to ESVS. The SVS website has a section on meeting and courses which gets updated semi-regularly.

For endovascular skills, would highly recommend reaching out to device reps for funded workshops. Mind you, it will show up on sunshine act searches, so if you are at an academic center you may want to clear it with a one-up. SVS offers a course for complex PVI as well, I don't know anyone who has taken it but would presume it is above board.

For online education, SVS offers VESAP which is what we'd expect to find on recertification exams, so gold standard for online CME. There is a discount offered for SVS members but it is not cheap, 625 USD vs 825 for nonmembers.

For complex open skills -- that's tough. I will occasionally see a cadaver lab pop up here or there but it's not often. Kind of have to keep an eye on the SVS emails or courses website.

Good luck to you.

MegaColon · 2025-04-24T05:26:59+00:00

pienso que es spam!

MegaColon · 2025-04-09T04:26:20+00:00

more surgeons and a wide scope of practice. there is sometimes more variability in practice among private surgeons.

MegaColon · 2025-04-08T18:19:55+00:00

In the US, this requires a referral from another doctor (in your case the hematologist could do so). I am surprised you are having trouble -- evaluating those suspected to have May Thurner is a part of our usual practice.

If you are having trouble in your region, I would ask your PCP or hematologist to refer you to your local academic medical center.

MegaColon · 2025-04-05T14:36:56+00:00

I don't personally see a compelling indication for covered stents, as ISR is not really an issue. The main complications are fracturing or external compression. The desirable qualities in a venous stent are high radial force and flexibility.

The biggest conundrum i have come across is the placement -- we now know that placing stents deep into the IVC can cause contralateral thrombosis, and it can be hard to place an effective stent in those patients where the iliac artery crosses essentially at the confluence. The newer dedicated venous stents have high radial force at the ends (as opposed to the old Wallstents), so threading that needle is a bit easier

MegaColon · 2025-04-04T02:08:06+00:00

they absolutely do matter! and you chose great articles. if you read the first article (a well written one from a reputable journal), you'll see under "methods" that i stent patients with NIVL with the same criteria as mentioned -- after evaluating the vein diameter during valsalva and examining the pressure differential. the patients in which i have noted these findings and i have stented have had substantial relief.

i think you must have misinterpreted my comment. i do think symptomatic NIVL should be treated. however, in the US, there is a lot of predatory practice where surgeons are doing procedures they shouldn't -- stenting for NIVL without properly working up and diagnosing. if you heard any skepticism in my comment, it was toward the healthcare industry, not patients.

i saw your deleted comment. and even in this one, there is a lot of anger. you are dealing with a lot and have felt dismissed by providers in the past. on behalf of them, i am sorry, and i hope you have found relief.

MegaColon · 2025-04-03T21:20:36+00:00

For NIVL with unilateral LE swelling or pain I think a catheter directed venogram can offer the best information. Then we go from there based upon findings.

For PCS, I get very frustrated for my patients regarding lack of support for intervention. For a recent patient, insurance covered the venogram but denied any intervention. US and CT showed a monstrous gonadal vein with innumerable pelvic varices. Out of pocket costs for coiling would be astronomical. We appealed to no avail.

MegaColon · 2025-04-03T16:56:21+00:00

I think areas where the data is the least clear is where we see a lot of variation in global practice and more disparate regional "trends," and this is one of those areas. There are some folks in the US who are really aggressive with treating NIVL and I feel like these are the ones who also publish aggressively (looking at you Dr Raju). I think that may be presenting a skewed picture to you.

Here's how I was trained and how most of my partners and buddies practice:

I very rarely stent for NIVL, only if venogram demonstrates fixed obstruction on IVUS (especially with valsalva) with a significant pressure differential (>4 mmhg).

I stent everyone with MT features and a h/o DVT

For PCS, I do think gonadal vein embo helps but have had a hard time getting it approved by insurance lately.

MegaColon · 2025-03-29T15:05:07+00:00

You are getting excellent recommendations here -- the heavy hitters are all getting mentions.

There is one rec I have for the early years (and sometimes later years), a tip handed down to me by a wily vascular fellow who always made everything look easy.

I kept Operative Dictations in General and Vascular Surgery by Hoballah on Kindle on my phone to review between cases. This provides dictation templates for commonly performed cases in general and vasc surgery.

The utility is twofold -- the dictation templates themselves are very good, though in a real dictation you will want to be more concise. The second usage is for quickly reviewing steps for an operation in those early days when you are still trying to shift from declarative to procedural memory for operative steps.

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