Manuel Garcia Toca
USA / Mexico
Current Position
Professor of Surgery
Stanford University
SVS Keynote Session

Topic: The Impact of the Veterans affairs AAA-screening program


The United States Federal Government enacted the Screen for Abdominal Aortic Aneurysms Very Efficiently Act in January 2007. The Department of Veterans Affairs (VA) implemented a more inclusive abdominal aortic aneurysm (AAA) screening policy for veteran beneficiaries shortly afterwards. Our study aimed to evaluate the impact of the VA program on AAA detection rate and all-cause mortality compared with a cohort of patients whose aneurysms were identified by other abdominal imaging.
We used a difference-in-differences regression model to evaluate the change in aneurysm detection rate and all-cause mortality.
We identified 3.9 million veterans with abdominal imaging, a total of 319,190 of whom were coded as having an AAA US screening between 2007 and 2018. An AAA diagnosis was made in 4.84% of the screening group vs 2.17% in the nonscreening imaging group (P < .001), yet more aneurysms were found with general imaging studies (77,763 vs 15,449) .On Kaplan-Meier survival analysis, patients with an AAA diagnosis had higher overall mortality than patients who screened normal; patients with aneurysms found with nonscreening imaging had the highest mortality (log-rank P < .001) . The difference in differences regression analysis demonstrated higher mortality for the nonscreening group (14.2%; 95% confidence interval [CI], 11.1%-17.2%); and higher AAA detection rate (1.55%; 95% CI, 1.2%-1.8%) using US screening (P < .001). Multivariate Cox regression analysis in patients with AAA diagnosis (range, 65-74 years old) demonstrated a significantly lower 5-year mortality (hazard ratio, 0.45; 95% CI, 0.43-0.48) for patients in the US screening group (P < .001).
In a nationwide analysis of VA patients, implementation of AAA screening was associated with improved survival and a higher rate of AAA diagnosis. These findings provide further support for this program's continuation vs defaulting to incidental recognition following other abdominal imaging.

SVS Keynote Session

Topic: Dialysis access outcomes in patient with cardiac devices


The number of patients with end-stage renal disease who require implantable cardiac devices is increasing.
Limited reports have documented the effect cardiac implantable electronic devices (CIEDs) have on arteriovenous (AV) access patency. Current recommendations suggest placing the access on the contralateral side of the CIEDs, as there is concern for increased central venous stenosis and access failure.
Rates of secondary interventions or fistula failure are not well studied in patients who have arteriovenous fistula (AVF) access placed on the ipsilateral side as a pacemaker. compare central vein-related interventions and failure rates of arteriovenous access in patients with pacemakers placed on the ipsilateral vs contralateral side.
A retrospective review was performed from 2008 to 2016 at a single institution identifying all patients who have received a CIED and the diagnosis of end-stage renal disease (ESRD).
There was no difference in intervention rates between ipsilateral and contralateral patients; however, the time to intervention was increased in patients who had arteriovenous access on the contralateral side to their pacemaker (9.5 months vs 19.5 months).. Patency rates did not differ (P = .068). I
CIED may lead to stenosis or occlusion to one's AV access; however, primary assisted and secondary patency rates are still acceptable at 6 months and 1 year compared to Kidney Disease Outcomes Quality Initiative guidelines. Despite a CIED, a surgeon's algorithm should not lead to the abandonment of an ipsilateral access if the central venous system is patent.