Vascular Surgery is Not in Vein with Dr. Yang Yang

Did you know that, according to the National Institute of Aging, if we stretched out our arteries, veins, and capillaries as adults, they would measure around 100,000 miles? This means that our blood vessels could circle the globe four times, given that the earth's circumference is about 25,000 miles! The human vasculature is truly an intricate system that literally supplies us with blood (with veins circulating around 2,000 gallons to all body organs every day) - with life. It is no surprise that pathologies and disease processes that involve our vasculature can result in life-threatening effects, like heart attacks and strokes from coronary vascular and cerebrovascular disease, respectively. However, diseases of the vasculature can also result in effects that can simply alter one's quality of life, such as limb loss from critical limb ischemia due to peripheral arterial disease, varicose veins from peripheral venous insufficiency, lymphedema from lymphatic diseases, the need for hemodialysis due to chronic kidney disease secondary to renal artery stenosis, erectile dysfunction from genitourinary vascular diseases, and much more.

We are joined today by fifth-year Integrated Vascular Surgery resident physician Dr. Yang Yang. She received her BS in Biochemistry and Neuroscience from Drew University, MD from Drexel University College Of Medicine, and is currently completing her Vascular Surgery residency at MedStar Washington Hospital Center/Georgetown University Hospital.

Livestream Air Date: April 16, 2023

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Episode Transcript

(00:00):
Hi friends, how are you all doing? Happy May! I cannot believe spring's in full bloom and

(00:10):
summer is soon arriving. I have been seeing everyone in the city walking with tank tops
and shorts and I love to see it. Gone are the days of the ashy legs after a long day
of flag warmers and heavy pants due to the cold weather. Everyone's so loud and proud.
Well, maybe not everyone. For example, my mom is very open about her reluctance to wear shorts

(00:33):
because she's so conscious of her legs having varicose veins. Ever heard of them? I call them
the nurse's disease because I think I'm developing them too. Varicose veins are bulging
large veins commonly seen in the legs caused by many things like age, pregnancy, being overweight,
having obesity or standing for long periods of time. These varicose veins look blue and twisted

(00:57):
and stretch and many even call them spider veins. Veins return blood from the rest of our body,
like our legs, back to the heart versus the arteries that carry blood from the heart to the
rest of the body. But to return the blood to the heart, the veins in the legs must work against
gravity and our veins have valves or like doors that prevent the backflow of blood. Sometimes these

(01:20):
veins get weak and damaged and then the blood can flow backward and pull in the veins. They get
twisted and stretch and boof varicose veins. Obviously for my mom and others, varicose veins
and leg discoloration are a cosmetic concern, but they can also result in leg pain and discomfort
and they can be a sign of something deeper and more worrisome. But our veins are just one facet

(01:43):
of our vasculature, our arteries, capillaries and even lymphatic vasculature. Did you know that
according to the National Institute of Aging, if we stretched out our arteries, veins and capillaries
as adults, they would measure around 100,000 miles. This means that our blood vessels could
circle the globe four times given the earth's circumference is about 25,000 miles. The human

(02:06):
vasculature is truly an intricate system that literally supplies us with blood, with life.
It is no surprise that pathologies and disease processes that involve our vasculature can result
in life-threatening effects like heart attacks and strokes, oncoronary vascular and cerebral
vascular disease respectively. But these are the big and feared ones. We view these as potential

(02:29):
death sentences. But other diseases of the vasculature may not seem as terrifying and a
life at peril status as these. Still, they can definitely alter somebody's quality of life
because of the diminished comfort and ability to live other life to the fullest. For example,
the cosmetic aspect of varicose veins that can hinder one from wearing the clothes they want,

(02:51):
potential leg amputation due to lymphoma from untreated peripheral artery disease or PAD,
requiring the eventual need for hemodialysis due to chronic kidney disease from renal artery
stenosis, impotent and erectile dysfunction from genitourinary vascular disease. And the list goes
on and on. I actually work at an intervegetal cardiology and vascular surgery hybrid practice

(03:14):
where we do arterial and venous endovascular procedures and I see these every day. Actually,
just yesterday at work, we had to send a patient to the hospital for leg amputation
because of an unsolvable limb after multiple events over years of procedures. Before leaving,
he told me, I woke up today hoping I'd go home but now I'm on my way to losing my leg. You can't

(03:37):
really anticipate life, he said. And hearing that from him really made my heart sink. And I hear of
other anecdotes from my patients, like former athletes who can no longer run because of PAD
and grandmothers who cannot walk with their grandkids because of leg pain. Okay, enough of
the long introduction. I have the biggest honor of being joined by Dr. Yang Yang, a fifth year

(03:59):
and final year vascular surgery resident physician to speak about all things vasculature and the
surgical interventions they do to hopefully alleviate these pains. From PAD to devine thrombosis
or DVT and EV fistulas for hemodeialysis to carotid underdirectomies to aortic aneurysms and
dissections, you name it. We have a lot to talk about and it won't be in vain. Do you get it?

(04:26):
Vain like V-A-I-N and V-E-I-N. Anyways, have a nice day everyone. I hope you enjoyed this episode.
Hello. Hi. How are you? I'm good. How are you? I'm good. Thank you so much for joining me after
work. Yeah, of course. Yeah, Simon's grubs. That's how a girl is. Well, thank you so much for joining

(04:51):
me after a tiring day at work. I've been looking forward. I mean, honestly, I've been wanting to
ask you for a year now. I was like, it'll come. It'll come. And it's finally here. I think you
just first please introduce yourself to everybody. Sure. So hi, everyone. First, thanks for inviting
me to be a part of this. I'm very excited. My name's Yang. I'm a fifth year integrated vascular

(05:12):
surgery resident based in DC. Year five means that I'm finally in my final year of training.
So that's right. Only 10 months ago, but who's counting? Who's counting? I mean, wow, that's such
a short time of training. Yeah. Just a short time of school and training. Just, you know, a decade,

(05:34):
over a decade of your life, right? Well, I'm so excited for you. You know, we first connected here
online. Since then, I've been watching your endovascular cases, your favorite femoral cases
or whatever. And I was like, we need to talk about this because I work in an interventional
cardiology and vascular surgeon's office where we do... How about recently? How did I know before?

(05:58):
Yeah. So that's why I always comment on your stories. It's like, I don't like femurals. I don't
like femurals. You know, the world of vascular surgery, the field is just so extensive. Even
when we were planning this whole live with the questions, we're like, okay, we can take that
out. This is too big of a topic. There's so many things to talk about. But first, I wanted to talk
about you and your journey to medicine. You're such an inspiration to me and to so many other

(06:23):
people. I wanted to know how your journey to medicine looked like throughout the years. And
also, what's the inspiration in pursuing this field? Is it like a family member, a friend,
or personal experience? Sure. So my grandfather was a doctor, but no one else really in the family
was a doctor. So I kind of just found it on my own. I kind of had an inkling in high school that
maybe that this is something I wanted to do. I was like, I like science. I kind of want to be in

(06:46):
something where I'm helping people and I'm kind of talking to people. So it just kind of seemed to
match up. I did go ahead then. I went and got my EMT certification. So I was an EMT in my local
town and then also in college. So when I was pre-med, I was also an EMT. And then after that,
you know, I did the usual like shadowing, like, you know, all the interest groups and stuff like
that. So actually for a while, I thought I was going to go into emergency medicine, just because

(07:09):
that was like so much of what I knew between like EMT and kind of work at ER and stuff like that.
So I took some time between college and medical school. I took about two years to kind of get all
my letters and prep and everything, because I did commit during college, but I needed to retake my
MCAT and I needed to what I felt like get stronger letters. So I took some time to be able to do all

(07:30):
of that. And then I got into medical school after a lot of studying and I'm sure everyone knows what
that's like. And then vascular surgery just kind of like came to me. It was very, very unexpected.
Like I said, I thought I was going to go into emergency medicine. It's really funny because
they're completely opposite. And I don't think I could ever ever do emergency medicine knowing
myself now. So I did a general surgery rotation as a third year and it kind of started because

(07:55):
I had done OB-GYN and I was like, oh, I think I like being in the operating room. Like maybe I
should consider something like that, which kind of really limited what I was focused on. And then
for a little bit, I thought about anesthesia just because everyone's like, yeah, you know,
if you want to lie, you shouldn't do surgery, yada yada yada. You know, like the things that
everyone hears and like, especially girls, we always hear. So I tried to convince myself to

(08:17):
like anesthesia, which was a mistake because it's nothing like just because you're in the OR doesn't
mean it's anything close to surgery. Yeah. So that wasn't for me. And then I had done a couple of
vascular cases. And at the time I was like, I like being in the OR, but I don't really like belly
stuff. I don't like hernias. I don't like lap coli. I don't like anything for gut, mid gut, anything.
And then when I scrubbed vascular cases, I was like, Oh, hmm, what's this?

(08:45):
Yeah. So that was very eye opening. That was really, really lucky. Honestly, I went to
Drexel for medical school. We didn't have a dedicated vascular department. So it was really
just like lucky that this happened to me. My chief resident at the time in general surgery was also
going to Vascularic and Fellowship. You know, it just takes one person. So she saw that I had an
inkling and she was like, Hey, like come with me to do this bypass or come with me to do this EVAR,

(09:07):
like go like see this patient and tell me what you think. And you know, the more involved I think we
are as medical students anyways, the more of an interest we have. And so she really kind of like
took me under. And then that's when I discovered there's like a whole integrated pathway similar
to like plastic surgery. But there's still an option for general surgery as well. And then you
kind of do fellowship afterwards. So I debated for a while because I found Vascular like March of my

(09:31):
third year, which is a little late. Yeah. So I didn't have a home program, meaning I didn't have
like a chair or a chief or like a program Dr. Chan helped me. So I did an endopachial researcher
at Penn State. And I did a lot of research. Then I did a lot of a bunch of a lot of conferences,
network, my little butt off. Then I did away rotations, which are really important in Vascular
surgery. And then ultimately I matched here at GC. So I'm very happy to be here. And I'm very happy

(09:56):
to be almost done. I can't imagine 10 months, he's counting. Yeah. Well, such a long road, right?
With a lot of ups and downs and even just the whole medical school application process,
such an emotional toll and so many other things involved. And I can't imagine like the whole
medical school around and the residency and all of those things. I mean, especially here in the

(10:19):
United States, right? The whole medical route entails so many sacrifices, whether it's financial
or time or efforts. And it's great to hear that, you know, you found something that you really love
doing, right? Which I guess took trial and rotations and shadowing. What do you think at this point in
your medical journey, given all of the time, the sacrifices, all the entailed sacrifices,

(10:44):
and whatever aspect of life, you may be having regrets in pursuing this field at all?
I think overall, no, I'm very happy with what I'm capable of both in and out of the operating room.
I'm very proud of what I'm able to do. And I feel very confident in my skills. I do think that
residency as a whole is very challenging. So there's definitely been days where I'm like,

(11:04):
why am I doing this? Like I've been here since 5am, I'm leaving at 10pm. I haven't seen my husband
for like three weeks. Like I'm just like a slob on weekends, you know, there's definitely challenging
times. And I think you kind of have to keep like the big picture in mind, at least for me when that
happens. I don't regret it as of like this moment right now. Obviously, I have yet to become an

(11:25):
attending and kind of like get to the final stage, you know, the light at the end of the tunnel,
whatever you want to call it. But right now, as of this moment, I don't really regret it.
That being said, I do think that I had to really take a good hard look at what was important to me
and like learn how to prioritize things. So I would say that maybe sometimes I'm not as social
in residency as I would like because I either have to do research, or I promised my husband,

(11:49):
I would do something with him or my parents are in town and you know, everything is like give and
take. And so, you know, there have been instances where I'm not maybe the best resident, because I
have to try and be a better daughter or I'm not a good wife because I'm trying to be a better
resident. It's just kind of all like ebbs and flows. And my husband will say the same exact thing
that sometimes I just ignore. But overall, no major regrets so far and I'm very happy with my decision.

(12:13):
Wow, I love that. And I'm so honored that after a long day of work, you're here right now.
I will be totally honest and say that I'm on a lighter rotation right now.
And my junior resident is very, very capable. So I have like somewhat more hours.
Speaking more about surgery and vascular surgery, I wanted to pull up the statistic that the American

(12:38):
Board of Surgery has on their website. They said that only 14% of board certified vascular surgeons
are women. I feel like you've known for a while, for so long from the beginning that what medicine
as a whole is a male dominated field, specifically the field of surgery, right? It's a very male
dominated field. And as you get into even more niche subspecialties, like for the last season,

(13:01):
we had Dr. Fannie Milhouse as a pelvic surgeon, neurologist. I feel like only 4% of the system
we saw that were female with pre-scripted and urological surgeons. For vascular surgery, it's
14%, which is such a small percentage, right? Given that, do you think being a woman in medicine and
a woman in vascular surgery, has it affected you think your experience as a resident physician,

(13:27):
as a resident surgeon? And how do you think we can increase this number from 14% to even bigger rates
for vascular surgery? Yeah, I think that I've been very fortunate because my program currently is
half females. My names are maybe I would say a third female. So we're getting there. The latest
ACGME data shows that 50% of the applicants who are applying vascular surgery are women. So we're

(13:52):
kind of making moves. I do feel like I sometimes either have to prove myself a little bit more,
or conduct myself in a certain way that perhaps my male residents don't necessarily have to do.
For example, when men throw tantrums in the OR, it's like, oh, that's just a surgeon's personality.
And then when women be more demanding or stuff like that, then it's like, oh, she's such a,

(14:14):
you know what, she's so whatever. And there's always this condescending tone to it. The other
challenge then I think that a lot of women struggle with is when you try to be too nice.
And you try to be too nice and they feel like they can walk all over you and there's just no
like kind of winning. So I do think that, there's a lot of introspection of where this is coming
from. I've been very fortunate that no one has, at least in recent years, outwardly said anything

(14:35):
to me about being a female in a surgical field. I do think that kind of all of the recent publications
about how like more than half of the students in medical school are girls now, and how there's
like social media to highlight all of this and a lot of accounts highlighting kind of women in
surgery, it's gotten a lot better. I think in medical school, and maybe, oh my God, like 10

(14:58):
years ago at this point, it was much, much more different because when I was applying, I remember
a lot, you know, I only had male surgeons who were supposed to kind of help mentor me. And my medical
school kind of person who was supposed to be helping me was like, are you sure you like
vascular? Like, are you sure that's right for you? Kind of with this undertone of like, you're too
nice, like maybe you can't handle it. And it's always backhanded comments like that, right?

(15:22):
People are always like, you're too nice to be a surgeon. And I'm like, I just don't understand
what that means because why would anybody want a nice surgeon? Like nice and capable are not
exclusive. So anyways, all of that to say that I do think that there are challenges and I think
been a little bit fortunate in terms of not having to experience so overt sexism. But I do still think

(15:43):
that we have a long way to go. And unfortunately, I do still feel like women really have to kind of
carry themselves in a certain way so you don't rock the boat. And it's really hard to make changes
until you're kind of at the top. And so that's kind of why I think women in leadership, women,
you know, promoting other women and men promoting other women into positions of power, that's how
you can really get change. You know, that's one of the things that I'm passionate about. I think

(16:06):
that's why it's important to have kind of like domain sexual media, like, you know, Twitter and
even like just these like conferences that pop up that have sessions dedicated to women. It's kind
of not just a safe space, but also a place for everybody to kind of talk about things and come
up with ideas and, you know, think about how to make things better for everybody. Because I don't

(16:26):
think that people should be selected based on their gender or their sex, but I do have to
acknowledge the fact that like, there is an inherent bias, I think, especially in surgery,
when it comes to having a male versus female surgeon. And I think that's something that we
are very much so trying to make better. Yeah, I love I love all of that. Even this podcast

(16:47):
series that we have, right, like it's our third season right now. And we're over 80 expert guests
right now. You're doing so great. This is so awesome. Thank you. And over 70% of our guests are women in medicine, right?
Because I think it's so important to tell those stories, right? That we can turn the tide even
on a small screen like social media, right? And thank you for being so present on social media,

(17:10):
too. I mean, it's just so inspiring seeing your journey and just this boss badass woman,
this sort of person on Instagram, you know, and, and yeah, so it's such an honor. And I think it's also
brings to light that like any field in medicine can be open to anybody, right? Even such a niche,

(17:32):
I find bachelor's surgery to be such a niche field that like, we've always had arteries and veins in
catheter. But I feel like it's only recently that I'm hearing more and more about like, really focused
education on the vascular chair, right? And I mean, you're the expert here, you're the vascular surgery
resident, can you take us to the basics? What is the premise of this whole field of vascular surgery?

(17:58):
Like, why do I need to see a vascular surgeon versus a cardiac surgeon who also deals supposedly
with the circulatory system? Yeah, no, those are all great questions. And I actually didn't even know
it was a specialty till I was like a third year myself. So yeah, and even sometimes my dad will be
like, Oh, yeah, you work with the heart, right? I know that same thing. No, vascular surgery,

(18:18):
the way they define it, the way we define it is that we are dedicated to the arteries and veins
of the body, excluding the brain and excluding the heart, obviously, because like things like
the coronary arteries and stuff are dedicated to cardiac surgery, and then neurosurgery, obviously,
for anything intracranial. So we'll do extracranial things like carotids, obviously, as you know,
vertebral, subclinians, and then anything of the heart is kind of for CT surgery. So then you kind

(18:44):
of break it down into, you know, arteries, what kind of diseases happen there, and then veins,
what kind of diseases happen there, and then slowly we kind of start to segue in that way.
A lot of vascular surgery, I think, is kind of difficult for people to think about because
also because it's really a majority of our patient population, especially for arterial diseases of an
older population. So, you know, it's not really something where people our age or people on social

(19:08):
media or something would kind of really be actively talking about. And especially when we start to
think about things like TAD and aneurysms and stuff like that, it's always like over 50, over 60.
You will see a little bit more of like the venous stuff, especially superficial venous, like
spider veins, varicose veins, and stuff like that. But those, sometimes the other specialties will
also treat them. So like interventional radiology sometimes will do like deep system reflux.

(19:30):
Dermatology will inject spider veins, you know, classic surgery will do like veins and stuff like
that as well. But you're right, like it's not really like very, very well known out there.
And people aren't like, oh, you need to go see a vascular surgeon the same way that they're like,
you need to go see a heart doctor. People don't really know what it is.

(19:50):
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(23:14):
So, I wanted to veer more into your daily life as a vascular surgery resident. I guess, take us to

(23:35):
a bread and butter of your work, especially in your training for the past five years. It probably
changes every year as you go into a different residency year. But what would you say are the
most common procedures that you would do? Like, you would go into the hospital today and you'll
be like, or you know, when you prepare your patient list the night before or whatnot, your case list,

(23:57):
it's like you already know in your mind, oh, I'm going to see this, this, and this. What would
be, you think, your top three procedures? Sure. So, since we're talking mostly in a hospital setting,
I'll just mostly talk about inpatient things. So, a lot of that will be arterial. But one of the most
common things that we treat would be peripheral arterial disease. And I just have to make a plug
because September is supposed to be PAD Awareness Month, which is Society for Vascular Surgery is

(24:19):
trying very hard to promote. But it's basically peripheral arterial disease, meaning it's the same
kind of atherosclerotic disease that you see in coronaries when people think about heart attacks
and stuff like that. But the important thing to kind of differentiate and remember is that it also
happens in your extremities and for a lot of people most commonly in their lower extremities. So,
a lot of kind of what colloquially we'll say for vascular is like, oh, today's like a leg day,

(24:43):
meaning that we're either going to do like angiograms, which is just a sort of like minimally
invasive procedure where you enter in your defemoral artery, your favorite, to get access
and do some kind of endovascular intervention. So, you know, the angiograms that we do, they're
usually in a hyper room or you have like a C-arm where you use contrast and fluoroscopy or x-ray

(25:05):
machine, kind of put the contrast inside the vessels and the vessels light up. And depending
on how things look, a kind of a combination of some other techniques that we use will be able
to tell if you have any narrowing in your blood vessels or not, or even any blockages. And depending
on how that looks, we'll either be able to treat it endovascularly with like a balloon or a stent,
or we'll say, you know, this is not a good pathology to treat endovascular and then we'll think about

(25:27):
something open, meaning bypass and arterectomy, et cetera, et cetera. PAD is one of the biggest
things that we do treat and that can obviously be further classified into like the QLM ischemia,
you know, there's a QLM ischemia, a chrofen ischemia, all that stuff, but that's just kind of
like, you know, leg day, PAD is very, very prevalent. A lot of people have it and it's
something that we see quite often. Top three, that's hard. I would say we don't do it as much

(25:52):
at my training program, but most vascular surgeons across the country will do dialysis access. That's
considered bread and butter. So when we're talking about, specifically we do hemodialysis, so not
peritoneal dialysis, but hemodialysis where they, you know, you go to a center and you're hooked up
to a machine three days a week. So we'll do fistula creations or we'll do graft creations and then
kind of the maintenance for those, we'll do fistula grams and kind of, you know, banding or

(26:15):
ligation or anything else that's kind of related to dialysis access. So it's another big thing that
we do. And then the last one, it would have to be between like carotid disease and aortic disease,
which is also like another huge topic. So aortic disease, meaning like aneurysms, dissections,
ruptures, intramural hematomas, any type of like acute aortic syndrome. And we do a good amount of

(26:36):
those as well. So those that have veered more towards an endovascular approach nowadays, we
don't do so much open just because of kind of the technology that's out there and kind of patient
recovery and all that stuff. So those come by pretty often, which is good for training. You know,
there definitely are more complex cases and the cases that everybody wants to be involved in.
And then, you know, finally, we have carotid disease, like symptomatic or asymptomatic carotid

(26:58):
artery stenosis, carotid artery aneurysms, carotid body tumors, lots of other things that we tackle.
But I would say probably carotid artery stenosis is probably the most common out of all those
pathologies, kind of with the same risk factors that everyone else has for like CAD and PAD,
you know, making sure that we can try and prevent stroke as much as we can. And then we kind of talk

(27:19):
into like, and then we kind of go into, you know, T-car, which is very popular now, which is kind of
a trans carotid, senting, and then there's also the good old carotid anorexia, which everybody loves.
Yeah, yeah. I love all of that. I mean, it's a disclaimer. I know. Let me just,
disclaimer, I love all of my patients, even the femoral ones. But I must say,

(27:45):
that when your blood pressure goes down to 40 over 30, I'm not that excited. I mean, I think also with,
I guess with medical technology and scientific advancements, right? I guess before the gold
standard and the only option is just femoral, right? I mean, now seeing, let's say more of
fetal access or interitibular, posterior tibial, or it's just, it's just like, or peroneal access

(28:09):
as well. It's just so interesting to see just how medicine, you know, takes its strides in these
diseases that probably are once death sentences or like sentences where people are like, oh,
you can't walk anymore. Oh, we have to amputate this, like the extremity, right? Or even,
I can't even imagine like before the days where we invented, I don't know, interventions for like

(28:34):
DVT and stuff like that. It's just waiting there and just waiting for someone to get a stroke,
right? Well, speaking of a DVT, I mean, what are the vascular surgery interventions for,
let's say a DVT or even let's say a pulmonary embolism? Yeah, so DVT and pulmonary embolism
is actually a very like hot new topic right now because it's also covered by interventional

(28:56):
cardiology, interventional radiology as we probably know. So vascular surgery is also kind of gaining
a lot of traction on that. A lot of what has been coming out for DVT and PE is thrombectomies,
but these are all done endovascular. So minimally invasive where we access the veins directly.
And then we have a series of catheters or thrombectomy devices where we basically use it

(29:17):
to remove the clot. So for a DVT, we have options depending on the kind of underlying pathology as
to why the patient has a DVT in the first place. We have technology with the catheters now to either
kind of suck out the clot directly. So it's like a big catheter, maybe like this wide, you know,
16 French, 18 French, whatever. And then just using negative pressure just sucks out the clot.

(29:39):
And then depending on how that looks, if the patient has like mini-thriller syndrome or something
like that, then there's consideration for stenting. And then if they've had like previous IVC filters
and their IVC is now narrowed and stuff like that, there's also options for stenting as well.
So that's kind of DVT. The thing that we used to do, which we've kind of moved away from,
at least at my institution, is thrombolysis. So where you put TPA in a catheter and you kind

(30:01):
of let the TPA just drift out into the clot. And that requires an ICU stay because it's such a scary
medication for risk of bleeding. So we'll lyse patients and then we'll bring them back the next
day to kind of finish everything. We will also lyse PEs, but we've also kind of moved away from
that. At least our institution, we have pretty good devices for removing clots. So we'll, you know,

(30:21):
access the femoral veins, get into the IVC, cross the heart, get into the pulmonary arteries,
and literally just like suck out clot. It's very, very popular right now. It's very hot, very
exciting. If you look on Twitter, there's all these things called like clot porn. People are so into
that, which is like a whole thing on its own. You're like, look at the clot I got out today.
And they like make it into heart. It's really weird. But people really like it because that's

(30:45):
the other thing, right? Like yeah, people are doing that to themselves on Twitter. But no, but in all
seriousness, it is very satisfying to be able to, you know, have a patient feel better and be able
to show them a picture of like, look at what was inside of you and like look at what we took out.
Yeah. I mean, you know, when we talk about something like pulmonary embolism, where it's

(31:06):
a little bit closer to more viral organs like the heart and the lungs, right? I think even when we
talk about it, and I guess the general public and someone said Zoom med school lecture, hello,
hello, sign your attendance. So when we're talking something like PE, right, where it's kind of so
much closer and it's in the viral organs, it can bring a lot more tension and fear, right? Like,

(31:29):
okay, we can get a heart attack or you can get a stroke. But when we're talking about things like
the peripheral things like peripheral artery disease or even like chronic venous insufficiency
or very close veins, the sense of urgency may not be there, right? Because it's peripheral,
it's the extremities. It's not something the general public might see as more life threatening,

(31:53):
let's say, again, as a PE that can lead to whatever, right? That's a vascular surgeon who
treats, you know, an array of these things from a PE to carotid endodectomy to PAD. How urgent
do you think patients should be when it comes to seeking help for more peripheral diseases like

(32:14):
PAD or... Yeah, I think that the, you know, PAD is a little bit more challenging because no one's
going to say like, I feel like I have PAD, I feel like I have claudication, I feel like I have
rest pain, right? In the same way that when people have like a heart attack or they're having chest
pain, right? They have their symptoms and they'll elude it to a diagnosis. So they'll be like, I have

(32:37):
chest pain, oh my God, maybe I'm having a heart attack. But you're right, peripheral doesn't kind
of exude the same amount of urgency, right? If someone's like, let's just take the PAD example,
someone's like, you know, my legs hurt when I walk. And that's, you know, something that we will say
claudication, the patient's not going to be like, hmm, I think I have PAD. People are going to be
like, maybe it's arthritis, maybe I pulled something, you know? And the same thing with like rest pain

(32:59):
and stuff like that. And so I think that's why it's important to have a lot more public knowledge
out there, especially for older patients about kind of what can happen. Because the thing with
PAD that we always worry about is like mortality, amputation, limb loss, right? And not to say that
people who have leg pain are going to, you know, head down to amputation or anything like that, but,
you know, there's a very, very large differential. And I think patients just need to be more aware

(33:24):
of kind of what the possibilities are. And it's just something because of like, kind of how our society
is, how like TV has sensationalized medicine, you know, PAD is not sexy, it's not exciting. Like the
most reference I've ever seen for PAD was on like a K-drama where someone has diabetes and they're
like, you need to get it under control or else your toes are going to be amputated. And I was like,

(33:45):
that is surprisingly accurate. But that's the only thing I've ever seen. Everything else though,
like PEEs, you know, heart attacks, strokes and stuff. When people have a stroke, they don't think
about carotid disease, right? People think about like, oh, like something's going on in my brain.
They don't think about like the arteries that are feeding the brain. And that's not to say that all
strokes have a carotid etiology or even, you know, anything extracranial, but it's just something

(34:10):
that's not really, really kind of at the forefront of everyone's mind. Yes. Superhero, I mean,
you're right. It's not as, I guess, as sexy. It's not as glorified, right? But even when you were
talking about, let's say like carotid patient or leg pain, no one in the general public would be
like, oh, I'm getting cramping in my legs. I have PAD. I have poor blood flow. Yeah. Yeah. Yeah.

(34:32):
People will be like, I didn't eat enough bananas, my potassiums. I don't lack, right? Yeah. It's
nothing too, I guess, starry-eyed as opposed to pee or like a heart attack or a stroke. We talk
a lot now about the legs and more of the peripheral stuff. And you said in the beginning that kind of

(34:54):
ex... Plastic nerve surgery kind of excludes mostly, I guess, the brain and the heart, but you do
do things like very close to cerebral vascular. And you mentioned some earlier, what would be your,
I guess, most favorite surgery to do when it comes to chest up, I would say. Chest up? So it used to

(35:17):
be carotid endarterectomy. There's not a lot of options for chest up. Depends on where you're
defining as chest. Cause then we could, we could talk about like upper extremity bypasses. Yeah.
And stuff like that. Those are fine. Carotid subclavian bypasses, those are a good case.
When it gets to, when you're talking about like the A sending and kind of the arch vessels,
that gets to be more CT surgery a little bit. But anything above the chest, it's probably going to

(35:42):
be a carotid endarterectomy. I mean, that was just like the first case that got me into vascular. It's
very delicate, very refined. It's great anatomy. Like everyone knows what, almost everyone knows
what a carotid endarterectomy is. It's like the most pimpable question in the OR. Like students
love it. And tend to love it. For the general public who may not know even what carotid needs,
can you explain what that procedure is? Oh, sure. Sure. So carotid endarterectomy is just where you

(36:06):
make an incision kind of along your neck. You're looking at the carotid arteries that go up to your
brain. There's a common carotid, internal carotid and external carotid. We care the most about the
internal carotid because that feeds the brain. And so if you have areas of narrowing with like plaque
and disease, the carotid endarterectomy is done to prevent future strokes. So essentially we open up

(36:27):
your neck right here along your sternocleidomastoid. We isolate out all of your carotid vessels. We get
control to make sure there's no bleeding. And we literally scoop out the plaque. It doesn't always
come easy, but you know, my attending used to say you get style points, you get all the plaque out
in one piece. So it's usually, it's very, very calcified, very, very hard and solid. Sometimes
it'll be a little bit more soft. You see that mostly in patients who have had recent strokes

(36:51):
where their afroma hasn't ruptured. So that kind of, that's what's causing their symptoms. But the
carotid endarterectomy is just, it's just a nice, nice surgery. It's a nice case. I think, you know,
it's just like very satisfying to do. I feel like, I feel like some people watching here
who are not in medicine are like, how? Yeah, it's better if I had a whiteboard to draw right here. An actual Zoom

(37:17):
lecture. You know, you also mentioned earlier about dissection and aneurysms. Actually, I got a few
questions in my DMs when I was promoting our lives from students asking to differentiate what an
aneurysm is and a dissection is. And I guess what intervention a vascular surgeon would do. Oh sure.
So there are two very different disease pathologies. An aneurysm is the weakening in the vessel wall.

(37:38):
And so essentially what happens is that you think of it like as a balloon. When there's weakening,
then it tends to expand, expand, expand, expand, and it keeps getting bigger. And the thing we worry
about most with an aneurysm is the risk of rupture. Because when it ruptures, it's a very, very high
mortality. It's like 50% of patients don't make it to the hospital and will die. That's like a very
broad overview. So that's specifically aortic aneurysms. You can have aneurysms anywhere in

(38:01):
your body. You can have carotid aneurysms, you can have femoral artery aneurysms, you know, anywhere.
But for aortic aneurysms, you know, I assume that's what you're talking about. Because then
when you lead into dissection, aortic dissection, that's just when you have a tear in the vessel
wall. And so what will then happen is instead of your aorta being one nice tube where the blood

(38:21):
is flowing, it creates a channel where we'll call it true lumen and false lumen. That's what we're
calling it. And then true lumen is kind of where normal healthy blood vessel is and kind of where
everything is flowing the way it should be. And then the false lumen is basically another plane
where blood is going. And depending on the area of dissection and what kind of end organs that's

(38:42):
feeding, that can lead to a variety of different symptoms. And so dissection most days now is fixed
endovascular aortic aneurysms, depending on where they are and kind of whether they're elective or
if they're emergent because they rupture, it can be open or endovascular. And there's all these
things that we need to know about like, you know, criteria for fixing aneurysms and what stent graft

(39:02):
is good for what and stuff like that. And for dissections, like I said, it's mostly endovascular
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(42:13):
type of surgeries you need to do obviously comes with a lot of preparation beforehand,
obviously it takes a lot of practice and skill, I mean that's what residency and training is for,
right? Take me to your brain when you're doing surgery, I guess, or I guess this would be true
for any other surgeon, right? How would one know the next step of what to do in a certain surgery?

(42:33):
Is that just like practice and studying? I think everyone does it a little bit differently and it
also depends on if you're doing an elective, like a planned nice outpatient case for who's in emergency,
but there's kind of standard steps and kind of an algorithm that everyone will eventually develop
depending on what pathology you're treating. So I think it's for me at least the way I do it,

(42:55):
and this was kind of what I did to transition from a junior resident to senior resident,
because obviously the expectations are a lot more. When I was a junior resident, I'd be like,
oh, you kind of do this and you kind of do that, and like if the example of the carotid ender
directed me, I'd be like, oh, you make an incision here and you do something and then the IJ shows
up and then carotid shows up and you sew and like you're done. But you know, as a senior resident

(43:16):
and kind of as we can, everyone can do the super res and stuff like that, and especially for,
you know, things like oral wards, I like to look at the relevant anatomy beforehand,
there are textbooks that are like operative anatomy as opposed to just like netters where
they list out every single organ. There's textbooks that are more dedicated to the operative steps,
as well as the operative anatomy. So it'll be like, you know, you find your landmarks and you have

(43:38):
your earlobe, you know, your mandible and then your sternal notch, and then this is the length
of the incision and it's much more technical. Whereas junior residents, I think you get more
of a general idea of what the surgery entails when you're a senior, and I'm sure beyond, you know,
what really helps me and the way I kind of do things now is I plan my cases the night before.
Some of the cases like angiograms, because they're both diagnostic and therapeutic, you don't really

(44:02):
know exactly what you're going to do because you don't know where you're going to see when you've
been in there. But for more of the more open cases, it's a little bit more standard just because the
anatomy is the anatomy. And I just know like if this then that and if I like open the carotid
sheath and this is what I expect to find. If I like dissect up this way, then this is what I expect to find.
And so it just becomes like second nature in terms of like what you're expecting. And then I think

(44:27):
also this is something that I'm still trying to work on, but you think two to three steps ahead.
And then you also have to think about like, okay, if this doesn't work or something is unexpected
or out of my algorithm, how am I going to adapt and how am I going to adjust? And kind of like
my attending said, like you kind of have to have a plan B and a plan C at all times. And then he
likes to do that. That's what he does all the time because he works with residents and we make us in

(44:48):
the car. But that's okay. That's what training is all about. But yeah, that's how I do it.
For things that are more complex, like the complex endovascular cases, I will try to
write out all of this stuff. If it's like for an iliac artery aneurysm and we're doing like an
EVAR plus an iliac branch device and it's much more like technically complicated, then I will

(45:14):
literally write out the steps. Like I'll use this wire, I'll use this catheter, I'm going to snare
this, I'm going to do that, I'm going to like enhance this sheath, exchange all that out.
And so it really becomes like a step-by-step thought process for me. And then the more I review it,
the more fluid it becomes. You've shared so much a lot about different diseases and
your interventions and it's so educational. And it's just so interesting to see again,

(45:36):
how much we can do, especially now, right, to save people, right? And to hopefully alleviate the pain
and all the symptoms they're feeling. I love all of that. What we can say would be your favorite
part about vascular surgery? My favorite part about vascular surgery is I think that we have
the ability to tackle almost anything, both in an endo and open manner. And our toolbox is very,

(46:01):
very, very, very large. So kind of like what you alluded to before, like we have femoral access,
we have radial access, we have fetal access now. We have so many different ways of coming up with
things. We can bypass literally anything we wanted to, if we wanted to. It's just our ability to kind
of tackle the disease process and kind of at least try to alleviate what's happening. We just have a

(46:22):
lot of options and we continue to, I think, advance the field. We have a lot of new technology coming
out. So, you know, industry relationships with us is very, very exciting, something that I really
like because it's nice to have new devices and it's nice to kind of try and see what new things
are out there and how we can better help our patients and kind of advance the specialty as

(46:44):
a whole. So I think from a technical standpoint and an operative standpoint, I think vascular
is one of the most unique and obviously greatest specialty out there just because we're able to
do a lot. If our endovascular options fail, then we'll convert to open. We can do hybrids and
features. I think there's a lot that we are able to do and I really love that because it doesn't

(47:06):
feel like anything is ever really routine. There's always a little bit of complexity. There's always
a little bit of critical thinking, being creative. I attend a lot of conferences and I hear the
attendings be like, well, I tried this and then this and then me and my co-residents are like,
what? They did what? That is so crazy but so smart at the same time. And it's just stuff like that
that really keeps me going because I just get so excited about it. I think it's so fun. So I really

(47:31):
love that. I love that and with all of that, with all the beauty of the field, you can also be really
taxing, right? Not just emotionally but also physically, especially being a physician and
especially being a surgeon, right? People's lives are literally in your hands in that moment, right?
Blood loss, like extreme blood loss is going to happen and I say, femoral. I don't hate femoral

(47:56):
though. I don't hate it. It's just my favorite. Through all of that, there can be a lot of
toll on the physician. How do you decompress from all of this? I think that I have different ways of
decompressing depending on what the issue was. So if I just had a bad day at work because residency
sucks and someone in the ICU is mean or whatever, like I have a cold or whatever, then I just kind

(48:21):
of play some Zelda, watch some CD, hang out with my husband, just completely step away from medicine.
If there's been a bad patient outcome or complication, then I handle it very differently.
I'll call my co-resident to kind of talk over the case and be like, what do you think happened?
I'll talk to my attending. They are usually very good about being like, hey, let's talk about what

(48:42):
happened and what we could have done better. I will call other attendings who weren't part of the
case and just be like, what do you think happened? So a lot of that just becomes an educational
learning thing for me. And also, I think it's helpful to hear from people who have been through
it and have seen a lot. There's that saying, if you don't have complications, you don't operate
enough. It's just inevitable and things are going to happen. And I think it's good to talk to people

(49:08):
who have been through it and kind of hear about how they like to process it and how they navigate
some of the challenges. Because at the end of the day, the surgeries are great. I am very open about
how I love the technology and how I love operating. But at the end of the day, it's like you said,
there's someone on the table, there's someone that we're trying to take care of. And it's very,
very hard when things don't go the way that we planned them to. So I think it's important to have

(49:31):
a good support system in place, both in and out of within your specialty. So I'll talk to my mom
who's in medicine, but not in vascular surgery. So sometimes that extra perspective will help a lot
as well. But I think for that stuff, it's important to reach out. It's important to
not just withdraw and try to keep it all for yourself. Because there's someone out there who's

(49:55):
seen it before. I guess it's also helpful to have like, try, I don't know how it is in residency,
to have a life outside of medicine somehow too. I guess hobbies and stuff.
At the top of your green, but still very good.
I agree. Dr. Yang, I learned so much today. And I'm so honored to have you on.

(50:16):
I'm honored to be here. You're on season three.
Season three. And it's such an honor to talk about one of my most favorite things.
Femoral arteries.
Femoral artery access. I mean, like, how, I cannot sleep. Literally, I cannot sleep.
But I am so honored. And thank you again for joining me. And I love this episode. Thank you so much.

(50:44):
Thanks for having me. This was a lot of fun.
Of course. Have a great rest.
Thanks. Bye.
Bye.