From the Editor

Endo hubris


 

I began to write this opinion piece on the red-eye flying back from the outstanding Vascular Annual Meeting, recently held in San Diego. I attended breakfast sessions at 6 a.m., as well as presentations and meetings going on well into the evening. I now have bloodshot eyes, tachycardia, and a heightened perception of things.

It is possible that I am just sleep deprived or maybe it’s a result of inhaling the ubiquitous “medical” marijuana vapors that constantly wafted outside the convention center. Whatever the reason, I have returned in a feverish state of excitement that accompanies a sudden significant insight ... that some of us are under the influence, not of some hallucinogenic, but rather an endovascular- induced euphoria whose spell has made us forget that we are still surgeons.

Dr. Russell Samson
Like most of the attendees, I was impressed by the many quality presentations, lectures, and the exceptional organization of this year’s VAM. However, it was the unsaid, the unprepared, and the less obvious undertones that had such a profound effect on me. For those who were not at the VAM, let me highlight the events that convinced me that it is time for a critical evaluation of who we are as vascular surgeons and where we are going as a specialty.

The exhibition hall had the few customary surgical equipment companies with their surgical loupes, vascular clamps, and needle holders. But it was the expansive displays of every type of endovascular tool, guidewires, catheters, x-ray equipment, endografts, and stents, that attracted the crowds. Not a single vascular ultrasound company showed off their duplex scanners despite the fact that vascular surgeons advanced the use of these instruments and made them as omnipresent as they now are in clinical practice. These companies now find it more profitable to show off their wares at cardiology and radiology meetings.

In the lecture hall, audiences packed in to hear the latest method to treat aortic aneurysms with every variety of endovascular device, but there was not a single presentation on open surgical alternatives. Further, an excellent vascular surgery resident was asked how he would handle a pararenal aneurysm in community practice. He admitted that, unless he could be assisted by an experienced surgeon, he would be uncomfortable performing an open surgical repair. Thus, he would be forced to perform an endovascular treatment even if it would not be the best alternative for the patient. But in the future, will there actually be accomplished surgeons who can assist the newly minted vascular surgeon with open procedures? At a breakfast session dedicated to the aging vascular surgeon, we learned that many will soon be retiring since 46% of the Society are now over the age of 50, and 30% are more than 60 years of age.

Where am I going with this? It is apparent my aphorism that a vascular surgeon can “Operate, Medicate, and Dilate” may no longer hold. Perhaps it should now be “Stent, Ablate, Dilate, and Dilate Again.” Future generations of vascular “surgeons” may be no more than cardiologists who don’t treat the heart, able to perform endovascular revascularizations but unable to perform open operations.

Training paradigms may be affected by middle-aged attending surgeons attempting to prove that they are current by adopting endo-treatments rather than open surgery. Some academic surgeons may see the need to experiment with new endo-techniques to advance their careers. Some may see profit patenting new devices. Some may just be enthralled by what Bruce Brenner refers to as “Endo hubris.” Irrespective, dwindling open procedures will inevitably result in inexperienced open surgeons who will feel comfortable only in an endovascular suite.

Payment inequities that undervalue open procedures and overvalue endovascular ones will promote a preference for endovascular alternatives, many of which are less physically demanding than open surgical procedures and bypasses. Thus, the preference for endovascular procedures will be perpetuated.

Concurrently, our cardiology colleagues will be honing their endovascular skills not only in the coronary arteries but also on the periphery. Soon they will claim superiority. Hospital administrators, already under the spell of Cardiology, will notice the declining profit generated by poorly performed open surgery and resultant prolonged hospitalizations. They will then continue to relegate vascular surgeons to even lesser roles than they now have in so-called Heart and Vascular Centers.

As our open skills deteriorate, patients will be forced to travel to the few centers where some exhausted elderly surgeons will perform the occasional open aortic procedure, distal bypass, or, heaven forbid, some ancient procedure referred to as a carotid endarterectomy.

Of course, some may argue that it is time that endovascular procedures replace “barbaric” or disfiguring open procedures. In fact, this may already be the case for the treatment of thoracic aortic pathology. However, I propose that the time for abandoning surgery has not arrived. There are now sufficient data to show that many endo-procedures are no panacea nor are they without significant limitations. Furthermore, if we abandon open surgery we essentially abandon our raison d’etre. What will then distinguish us from interventional radiologists and cardiologists?

I propose it is time for us to embrace our surgical prowess rather than to treat open procedures like Cinderella’s ugly sisters. I would encourage program directors not to stretch indications for use to justify endovascular treatments but rather adopt standard open procedures. If the volume of indicated open procedures is insufficient, then arrange for the trainee to visit another institution.

We must educate referring physicians and hospital administrators about the benefits of well performed open surgery, and we must make sure that such procedures are, in fact, successfully and expeditiously executed. Non-surgeons also need to be informed about some of the drawbacks of endovascular procedures so that they gain a realistic understanding of the pros and cons.

This does not mean being disparaging, but they should be educated about the occurrence and significance of endoleaks, stent fractures, early recurrence, and other complications. Thus informed, they will better understand the rationale for choosing a vascular surgeon to take care of their patients. They will realize that we remain the only specialists devoted to the understanding and treatment of vascular pathology and consequently able to perform the most appropriate and best treatment for that patient.

I am now fully awake. I am convinced that my evaluation of the events at the meeting were not some sleep-deprived or hallucinogenic aberration. I sincerely believe that it is time for drastic adjustments in our thinking about endovascular and open procedures. If not, vascular surgeons and our specialty may become irrelevant and the repercussions for our survival and that of our patients may be devastating. ■

Russell Samson, MD, a physician in the practice of Sarasota Vascular Specialists, Sarasota, Fl., and a clinical professor of surgery, Florida State University, Tallahassee. He is the medical editor of Vascular Specialist.

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