Disappearing Act

So that may be one reason that these non–vascular surgeon symposiums are starting to explode. But even more troubling is the role of industry, the suppliers of all the devices that allow physicians and surgeons to perform these endovascular procedures. Certainly, the major medical device manufacturers have been, and still are, very supportive of vascular surgery and vascular surgeons, but it is the endo world that is now their major playground. After all, how much profit will a company make when we bypass with a saphenous vein or use the cephalic vein for a fistula? It’s no wonder they want to exhibit at these endovascular meetings because it’s their stents, balloons, wires, catheters, lasers, and ablation devices that return a profit. And really, is it rational to expect industry to determine which specialist is most suited to use their product? One may hope that they would not sell a device to an untrained physician but, other than for insisting on some basic training, we cannot count on industry to credential its users.

However, the reasons for vascular surgeons becoming marginalized are even more complex. Further, I fear they may be insurmountable unless vascular surgeons admit that we are also partly responsible. First is the fact that, as a specialty, we were late to the party. Let’s face it, vascular surgeons did not invent endovascular procedures. It was Charles Dotter and cardiologists Gruentzig, Palmaz and Schatz who started the revolution. In fact, many of our earlier vascular leaders were so unimpressed that it took years before presentations about endovascular procedures made it into the SVS annual meeting or became part of vascular surgical training. Admittedly, since then many advances in these procedures have resulted from the genius of some vascular surgeons, especially in the treatment of aortic aneurysms, but which catheter or wire is named after a surgeon? Which surgeon invented the latest stent, ablation catheter, or saphenous venous ablation method? We have largely benefited from the inspirational work of interventional radiologists and cardiologists. They have invented the technologies and pushed the boundaries that have allowed us to access pedal and radial arteries, obliterate calcified arterial plaque, place medicated balloons and stents, and replace venous stripping with less invasive ablations. Moreover, they proved that these procedures can be done in outpatient centers where the remuneration exceeds that which we can earn when these procedures are performed in a hospital. So should we complain when cardiologists or interventional radiologists mount major symposiums dealing with vascular conditions? Yes, we may be correct that only vascular surgeons have been trained to understand all the ramifications of vascular disorders. However, this is changing as radiology and cardiology training programs increasingly add peripheral vascular disease to their curricula. Further, although vascular training programs now involve a great deal of endovascular training, many still do not offer significant exposure to some of the more “radical” therapies such as pedal access and advanced CTO techniques.

However, there is a more significant reason vascular surgeons are partly responsible for losing control over these symposia and vascular patients. That is, we have embraced endovascular therapies as being more financially remunerative, more “fun,” and less time consuming than open surgery. Why spend 4 hours bending over an operating table, harvesting veins from all over the body, staring through illuminated loupes and tediously sewing in a flimsy basilic vein into a tiny calcified tibial artery when, for a multiple of the payment that procedure would generate, one can spend an hour in the angio suite ballooning the responsible lesion. Better still, you get to do it all over again later and make the same amount of money twice! We probably have also brainwashed our referring physicians that this is best for the patient. After all, most internists still laughingly repeat the mantra “fem-pop, fem-stop, fem-chop.” Once convinced that endo is best, what’s to stop those doctors from allowing their favorite radiologist or cardiologist to treat their patient? That’s especially so since as a specialty we have not done a good job educating doctors and patients that vascular surgeons are also equally proficient in endovascular treatments. Vascular surgeons have been given an opportunity to prove one way or another whether surgical bypass plays a significant role in the management of CLI. That is by enrolling patients in the BEST trial, the first large NHLBI-supported RCT comparing endovascular to open surgical therapies. However, enrollment has been lagging to the point that the study may be prematurely terminated. Why is it that we have been so reluctant to enter patients? Is it ennui or is it that we lose income every time a patient is randomized to bypass rather than a lucrative outpatient atherectomy?