Peripheral interventions editorial

I read Dr. Samson’s recent critique of nonvascular surgeons foray into the world of peripheral vascular interventions with interest. He points out in his article how the American College of Cardiology has changed its guidelines for percutaneous coronary interventions.

Suddenly, what once lacked evidence-based medicine now becomes justified. Is it a surprise to anyone that these same "vascular specialists" use the "rarely appropriate" indication to justify countless unnecessary peripheral vascular interventions?

Until the advent of percutaneous endovascular interventions, these "vascular specialists" had little to no interest in the treatment of peripheral vascular disease. It is only within the past decade that we have seen the emergence of "vascular specialists" who portray themselves as experts in the field of peripheral vascular disease.

Even more astonishing is that hospitals have embraced the concept of "heart and vascular centers" to bring these "vascular specialists" into the mainstream treatment of what was once the domain of vascular surgery.

I think three factors have led to Dr. Samson’s poignant set of observations. First, the number of cardiology trainees continues to outpace the need for coronary interventions. Since our cardiology colleagues already have access to patients with peripheral vascular disease, it is only logical that there would be interest in peripheral interventions.

Second, industry-sponsored trials have sought out high-volume physicians to enroll patients. Vascular surgeons are generally a conservative group, which is comfortable with the medical management of intermittent claudication and asymptomatic carotid stenosis, to name just a few examples.

The medical device industry quickly moved to physicians with a more aggressive approach to peripheral vascular disease. Lastly, hospitals needed to maintain the lucrative revenue stream afforded by coronary interventions and cardiac surgery.

With declining revenue it made sense for hospitals to economically credential "vascular specialists" to be the spokespersons for their "heart and vascular centers."

Proponents of "vascular specialists" argue that with an aging population, we will need a substantial influx of providers who can manage peripheral vascular disease. The flaw in this argument is that all of these patients are going to need procedures. Most vascular surgeons would argue that substantial numbers of patients with peripheral vascular disease would do quite well with medical management alone.

Certainly, we need to deal with symptomatic carotid disease, large aneurysms, and critical limb ischemia, but these patients account for a small proportion of those with vascular disease. It may well be that with shrinking Medicare, Medicaid, and third-party insurance coffers, government regulations will finally put an end to the countless number of unnecessary endovascular procedures.

Unfortunately for Dr. Samson and the rest of us, the future is not bright. Whereas inside the university there may be harmony among vascular surgeons and "vascular specialists," that is surely not the case in the community where vascular surgeons are faced with increasing competition.

With the tacit approval of hospitals and their hired consulting firms – who champion profits over delivery of evidence-based vascular care – the role of vascular surgery is becoming marginalized.

I would suggest that there has been deafening silence from our societies about the unique role vascular surgery has in treating peripheral vascular disease.

Who else has the training and skill to treat vascular disease with the most appropriate open or endovascular procedures – and more importantly, knows when to apply each method?

Perhaps the unbiased observer might ask the obvious, who needs a "vascular specialist"?

Dr. Samson’s observations point us to the answer in my view – the hospital.

– Richard David Edrington, M.D. Raleigh, N.C.

Carotid screening

I read your commentary article published in the online Vascular Specialist re: carotid screening and I have to say that you nailed it. I would think that any conclusion must be suspect if it is drawn on the basis of studies that are poorly performed by technologists of questionable skills who are usually not RVT’s, then are interpreted (if we are lucky) by internists or radiologists with no particular expertise in vascular disease. Worst-case scenario is that the techs actually interpret the study, as you noted. These are the same people that perform a duplex scan of the leg arterial system to evaluate the significance of arterial occlusive disease – no pressure studies at all!

I have had the same experience you have noted many times of having a patient come into the office holding a carotid scan report claiming a critical stenosis and our RVT finds no significant disease at all. The opposite is also true.

As is your practice, we never initiate treatment based on results from an outside lab. I believe that the only way we’ll see any change in this "open season" on performing noninvasive studies is to make reimbursement contingent upon lab accreditation.

This whole situation is reminiscent of that in the ’90s when carotid endarterectomy came under assault from studies designed and conducted by neurologists who had already drawn their conclusions before they enrolled the first patients.

Good job. Keep up the fight to inject a bit of reason into this, so far, one-sided debate.

– William M. Blackshear Jr., M.D.

Director, Vascular Institute of Florida, St. Petersburg

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