The future of vascular surgery
2015; Elsevier BV; Volume: 61; Issue: 5 Linguagem: Inglês
10.1016/j.jvs.2015.01.054
ISSN1097-6809
Autores Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoBefore we dig into where we are going, let's talk about how we got here. Any coherent discussion about the past always involves those who influenced us greatly; those who helped us get to where we are. I would like to honor two individuals who are no longer with us, both of whom had a permanent influence on our field and on me. The first is William C. Krupski, MD (1947-2004; Fig 1). He died in a tragic diving accident off the Mendocino coast. Bill was the most gifted teacher I met in my career, and the influence he had on those around him and on the students and residents was profound. My considered plan as a student was to become a pediatric surgeon. After medical school at Johns Hopkins, and having grown up in California, I wanted to return West. That meant the University of California, San Francisco (UCSF) would be at the top of my list. My wife Vicky, also a medical student, was 7 months pregnant while we were interviewing. We had to make the usual residency tour on whatever schedule that we could arrange because we had a narrow window for travel. Although we were not able to make the mass interview day, the UCSF Surgery Department made arrangements for me to be interviewed. I believe this was primarily because the Pediatrics Department really wanted my wife. On the arrival of the appointed day, my big day, no one at the Surgery Department seemed to know anything about it. They were suddenly searching for someone, anyone, who could potentially speak to me, and call it an interview. I went by cab over to the San Francisco VA Hospital where Dr William Krupski, the newest faculty member and the first vascular surgeon I had met, was figuring out how to fit an interview into an already busy day. He ended up spending more than an hour with me, and I went away with a lifelong friend. Several years into residency at UCSF, Dr Carlos Pellegrini shared with me over the scrub sink one day the story of how Bill Krupski had been my advocate on the residency selection committee. You never know those moments, those chance encounters, that are going to shape your life in some major way. The other individual who had that personal effect on so many of us is Eugene F. Bernstein, MD, PhD (1930-1995; Fig 2). Gene Bernstein was one those unusual individuals who could analyze an incredibly complicated scenario and make it understandable. Vascular surgery was so much better to have had Dr Eugene Bernstein in its ranks during its developmental era. After my first 3 years as a general surgery resident, I decided that vascular surgery was the right choice for me. I had the idea of going home to San Diego for my research fellowship. I liked the possibility of having my kids around the grandparents for a couple years and to get to go surfing regularly at my familiar spots. I was introduced to Gene by my advisor, Dr Jerry Goldstone, who was UCSF Chief of Vascular Surgery. I worked in the laboratory with Dr Bernstein for 2 years. During that time I developed an appreciation for his finesse, skill at motivating others, and ability to communicate complicated ideas. He taught me how to develop and give a presentation, something I have done many times since then. A few years later, Gene's daughter became deathly ill. He spent a year nursing her and near the conclusion of that time was diagnosed with a brain tumor. He died shortly after she did. If you saw that in a movie, you might say, “that would never happen.” Bill Krupski and Gene Bernstein were both good-hearted people, who wanted the best for others. These are the kind of folks who draw you in and make you proud to follow the same career path. What about the role of the Western Vascular Society? All of my mentors and teachers came from the West. Many former presidents of the Western Vascular Society are counted among my professors, including Bill Krupski, Gene Bernstein, Ralph Dilley, Jerry Goldstone, Ron Stoney, and Linda Reilly. The Western Vascular Society and its members have played a major role in the development of vascular surgery and have helped to shape its future possibilities. I will come back to that later. Discussing our future requires understanding where we are. What is vascular surgery in the 21st century, the Information Age? I describe vascular surgery in this way. Full-spectrum care and long-term relationships constructed to make a difference in our patients' lives. The goals are practical, and the dilemmas are intellectually stimulating. The procedures include multiple techniques, are anatomically based, aesthetically pleasing, and technically challenging, with opportunities for innovation. There is a beautiful simplicity to vascular work. If some part of the body has no blood supply, it is blue and cold and painful. When perfusion is returned, it is warm and pink and happy. Vascular surgeons work hard, take on seemingly impossible cases at times, have incredible persistence, and are strong patient advocates. What could have motivated us to throw in with this lot? To help address this question, I recommend a book called Drive: The Surprising Truth About What Motivates Us by Daniel H. Pink.1Pink D.H. Drive: the surprising truth about what motivates us. Riverhead Books, Penguin Group, New York2009Google Scholar The ideas presented apply well to the practitioners of vascular surgery. Pink asserts, after extensive study, that we are searching for three desired qualities in our careers: autonomy, mastery, and purpose. Highly technical and proud vascular surgeons seek some level of “autonomy.” We want to know that, along with the patients, we are the decision makers. We want to take responsibility. We do not want to be interchangeable. With respect to “mastery,” we want to be able to provide the best possible techniques and procedures for our patients. Surgery is about “mastery.” “Purpose” in vascular surgery is an easy one: What higher “purpose” can there be than saving lives and limbs and preventing mayhem? Vascular surgeons spend their expertise and hard work to make a difference in the lives of patients. These things are not going to change, almost no matter what the future brings. Obviously, there is no way of predicting what will happen next. Humans are bad at that. In fact, we have a track record of poor performance. In 1876 Alexander Graham Bell presented to Western Union, one of the largest companies in the United States, the offer to sell his invention, the telephone. William Orton, president of Western Union, responded that, “the telephone has too many shortcomings to be seriously considered as a means of communication.” Where is Western Union today? Around the same time, Lord Kelvin, President of the Royal Society, one of the greatest theoretical physicists of all time and the person that figured out so many things, including absolute zero, had this reaction to the possibility that X rays might affect medical care. “X rays will prove to be a hoax.” Human nature has not changed. In 2007, Steve Ballmer, the chief executive officer of Microsoft said, “There is no chance, that the smart phone is going to get any significant market share, no chance.” Even the brilliant among us face a real challenge in this regard. Paid professionals are consistently wrong about politics, finances, diplomacy, and major issues. The three biggest collapses during my career have not been in the vascular field but in world events and institutions. It did not seem that anyone saw coming the fall of the Berlin Wall, the implosion of the World Trade Centers, or the rapid fall of the global financial system in 2008 (except for perhaps Nassim Taleb).2Taleb N. The black swan: impact of the highly improbable. Random House, New York2007Google Scholar If we don't get it right, we will likely be in good company. However, it might be worthwhile to take a periodic break to assess the forces and influences that help shape our field and to make some guesses about where they are leading us. The present era has been marked by some specific and unusual characteristics. Human diseases that have killed or maimed for as long as humanity has existed have come under better control with innovative approaches. Everything we have or need is being reinvented at a rapid pace, and unplanned obsolescence seems to rule the day. The Information Revolution has left no stone unturned. What happened to dial telephones, cash registers, Life Magazine, vacuum tube television sets, and typewriters? Why do we need Post-it notes? Why is everyone fondling their cell phones? We have become dependent on some items and some activities that we did not even know we needed. Ipads? Starbucks? Developments in medical care and practice parallel the major trends being exhibited in society today. We are incredibly fortunate to have experienced vascular practice in this era, where the pace of development has been shocking. For readers under 30 years of age, I just wanted to inform you that we used an X-ray light box for decades to view any radiographic studies. Can you believe we actually used these things (Fig 3)? Now I do all my squinting in front of a different type of screen. When the work order came through to have my X-ray box removed, I canceled it because I was convinced that I would need it some day for something. Now it remains as a reminder of how wrong I was. The X-ray viewing box is never coming back. The procedures we perform, the ones we perfect and offer to patients, are the most outward manifestation of vascular surgery. Let's look at how these procedures have changed in recent decades. Common vascular operations 50 years ago included amputation, sympathectomy, and trauma (Table). Balloon angioplasty was invented in 1964. Vascular surgery as a group did initially not embrace this new tool. Balloon angioplasty is one of the few things on earth that has not changed much since 1964, but we are using it a lot more now.TableMost common vascular operations19641989Now25 years from now50 years ago25 years agoAmputationCEACEA/CAS?SympathectomyOpen AAAEVAR/PEVARTraumaFemoropoplitealLower extremity PTA/stentFemorotibialWay distal bypassAortobifemoralAAA, Abdominal aortic aneurysm; CAS, carotid artery stent; CEA, carotid endarterectomy; EVAR, endovascular aneurysm repair; PEVAR, percutaneous endovascular aneurysm repair; PTA, percutaneous transluminal angioplasty. Open table in a new tab AAA, Abdominal aortic aneurysm; CAS, carotid artery stent; CEA, carotid endarterectomy; EVAR, endovascular aneurysm repair; PEVAR, percutaneous endovascular aneurysm repair; PTA, percutaneous transluminal angioplasty. By the time 1989 rolled around, about 25 years ago, I was chief resident and the most common vascular operations were carotid endarterectomy, open aneurysm repair, femoral-popliteal bypass, femoral-tibial bypass, and aortobifemoral bypass. Now what are the most common operations? Carotid endarterectomy is still useful and safer than ever, but the addition of carotid stenting has provided an option for anatomic high-risk patients and also forced us to re-examine our approach to asymptomatic patients, the elderly, and those with coronary disease. Endovascular aneurysm repair (EVAR) has largely replaced open abdominal aortic aneurysm (AAA) repair. Now EVAR is almost exclusively performed percutaneously in our practice. Lower extremity angioplasty and stenting has mostly replaced infrainguinal bypass. When we perform a distal bypass, it is usually to a very distal and challenging target. What will the landscape look like 25 years from now? We know we have a lot of work to look forward to. We just don't know exactly what we will be doing, yet. Eventually we will have a Tricorder as predicted on the old Star Trek series (Fig 4). Until then, we will need to be diligent and forward looking. The pace of change alone should help convince us that we must look ahead. Looking to the future might help us prepare for the next wave of innovation. We definitely need to understand any new tool before we offer it to our patients. However, when we resist innovation, we do so at our peril and possibly our patients' peril. Throughout human history, there has been a drive for innovation if a group wants to remain vital and prosper. Jared Diamond described it well in Guns, Germs, and Steel: The Fates of Human Societies.3Diamond J. Guns, germs, and steel: the fate of human societies. Norton and Co, New York1997Google Scholar…for thousands of years and over entire continents… containing hundreds of competing societies, some societies will be more open to innovation, and some will be more resistant. The ones that do adopt new crops, livestock, or technology may thereby be enabled to nourish themselves better and to outbreed, displace, conquer, or kill off societies resisting innovation. The point is not the potential to compete with other groups. We have had some competition between specialties wanting to help take care of vascular patients, and some of it has been regrettable. In the big picture, we are fighting a disease process, not each other, and thank goodness that a lot of folks from different specialties believe this is a special cause and want to participate. The point Diamond is making is that when we stop innovating, we are done. This means that constant change is in our future, and that is only if we are fortunate. One more thing before looking forward, let's look back. Here is an abbreviated history of the human race and the role of vascular care. It began ∼5 million years ago with the era of Australopithecus. Medicine as we think of it, has developed over the most recent 0.001% of that time span. Homo erectus came upon the scene ∼1 million years ago. Neanderthals disappeared ∼100,000 years ago. The species that most closely resembles modern humans appeared ∼80,000 years ago, and modern civilization has been developing for ∼6000 to 7000 years. Modern medicine has developed in tandem with modern civilization, although most of the aspects we think of as “modern medicine” have really been developed in the past 50 years. Bloodletting, the most common vascular operation of all time, has been known to be a common practice since 5000 b.c. Now when we “let blood,” we don't do it intentionally. In 200 a.d., Galen very smartly determined that the balance of the four humors (phlegm, yellow bile, black bile, and blood) must be maintained. The easiest way to adjust the balance, of course, was bloodletting. John Hunter may have been the first vascular surgeon.4Moore W. The knife man: blood, body snatching, and the birth of modern surgery. Broadway Book, a division of Random House, New York2005Google Scholar He is known for the first attempts to treat popliteal aneurysms, but he was also a battlefield surgeon who noticed that the wounded got worse when they were bled. He did not win many friends by standing against bloodletting in the 1740s. Throughout his career Hunter caused controversy because he had trouble getting along with people and because he was usually right. Bloodletting may have contributed to the demise of George Washington.5Kane J. The nine deadly diseases that plagued George Washington.July 4, 2011http://www.pbs.org/newshour/rundown/george-washingtons-medical-chart/Google Scholar He apparently had a very severe infectious pharyngitis in December 1799. An aggressive infection required aggressive medical care and he was bled 8 pints of blood over the course of 2 days and subsequently died. Whether the bloodletting contributed, we don't know, but it could not have helped. Bloodletting remained a common practice until the beginning of the 20th century. It lasted a lot longer than aortobifemoral bypass. The tools that we need to care for vascular patients have not been around very long. In October 1978 I was sitting in anatomy class in the Hunterian building (named, of course, for John Hunter). Alan Walker, our anatomy professor and world famous paleontologist, came in one day and casually placed on the overhead projector an image of a cross-sectional anatomy (note: PowerPoint not yet invented). Most the time we had learned the anatomy longitudinally and rarely took the time to get too specific about the cross-sectional anatomy. He mentioned that there was this new thing called a “CAT scan” and that there was a fair chance that we would encounter one of these some day in practice and that we all needed to learn cross-sectional anatomy. After the collective groan dissipated, he simply shrugged and said that maybe it won't turn out to be a big deal, but we ought to learn it anyway. A year later, Hounsfield and Cormack won the Nobel Prize for the invention. Today's computed tomography scans are a crucial step of the evaluation and treatment of vascular patients. Advanced imaging of all kinds has been completely adopted into the field of vascular surgery, and we should be quite proud of this development. There is a clear advantage to having an exquisite level of anatomical detail that could not have been contemplated in a previous era. How would we practice without these? Blood types were identified in 1901 by Landsteiner. Insulin was invented in 1921 by Banting and Best. Penicillin was discovered in 1928 by Fleming. Koff designed the first dialysis machine in 1943. In 1953, a watershed year, the heart-lung machine was developed by Gibbon, medical ultrasound was introduced by Edler, and the double helix was described by Watson and Crick. The results of these advances have been so pervasive that it is difficult to imagine what vascular practice would be like without them. The concept of the paradigm shift was described by Thomas Kuhn in 1962.6Kuhn T.S. The structure of scientific revolutions. University of Chicago Press, Chicago1962Google Scholar He was a sociology professor at Columbia University. In The Structure of Scientific Revolutions, he explained that the paradigm was something that would be used as a standard course of action. Over time, anomalies, or what are initially considered aberrancies, appear within the paradigm. Eventually, these anomalies are solved with innovations. As these innovations are added to the system, the paradigm shifts. I suggest to you that vascular surgery has been in a shifting paradigm throughout its modern existence. To analyze where our field will go next, I will focus on three key issues: demographics, techniques, and new opportunities. Because medical care is a service, it is driven by demographics. Because vascular care is delivered in higher proportions to certain demographics, the facts and figures behind those population shifts will have a major effect upon our future. Life expectancy in the United States has risen dramatically since 1900. At that time it was under 50 years of age. When Medicare was established in 1965, with the qualifying age of 65 years, life expectancy was ∼66 years. In 2012, life expectancy in the United States reached 79 years.7Centers for Disease Control and Prevention. National Center for Health Statistics. October, 2014. Available at: http://www.cdc.gov/nchs/fastats/life-expectancy.htm. Accessed March 9, 2015.Google Scholar The number of people living in the United States at age 65 or older is increasing dramatically as the baby boomers reach the Medicare age range. The number will double between 2000 and 2030, when it is estimated that there will be 70 to 90 million Americans over the age of 65.8United States Census BureauThe older population: 2010.November 2011http://www.agingstats.gov/main_site/data/2012_documents/population.aspxGoogle Scholar It is clear from demographics that we will have plenty of vascular work to do. There is also a predicted shortage of vascular surgeons in the United States. A 2009 study showed the number of new vascular surgeons was only slightly in excess of those predicted to leave the workforce due to retirement.9Satiani B. Williams T.E. Go M.R. Predicted shortage of vascular surgeons in the United States: population and workload analysis.J Vasc Surg. 2009; 50: 946-952Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Between 2010 and 2030, our numbers will increase only slightly while the population of patients that may benefit from our services may double. The predicted population of vascular patients may also be an underestimation due to the following factors. There has been a dramatic decrease in cardiovascular death rates in the United States. This is still the most common cause of death but the rates decreased from 340 per 100,000 population in 2001 to 240 per 100,000 in 2010.10National Heart, Lung, and Blood Institute. 2012 NHLBI morbidity and mortality chart book. Available at: http://www.nhlbi.nih.gov/research/reports/2012-mortality-chart-book. Accessed January 22, 2015.Google Scholar This is a 29% decrease in a single decade. Cardiac mortality rates have dropped in men and women and across ethnicities. There are multiple reasons for this, including improved medical care, more aggressive management of acute coronary syndromes, and the widespread use of coronary drug-eluting stents. Between April and August 2003, drug-eluting stents went from 0% to >90% of the stents used, with the associated significant decrease in recurrent myocardial infarction, in-stent restenosis, and repeat revascularizations.11Jonas M. Resnic F.S. Levin A.D. Arora N. Rogers C.D. Transition from bare metal to drug eluting stenting in contemporary US practice: effect on incidence and predictors of clinically driven target lesion revascularization.Catheter Cardiovasc Interv. 2007; 70: 175-183Crossref PubMed Scopus (5) Google Scholar We now have the system not only to develop fantastic new tools but also to disperse them widely for maximum effect. As it happens, cancer death rates are also dropping in every single state.12National Cancer Institute. Surveillance epidemiology and end results program. Cancer Statistics Review, 1975-2011. Available at: http://seer.cancer.gov/statistics/summaries.html. Accessed March 9, 2015.Google Scholar Between 2000 and 2009, cancer mortality decreased in the United States from 199 to 173 per 100,000 population. The number of people living after cancer increased in the United States from 6.5 million to 12 million between 1990 and 2008. What does all this mean? First, the need for vascular care will be higher than what has been estimated, in my opinion. Second, we are in a Renaissance in medicine today. The European Renaissance didn't happen by accident. Many very bright people were competing for resources. Financing was available through families dedicated to advancing thought, art, architecture, and ideas. There was geographic proximity and there was an explosion of knowledge after the years in which minimal progress was made. The result was that it seemed natural for Bernini's sculptures, da Vinci's drawings, Brunelleschi's dome, and Michelangelo's ceiling to all happen around the same time. The results of these efforts left an indelible mark on our society. In much the same way, the dramatic explosion of new technologies, advanced treatments, and decreasing rates of death and disability have set a new standard. The Renaissance was a performance environment that produced innovations far outpacing previous centuries. We have the same situation in medicine today and we are so fortunate to be practicing now. What about the specific risk factors for vascular disease? In America today, fewer people smoke than any time since records have been kept. The Gallup organization reported in July 2014 that slightly less than 20% of adults smoke.13Saad L. Gallup poll results, July 9-12, 2012. One in five US adults smoke: tied for an all time low. Available at: http://www.gallup.com/poll/156833/one-five-adults-smoke-tied-time-low.aspx?utm_source=percentage%20of%20US%20adults%20who%20smoke%20cigarettes&utm_medium=search&utm_campaign=tiles. Accessed March 9, 2015.Google Scholar This has decreased from a high of ∼45% in the late 1940s. There are a number of reasons for this, but at least one of them is the counseling provided by vascular clinicians about smoking cessation. As smoking decreases, the prevalence of large-vessel disease may also decrease. Concomitantly, the number of people with diabetes is increasing dramatically in the United States. In 1980, there were 21 million.14Diabetes Report Card. National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation, Centers for Disease Control, Department of Health and Human Services. Available at: http://www.cdc.gov/diabetes/pubs/pdf/DiabetesReportCard.pdf. Accessed Accessed March 9, 2015.Google Scholar The estimated prevalence of diabetes in the United States was 8% to 10% in 2007. In 2025, it is estimated that the prevalence will be 10% to 14%.15Global Nutrition Market, Obesity and World Heath, 5/11/11. Global Sherpa: globalization, sustainable development and social impact in world rankings, countries, and cities. Available at: http://www.globalsherpa.org/nutrition-market-obesity-malnutrition. Accessed March 9, 2015.Google Scholar More diabetes means more chronic kidney disease (CKD). The prevalence of end-stage CKD increased from 250 cases per 1 million population in 1980 to 1750 per 1 million in 2009.16US Department of Health and Human Services, National Institutes of Health, National Kidney and Urologic Diseases Information Clearinghouse. Available at: http://kidney.niddk.nih.gov/KUDiseases/pubs/kustats/#7. Accessed March 9, 2015.Google Scholar The demographics of vascular care include more diabetic patients, more dialysis, fewer smokers, and more elderly. Patients will have at their service drug-eluting coronary stents, statins, and other medications to control risk factors, and excellent cancer treatments. There is a good chance that patients with a variety of chronic disease will live into an age group that previous generations could not have imagined. Our field developed open vascular reconstruction to the point where major operations on the sickest possible patients became a routine in the 1980s and 1990s. The result was that many conditions that were not survivable in all previous generations of human history had become treatable. It seems that before we could even congratulate ourselves about reaching that milestone, endovascular techniques were becoming clinically viable. The potential benefit of an upfront decrement in morbidity was substantial, even if the durability was not yet satisfactory. Despite the wide adoption of endovascular techniques at present, the durability of is still not adequate, even if there has been dramatic improvement during the past decade. The challenge with occlusive disease is that our endovascular treatment options cause too much local injury. Balloon angioplasty causes too much acute injury in the form of dissection. After the dissection occurs, we need to stabilize the lesion with a stent. Stents cause too much chronic injury and provoke an untreatable new problem, in-stent restenosis. This standard is about to be disrupted. We now have excellent data from three prospective randomized trials of femoral-popliteal occlusive disease showing substantial benefit to long-term patency when medication is delivered to the lesion by balloon or stent. The IN.PACT SFA trial and the Levant 2 trial both demonstrated a significant improvement in patency at 1 year after the use of drug-coated balloons vs plain balloon angioplasty.17Rosenfield K. Results of the Levant-2. Prospecive randomized controlled trial of drug-coated balloon angioplasty vs standard balloon angioplasty. Presented at the TCT meeting (Transcatheter Therapeutics form the Cardiovascular Research Foundation), Washington D.C., October 31, 2014.Google Scholar, 18Tepe G. Laird J. Schneider P. Brodmann M. Krishnan P. Micari A. et al.Drug-coated balloon versus standard percutaneous transluminal angioplasty for the treatment of superficial femoral and popliteal peripheral artery Disease: 12-month results from the IN.PACT SFA Randomized Trial.Circulation. 2015; 131: 495-502Crossref PubMed Scopus (477) Google Scholar The study sponsors and investigators have committed to monitoring these patients for 5 years after the study. Likewise, the Zilver PTX study showed a benefit vs balloon angioplasty and also bare-metal stent and that advantage has been shown to last up to 5 years.19Dake MD. Zilver PTX randomized controlled trial of paclitaxel-eluting stents for femoropopliteal disease: Five year results. Presented at the Vascular and Interventional Advances (VIVA) Meeting, Las Vegas, NV, November 4, 2014.Google Scholar The use of medication, topically applied to the vascular surface to enhance patency, is in its infancy. There are many issues requiring development, including the optimal drug, dose, excipient, delivery, how to prepare the vessel, and use in other vascular beds. Nevertheless, the possibilities for all kinds of reconstructions for occlusive disease are significant and just waiting for further advancement. The treatment of aneurysmal and large-vessel disease is also likely to change substantially in the next couple decades. We are well on our way to a time frame where we can achieve a total relining of the aorta from the coronary ostia to the femoral bifurcations. The management of infrarenal AAA with EVAR seemed like a reasonable end goal, especially since AAA is a common problem afflicting our patients and one of the main disease processes for which we take responsibility. However, it turns out that EVAR is just the beginning and has pushed our field to go further and to apply these techniques to the whole aorta. Issues remain to be worked out such as durable side-branches and minimizing organ ischemia, stroke, and paraplegia. However, there has been a steady march toward the ability to reline the aorta, and Western Vascular membe
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