Vascular Lab 360: Are we losing control?
2012; Elsevier BV; Volume: 55; Issue: 2 Linguagem: Inglês
10.1016/j.jvs.2011.10.125
ISSN1097-6809
Autores Tópico(s)Cerebrovascular and Carotid Artery Diseases
Resumo"Only one who devotes himself to a cause with his whole strength and soul can be a true master. For this reason mastery demands all of a person"–Albert Einstein It is with the greatest honor that I stand before you today as president of the Eastern Vascular Society on this special 25th Anniversary of the society. This society has been very special to me since I joined 21 years ago, and I have not missed one single meeting since I joined in 1990. The Eastern Vascular Society was founded in 1987 by leaders in vascular surgery on the east coast of the United States, who have led the way in our society and played a prominent role in the leadership of our national Society for Vascular Surgery (SVS). In looking at the names of our past presidents, eight of them have served as president of the SVS/American Association for Vascular Surgery. It should also be noted that from the current officers of the Society for Vascular Surgery, the president, the vice-president, secretary, and the treasurer are current members of the Eastern Vascular Society. Over the past 25 years, our specialty has matured substantially. Today's vascular and endovascular surgeons provide the most comprehensive diagnosis and management of the entire spectrum of vascular disease, particularly in an era where several other specialists are engaging in treating patients with peripheral vascular disease. Today's vascular surgeons provide not only the best open vascular techniques but also the most modern endovascular therapy and comprehensive medical therapy. As vascular surgery has matured and expanded over the past 25 years, the Eastern Vascular Society has also expanded significantly. Today's Eastern Vascular Society is the largest regional vascular society in the United States, with approximately 600 members representing major academic medical centers and community hospitals in the eastern region of the United States and Canada. I would not be standing here in front of you today without the assistance of many people who have had a huge impact on both my personal life and my professional career. I want to apologize in advance to anyone that I may miss who has influenced me, personally or professionally, but I must recognize those who have had special roles in my life. I would like to start by thanking my parents, who unfortunately cannot be with us today, since my father passed away 25 years ago and my mother 15 years ago. They would have been extremely proud of my achievements in the United States of America after their hesitancy regarding whether or not I should leave my native country and immigrate to the United States. Both parents instilled in me the importance of work ethics and integrity and taught me very important values regarding honesty, caring, and genuineness. Both were simple country people who would be proud of the achievements of their son on this occasion. My wife, Marion, has given me unwavering love, support, and understanding. She has been my companion for close to 30 years and has been, and always will be, my closest friend. I want to thank you, Marion, for the tremendous support you gave me in the early years when I barely had time to arrive home in time for dinner or for special occasions. As a surgical nurse, she always understood the duties and responsibilities that come with being a vascular surgeon. I also appreciate her hard work and dedication to our family. You are a loving mother and wife who has inspired all of us to be the best we can be. Thank you. I would also like to thank my three children, who have been patient and understanding, at least during the later stage of their life, regarding my duties as an academician and vascular surgeon. My two sons, Zachary and Joseph, and my daughter Chelsea, have given me a fulfillment that professional success alone could never have provided. My children provide me insights into my flaws. On a professional level, I want to recognize a few important leaders who have had the greatest impact on my professional career, and I would like to start with the late Dr James Boland (Fig 1) , who chaired the Department of Surgery at the Charleston Campus of West Virginia University/Charleston Area Medical Center (CAMC) for 35 years. Dr Boland fostered my interests in vascular surgery during my senior surgical residency and served as a talented and unselfish mentor during my early academic career, which continued until his death in April 2011. Dr Boland was an inspiring leader, master surgeon, and a man of few words who had the utmost integrity and dedication to surgical education. To me, he was a mentor, great friend, father figure, and my true hero. I wish he could have been with us today because he would have been very proud of my achievements. Dr Boland, we miss you. I would also like to acknowledge Dr Edward Diethrich, who taught me most of my vascular technical skills during my vascular fellowship. I also credit Dr Diethrich for my early career in endovascular intervention during several visits to the Arizona Heart Institute, where I learned many of the endovascular skills in the late 1980s and 1990s, such as percutaneous transluminal angioplasty and stenting. His visionary ideas and enthusiasm were highly motivating to me. Dr Diethrich is a powerful leader who has redirected the path of our specialty and kept us in the endovascular game when many people were denying our role in this new field. In my mind, I consider Dr Diethrich and Dr Frank Veith as the two most powerful leaders in our specialty and who kept endovascular procedures in the domain of our specialty. I would also like to acknowledge three national leaders who have had a significant impact on my professional career, and I give them credit for many advances in my academic career and national recognition. These leaders are John Bergan, Frank Veith, and Robert Rutherford. My contact and personal communication with these three vascular surgeons extended over 20 years through visits to my institution and assisting me in establishing my annual West Virginia Vascular/Endovascular Symposium for over 20 years in both Charleston and at the famous Greenbrier Resort in West Virginia. In fact, Dr John Bergan assisted me in establishing my first symposium 21 years ago, and he continued as a partner in this endeavor for 20 years. Similarly, Frank Veith has been a powerful leader in our specialty and has tirelessly fought to establish our specialty as an independent vascular specialty. Frank redirected the path of the vascular specialty and kept us from extinction. I cannot resist reminding our members of the 50th Presidential Address by Frank Veith, "Charles Darwin and Vascular Surgery," who likened the evolution of vascular surgery to the observations of Charles Darwin on the evolution of the species. At that time, Frank felt that we, too, were evolving, but that we must be aggressively proactive in what is now a very rapid evolution; in Darwin's terms, we have to be the fittest if we are to survive. Perhaps, most of the members remember Frank Veith's statement over a decade ago: "Become endo-competent or become extinct."1Veith F.J. Presidential address: Charles Darwin and vascular surgery.J Vasc Surg. 1997; 25: 8-18Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar I learned, through my communications with these leaders, the wisdom of critical thinking. I don't want to finish this portion of my presentation without recognizing the friendship, support, and guidance that I received from several of the past presidents of our society with whom I worked closely during my tenure on the executive council or as an officer: Anton Sidawy, Bruce Perler, Enrico Ascher, Dhiraj Shah, Bill Flinn, Clem Darling, Keith Calligaro, and Michel Makaroun. Thanks to all of you. Finally, I am indebted to my associates at the Charleston Division of West Virginia University and all of the members of our team at the Vascular Center of Excellence at Charleston Area Medical Center (Fig 2) , who have been very supportive of me, particularly over the past decade. They tolerated my excessive absence, mostly for academic purposes, both nationally and internationally. They also relieved me of the duties of taking call for the past few years, and more often than they think, they taught me so much. Specifically, I want to thank one of my associates, Dr Mark Bates, who helped me in this regard. I give credit to Mark, who helped me during my first carotid stenting in the 1990s and continued until I had mastered this technique. He was instrumental in teaching me advanced and complicated endovascular skills. I also want to thank Mark for standing with me, along with our late chairman, in developing our Vascular Center of Excellence almost 15 years ago, which is now considered the most outstanding facility for vascular care in the state of West Virginia. For those of you who may not know much about West Virginia, I would like to take this opportunity to let you know that several years ago we opened a modern Heart and Vascular Center of Excellence ($80 million), which has a joint medical directorship between Dr Bates and me. We also believed that having a multidisciplinary team would be beneficial to patient care and also to our success. Today, our Vascular Center of Excellence has 10 full-time faculty members, consisting of 6 board-certified vascular surgeons, 2 interventional cardiologists who completed an extra year of dedicated vascular intervention fellowship and have expertise and interest in vascular surgery, 1 vascular medicine/vascular interventionist with 2 years of a vascular intervention fellowship, and 1 physician who is dedicated to preventive vascular medicine. I also want to thank Dr Patrick Stone for returning to Charleston, after completing his vascular fellowship in Florida, to join Dr Boland, Dr Bates, and I in establishing our accredited vascular fellowship several years ago. I strongly believe that with this nucleus we were able to recruit several young talented physicians: Aravinda Nanjundappa, Stephen Hass, John Campbell, Albeir Mousa, James Campbell, Shadi Abu-Halimah, and Mohit Srivastava. Over the past several months, as I reflected on a topic for the presidential address, I reviewed more than two dozen previous presidential addresses of both regional and national vascular societies. I also discussed this with several of our past presidents to elicit their ideas. One thing I realized is that our members don't need another lecture on endovascular surgery or another "state of the union" address from another president. After looking into the main component of our specialty, which includes open vascular surgery, endovascular surgery, venous diagnosis and intervention, and vascular laboratory and imaging, I would like to remind you that nationwide, we perform 70% of the endovascular aneurysm repairs and about one-third of peripheral and carotid stent procedures, while numbering less than 20% of physicians who lay claim to vascular care.2Centers for Medicare & Medicaid ServicesPart B physician/supplier procedure summary public use file.Aug 3, 2009Google Scholar, 3Steppacher R. Csikesz N. Eslami M. Arous E. Messina L. Schanzer A. An analysis of carotid artery stenting procedures performed in New York and Florida (2005-2006): procedure indication, stroke rate, and mortality rate are equivalent for vascular surgeons and non-vascular surgeons.J Vasc Surg. 2009; 49: 1379-1385Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 4Vogel T.R. Dombrovskiy V.Y. Haser P.B. Graham A.M. Carotid artery stenting: impact of practitioner specialty and volume on outcomes and resource utilization.J Vasc Surg. 2009; 49: 1166-1171Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar After a lengthy debate, I realized that covering the present topic related to vascular laboratories would be of great interest based on the evolution of the vascular laboratory over the last 30 years and the present abuse of vascular laboratories all over the country. I am not here today to expound on politics and what should be done regarding endovascular procedures. However, you can't help but notice that for peripheral endovascular procedures, close to 70% are performed by nonvascular surgeons, and I don't want this trend continued for vascular laboratory dominance also. Therefore, this is why I chose to speak on "Vascular Lab 360: Are We Losing Control?" Noninvasive testing has its roots in the early research laboratories over 50 years ago. The first laboratory was established at Massachusetts General Hospital in 1946. These early efforts of objective assessment of vascular disease date to the days when sympathectomy was the only surgical treatment for vascular insufficiency. Measurements of changes in skin temperatures or vascular resistance was used to demonstrate changes in the sympathetic activity. These led to the introduction of plethysmographic devices to record pulse pressure waveforms. Several methods included application of a variety of pneumatic and strain-gauge sensors. Some of these were the Windsor pneumatic plethysmograph, followed by the pulse volume recorder, which continues to be used today. Further applications of pneumatic plethysmography were the Cranley phleborheograph, Gee's ocular pneumoplethysmography, Kartchner's plethysmography, and more recently, air plethysmography by Nicolaides. Other innovations include recording and analysis of vascular bruits (carotid phonoangiography), electrical impedence plethysmography of Wheeler for detection of deep vein thrombosis, and photoplethysmography. The application of ultrasound techniques for vascular diagnosis has played a major role in this field. Satomura used Doppler signal processing for transcutaneous detection of blood flow, which led to the development of the early nondirectional continuous-wave detectors. Technical improvements in this initial discovery included the design of directional detectors and, later, the evolution of processors to measure the frequency characteristic of the Doppler-shift signals. The continuous-wave Doppler velocity detector was responsible for the rapid growth in noninvasive testing in the 1970s. A parallel development was achieved in the ultrasound imaging of blood vessels. Initially, this equipment provided static, low-resolution images; however, technologic improvements provided real-time images that helped to advance this field. Perhaps one of the most important advances was noticed after 1972, when Strandness and his associates at the University of Washington developed duplex scanning, combining flow and image information in the same examination. By the early 1980s, the duplex scanner became widely used in clinical practice. Its initial application was for the noninvasive examination of the carotid artery, followed by its application in the peripheral arterial and venous systems and later into the abdominal visceral vessels. This was followed by the development of color-flow encoding, which has simplified and shortened many of the difficult examinations. As indicated earlier, the first laboratory designated for the study of human peripheral circulation was established by Linton at Massachusetts General Hospital in 1946.5Cranley J.J. Lohr J.M. Evolution of the vascular laboratory.J Vasc Technol. 2001; 25: 185-193Google Scholar Other laboratories that followed in the 1950s and 1960s included those of John Cranley at Good Samaritan Hospital in Cincinnati, Ohio, and the blood flow laboratory of Professor W. T. Irvin at St Mary's Hospital in London, England. In the 1970s, vascular laboratories and noninvasive testing became the focus of many vascular surgeons. In 1971, using the pulse volume recorder, R. Clement Darling and Jeff Raines reopened the vascular laboratory at Massachusetts General Hospital for clinical use. Other vascular laboratories were established soon after that at Northwestern University Medical School in Chicago, Illinois (John Bergan and Jim Yao); Good Samaritan Hospital in Cincinnati, Ohio (Cranley); the VA Hospital at the University of Washington in Seattle, Washington (Gene Strandness); Scripps Clinic in San Diego, California (Eugene Bernstein); the University of Colorado, Denver, Colorado (Bob Rutherford and Richard Kempczinski); and the Arizona Heart Institute, Phoenix, Arizona (Edward Diethrich). Our noninvasive vascular laboratory at CAMC was started in 1978 as one of the early vascular laboratories in the mid-Atlantic region. In 1976, the TransAtlantic Inter-Society Consensus task force of the American Heart Association, the Inter-Society Commission for Heart Disease Resources, published their report on testing for peripheral arterial disease (PAD).6Bergan J.J. Darling R.C. DeWolfe V.G. Raines J.K. Strandness Jr, D.E. Yao J.S. Report of the Inter-Society Commission for Heart Disease Resources Medical instrumentation in peripheral vascular disease. Resource and planning guidelines for the hospital and physician.Circulation. 1976; 54: A1-A9Crossref PubMed Scopus (1) Google Scholar The group concluded that a clinical vascular laboratory was desirable in institutions treating vascular disease, including venous thromboembolism. They recommended the establishment of a clinical laboratory in a hospital was desirable to provide studies vital to preoperative and postoperative management of patients undergoing arterial reconstruction and to provide services to patients suffering from venous thromboembolic disease. This document provided the blueprint for many hospitals in the United States to establish a fee-for-service vascular laboratory. This development could not have been achieved without the assistance of vascular technologists. In 1977, the Society of Vascular Technology was established during a noninvasive diagnostic symposium organized by Gene Bernstein in San Diego. This cooperative work between vascular technologists and vascular surgeons has fully developed the vascular laboratory as it is known today. Most techniques used during the early stages were indirect testing: supraorbital Doppler or ocular plethysmography for carotid stenosis, or impedence plethysmography or phlebogram for venous thrombosis. However, with the introduction of duplex scanning in 1979 by Gene Strandness and David Phillips of the University of Washington, the evolution of the modern vascular laboratory was created. Perhaps the two most important events that popularized noninvasive vascular technologies in the late 1970s and through the 1980s were the vascular symposium of noninvasive diagnostic techniques by Gene Bernstein in San Diego and the annual international noninvasive cardiovascular congress sponsored by the Arizona Heart Institute in Phoenix, which was conducted for over 10 years. Several hundred people attended these meetings and eventually spread this technology both nationally and internationally. The growth in noninvasive vascular testing has required trained people to carry out these examinations. Much of the original work was performed by the doctors, primarily vascular surgeons, who developed this kind of testing. With time, other physicians studied and duplicated the work reported by the early pioneers, but the problem came when clinicians decided to create a new testing facility without going through learning-curve experience by the researchers. In some cases, interested physicians visited established laboratories for brief periods to learn techniques and to pick up the practical tips. Lectures and dedicated courses helped to school many in the basic components of this new field. With the growth of the complexity of noninvasive testing and the time required for examinations exceeding the time that physicians could dedicate to these studies, technologists were increasingly recruited from a variety of backgrounds, including nurses, physician assistants, catheterization laboratory or operating room technicians, and a variety of research assistants. By the 1980s, almost all vascular laboratory testing in the United States was being done by technologists under the direction of physicians. As indicated earlier, most of the developments of early physiologic testing were carried out by vascular surgeons and other researchers in the field of vascular disease. As technologic improvement made ultrasound imaging a clinical reality, there came an increasing interest by radiologists. There was an explosion in noninvasive testing by the mid-1980s, and other specialties became involved, including neurology, neurosurgery, cardiology, and even urology. Noninvasive testing is currently performed in a wide variety of settings, ranging from solo practitioners doing the tests themselves in their offices to large hospitals, vascular centers, and vascular mobile units. Presently, noninvasive vascular laboratories are an integral part of the fee-for-service diagnostic services in any hospital providing care to patients dealing with vascular disease. It is estimated that close to 10,000 vascular laboratories exist in the United States, and only 2400 of these are accredited.7Bandyk D.F. Being a profession of vascular ultrasound.J Vasc Ultrasound. 2003; 27: 153-156Google Scholar Recognizing the importance of the noninvasive vascular laboratory is now designated, along with open vascular surgery, endovascular surgery, medical management, and critical care, as one of the five components of training requirements and credentials for hospital privileges in vascular surgery.8Moore W.S. Clagett G.P. Veith F.J. Moneta G.L. Webster M.W. Stanley J.C. et al.Guidelines for hospital privileges in vascular surgery: an update by an ad hoc committee of the American Association for Vascular Surgery and the Society for Vascular Surgery.J Vasc Surg. 2002; 36: 1276-1282Abstract Full Text PDF PubMed Scopus (14) Google Scholar In the late 1980s, there was growing concern among the leaders in noninvasive vascular testing about the call from the medical insurance companies for the regulation of all noninvasive testing and for elimination of payment for vascular testing. Isolated cases of highly fraudulent operations were well publicized and caught the attention of many payors. Leaders in the field voiced the need for better self-policing of this entity. There was also concern that some specialty organizations might take the initiative to create standards for vascular laboratories. Finally, in 1989, an informal meeting of leaders in the field of noninvasive testing proposed studying the possibility of establishing a voluntary accreditation process. This initial group included vascular surgeons, radiologists, and vascular technologists. Support and financial sponsorship were sought from a variety of professional societies whose members at that time were involved in noninvasive vascular testing. The initial meeting was dedicated to defining the scope of the noninvasive vascular laboratory accreditation and the minimum guidelines necessary for quality assurance. The overall objective was to ensure high-quality patient care by providing a mechanism that recognized laboratories providing quality vascular diagnostic techniques through the process of voluntary accreditation. Earlier, the accreditation was felt to be as inclusive as possible, something that could be achieved by even the smallest laboratory that was doing quality work. Another important principle that was adopted was that accreditation would not require specific medical specialty training but would evaluate the particular education and expertise of the doctors and technologists in each laboratory, which I personally felt was abused in the later stages of vascular accreditation. In March 1990, a group adopted the constitution and bylaws for the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL), and in November 1990, ICAVL was incorporated as a nonprofit corporation in Maryland. The members of the ad hoc work group became the original board of directors, and Brian Thiele, who had chaired the work group (the SVS secretary later), became the first president of the ICAVL. In January 1991, Sandra Katanick, RN, RVT, was selected as the executive director and charged with creating the administrative structure for the commission. The initial group of 36 laboratories was accredited in January 1992. Presently, approximately 2000 vascular laboratories are accredited by the ICAVL (Fig 3) . It is not uncommon for many of our vascular surgeon colleagues to see patients for a vascular evaluation who have already undergone noninvasive testing, whether in a nonaccredited vascular laboratory or even an accredited one, which has already been interpreted by physicians who are not qualified to read the tests. Many of these tests are done by unqualified technicians or are interpreted by physicians who lack the vascular training background to qualify them to properly interpret these tests, giving either falsely positive or negative results, with major clinical implications. Many of us would then be facing the dilemma of whether to order further imaging, which may be associated with excessive costs, or ordering another vascular laboratory test in a more qualified vascular laboratory, which unfortunately, would end up not being paid for by insurance companies, thus raising a major dilemma for physicians, patients, and hospitals alike. This trend is becoming so frequent that my own estimate at our institution is that more than 50% of patients referred to us will fall under this description. The increasing number of nonaccredited vascular laboratories and an increasing number of physicians (nonvascular surgeons or vascular specialists) who may not be qualified in vascular laboratory interpretations, as reflected by the statistics that will be shown later, is a significant challenge to us all. Recent ICAVL statistics (March 2011) show that the percentage of vascular laboratory medical director qualifications was as follows: 47% vascular surgery, 22% cardiology, 10% radiology, 6% vascular medicine, 4% neurology, 4% general surgery, 2% internal medicine, and 1% family medicine. The percentage of medical staff specialties were radiology as the dominant medical staff, constituting 41%, followed by vascular surgery at 27% and cardiology at 17%; however, other noted specialties who interpret vascular laboratory tests include cardiovascular and thoracic surgery, family medicine, general surgery, and even phlebology (Table I and Fig 4) .Table ICurrent specialties in laboratories accredited by the Intersocietal Commission for the Accreditation of Vascular LaboratoriesSpecialtiesNo. (%)Medical director Vascular surgery293 (47) Cardiology139 (22) Radiology/interventional radiology71 (10) Vascular medicine37 (6) General surgery28 (4) Neurology/neurosurgery27 (4) Internal medicine13 (2) Cardiovascular and thoracic surgery3 (1) Family practice2 (1)Medical staff Radiology/interventional radiology808 (41) Vascular surgery549 (27) Cardiology353 (17) Neurology/neurosurgery82 (4) General surgery78 (3) Vascular medicine48 (2) Cardiovascular and thoracic surgery7 (1) Family practice5 (1) Phlebology1 (1) Open table in a new tab What is more interesting is the trend in the dwindling number of vascular surgeons as the dominant percentage of vascular laboratory directors, or even as physicians interpreting studies in the vascular laboratory. As noted in Table II, there was a decreasing trend in the number of vascular surgeons as medical directors for the vascular laboratory, dropping from 76% in 1993 to 51% in 2011. In contrast, the number of cardiologists rose from 2% in 1993 to 27% in 2011. This is very clearly shown in Fig 5, which shows the significant drop in the number of vascular surgeons and the significant increase in the number of cardiologists as medical directors of these laboratories. These numbers can even be misleading if you take into consideration the majority of laboratories that are not accredited in the United States because many of these are located in cardiology offices.Table IIPercentage of specialties of medical directors in laboratories accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories from 1993 to 2011YearsVascular surgeon (%)Radiologist (%)Internal medicine (%)Cardiologist (%)Neurologist (%)19937611522199470154231995671742419966518434199762203441998592245319995724464200055243732001512448320025323483200354234103200453224113200553214113200654184163200753165193200854165203200951144244201052144254201151103274 Open table in a new tab I believe that the proliferation of nonvascular surgeons as medical directors or as physicians in general interpreting vascular laboratory tests can be explained by several reasons: 1the market share of the cardiology group, which far exceeded the number of vascular surgeons or other vascular specialists in this field;2concern for increased revenue, at least in some practices;3many others believe the present standard of the ICAVL in regards to the minimal physician qualifications for physicians to interpret vascular laboratory testing would only encourage many physicians, regardless of their background, to qualify to interpret these tests, particularly in the informal training pathways; and4the American Registry for Diagnostic Medical Sonography (ARDMS) standards in granting physicians to qualify in taking the examination of the Registered Physicians Vascular Interpretation (RPVI) are somewhat similar. The present standards of ICAVL are summarized in the following: Standard for Medical Director AMedical Director qualificationsBTraining and experience requirements 1The Medical Director must demonstrate an appropriate level of training and experience by meeting one or more of the following: aFormal TrainingCompletion of a residency or fellowship that includes ap
Referência(s)