Breaking Down the Silos of Medicine
2014; Lippincott Williams & Wilkins; Volume: 61; Issue: Supplement 1 Linguagem: Inglês
10.1227/neu.0000000000000403
ISSN1524-4040
Autores Tópico(s)Acute Ischemic Stroke Management
ResumoI would like to thank Robert Spetzler for his entertaining introduction. Being a special honored guest at the Congress of Neurological Surgeons is indeed the greatest honor I have ever had, and I was reminded that none of my achievements would have been possible without support from great colleagues and my family. The vascular and endovascular neurosurgery team at Buffalo includes Elad Levy, Adnan Siddiqui, Kenneth Snyder, colleagues in other specialties such as neurology, anesthesiology, radiology, and neurointensive care, as well as all staff in the operating room and neuroangiography suite. In addition, I would like to thank the Jacobs family, whose generous help has turned our vision of an integrated vascular center into reality. Moreover, I would like to publicly express my appreciation to my wife, Bonnie, who is really everything to me. The balance of family and professional life can be perfectly summarized by this quote attributed to the Dalai Lama. When asked what surprised him about humanity the most, he answered: Man, because he sacrifices health in order to make money. Then he sacrifices money to recuperate health. And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future; he lives as if he is never going to die, and then he dies having never really lived. It is in this spirit that I remind all of you, young and competitive, that there are more important things in life than your professional work. The theme of the 2013 Congress of Neurological Surgeons Annual Meeting, “Evolution of Neurosurgery,” explores the path neurosurgery has taken from the past to the present and illustrates what is needed for the future of our specialty. My talk today, “Breaking Down the Silos of Medicine,” fits well into this theme. I will discuss the history and evolution of endovascular neurosurgery and offer a solution of building a more integrated, comprehensive, and innovative vascular neurosurgery of the future by breaking down the “silos.” HISTORY AND EVOLUTION OF VASCULAR AND ENDOVASCULAR NEUROSURGERY Compared with the long history of medicine, vascular and endovascular neurosurgery is a relatively young specialty, yet it has gone through such remarkable technical advancement during the past century that catheter-based minimally invasive treatment of vascular pathology in the brain and spine has become neurosurgery's greatest opportunity.1 The birth of endovascular neurosurgery was through an intertwined history among groups of neurosurgeons, neuroradiologists, and neurologists. Egas Moniz, a Portuguese neurologist, performed the first catheter-based cerebral angiography in the 1920s,2,3 and the first embolization of an intracranial arteriovenous malformation was performed by Luessenhop and Spence4 in 1960. Endovascular neurosurgery at that stage was primitive and crude, with only large-caliber, nonflexible catheters available for access and a variety of nonspecialized materials for embolization, such as beads, pellets, muscle and fascia, Gelfoam sponge (Pharmacia & Upjohn, New York, New York), and silk.5-8 Moreover, endovascular treatment initially relied upon open surgical approaches to the carotid system, and it was not until the 1970s that the field of endovascular neurosurgery became independent and self-sustainable from open vascular neurosurgery.1 This milestone further spurred the rapid development of microcatheter technology for vascular access and new, visualizable embolizate that would allow controlled polymerization and distal penetration. An important figure in the history of endovascular neurosurgery is Charles Kerber, who, through tireless investigation, innovation, and mentorship, presided over a chronology of endovascular inventions and milestones.9 A naval aviator and flight surgeon, Chuck Kerber was seriously injured in an airplane accident and was hospitalized for more than 2 years, yet he overcame such adversity to become one of the greatest innovators in the field of endovascular neurosurgery. Kerber was one of the first interventionists to utilize the liquid embolic material of cyanoacrylate glue and performed the first arteriovenous malformation embolization with radiolucent isobutyl cyanoacrylate in 1974.10 Subsequently in 1979, he successfully opacified the isobutyl cyanoacrylate glue and made it radiopaque and visualizable during angiography.11 Additionally, he invented the calibrated-leak balloon catheter, which allows flow-directed placement of the catheter with the balloon inflated and distal fluid delivery with a calibrated leak.12 These catheters could still be used effectively today. Among Kerber's other achievements were his expertise in treating carotid-cavernous fistula by detachable balloons and carotid angioplasty, which he was the first to perform in 198013 and which was the ancestor to modern-day carotid angioplasty and stenting. Many recent milestones and their impacts on our field, such as detachable coils, Onyx (Covidien, Irvine, California) embolization, and mechanical thrombectomy for acute stroke intervention, have been discussed extensively by several investigators.1,14-16 Nevertheless, there were a few developments that also helped make endovascular neurosurgery a safer and better specialty, yet received little attention. One such event was the creation of a multidisciplinary morbidity and mortality conference at the national and international level (the Cerebrovascular Complications Conference), where the worst types of complications were brought together from around the world so that everyone could learn from them. In addition, surgeons have started to learn from the aviation industry about crisis management and safety improvement.17 Approximately 70% of all aviation accidents can be attributed, at least in part, to human error,18 and similar safety concerns exist in medicine and in endovascular neurosurgery. Adapting what has been learned and tried in other industries, such as the preoperative checklist,19,20 could help take our specialty to another level. NEW FRONTIERS OF ENDOVASCULAR TECHNOLOGY Even with numerous breakthroughs in the past few decades, endovascular neurosurgery continues to evolve and advance with remarkable speed as new technologies have made therapeutic options possible from simple observations. Aneurysm treatment is 1 example. To develop an effective endovascular treatment of intracranial aneurysms, one must understand 2 fundamental aspects of aneurysm physiology: blood flow and the platelet and coagulation cascade. The constant interaction between turbulent flow and laminar flow within the aneurysm sac and the parent vessel plays an important role in aneurysm rupture, thrombosis, and recanalization. Minor modification of flow, such as multiple stents placed at the base of a wide-necked aneurysm,21 could result in stasis and trigger platelet activation and the coagulation cascade, and eventually, aneurysm thrombosis. The idea of managing flow as a therapeutic means for intracranial aneurysms led to the invention of the Pipeline embolization device (Covidien), which is a pure flow diverter and can be a stand-alone device to treat an aneurysm without other embolic material. The concept of flow diversion is revolutionary, and we are only seeing the first generation of such devices, which, given time, will undoubtedly become an essential and integral part of aneurysm management in the future. Another exciting area of technological development is the design of smart endovascular devices, utilizing engineering advancements in the past decade, especially nanotechnology and material science. Wires and catheters can be coupled with miniature guiding systems to form self-steering “smart wires” and “smart catheters.”22 Advanced imaging modules can also be implanted in catheter and wire tips to provide real-time, intraluminal imaging. Moreover, microelectromechanical system devices and nanochips can be embedded in wires, catheters, or even stents and coils to give feedback information from the true “battleground” of vascular pathology (eg, aneurysm dome, site of carotid stenosis).23 These micromachines are versatile and could function as delivery vehicles; for example, specific proteins and other bioactive materials could be delivered into the aneurysm sac to induce macrophage activation, thrombosis, and endothelialization. One significant challenge facing any field of medicine driven by innovation is a balanced platform that allows new treatment strategies to be evaluated, keeps pace with fast-growing technology, and maintains a high standard of patient safety. Although randomized, controlled clinical trials remain the gold standard for testing medical therapies, well-designed multicenter registries are valuable tools to assess surgical procedures and devices. Proper patient selection and sufficient operator experience are essential when a clinical trial is designed to evaluate a device-related procedure.24 Continued success of vascular and endovascular neurosurgery requires multidisciplinary collaboration among cerebrovascular specialists as well as clinicians treating diseases in other parts of the human vasculature. Such collaboration can be hindered by the tradition of subspecialization or silo building. SILOS IN MEDICINE AND IN VASCULAR NEUROSURGERY According to the World Health Organization, vascular diseases, including ischemic heart disease and stroke, are the leading causes of death worldwide.25 Although located in different parts of the human body, certain pathological conditions in the cardiovascular, neurovascular, and peripheral vascular systems share a common pathophysiology (eg, build-up of atherosclerotic plaques) and could be treated similarly (eg, aspirin, statins). Yet, clinicians who manage vascular diseases, such as cardiologists, neurosurgeons, vascular surgeons, and radiologists, as well as scientists and engineers who study vascular biology and physiology, usually work within their respective subspecialty and rarely collaborate across the specialty line (Figure 1). Such “silo building,” or subspecialization, has been the model for modern medicine for more than a century. Although subspecialization has the benefits to concentrate resources and facilitate advances within a particular specialty, the rapid growth of medical knowledge and technology has deemed the system sclerotic and obsolete. In the current environment of health care reform and cost reduction, silo building results in turf wars within medicine and hinders therapeutic progresses that require multidisciplinary collaboration, rather than competition.26FIGURE 1: Silo building among vascular specialties. Although clinical specialists in cardiology, vascular surgery, neurosurgery, and interventional radiology all treat vascular diseases, they traditionally operate in respective subspecialties, or silos. Investigators of vascular diseases, such as engineers, physicists, cell biologists, and nanotechnologists, also work within the boundaries of such silos. To break down the silos and improve overall patient care, an integrated vascular center is needed where vascular specialists of different disciplines, as well as basic and translational researchers, can practice, collaborate, and innovate in close proximity.Working in silos not only affects the ability of clinicians to deliver the best possible care, it also leads to unnecessary duplication of similar facilities, inefficient utilization of resources, and a lack of experience sharing and complication solving among groups of physicians who encounter common problems. Patient records and care delivery become fragmented, and the responsibility of patient safety is diffused. This is particularly true with physicians and training programs focused more on organ systems rather than specific organs alone, such as the vascular tree. In short, silo building has become a barrier to advancements of biomedical knowledge and biomedical technology, especially in the field of vascular and endovascular neurosurgery. How do we encourage clinicians, scientists, and engineers to walk across the specialty lines and to communicate, collaborate, and ultimately improve patient care? We propose the formation of an integrated, multidisciplinary vascular center that encompasses not only practices of all vascular specialties, but also basic and translational investigation in vascular biology. Our goal is to break down the silos and change the paradigm of treatment for vascular diseases in this country. BREAKING DOWN THE SILOS: FUTURE OF VASCULAR NEUROSURGERY To form a vascular institute focused on collaboration and innovation, we have developed a free-standing facility that is led and governed by physicians, connected to a comprehensive hospital, and serves to promote minimally invasive treatment and prevention of vascular diseases. All disciplines of vascular disease specialists, as well as research scientists and engineers, should practice in close proximity, and the geography of this facility inherently “forces” such collaboration. As a result, the design of the building reflects the ideas of connectivity, collaboration, and flexibility. It almost looks like a sandwich (Figure 2), with research space on the top floors, clinical space, operating rooms, and angiography suites on the bottom, and the Jacobs Institute as the “meat” in the middle. In particular, all catheter-based specialists practice on the fourth floor of the building, which includes a core collaboration area at the center surrounded by 16 angiography suites located in the periphery. The vascular institute serves as a fertile ground that allows collisions of ideas among clinicians from different disciplines and encourages collaboration between clinicians and scientists.FIGURE 2: Design of an integrated vascular center. The Gates Vascular Institute (GVI) is designed to be a free-standing facility for the delivery of multidisciplinary, integrated care for patients with vascular diseases. The lower floors consist of clinical spaces including the emergency department, outpatient suites, operating rooms, and angiography suites. The upper floors are occupied by research laboratories including bench space and an animal facility. The Jacobs Institute, an independent partner of the GVI, is located in the middle. The design encourages interaction and collaboration of clinicians from different subspecialties, scientists, and industry partners. ICU, intensive care unit; UB CTRC, University at Buffalo Clinical and Translational Research Center.Moreover, although doctor-industry relations are increasingly scrutinized by regulatory agencies, partnership with industry is vital for medical research, training, failure analysis, and quality improvement. Even the patients can be our partners who participate in the innovative efforts to improve care delivery and benefit in the process. The integrated vascular center harvests ideas from clinicians, scientists, and entrepreneurs and the resulting synergy through multidisciplinary collaboration, and provides resources to cultivate and nurture these ideas. For example, the Jacobs Institute has expertise in intellectual properties, market research, clinical regulatory research, and prototype testing. The animal facility in the vascular center ensures that a prototype can be readily implanted in vivo. Through collaboration with industry, scientific ideas can be fast-tracked into viable enterprises and risks associated in the process can be reduced. In summary, establishing an integrated vascular institute is our solution for the challenges facing vascular medicine and vascular neurosurgery. It is an experiment to test whether we can improve patient care through innovation and collaboration among multidisciplinary clinicians, scientists, and industry partners. It may not be the only solution, but is an opportunity that we must seize. After all, one always misses 100% of the shots not taken. I encourage all of you to get involved to build a brighter future for vascular and endovascular neurosurgery. Disclosures Dr Hopkins receives grant/research support from Toshiba; serves as a consultant to Abbott, Boston Scientific, Cordis, Micrus, and Silk Road; holds financial interests in AccessClosure, Augmenix, Boston Scientific, Claret Medical, Endomation, Micrus, and Valor Medical; holds a board/trustee/officer position with Access Closure and Claret Medical; serves on Abbott Vascular's speakers' bureau; and has received honoraria from Bard, Boston Scientific, Cleveland Clinic, Complete Conference Management, Cordis, Memorial Health Care System, and the Society for Cardiovascular Angiography and Interventions. Dr Lin has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Acknowledgments We thank Paul H. Dressel, BFA, for preparation of the illustrations and Debra J. Zimmer, AAS for editorial assistance.
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