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Pushing the limits in vascular surgery: Our past, present, and future

2020; Elsevier BV; Volume: 72; Issue: 2 Linguagem: Inglês

10.1016/j.jvs.2020.03.026

1097-6809

Anil Hingorani,

Cardiac, Anesthesia and Surgical Outcomes

I want to thank all of you for the honor and privilege of being the Eastern Vascular Society (EVS) President for the last year. This is truly one of the greatest honors for me, especially working with some wonderful colleagues in the EVS. I want to especially thank the EVS council, committee chairs, and staff. It has been a pleasure working with such a talented group of individuals. I also want to thank my family for putting up with endless conference calls, missed soccer games and dinnertimes. To my wife of 25 years, Renu, thank you for being at my side all the way, and to our two kids, Amrit and Aarthi, I have truly enjoyed seeing you grow up into such wonderful individuals. I love you all. “Pushing the envelope” comes from a field where tremendous risk is the whole point. It's drawn from the lingo of test pilots, whose job consists of pushing their aircraft right up to and often beyond the technical specifications and theoretical limits of their craft. While pushing the envelope (originally in the form “pushing the edge of the envelope”) has probably been in use among test pilots since World War II, it was propelled into general use by Tom Wolfe's 1979 book and the subsequent movie about test pilots and the early U.S. space program, The Right Stuff. The “envelope” being pushed in pushing the envelope is a mathematical construct, which is called the “flight envelope” of a given aircraft—combinations of speed and altitude, range and speed, or speed and stress on the aircraft's frame that are considered the limits of the plane's capabilities (Fig). Within the envelope formed by these parameters, you're (at least theoretically) OK. Push those limits, however, and you're asking for trouble, which is what test pilots do for a living. In the process, they verify the safety of the aircraft within those limits and pinpoint possible points of failure if the envelope is pushed too far. I suggest that these concepts are exactly what vascular surgery is all about. As an example of this, in 2005, an 85-year-old man presented to our office (Supplementary Fig 1, online only), a left above-knee amputation.1Hingorani A.P. Ascher E. Marks N.A. Jung D. Ignatiev I. Hingorani A. Interposition bypass of the popliteal artery using the popliteal vein in 1943.J Vasc Surg. 2016; 63: 1400-1403Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The patient insisted that he had a right lower extremity bypass and had proof. On a subsequent visit, the patient produced a note (Supplementary Fig 2, online only) written by a surgical assistant to a Dr Nikolai Bogoraz attesting to a right arterial bypass performed in 1943. Indeed, in his monograph (Supplementary Fig 3, online only), Bogoraz describes that on arrival to his clinic, our patient had injuries of the left superficial femoral artery in the midthigh with leg gangrene that prompted superficial femoral artery ligation and an above-knee amputation. The right lower extremity had suffered a popliteal artery transection with pseudoaneurysm and arteriovenous fistula formation, which was repaired through a posterior incision with a 14-cm bypass with popliteal vein (Supplementary Fig 4 (online only), Supplementary Fig 5 (online only), Supplementary Fig 6 (online only), online only). Previous literature suggested that the use of the arterial bypass was developed in Europe. Kunlin has described having performed the first bypass for occlusive disease using a venous conduit in 1945. Bogoraz in his monograph described his successful replacement of an injured long segment of the superficial femoral artery with an interposition bypass with the great saphenous vein in 1935. In 1912, he also described transposition of the superior mesenteric vein to the inferior vena cava in patients with liver cirrhosis. Although Kunlin contributed significantly to vascular surgery, this case suggests that Bogoraz and others might have performed these procedures even before Kunlin. Although the work of Dr Bogoraz was not published in Western literature, he should be listed among the pioneers of vascular surgery. I would suggest Dr Bogoraz was an excellent example of “pushing the envelope” not only on a professional level but also on a personal level. I would also suggest that if he had not been pushing the envelope, he would not have been able to do the great work he did behind the Iron Curtain. I also suggest the foundations of vascular surgery are based on this very principle of pushing the envelope—going beyond what is considered standard and safe practice—be it from Drs Eastcott and DeBakey developing the carotid endarterectomy, Gruntzig with lower extremity angioplasty, Dr Matas with open abdominal aortic aneurysm repair, or Dr Juan Parodi with endovascular aneurysm repair. Each one of these pioneers helped push the field forward by going up to the edge of current techniques and tools and testing the boundaries. One of the first patients I saw as a new attending came into our office with a gangrenous toe. I was young and eager and went in to see what we could do to revascularize his foot. He was only 52 years old and an ex-smoker. When I asked him how may prior attempts he had at revascularization of bilateral lower extremity, he said he lost count after 25. When I examined him, I found he had multiple scars from his neck to his feet from his multitude of open procedures. They had been performed at almost every major and minor institution in the greater New York City area. Needless to say, my enthusiasm was quickly deflated. I could not see how we could even make an incision on him safely without compromising the pre-existing tenuous scars from the previous infected wounds that had taken months to heal. After speaking to my senior partner, I obtained an angiogram, found inflow and outflow vessels, and performed an ax-profunda with a jump bypass with polytetrafluoroethylene to the anterior tibial artery with an adjunctive arteriovenous fistula. These stayed patent and the patient eventually passed from his acute myocardial infarction 3 years later with his leg intact. We routinely saw patients with multiple prior revascularizations and by pushing the envelope were able to successfully revascularize many of them with polytetrafluoroethylene to the tibials2Hingorani A.P. Ascher E. Marks N.A. Schutzer R.W. Mutyala M. Nahata S. et al.A 10-year experience with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal prosthetic bypasses.Vasc Endovascular Surg. 2005; 39: 401-409Crossref PubMed Scopus (14) Google Scholar and sometimes well beyond, at times, with what would be extended procedures that would sometimes even test the boundaries of safety. Sometimes, we would use cadaveric vein bypasses to the tibial and pedal vessel branches. These experiences taught me that pushing the envelope beyond what I had learned from the books and papers was often the best course for the patient. Vascular surgery has always been about testing the boundaries. I would suggest that without this characteristic, vascular surgery would not have made the progress it has made in its very short lifetime. In addition, while knowing what the books say is important to help you pass the exams when you are a trainee, I often found that patients do not read the books and do not fit into the categories or treatment plans outlined in the books. Texts often categorize lower extremity ulcers as arterial or venous in origin and set up individual treatment algorithms for each. While this works for many patients, a significant portion have combined disease and often need treatments that do not follow the classic algorithms found in these books. The literature does not really address these patients well. While I claim that pushing the boundaries is one of the hallmarks of vascular surgery and has helped shaped the past and established the modern field of vascular surgery, testing the limits is still going on today in our field. Present examples for pushing the limits include transcarotid artery revascularization, aortic stent graft placement down to the coronaries, nontumescent nonthermal vein ablation, percutaneous arteriovenous fistula placement, and three-dimensional duplex imaging with fusion computed tomography angiography and magnetic resonance angiography. Many of the leaders of these fields are members of the EVS and are here in the room today. These are areas that vascular surgery needs to stay in positions of leadership or be faced with being left behind. This lesson of staying in the lead and not leaving a position of leadership has been exemplified time and time again. Cardiothoracic surgeons developed coronary angioplasty techniques but did not pursue these new innovations. Subsequently, this very field that they developed has replaced the majority of their open interventions. General surgery developed gastrointestinal endoscopy but did not pursue the field, and today general surgery trainees are struggling to regain these skills and make their required numbers. If we do not maintain our leadership in pursuing these new innovations, our competition will most certainly be more than willing to. This also stresses the importance of funding for research to keep vascular surgery pushing the boundaries. For the last 2 years, EVS has funded the research grants for promising new young surgeons. These were presented at our meeting yesterday. These grants represent our commitment to the future of vascular surgery. We need to commit ourselves to research as this represents our future. This concept of testing the limits also applies on a larger scale, even to our vascular societies. This past year, we have made a deliberate effort to taking down barriers, reaching out, and working with over 20 local, regional, national, and international societies. These include the Society for Vascular Surgery (SVS), American College of Surgeons, Vascular Low Frequency Disease Consortium, Frank J. Veith Society, South Asian American Vascular Society, Women in Vascular Surgery, New York Dialysis Access Club, Vascular Society of New Jersey, New York Society for Vascular Surgery, Delaware Valley Vascular Society, Vascular Techniques & Technology Thinktank, and Pittsburgh Vascular Symposium. By working together, we can succeed. Often our goals are similar, and we each have tools and resources that are specific for each group but can help the others reach their goals. We have been trying to promote each others' meetings, share our experiences, and work together on joint research projects. The more we work together, the stronger we all are. EVS has also been working V-Heathy under the leadership of Dr Manny Mehta with an outreach to community high schools. In this model, groups of volunteers reach out to their local schools to raise awareness of vascular disease to high-school students. The students in turn take this knowledge and screen their own families for risk factors for vascular disease. This places vascular surgeons at the forefront of promoting vascular awareness at a grassroots level. We need to take charge as other specialists will supersede us if we do not. With V-Aware, we have reached out to offices all across the EVS catchment area. In this project, we reach out to patients directly to promote education and awareness of vascular disease. Finally, under the direction of Dr Palma Shaw, we have started a radiation safety course with a certification process. This is our first attempt to cross institutional silos for radiation safety at the regional level. Increasingly, we use radiation everyday but do not have uniform standards for training and safety. This course will be the first step in establishing standards with a certification process. On the other hand, I would also suggest that we need to test the boundaries on a personal level, even down to the level of individual practices. American medicine has been reluctant to join many businesses that routinely advertise. It has been looked down on and seen as unnecessary and base. I would suggest that not only is advertising not unnecessary, but it is actually becoming essential. As urban areas are becoming saturated with vascular specialists, the vascular surgeons need to get the message out about who we are, the great work we do everyday, and how we are different from other vascular specialists. If we do not, I assure you, our competition is more than willing to fill this space. Medicine is becoming more corporate. The corporate world already knows that advertising works. It is time for vascular surgery to follow suit. Vascular surgery needs to stop with this prudish misconception that advertising is a necessary evil. We need to focus on marketing and branding ourselves and actually set up a budget for advertising in our local markets. At least 4 % of the gross of each division should be the baseline. I would suggest that advertising with the increased competition in the vascular space will not only be necessary but help us compete with other specialists in our space. If you do not advertise and your competition down the street does, there is a very good chance that the patients will end up going to your competition despite what you may think of the results of your competitors. Again, we need to push the limits of ourselves and our own misconceptions. Testing our personal boundaries also extends to our daily routines. Dr Clem Darling focused his SVS presidential address on the vascular team.3Darling 3rd, R.C. Looking forward through the past and changing me to we in the evolution of team-based vascular care.J Vasc Surg. 2019; 70: 347-357Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar We can no longer be “one-man teams.” We need to work as multidisciplinary teams to be successful. If my front desk pisses off a patient who complains about the wait and the secretary makes the situation worse with an inappropriate response, the patient blames me and my entire service and walks out. On the other hand, if one of my residents does an exceptional job in diffusing a tense situation with a thoracic endovascular aortic repair patient getting ready to leave to go to the hospital down the street and the case goes well the next day, I get the credit for something that would not have happened if the house staff had not intervened. Every day, we rely on our friends, family, and co-workers to do the great work that we take for granted. It really takes team work to make the dream work. This is a different form of pushing the boundaries, but I would say in today's medical-industrial complex, it is actually a key to success. You can do amazing work in the operating room, but if your team does not help set up the procedure or do their part after the procedure, it is all for naught. If you want to compete with your local vascular interventionalist, sometimes it is better not to focus on the competition but more so on your own team—to empower them to make your team shine. This may mean a personal transformation from focusing on “me to we” to push your inner boundaries to include the others on your team. Our community for vascular surgery includes our administrators, medical assistants, researchers, nurses, registered vascular technologists, and our trainees. I would suggest we need to focus more on our team, not only the individual. This represents a change in thinking and approach to medicine and surgery. Teams are what make us wake up in the morning and want to go to work. This is one of the reasons why having the allied health section at the EVS meeting is so important. Under the leadership of Dr Brajesh Lal, this program continues to grow and allow all of our teams to grow and prosper. For the future, where will pushing the boundaries lead us? We are not general surgeons, and general surgeons are not vascular surgeons. The transformation of vascular surgery after the endovascular revolution means that no general surgeon with 5 years of training alone should be performing elective vascular surgery as they can no longer offer the full range of options to care for these patients. At the same time, we are becoming as different from general surgery as orthopedics or urology. This separation between our fields is accelerating and will continue. I want to present a future vision of vascular surgery with vascular surgeons no longer attending weekly general surgery morbidity and mortality conferences and hearing about cystic duct leaks after lap cholecystectomies or abscess drainage after emergency colonic resections. Rather, I foresee a separate robust vascular morbidity and mortality conference that will become the norm with only vascular cases being presented. An in-depth analysis of each case highlighting the teaching points for the trainees will be the focus. This will be run by the Department of Vascular Surgery. Having a seat at the table as a department is good for patient care as the resources can be focused on issues specific to our patients. It is good for vascular research and the education of our trainees. It is good for vascular surgery. The Department of Vascular Surgery will be directly accountable to the president of the hospital. If we are not at the table at the meetings with the president of the hospital and the other department heads, we are not involved with the decisions for budgeting, new directions for the institution, or hiring and firing. The Department of Vascular Surgery will be responsible for its own budget. Recently, we started a survey looking at the number of vascular surgeons who are the chief of surgery at their institutions. We started the survey in 75 hospitals in New York City. The results were normalized for the number of surgeons in New York City. While we have not finished the analysis, the preliminary results suggest that the number of vascular surgeons who are chairs of surgery is under-represented by a factor of 4 as compared to other specialties. We suggest that the number of vascular surgeons as chief of surgery is growing and will continue to grow. In addition, the size of vascular departments will continue to grow and eclipse the largest divisions we have now. Routinely, complex procedures will be performed by teams of vascular surgeons, not just by one person. Vascular surgery will have its own salary lines, policies, and standards. Having a cardiologist or cardiac surgeon in charge will be unheard of as this does not result in the optimal development of a vascular surgery department. More and more procedures will be shifted from the inpatient to outpatient setting as tools and techniques change. Outpatient carotid stenting or even endovascular aneurysm repair for selected patients will become routine. Furthermore, vascular surgery will undergo subspecialization: venous, peripheral arterial disease, aortic, vascular laboratory, and arteriovenous access. Indeed, this is already happening on a local level. I suggest that this will occur at a regional and national level also. Consider vascular modular recertification consisting of lower extremity peripheral artery disease, venous, carotid, aortic, or vascular laboratory. This would actually more reflect what is happening today and is accelerating. We now have individual surgeons who are gravitating to each of these fields, and referral patterns are reflecting this. Each of these individual fields of subspecialization is becoming more and more detailed and developing their own body of literature, tools, and techniques. Vascular surgery trainees will have to do rotations in each of these subspecialties for a dedicated amount of time and even have a minimum number of cases needed in each subspecialty. No such requirement exists today for arteriovenous access or venous disease. Indeed, this already is becoming a reality for general surgery and its subspecialties (breast, colon, emergency, critical care, oncology). Patients are preferentially sent to these subspecialists for their focused expertise, ability of handling complex cases, and better results. These changes are already taking place, and while sometimes their progress seems glacial, the progress is stepwise and inevitable. This is not to say we should not work with general surgery, the American College of Surgeons, and the American Board of Surgery but rather that we should work with them and not subordinate to general surgery but as equal players. Under the leadership of Dr Alan Dietzik, the American Board of Vascular Surgery has witnessed a reinvigoration. Talks with the SVS are ongoing, and we will see where this will lead. While progress is slow, it will happen. So thank you for indulging me by listening to my monologue and staying until the last session of the meeting. I hope I was able to convince you that pushing the limits has shaped the past and present and I believe will continue to shape the bright future of the field of vascular surgery.