A look at the future of vascular surgery
Frank J. Veith, MD, New York, NY; and Cleveland, Ohio.
I would first like to thank Dr Perler and the Society for Vascular Surgery (SVS) for the singular honor of giving the Eleventh John Homans Lecture. This list of previous Homans lecturers shows why I am humbled by this invitation (Table I). Men like Elkin, Fontaine, Crafoord, Kirklin, Linton, DeBakey, Crawford, Thompson, Hollier, and Moore are the superstars of our specialty. So I am deeply indebted to Bruce Perler for adding meda maverick from the Bronxdto this list. First, a word about John Homansda free spirit and giant in vascular surgery (Fig 1).1 John Homans was the fifth generation of Boston doctors, dating back to one of his ancestors who was a regimental surgeon in the Continental Army. He was educated and trained at Harvard, the Massachusetts General Hospital, and Hopkins. In 1912 he was picked by Harvey Cushing as one of the first two surgeons at the new Peter Bent Brigham Hospitaldw here he spent his entire career and became one of the most respected surgeons in the worlddlargely because of his seminal contributions in venous disease. Dr Homans was a founding member of the SVS. And he wrote two classic textbooks, one on Circulatory Diseases of the Extremities and an even more important Textbook of Surgery (Fig 2).
This text was the most widely read of its time and was published in six editions and several languages.
John Homans’ career was honored by the John Homans Chair of Surgery at Harvard Medical School and the John Homans Lectureship at the SVS. So it is for me the greatest honor to give the Eleventh Homans Lecture, and, at Dr Perler’s suggestion, I have titled it “A Look At the Future of Vascular Surgery.”
I realize that predicting the future is risky and that my predictions can be wrong. Also, as Yogi Berra said, “The future ain’t what it used to be,” and this applies particularly to vascular surgery because the health care system and vascular surgery’s position in it has become so different from what it was. However, this topic allows me to tell you what is right and bright about American vascular surgery and the challenges it faces. It also allows me to advise vascular surgery and its future leaders how to help meet these challenges.
Before dealing with the future of vascular surgery, let me touch on the past and the present. In 1992, I had the good fortune to bring Parodi, Schonholz, and Barone to our poor institution in the Bronx, where they, Marin, I, and others performed the first United States (U.S.) endovascular aneurysm repair (EVAR).2 Seeing the way that case went was an epiphany for me. I had always been enthusiastic about angioplasties, stents, and other endovascular techniques performed by our radiologists. However, that case and our subsequent success with surgeon-made endografts for various arterial lesions made me realize that vascular surgeons hadto changeor risk becomingextinct.3
As a result of that realization, in 1996 I gave my SVS Presidential Address on “Charles Darwin and Vascular Surgery” (Fig 3).4 In that address, I likened specialties to species and indicated that specialties, like species, had to evolve and become different from their ancestors if they were to avoid extinction and survive (Fig 4). I also made three predictions and associated recommendations for future survival adaptations. Two of these recommendations proved to be unworkable or unsuccessful. One proved to be remarkably right.
One errant recommendation was that we work collaboratively with interventional radiologists or cardiologists in dedicated vascular centers.4 That Kumbaya recommendation proved unworkable because of medical tribalism, competitive human nature, and greed. A second recommendation was that vascular surgery become more independent as a specialty, separate from general and cardiac surgery, separate administratively and with an American Board of Medical Specialties (ABMS)-recognized governing board and Residency Review Committee (RRC). A vigorous attempt to accomplish this was made between 1996 and 2007, but was only partly successful.5 As a result, vascular surgery still remains a subspecialty in North America, although it is not in most other parts of the civilized world.
Fig 1. John Homans (1877-1954). Reprinted with permission
from Yao and Brewster
My third recommendation in 1996 fared better. I predicted that 40% to 70% of the open operations we were then doing would be replaced by endovascular procedures.4 Accordingly, to survive, I recommended that vascular surgeons become endocompetent, learn how to do these procedures, and embrace them. Although this recommendation was greeted with disdain and strongly resisted by many senior vascular surgeons at the time, this resistance was gradually overcome. Our specialty has embraced the endovascular revolution and become endocompetent, and this is why vascular surgery is doing as well as it is today. Indeed, vascular surgeons often lead in developing many evolving endovascular procedures that are currently the standard of care.
As a result, vascular surgery is presently an exciting, vibrant specialty in the U.S. Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart, whether that treatment be medical, endovascular, or open. Abundant numbers of patients require our skills. In addition, we use fascinating technology and have good industry relationships. And finally, many patients regard their vascular surgeon as a key doctor who they see regularly. As a result of these advantages, many bright medical students and general surgery residents are choosing to train as vascular surgeons. Vascular surgery should be flourishing.
What has been the effect of the endovascular transformation on vascular surgery to date?
Currently, only these vascular conditions or lesions are best treated by open surgery: thoracic outlet and entrapment syndromes, some ascending aorta and arch lesions, a few rare aneurysms not suited for endovascular treatment, some Takayasu lesions, some congenital and genetic aortic and renal artery lesions, some infected arteries and arterial grafts, a rare recurrent or complex lower extremity lesion, some carotid lesions, and some failed endovascular treatments (Table II).
Admittedly there are some vascular lesions for which treatment is still controversial. Carotid stenosis is one such lesion. Presently, endarterectomy, stenting, and best medical treatment all have their advocates in various settings; however, carotid stenting will likely regain increasing favor as technology improves.6 Another controversial area is the treatment of ruptured abdominal aortic aneurysms (AAAs). Although recent randomized trials show no survival benefits for EVAR, the applicability of these trials is questionable, and EVAR will likely become the standard of care for most ruptured AAAs.7
Vascular Surgery in the Future
What about the future for vascular surgery in 10 years and beyond?
What changes should we expect?
What are our challenges, and how should we meet them?
First, the easy prediction. How far will the endovascular revolution go? Will all invasive treatments for vascular lesions become endovascular? It does not take a soothsayer to realize that more and more vascular lesions will become amenable to endovascular treatment. By 2026, one can predict that 75% to 95% of all vascular lesions requiring treatment will undergo an endovascular procedure (Table III). With the creativity of vascular surgeons and others, this percentage will likely increase. Moreover, all of these treatments will be deliverable via percutaneous approaches.
Does this increasing role for endovascular treatments mean that the day of open surgery is over? Definitely not. There will always be a need for hybrid (open + endovascular) repairs in ~5% of vascular lesions. Cervical approaches to the carotid artery, the need for conduit access, and some open treatments after EVAR are three examples. Also, there will always be a need for fully open surgery in ~5% to 15% of patients requiring invasive treatment, although some of these procedures may be improved by endovascular adjuncts. Open surgical treatment will always be best in some patients with the conditions and lesions I have already mentioned (Table II), although the numbers and proportions of these lesions will decrease as improved endovascular technology and techniques are developed and are proven superior. How should vascular surgery deal with the decreasing numbers of complex open procedures and who should do them? One solution is to have centers to which these patients are sent and in which vascular surgeons seeking this skill can get adequate open training.
Fig 2. John Homans and his A Textbook of Surgery. Reprinted with permission from Yao and Brewster.1 / Fig 3. Charles Darwin (1809-1882).
Fig 4. Charles Darwin’s classic and disruptive book, The
Origin of Species, on evolution and survival of the fittest.
Other thoughts about the future
Seminal advances in vascular surgery have always been made possible by advances in other fields, most importantly pharmaceuticals and technology Heparin, safe contrast agents, and prosthetic vascular grafts are three prominent examples. Similarly, the explosive progress in endovascular treatments was made possible by improvements in digital imaging and the catheterbased technology our industry partners provided.
In like fashion, future advances in vascular surgery and vascular disease treatment will depend on advances in other fields. On the horizon are better medical treatments to arrest and even reverse atherosclerosis. Statin drugs are just the beginning and have already decreased rates of heart attacks, strokes, and death.8 Better use of these drugs will make them more effective, improve our treatments, and help our patients have longer and better lives. Despite this and the possibility of even more effective lipid-lowering with proprotein convertase subtilisin/kexin type 9 (PCSK 9) inhibitors, complications of atherosclerosis will still occur and require our interventions, probably in increasing numbers as our population ages. This ensures a continuing need for the services vascular surgeons provide.
Also brightening the future of vascular surgery and our patients will be advances in the technology that will improve our treatments. This is particularly true with endovascular procedures because of their need for guidance within the vascular system. Glimpses of computerassisted three-dimensional device navigational tools are already appearing. So also are systems analogous to global positioning within the vascular tree. Radiation will not be required, thereby decreasing hazards to patients and operators. Advances in robotic guidance will also decrease radiation exposure and facilitate device placement. Computer-enhanced simulation will improve training and, when patient specific, will allow procedure planning and rehearsal, thereby improving patient outcomes. Three-dimensional printed models of lesions and blood vessels will contribute to these improvements.
Patient outcomes and the durability of endovascular treatments will also improve with better stent technology. This includes advances in bioresorbable and drugeluting stents. Similarly, the already promising results of drug-coated balloons will be enhanced. All these devices are complicated with many variable factors. The bottom line is that intimal hyperplasia will be overcome by antiproliferative drugs in all vascular beds once the best way of getting the best drug to the proper location is found. And finally, computer-enabled remote monitoring of flows within grafts and stents will allow corrective treatment before occlusion occurs. Miniaturized piezoelectric sensors are one way to do this.
All these promising new vascular devices and treatments need validation. Their value and cost effectiveness will have to be documented. This will create enormous research opportunities for all academically ambitious vascular surgeons.
So the future for vascular surgery, vascular surgeons, and their patients is bright. There will be exciting new treatments, good research opportunities, and lots of patients needing our attention. However, there are some challenges that vascular surgery must face. How well the specialty deals with these challenges will affect the brightness of its future.
First is the current status of the u.s. health care system
We live in an imperfect world. We see it in our political leaders who are owned by special interests. We see it in many lawyers who want to translate every untoward effect or bad outcome into a compensatory judgment, with a large share for themselves. We see it in Wall Street and insurance companies that place profit above all else. And yes, we see it in our health care system, in which doctors are able to perform unnecessary procedures for financial gain.
The overuse of outpatient vein centers by those who are not even vascular specialists is only one example. More importantly, institutional leaders view everything through their prism of diagnosis-related groups, relative value units (RVUs), and dollars. Quality care and appropriate care are totally overshadowed by the need to generate money, and poor or unnecessary care is tolerated if providers bring in the patients, the RVUs, and the dollars. There is no easy solution, but clearly, we need an ethical revolution in our countryda return to old-style moral values and behavior. How to do this or how to solve other problems in the U.S. health care system are challenges beyond the scope of this discussion.
A second challenge is vascular surgery’s ability to compete with other specialties
Vascular surgery occupies a competitive niche in the medical environment. Like species in the Darwinian analogy, vascular surgery is competing with other specialties for the institutional resourcesdor the food and environmental nichedit needs to provide the best care and to survive. These resources include patients, equipment, space, and dollars.
For these essentials, vascular surgery competes, as it always has, with general and cardiac surgeons. General surgeons, however, have become less competitive, but cardiac surgeons have become more in need of work and, thus, more active beyond the heart and thoracic aorta as their open operations are replaced by coronary stents and transcatheter valves. More importantly, as vascular treatments become increasingly endovascular, vascular surgery will be competing with interventional radiology and, importantly, interventional cardiology. The last two specialties have both made contributions to the vascular field and deserve to share in it.
However, the competition with interventional cardiology is and will be intense. Cardiologists do a spectacular job caring for patients with heart disease. However, they also want to expand their role into noncardiac vascular disease, and they have enabling assets. Cardiologists control patients and have a financial incentive to refer to each other. They are capable and much more numerous than vascular surgeons, and they are vigorous in adding to their numbers and aggressively expanding their treatments to areas outside the heart. In fact, many of them have been heard to say publicly that they should replace vascular surgeons. Two exemplary direct quotes from leading cardiologists are: “Vascular surgery is dead, R.I.P.,” and “Vascular surgeons, bend over and kiss your butt good-bye.”
How can this be? Cardiology is defined in all dictionaries as “the area of medicine that deals with the heart and diseases that affect it” or “the study and treatment of medical conditions of the heart.”9 Nowhere in the definition is the vascular tree mentioned. Nevertheless, in 1988, A.N. DeMaria, then President of the American College of Cardiology, recommended that cardiologists get involved in noncardiac vascular disease treatment because “board certification in the field. is nonexistent.”10
Moreover, interventional cardiologists have the catheter and imaging skills to do so, even though they may lack adequate disease-specific knowledge to go with these skills. This leads them to perform unnecessary carotid and femoral proceduresdclearly not good for patient care. Another recent example is their expanding effort to perform endovascular graft repairs for AAAs.
What can vascular surgeons do about this?
As individuals or groups, we can practice the best and most appropriate medicine possible and be responsive to patients’ needs. These efforts may help us maintain our practice niche. We are, after all, the only specialty devoted solely to vascular diseasedits natural history, conservative management, medical treatment, and invasive treatments. Unlike others, we are not just proceduralists. However, this may have little effect: firstly, because of the diagnosis-related group, RVU, and dollar orientation of institutions, and secondly, because in most institutions we are still considered a subspecialty of general or cardiac surgery, or worse still, a subordinate part of a heart and vascular center. Administrative control of these centers is rarely in the hands of vascular surgeons. Moreover, when institutional resources, such as angiography suites or hybrid operating rooms are distributed, the interests of vascular surgery are often represented by a general or cardiac surgeon, or worse, a cardiologist.
This limits vascular surgery’s ability to get its fair share of institutional resources. The competitive playing field is not level, and vascular surgeons are disadvantaged in the Darwinian struggle to survive. To survive, vascular surgery needs to unify, recognize this inequity, and fix it. This can only be done if all vascular surgeons and the SVS engage vigorously in this issue. We need equal administrative status with cardiac and general surgery in our institutions. Having an ABMS-recognized governing body with its own RRC will help to achieve this improved status. It can also help vascular surgery brand itself as the specialty that best takes care of blood vessels and their diseases, something vascular surgery has not done well to date.
Vascular surgery attempted to get such an ABMSrecognized board and associated RRC from 1996 to 2007.5,11 The main goal of this initiative was to improve patient care and outcomes. The effort had strong support within the SVS but was opposed by the ABMS and some of its member boards. When our application was submitted in 2002, vascular surgery fulfilled the ABMS board requirements. Nevertheless, our application was “denied,” and a subsequent appeal was “rejected”dboth without explanation. However, vascular surgery did get approval for a “primary certificate” within the American Board of Surgery, and we got improved training with 0 + 5 year vascular surgical residencies for graduating medical students. But vascular surgery still does not have the full recognition of independent specialty status afforded by an ABMS-recognized board and RRC. Since 2007, vascular surgery has evolved more and is now further differentiated, in a Darwinian sense, from its general surgery ancestor. We have become more endovascular, while general surgery has become more laparoscopic. So vascular surgery is even more qualified now for separate specialty status than it was in 2007.
Because separate specialty status is important to the survival of vascular surgery in our competitive medical environment, the specialty should re-engage in its effort to obtain ABMS approval for such status. Although there may be opposition from several quarters, with strong unity within the specialty, this opposition can be overcome. Other evolving specialties have done it. Vascular surgery can do it too.
Success in this quest will help vascular surgery to flourish and be recognized as the main specialty devoted to patients with noncardiac vascular diseases. Vascular surgery can then fulfill its potential for a brighter future. More importantly, patients and society will be the ultimate beneficiaries.
Thanks for the honor of giving this Eleventh Homans Lecture, and thank you all for your attention.