Choosing between Vascular Surgery vs. Neurosurgery

[m2regen]

I am looking for advice on choosing between two specialties. I've completed my M3 year and am doing PhD research at the moment. I'm interested in doing a specialty that does both endovascular and open work, so vascular surgery seemed the natural choice. However, my collaborators, who are vascular neurosurgeons, have recently been suggesting I do neurosurgery (presumably with vascular fellowship(s)) instead. I hadn't considered neurosurgery before, so I wanted ask if anyone can provide some insights as to what to consider in differentiating between these specialties, so I can be prepared to ask the right questions for myself when I rotate on each service. My personal pros and cons of each specialty are as follows:


Vascular Surgery

Pros

• 5 years integrated residency, no fellowship to do open or endovascular work
• Balance of "easier" and more difficult types of surgeries leading to more options for lighter work nearing retirement.
• Some focus on carotid and stroke prevention through CEA and TCAR (although I've heard this is decreasing?)
• Operate all around the body

Cons

• Bread and butter lower extremity disease is less interesting than stroke/cerebrovascular.
• Patient population can be difficult.
• Neurosurgery seems to be taking control over cerebrovascular

Neurosurgery

Pros

• Cerebrovascular is becoming more dominated by neurosurgeons rather than IR/vascular.
• CNS tumors are interesting, not much directly oncology in vascular.
• My PhD research is directly relevant, and the specialty seems to value MD/PhD students more

Cons

• Have to do 7 years residency before doing 1-2 years fellowship.
• Not that interested in open neurosurgery (especially spine), compared to open vascular (aortic, bypass, CEA).
• All open neurosurgeries seem difficult with long procedure times and attending life seems more difficult overall.

I've accepted that residency is brutal for both, so my main priority is to figure out is whether the life of a neurosurgeon attending (especially cerebrovascular) is more or less stressful overall than that of a vascular surgery attending and how this plays out over the arc of a career. Based on scattered shadowing throughout my research years, I feel subjectively that neurosurgeons, especially in the vascular space, end up working more, as all open vascular neurosurgery cases seem long and difficult. It also seems that vascular surgeons have more options for lighter work as they near retirement age, while neurosurgeons don't. However, I've only seen my own institution and am interested in the community's opinion on this, and whether there are additional major things I have missed or should consider.

Thank you to everyone who reads this far and considers advising! I greatly appreciate your time and insights.

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[Starbuxian]

Neurosurgeons nearing retirement can pick their own hours and opt for lighter work that way.

 

[LucidSplash]

As a vascular surgeon I don’t do work inside the skull or even really near the skull base. The cervical carotid is as high as I go. Reading this as a vascular surgeon, you’re not interested in vascular, you’re interested in cerebrovascular. I could say more, especially the perspective about PAD as “easier” than aortic work being largely incorrect, but overall I think you are more interested in neurosurgery and then a neurovascular fellowship or possibly neurointerventional IR. Of note, my understanding is that vascular is the most competitive fellowship out of neurosurgery, just so you can take that into account.

 

[m2regen]

As a vascular surgeon I don’t do work inside the skull or even really near the skull base. The cervical carotid is as high as I go. Reading this as a vascular surgeon, you’re not interested in vascular, you’re interested in cerebrovascular. I could say more, especially the perspective about PAD as “easier” than aortic work being largely incorrect, but overall I think you are more interested in neurosurgery and then a neurovascular fellowship or possibly neurointerventional IR. Of note, my understanding is that vascular is the most competitive fellowship out of neurosurgery, just so you can take that into account.

Thank you very much for your perspective and advice. Unfortunately, mine was from 1-2 attendings I work with at my institution, so I've revised my statement about PAD. However, I have heard that there is more flexibility in choosing lighter work towards retirement than neurosurgery. Is this accurate, and, if so, what kind of work does that refer to?

 

[LucidSplash]

I can’t speak to a comparison with neurosurgery.

Some vascular surgeons transition to vein and/or wound care heavy practices at the end of their career. These are typically outpatient only/no call types of employed practices OR they negotiate with their group/employer to transition to vein/wound care mostly and to take less call, but may agree to be available to help younger surgeons with more complex cases as needed.

Venture capital is investing heavily in vein centers so I suspect that eventually the “vein centers” may be less pleasant to work for as a result.

Also many vascular surgeons do not enjoy doing vein/wound care so do not pursue this kind of thing. It depends on the person.

 

[m2regen]

I can’t speak to a comparison with neurosurgery.

Some vascular surgeons transition to vein and/or wound care heavy practices at the end of their career. These are typically outpatient only/no call types of employed practices OR they negotiate with their group/employer to transition to vein/wound care mostly and to take less call, but may agree to be available to help younger surgeons with more complex cases as needed.

Venture capital is investing heavily in vein centers so I suspect that eventually the “vein centers” may be less pleasant to work for as a result.

Also many vascular surgeons do not enjoy doing vein/wound care so do not pursue this kind of thing. It depends on the person.

Thank you for clarifying! What are your thoughts on extracranial cerebrovascular work between neurosurgery and vascular surgery? In my institution, vascular surgeons do all CEAs and TCAR, while neurosurgeons do carotid artery stenting (CAS). The neurosurgeons I work with say the share of CEA is expected compared to decrease in favor of TCAR and CAS, shifting extracranial carotid work in the long term to neurosurgeons, although I suspect they may be biased towards their own specialty. What is your perspective on this?

 

[LucidSplash]

Thank you for clarifying! What are your thoughts on extracranial cerebrovascular work between neurosurgery and vascular surgery? In my institution, vascular surgeons do all CEAs and TCAR, while neurosurgeons do carotid artery stenting (CAS). The neurosurgeons I work with say the share of CEA is expected compared to decrease in favor of TCAR and CAS, shifting extracranial carotid work in the long term to neurosurgeons, although I suspect they may be biased towards their own specialty. What is your perspective on this?

I can’t promise I’m not biased to my own specialty. But I do suspect that the people you are working with have spent most of their careers at an ivory tower type place. Which to be clear, are very necessary parts of the healthcare system. However the reality is that on a statistical basis, while complexity is higher at those locations (appropriate), the majority of surgeries and procedures done in this country do not occur at the big quaternary care centers.

Overall, I think this is going to continue to be regional. Referral patterns vary from city to city and hospital to hospital. I think that patient flow patterns at large academic centers do not always reflect what happens in smaller centers.

I think that it takes a neurosurgeon a little longer on average to do a CEA, because they are taught to do them under the microscope and peel off every tiny piece of media, and vascular surgeons look for loose pieces of media only and only with loupes. The outcomes are the same in the data between the 2 techniques. As hospitals and practices transition to value based care models, this may eventually affect privileging. Or it may not.

Where I did my Gen surg training, which was a level I trauma center but a tertiary care center rather than a quaternary center, there was a group of 7 private practice neurosurgeons without a residency program who had no interest in carotid anything. All cervical carotid work done by vascular. In some (many) hospitals, vascular neurosurgery doesn’t exist. CAS, CEA, TCAR are all done by vascular. Or TCAR and CEA done by vascular and CAS done by cards and/or IR. I don’t think the distribution of vascular neurosurgeons will change. I think there are going to be more general vascular surgeons who will do CEA and TCAR. I think fewer people will be facile with CAS because TCAR has replaced CAS for a lot of cases and so the volume of CAS is going to be concentrated in a few specialists who get the few cases not appropriate for both open and TCAR.

The population is aging so there will be more patients who need these procedures. Fewer people are smoking but I think vaping is going to cause a lot of problems down the road that we won’t see for a couple decades so it may be a wash (or maybe worse).

I don’t think CEA is going away. There are patients who are not good anatomic candidates for those procedures. I think it is possible Medicare will ultimately follow Europe and stop doing carotid procedures on asymptomatic patients. The big famous studies looking at stroke prevention in asymptomatic carotid patients were all done before statins were a thing and to some extent plavix. I think TCAR is a good procedure but I think I’m terms of OR time and making an incision, there isn’t that much different with CEA once a surgeon AND THE TEAM have done enough of them. There are more moving parts to a TCAR and you need a good team for it, which you also need for CEA, but the effect is not as pronounced as it is for TCAR. Stents do not do well in highly calcified lesions. Some people are doing shockwave off-label for those lesions and anecdotally it seems to work ok but we don’t have data yet. Also, TCAR is already a lot more expensive than CEA and adding shockwave… at some point in the era of rising costs and decreasing reimbursement and insurance companies outright refusing to cover a lot of things… well at some point we need to ask who is paying for stuff. If patients have financial skin in the game, they might decide to stick with the procedure with decades of data showing low rates of reintervention which costs less. Right now, the insured patient doesn’t have much skin in the game as far as they can see but that may change.

Anyway, that was a bit of a ramble. But I think on balance I think it is unlikely that TCAR, CEA, CAS are going to be concentrated in neurosurgery’s hands. Just my perspective on the fields and the marketplace.

 

[m2regen]

I can’t promise I’m not biased to my own specialty. But I do suspect that the people you are working with have spent most of their careers at an ivory tower type place. Which to be clear, are very necessary parts of the healthcare system. However the reality is that on a statistical basis, while complexity is higher at those locations (appropriate), the majority of surgeries and procedures done in this country do not occur at the big quaternary care centers.

Overall, I think this is going to continue to be regional. Referral patterns vary from city to city and hospital to hospital. I think that patient flow patterns at large academic centers do not always reflect what happens in smaller centers...

Thank you so much for the detailed response, I hadn't considered many of these points, especially related nuance of how practice setting affects what procedures are done by whom. I certainly agree my perspective, so far, is skewed by being at an "ivory tower type place", so I greatly appreciate your insight!

 

[m2regen]

I can’t promise I’m not biased to my own specialty. But I do suspect that the people you are working with have spent most of their careers at an ivory tower type place. Which to be clear, are very necessary parts of the healthcare system. However the reality is that on a statistical basis, while complexity is higher at those locations (appropriate), the majority of surgeries and procedures done in this country do not occur at the big quaternary care centers...

Another related question comes to mind... is there any setting where vascular surgeons do thrombectomy for stroke and/or any reason why they don't?

I haven't seen or heard of any, and most answers I've gotten are related to neurosurgeons and neurologists being the primary managers of patients after the procedure. However, radiologists (IR) also don't manage patients in the ICU, and appear to be significant players in stroke thrombectomy. Since vascular surgeons do thrombectomies in other settings and CAS, stroke thrombectomy doesn't seem too beyond scope, but I haven't heard of any vascular surgeons either training or doing stroke thrombectomy.

Additionally, in centers where there isn't vascular neurosurgery, I would imagine that vascular surgeons should be among the most qualified. I would imagine one reason against this so far is that most centers that are comprehensive stroke centers probably have vascular neurosurgeons, but I am wondering with the changes in stroke thrombectomy over the last decade, might vascular surgeons get involved?

 

[LucidSplash]

Another related question comes to mind... is there any setting where vascular surgeons do thrombectomy for stroke and/or any reason why they don't?

I haven't seen or heard of any, and most answers I've gotten are related to neurosurgeons and neurologists being the primary managers of patients after the procedure. However, radiologists (IR) also don't manage patients in the ICU, and appear to be significant players in stroke thrombectomy. Since vascular surgeons do thrombectomies in other settings and CAS, stroke thrombectomy doesn't seem too beyond scope, but I haven't heard of any vascular surgeons either training or doing stroke thrombectomy.

Additionally, in centers where there isn't vascular neurosurgery, I would imagine that vascular surgeons should be among the most qualified. I would imagine one reason against this so far is that most centers that are comprehensive stroke centers probably have vascular neurosurgeons, but I am wondering with the changes in stroke thrombectomy over the last decade, might vascular surgeons get involved?

I don’t go above the skull base. I don’t personally know of any vascular surgeons who do, although I wouldn’t totally rule it out. But it would be an outlier. Our training does not include intracranial vascular intervention at all.

Where there is no vascular neurosurgery, these procedures go to neurointerventional IR, if the hospital has it. Not all hospitals do. If there isn’t one, the patient gets shipped if that service is needed.

During Covid I had a patient with an unstable thrombus in the cervical carotid. I was very concerned about the possibility of it embolizing further (already had a small stroke) during dissection. I was at a hospital where IR did not do neurointerventional. I shipped it to the mothership hospital emergently; neuroIR and vascular agreed should try for open embolectomy first based on anatomy and my partner there took the patient to the OR for embolectomy with IR on backup. Despite having the patient on a heparin gtt, and very careful dissection, patient did embolize. But was able to go to neurointerventional IR and get embolectomy and ultimately did pretty well.

Sometimes it’s not about what you can do, it’s about what the multidisciplinary needs of the patient are. If I had tried to handle that and had a bad outcome because no neuroIR nearby to help, that’s poor judgement on my part. But even though the high risk patient had a high risk embolism, all hands were on deck to handle it and it worked out. Like I alluded to previously, quaternary centers exist for a reason.

 

[LucidSplash]

One additional thing not mentioned here so far, but which I always discuss with students and residents. Much of the time if trying to decided between two specialties, it doesn’t come down to what you like the best.

You need to give special attention to what you like the least. Because chances are you will still have to do at least some of that in your career. Figure out what you like least from each specialty and think hard about how you will handle it.

When I was a gen surg resident, I liked a lot about gen surg. I initially thought I would do trauma/critical care. In the end, in gen surg I hated enterocutaneous fistulas and sacral decubs. In vascular, I really hate maggots and the smell of wet gangrene. I decided I would rather take 30 seconds to take off a necrotic limb on occasion or deal with maggots in wounds on occasion, rather than ECF or the misery of bed bound patients who should be in hospice but families won’t let them go and need diverting colostomies and multiple takebacks for horrible decubs. Also IMHO the best trauma cases were vascular cases.

You have to consider the lowest common denominator. If all vascular surgery involved was CEA and TCAR, everyone would want to do it. Seriously all my Gen surg classmates would jump at a chance to cover a CEA, but harder to find takers for fistulas or angios or fistula declots or cold legs. Gen surg residents tend to be pretty polarized about vascular, they either love it or hate it. I was not a fan as an intern when mostly I had to scrub just amputations, but as I got to do more I changed my mind. CEA and TCAR are a pretty small part of the practice overall; if you want to do vascular, figure out how you feel about dialysis access, aortic work, and PAD. If you aren’t really interested in the bread and butter stuff, best not to pursue the field.

 

[m2regen]

I don’t go above the skull base. I don’t personally know of any vascular surgeons who do, although I wouldn’t totally rule it out. But it would be an outlier. Our training does not include intracranial vascular intervention at all.

This is interesting, since vascular surgery training itself does not include intracranial intervention, do you know if vascular surgeons can train in Neuro IR. Since neuro IRs are usually fellowship-trained after body IR, I would imagine vascular surgeons have at least a similar qualification for additional training in Neuro IR.

 

[m2regen]

You have to consider the lowest common denominator. If all vascular surgery involved was CEA and TCAR, everyone would want to do it. Seriously all by Gen surg classmates would jump at a chance to cover a CEA, but harder to find takers for fistulas or angios or fistula declot a or cold legs. CEA and TCAR are a pretty small part of the practice overall; if you want to do vascular, figure out how you feel about dialysis access, aortic work, and PAD. If you aren’t really interested in the bread and butter stuff, best not to pursue the field.

Agree with this definitely. This was the reason I initially ruled out neurosurgery, because I wasn't interested in spine, and I heard that's a major share of neurosurgery. However, since I have been in research, I haven't yet formally rotated on cerebrovascular and vascular services outside my research areas, so hopefully that will allow me to answer these questions more definitively.

 

[LucidSplash]

This is interesting, since vascular surgery training itself does not include intracranial intervention, do you know if vascular surgeons can train in Neuro IR. Since neuro IRs are usually fellowship-trained after body IR, I would imagine vascular surgeons have at least a similar qualification for additional training in Neuro IR.

IR fellowships are for IR. I am not aware of intracerebral fellowship opportunities after vascular fellowship or residency. It’s a different field entirely. A few integrated vascular trainees I know went on to do cardiac surgery fellowships so they could operate on the entire aorta. I know of one vascular surgeon who went back to do a CT surg fellowship after being in practice for 10 years and one CT surgeon who went back to do a vascular surgery fellowship after being in practice for 10 years but these are outliers.

But you will not be doing intracerebral work from a vascular surgery pathway.

 

[LucidSplash]

Agree with this definitely. This was the reason I initially ruled out neurosurgery, because I wasn't interested in spine, and I heard that's a major share of neurosurgery. However, since I have been in research, I haven't yet formally rotated on cerebrovascular and vascular services outside my research areas, so hopefully that will allow me to answer these questions more definitively.

My experience with neurosurgeons is that they tend to gravitate toward spine or brain. You should talk to some to differentiate between what you will do while in training vs how you can set up your practice once you are done with training.

While they may cover for emergent spine or brain consults while on call as attendings in a non-quaternary center, the ones I know typically handed off the non-emergent stuff in the area that wasn’t their focus to the partners that were. And at a larger center, the spine guys did spine and the brain guys did brain and nary the twain did meet.

 

[longhaul3]

The posts above are full of good information. I'll share the neurosurgery perspective. There are a few points that I think are important for you to understand before you make a decision.

First, there is very minimal direct overlap between vascular surgery and neurosurgery. In fact, extracranial carotid surgery/stenting (plus the occasional consult for an extracranial vert/subclavian injury) is about it. I've never heard of a vascular surgeon doing a case involving the intracranial or spinal vasculature, except to the extent that the segmental arteries are involved in aortic surgery.

Second, extracranial carotid surgery is the sort of the stepchild of vascular neurosurgery, to the extent that frankly many vascular neurosurgeons are not interested in doing it (except direct carotid bypasses, which are extremely rare). I also think the CREST 2 trial will be the last nail in the coffin for routine CEA. The crux of vascular neurosurgery is intracranial cerebrovascular work, like aneurysms, bypasses, AVMs, cavernous malformations, cranial/spinal AV fistulas, etc. Historically these were the insane neurosurgeons clipping basilar tip aneurysms with a comically high mortality rate. These cases are much less common with the advent of endovascular neurosurgery. Since thrombectomy arrived (very recently), stroke has become a big part of their practice volume-wise, though it's the worst part of the job.

Third, vascular is a small part of neurosurgery. It's mostly spine, trauma/hemorrhages, hydrocephalus, and tumors, then also vascular, skull base, peds, and functional. You have to be willing to dive head-first into all of it if you're going to survive the residency.

If your greatest interest is in endovascular (particularly neuroendovascular), honestly I think your best fit would be IR.

 

[m2regen]

Third, vascular is a small part of neurosurgery. It's mostly spine, trauma/hemorrhages, hydrocephalus, and tumors, then also vascular, skull base, peds, and functional. You have to be willing to dive head-first into all of it if you're going to survive the residency.

If your greatest interest is in endovascular (particularly neuroendovascular), honestly I think your best fit would be IR.

Thank you very much for your thoughtful insights. I went through a similar rationale with IR earlier in my journey and rotated with DR and IR. Similar to your point about neurosurgery, I realized I the non-endovascular parts of IR were a large part of the day-to-day and did not fit my interests.

How do neurosurgeons manage the end of their operative careers? Above it was mentioned that vascular surgeons can transition into vein and/or wound care heavy practices at the end of their career; are there analogous options for neurosurgery? I've heard also that some neurosurgeons increase their research or administrative duties as they transition out of their operative career. What have you seen in your experience?

 

[longhaul3]

How do neurosurgeons manage the end of their operative careers? Above it was mentioned that vascular surgeons can transition into vein and/or wound care heavy practices at the end of their career; are there analogous options for neurosurgery? I've heard also that some neurosurgeons increase their research or administrative duties as they transition out of their operative career. What have you seen in your experience?

It depends on the practice setting. In academics, the more senior surgeons may start doing fewer cases and take more time for research, admin time, or just stop operating. Eventually they start to fade away and either find a retirement academic job (in a sunny location like Tampa, etc.) or retire altogether. In private practice, they have junior partners who start to take over their practice, and they start doing fewer and fewer cases until they've had enough.

But, the current generation of neurosurgeons at or nearing the point of retirement is the last of those who trained when what we now call "general neurosurgery" was just "neurosurgery." So you still have older surgeons who feel comfortable clipping aneurysms, resecting tumors, and doing moderately complex spine. For everyone who follows, our late careers may look different since we are becoming so subspecialized, especially in academia.

 

[LucidSplash]

N=1, but the PP neurosurg group where I trained had it written into their bylaws that partners had to retire from operating independently at 65. There was one senior guy older than that who then first assisted his partners for complex cases. I’m not sure why that was in their group bylaws but the gossip was there was previously and older surgeon (different than the one who first-assisted) who had refused to retire when his technical skills declined.

I don’t know if this kind of thing is typical for PP neurosurg groups but I suspect not.

But anyway, first assisting partners is probably an option in the right setting.

 

[bobjonesbob]

This is interesting, since vascular surgery training itself does not include intracranial intervention, do you know if vascular surgeons can train in Neuro IR. Since neuro IRs are usually fellowship-trained after body IR, I would imagine vascular surgeons have at least a similar qualification for additional training in Neuro IR.

To get into neuro IR from radiology residency, most do diagnostic neuroradiology fellowship prior to NIR fellowship without doing general IR training. There are exceptions, but most IRs don't do any cerebrovascular work.

 

[irwarrior]

To get into neuro IR from radiology residency, most do diagnostic neuroradiology fellowship prior to NIR fellowship without doing general IR training. There are exceptions, but most IRs don't do any cerebrovascular work.

There are a few (Mt Sinai in NYC as an example) 7 year tracts for neurointerventional and vascular interventional radiology training where you train in both. The integration requires NeuroICU/ Stroke neurology/ neurosurgery blocks as well as quite a bit of neuroimaging/neurosciences throughout the 7 years. Many peripheral VIR also do stroke work as an assist to the neuroIR service as stroke call can be quite busy. The key is learning the cerebrovascular imaging and the catheters and devices such as stent retrieval systems/aspiration catheters/ neurowires/neuromicrocatheters and core concepts of NISH /neuro exam and cerebral vascular / perfusion imaging . Having a background in the clinical trials such as MR CLEAN, revascat, swift prime, extend IA, Dawn, Defuse 3, and most recently Select 2 will give you some background on patient selection. Many peripheral VIR also do some embotherapy in the setting of epistaxis, MMA embo and most recently TAEGR (thyroid artery embolization for goiter).

 

[m2regen]

But, the current generation of neurosurgeons at or nearing the point of retirement is the last of those who trained when what we now call "general neurosurgery" was just "neurosurgery." So you still have older surgeons who feel comfortable clipping aneurysms, resecting tumors, and doing moderately complex spine. For everyone who follows, our late careers may look different since we are becoming so subspecialized, especially in academia

This is an interesting point that I'd like to learn more about. How do you think the combination of sub-specialization and academia will impact the late careers of current neurosurgeons? Will certain subspecialities have more or fewer options than others? And how does academia factor into this?