Editorial: vascular surgery "disappearing"

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Fab5Hill33

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http://www.vascularspecialistonline...ent=Dr. Russell Samson sees vascular surgeons

"However, the reasons for vascular surgeons becoming marginalized are even more complex... First is the fact that, as a specialty, we were late to the party. Let’s face it, vascular surgeons did not invent endovascular procedures. It was Charles Dotter... who started the revolution. In fact, many of our earlier vascular leaders were so unimpressed that it took years before presentations about endovascular procedures made it into the SVS annual meeting or became part of vascular surgical training. Admittedly, since then many advances in these procedures have resulted from the genius of some vascular surgeons, especially in the treatment of aortic aneurysms, but which catheter or wire is named after a surgeon? Which surgeon invented the latest stent, ablation catheter, or saphenous venous ablation method? We have largely benefited from the inspirational work of interventional radiologists. They have invented the technologies and pushed the boundaries that have allowed us to access pedal and radial arteries, obliterate calcified arterial plaque, place medicated balloons and stents, and replace venous stripping with less invasive ablations. Moreover, they proved that these procedures can be done in outpatient centers where the remuneration exceeds that which we can earn when these procedures are performed in a hospital. So should we complain when cardiologists or interventional radiologists mount major symposiums dealing with vascular conditions? Yes, we may be correct that only vascular surgeons have been trained to understand all the ramifications of vascular disorders. However, this is changing as radiology and cardiology training programs increasingly add peripheral vascular disease to their curricula. Further, although vascular training programs now involve a great deal of endovascular training, many still do not offer significant exposure to some of the more “radical” therapies such as pedal access and advanced CTO techniques."

Dr. Russell H. Samson is a physician in the practice of Samson, Showalter, Lepore, Nair, and Dorsay and clinical professor of surgery, Florida State University, Tallahassee. He is also the medical editor of Vascular Specialist.

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Are vascular surgery and IR competing for each others' bread and butter or butting heads at the periphery of their respective turfs?
 
Vascular Surgeons are becoming Interventionalists because they realize the field is more enjoyable and interesting compared to surgery.
 
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Vascular Surgeons are becoming Interventionalists because they realize the field is more enjoyable and interesting compared to surgery.
Truth. Many vascular surgeons even advertise that they are trained in "interventional radiology" these days.
 
I think vascular surgery should have stuck to surgery just like cardiothoracic surgery did. Stick to what you spent most of your residency and fellowship doing, and what you do best... surgery.

Cardiothoracic surgeons don't do cardiac caths. Instead they focused on what they do best and now they have made great advances in heart and lung transplants, robotics, VATS, and of course the necessary bypass procedures. I fear for the next generation of patients because there will no longer any well-trained vascular surgeons who can do complex open AAA repairs.
 
It's pretty arrogant to suggest that vascular surgery is disappearing any time soon. Bypass is clearly superior to endovascular techniques for a great proportion of patients, and most vascular surgeons that I know much prefer working an open AAA to EVAR, not the other way around.

Besides, someone's got to amputate all those ischemic limbs. Sorry, couldn't resist.
 
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There will still be competent surgeons at tertiary care centers who can handle the difficult open cases. Community surgeons? Probably not.

In reality such disparities apply to a range of specialities (including IR).
 
How is it arrogant when the opinion piece was written by a vascular surgeon? He's entitled to his opinion as a practicing vascular surgeon.

Nobody is saying bypass isn't superior to endovascular treatment for some diseases. What I would say, though, is that vascular surgery needs to focus on surgery and leave endovascular work to the experts.

As far as surgeons preferring open AAA to EVAR, I would bet that sentiment holds for most surgeons who are over 40 year old. The newer generation? Nowadays they get far less exposure to open AAA repair in training because of the shift toward "easier" endovascular work.


It's pretty arrogant to suggest that vascular surgery is disappearing any time soon. Bypass is clearly superior to endovascular techniques for a great proportion of patients, and most vascular surgeons that I know much prefer working an open AAA to EVAR, not the other way around.

Besides, someone's got to amputate all those ischemic limbs. Sorry, couldn't resist.
 
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How is it arrogant when the opinion piece was written by a vascular surgeon? He's entitled to his opinion as a practicing vascular surgeon.

Vascular surgeons can be arrogant (trust me). And I don't think I ever attempted to revoke anyone's right to speak their opinion.

That said, I don't think the speaker was being arrogant, because I don't think he really believes vascular surgery is going away. If you've been to a professional conference or two you'll see this kind of language is pretty common when someone is trying to "shake things up" and start a conversation. He doesn't believe vascular surgery is going away, he wants to spur his profession out of what he sees as complacency. Go to any major IR meeting and you can find someone sounding alarm bells on IR, particularly for peripheral vascular work. Frankly we've probably already lost that war to the vascular surgeons. They're more worried about cardiology than us at this point.
 
I respectfully disagree. I think vascular surgery is dying. At the very least it's not advancing (which is effectively dying). Contrast that with IR that is growing and expanding like gangbusters - the newer generations of IR trainees are fare more clinically savvy and have an aggressive mindset that was lacking in the older generation. Or compare vascular surgeons with cardiologists who are greedy by nature and trying to expand into vascular work to compensate for the declining reimbursement for cardiac caths. Just my opinion, but I think vascular surgery is in trouble... not necessarily in the next 5 years, but long term.

Vascular surgeons can be arrogant (trust me). And I don't think I ever attempted to revoke anyone's right to speak their opinion.

That said, I don't think the speaker was being arrogant, because I don't think he really believes vascular surgery is going away. If you've been to a professional conference or two you'll see this kind of language is pretty common when someone is trying to "shake things up" and start a conversation. He doesn't believe vascular surgery is going away, he wants to spur his profession out of what he sees as complacency. Go to any major IR meeting and you can find someone sounding alarm bells on IR, particularly for peripheral vascular work. Frankly we've probably already lost that war to the vascular surgeons. They're more worried about cardiology than us at this point.
 
Most surgeons prefer EVAR to open these days. Maybe you work with a bunch of dinosaurs. But even the dinosaur surgeons I know will refer to IR for EVAR.
 
Most surgeons prefer EVAR to open these days. Maybe you work with a bunch of dinosaurs. But even the dinosaur surgeons I know will refer to IR for EVAR.

Well I do work with some dinosaurs, but I meant more that they enjoy performing open cases more than EVARs. I don't think any would doubt that EVAR is a much better option for many people.
 
That is true. the vascular surgeons I know prefer open surgery to endovascular. They enjoy suegery.
 
That is true. the vascular surgeons I know prefer open surgery to endovascular. They enjoy surgery but accept that endovascular treatment is the way to go for a large chunk of cases.
 
Just to color the editorial it comes from an "old school" vascular surgeon, who trained prior to the endovascular revolution.

Anyone who thinks vascular surgery is dying or even "not advancing" does not have their finger on the pulse...lol

The truth is that vascular surgeons training nowadays have excellent endovascular skill sets and will not need to refer anything out to IR or any other speciality. Furthermore, vascular surgeons control their referrals to a far greater deal than IR, who often depends upon other people to refer cases to them. They follow their patients often for life (for better or worse, till death do they part) and control the vascular labs in most places. This equals cases and control over the patient population.

My honest opinion is that vascular interventions by IR will markedly decrease as the younger generation of vascular surgeons replace those who never truly trained in endovascular interventions.

This does not even mention the interventional cardiologists who are the bigger threat, as they are a much larger group than either IR or vascular surgeons and control their own referrals to some degree too. Hopefully the new york times will keep exposing them for performing unnecessary peripheral interventions in claudicants which seems to be the majority of their practices...

Lucky for IR you guys have so many other procedures and your field will continue to evolve. I have no doubt that IR will continue to grow and grow and grow, just not as much in the vascular domain.
 
I would agree. The surgeon in this article comes off as saying that open vascular surgery volume is decreasing while endovascular intervention is increasing (be it vascular surgeon, cardiologist, or vascular radiologist).

I also agree with you that vascular surgeons over the past 5 to 10 years have gotten much better at endovascular by leaps and bounds (the ones I have seen <5 years out of training are significantly better than the ones that are 5-10 years out of training). They do have the referral base. However, vascular radiologists are produced at a 3:1 ratio compared to vascular surgeons. There are enough PAD patients to allow both to practice treating arterial occlusive disease, particularly radiologists who perform these procedures as the surgeons may not be able to keep up with the volume.. The giant elephant in the room is cardiology, who outnumber vascular radiologists by 3:1 and vascular surgeons by 9:1. With huge numbers, huge patient base, decreasing coronary volumes, they are shifting to maintain there income by picking up PAD.

Just to color the editorial it comes from an "old school" vascular surgeon, who trained prior to the endovascular revolution.
 
I do think that the scope and breadth of IR is what is alluring for me. I am lucky enough to be involved in aortic and peripheral vascular interventions ,oncologic interventions , hepatobilliary interventions, vertebral augmentation , fibroid therapy. It was one of the reasons I chose IR over a surgical subspecialty or procedural medical specialty such as cardiology or GI. I often see the specialists so focused on their organ of concern, that they lose sight of the whole patient. As a clinical IR you have a more general understanding of numerous conditions at a surprisingly deep level. This I believe comes from our advanced imaging training and our extensive interaction with numerous disciplines throughout our training and beyond.

The weakness inherent in IR was that the training did not encompass adequate clinical integration. The IR residency is a move in the right direction. Many academic IR programs are still old fashioned and not doing formal consults, do not have robust outpatient clinics or have poor longitudinal fellowship and may not be admitting their own patients. I would strongly avoid going to such a program for training as you will be ill prepared to be a competent clinician. It is not whether you can do it, it is more important to decide should you do it. Also, pharmacologic adjuncts work wonders these days and it should be in your armamentarium as a clinician. If you have a hammer , everything you see is not a nail. Least invasive options provided they are equally efficacious are the way to go, but that may be pharmacologic therapy and not interventional or surgical treatments (i.e. courage trial).

Following patients is where you learn how to be a good interventionalist and if you are not following patient for years post these interventions you can not assess your efficacy or learn how you can improve your outcomes.

I do think there are multiple disciplines involved in vascular care (vascular medicine, cardiology, vascular surgery, IR) and I think this is overall a good thing for patients and hopefully increasing options for treating these patients and ultimately hopefully preventing vascular conditions from ever arising. I think there is a lot to learn from vascular surgery, cardiology, vascular medicine, nephrology, and IR . They all bring different knowledge sets to the table.
 
Actually I think my finger is very much on the pulse. I've spoken at SVS and SIR. The attendance and depth of research presented at both is alarming. Also, the actual procedure statistics show that there's been a rebound in both the number of vascular cases done by IR and the percent of the pie that they have.

The problem with vascular surgery is that it's the one surgical specialty stuck in no mans land. Colorectal surgeons didn't try to become experts at endoscopy and cardiothoracic surgeons didn't try to become experts endosvascular coronary work. Vascular surgery tried to fill the void of endovascular work that was created by a generation of IRs who didn't care to deal with PAD patients and made more money doing part time diagnostic radiology. But that's changed now. That void is no longer there. IR is no longer a referral based specialty. They own their own patients just like any other specialist.

Lastly, anyone who thinks that vascular surgerons have "excellent endovascular skills" is a vascular surgeon themselves and in denial. That would be like an interventional radiologist or cardiologist claiming they can suture better than any surgeon because they do a few ports or ICDs.

If you're buying stock, it's time to sell vascular surgery and buy IR.


Just to color the editorial it comes from an "old school" vascular surgeon, who trained prior to the endovascular revolution.

Anyone who thinks vascular surgery is dying or even "not advancing" does not have their finger on the pulse...lol

The truth is that vascular surgeons training nowadays have excellent endovascular skill sets and will not need to refer anything out to IR or any other speciality. Furthermore, vascular surgeons control their referrals to a far greater deal than IR, who often depends upon other people to refer cases to them. They follow their patients often for life (for better or worse, till death do they part) and control the vascular labs in most places. This equals cases and control over the patient population.

My honest opinion is that vascular interventions by IR will markedly decrease as the younger generation of vascular surgeons replace those who never truly trained in endovascular interventions.

This does not even mention the interventional cardiologists who are the bigger threat, as they are a much larger group than either IR or vascular surgeons and control their own referrals to some degree too. Hopefully the new york times will keep exposing them for performing unnecessary peripheral interventions in claudicants which seems to be the majority of their practices...

Lucky for IR you guys have so many other procedures and your field will continue to evolve. I have no doubt that IR will continue to grow and grow and grow, just not as much in the vascular domain.
 
Also, the actual procedure statistics show that there's been a rebound in both the number of vascular cases done by IR and the percent of the pie that they have.

With regard to the numbers of vascular cases performed by IR and the "piece of the pie", here is some data...



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J Am Coll Cardiol. 2015;65(9):920-927.
J Vasc Surg. 2015 September ; 62(3): 562–568.



On the left is the 5% medicare sample (which looks at a random 5% of all medicare claims) from 2006-2011 (somewhat newer but still not 2016) showing the number of peripheral vascular interventions performed by specialty.

On the right is the nationwide inpatient sample data looking at AAA repairs from 2001 to 2009 (Old data yes but not that old).

The data is pretty self explanatory.


Lastly, anyone who thinks that vascular surgerons have "excellent endovascular skills" is a vascular surgeon themselves and in denial. That would be like an interventional radiologist or cardiologist claiming they can suture better than any surgeon because they do a few ports or ICDs.

Vascular surgeons are performing more peripheral vascular interventions and endovascular aneurysm repairs than any other specialty. I think that experience amounts to a bit more than an IR or IC doing a few ports or ICDs. While I don't have data to support it, I would venture to claim that vascular surgeons in training nowadays spend more time learning endovascular skills and performing endovascular peripheral and aneurysm interventions than either IR or IC.



Again IR is a GREAT specialty with a bright future, but you are just plain wrong if you think vascular surgeons are going the way of the dinosaurs...
 
Can we delete this thread? The original post isn't even about IR, it's about surgery. Post on the surgical board if you want to continue this discussion.
 
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