Speakers Debate New Arenas For Endovascular Surgery

By Janice Rosenberg

CHICAGO -- Vascular specialists must expand their practices by adding new skills and procedures to their armamentarium, said speakers at the Vascular Annual Meeting. Doing so will provide the excitement of learning new techniques and means to diminish competition from other specialties.

Seven speakers addressed the topic "Expanding Horizons of Endovascular Surgery: Tomorrow Is Now?" Their talks focused on specific procedures and techniques, encouraging others to join efforts to expand the field.

Some in attendance responded to the forum with caution. But Enrico Ascher, M.D., panel moderator and president of the society, said that vascular specialists must start thinking about what they are going to do tomorrow.

"Don't miss the boat. Go, learn, and expand your world. The excuse that we don't know how to do something won't save us any longer," said Dr. Ascher, Professor of Surgery at Mount Sinai School of Medicine and Director of Vascular Surgery at Maimonides Medical Center, both in New York.

Vascular specialists can expand their practices in a number of ways. First, make increased use of knowledge gained during general surgery training. For instance, treating the pathology and complications of liver abscess and necrosis that can arise in hepatic-chemo embolization is very similar to mesenteric interventions and is relatively simple for the experienced endovascular surgeon, said Michel S. Makaroun, M.D.

"Adding this requires excellent catheter guide wire skills," said Dr. Makaroun, Chief of Vascular Surgery at the University of Pittsburgh Medical Center. "In fact, it is a direct extension of what you are already doing typically in your endovascular practice."

Second, apply familiar endovascular techniques to new procedures. Endovascular skills can be useful in managing gastrointestinal pathology, said Michael B. Silva Jr., M.D., Chief of Vascular Surgery and Vascular Interventional Radiology at Texas Tech University Health Sciences Center in Lubbock. These procedures require a minimal investment in new equipment and should be part of every practice.

Endovascular techniques also are transferable. For example, skill used in embolizing type II endoleaks allows Anthony Rizzo, M.D., of the department of vascular surgery at the Cleveland Clinic Foundation, to offer uterine fibroid embolization as an alternative to hysterectomy.

Perfecting less familiar endovascular techniques that require the use of microcatheters, such as approaches to brain aneurysms and cerebral arterial-venous malformations may allow vascular specialists to incorporate these new interventions into their practices, said Richard W. Schutzer, M.D., of the division of vascular surgery at Maimonides Medical Center.

Third, treat patients whose conditions currently lack a dedicated home within another specialties, for instance, those with peripheral arterial-venous malformations, said Alan B. Lumsden, M.D., chief of the division of vascular surgery and endovascular therapy at Baylor University, Houston.

To do so, physicians must acquire high level angiographic and endovascular skills. But the result--establishing lifetime relationships with these patients--has significant implications for patient care, said Dr. Lumsden.

Fourth, broaden the scope of training. Elliot L. Chaikof, M.D., Chief of the Division of Vascular Surgery at Emory University, Atlanta, suggested that a combination of 100 diagnostic angiograms, 50 coronary interventions, and 10 thrombolitic or thrombectomy cases be approved as a training requirement for a certificate of added qualification in coronary angiography.

During the discussion that followed, several physicians voiced reservations about the speakers' suggestions. "I would have difficulty calling a gynecologist and saying I'm doing uterine embolizations now; why don't you send me these patients?" said Keith Calligaro, M.D., Chief of Vascular Surgery at Pennsylvania Hospital, Philadelphia.

Curtis A. Lewis, M.D., President of the Society of Interventional Radiology, emphasized the top-quality skills required to handle such procedures. "The ultimate issue here is about patient care and patient outcomes," said Dr. Lewis, Director of Vascular and Interventional Radiology at Emory University, Atlanta. "We need to be focused on that issue. It's not about turf."

Gregorio Sicard, M.D., past president of the society, asked how vascular specialists were to learn the skills needed to work in new areas. He referred to a questionnaire in which only 30% of recent fellowship graduates responded that they had enough training in first degree endovascular procedures.

"How do we make the jump from a training point of view when 70% of our trainees have not trained in basic techniques?" asked Dr. Sicard, Chief of the Section of Vascular Surgery at Washington University in St. Louis. "A lot of us are in institutions where there are skilled interventionists in some of those areas you are speaking about. How are we going to present to the public that our outcomes are good if we have only five or six guys in the country with the skills to do them?"

Expanding the specialty won't happen overnight, Dr. Ascher said. "You have to remember that 10 years ago we started talking about doing balloon angioplasty and we came to the same point--others are doing it better. And, yes, we learned the procedure slowly and effectively and have outcomes now as good as anybody else. It's just a matter of getting started and not becoming cavalier about it, being very careful, and going to institutes that teach us exactly what to do and how to get the best results."

'IT'S JUST A MATTER OF GETTING STARTED AND NOT BECOMING CAVALIER ABOUT IT, BEING VERY CAREFUL, AND GOING TO INSTITUTES THAT TEACH US. . . .'