Still 'Gold on the Ground' in Clinical Research

BY FRANK VEITH, M.D.

Endovascular treatments, which began in earnest in the early 1990s, have revolutionized vascular surgery. Because these technologies are less invasive, they are attractive to patients and referring physicians; because they are gratifying to perform and often result in lower morbidity in patients, they have been embraced by vascular surgeons as well as by other interventional specialists.

In my column, "The Rush to Stent: A Cause for Concern" (VASCULAR SPECIALIST, March/ April 2006, p. 2), I discussed some of the pressures to overuse these endovascular treatments. For vascular surgeons, there is another strongly positive aspect to the "endorevolution." This aspect, which has no downside, is the opportunity the endorevolution offers to those interested in endovascular treatments to perform important research related to their area of interest.

In the 1980s, research opportunities for vascular surgeons were limited and somewhat dull. They were confined to basic science investigations largely related to intimal hyperplasia and its mechanisms and prevention. Clinical studies could rehash the epidemiology of vascular disease or deal with reevaluations of graft materials for lower-extremity bypass or techniques for carotid endarterectomy and abdominal aneurysm repair. From a scholarly activity point of view, vascular surgery had become a relatively unexciting specialty.

The endorevolution changed all that. Suddenly, opportunities for important clinical research abounded. The gold was lying on the ground as nuggets. All that those of us who participated in the early years of the endorevolution had to do was to pick them up, and we had an important scientific article that justifiably attracted interest because it described a better way to treat vascular patients.

Two simple examples are the use of stents to treat iliac occlusive disease and endovascular grafts to treat inaccessible arterial injuries, such as those to the subclavian artery. Such endografts converted a morbid, technically challenging problem into a fairly simple one. The simple description of several cases of endograft treatment of subclavian artery injuries or arteriovenous fistulas was one gold nugget on the ground.

What was remarkable was that some older, conventional vascular surgeons did not want to hear about these nuggets. But these early negative voices have now been largely silenced as the endorevolution has become an irresistible tidal wave, and it has become clear that vascular surgeons have to become expert in these techniques to survive as vascular therapists.

Today, there are fewer gold nuggets lying on the ground, waiting to be picked up. However, there is still much research gold lying just below the surface to be harvested by interested and creative vascular surgeons who wish to engage in clinically relevant scholarly activity. The development of innovative adaptations of established endovascular techniques, the combinations of endo and open methods of treatment, the careful establishment of the proper indications for use of endovascular treatments, and the controlled comparisons of endo and open methods of treatment represent opportunities to gather with a little greater effort the gold just below the surface.

Clearly, the endorevolution has reinvigorated the field of vascular disease treatment from a scholarly and a patient benefit point of view. It has afforded vascular surgeons and others a wonderful opportunity to pick up newly scattered gold on the ground as well as gold nuggets lying just below the surface. The presence of such gold should attract trainees to our field. These trainees, if the gold is harvested well, should help us use endotechnologies in a way that benefits patients optimally.