Confronting Fads in Vascular Surgery

BY FRANK J. VEITH, M.D.

Participation in and support of fads are a part of human behavior. Webster's dictionary defines a fad as a custom, style, or behavior that many people are interested in for a short time; a passing fashion or a craze. Fads often account for the popularity of clothing styles, automobile designs, dance steps, diets, and the success of certain entertainers. Key characteristics of fads are that their adoption and popularity are often based on little in the way of evidentiary support, and that they are promoted by marketing, publicity, and hype.

Fads also influence the practice of vascular surgery. One example was the widespread advocacy and adoption of in situ vein bypass for lower extremity arterial revascularization in the 1980s. This procedure swept the vascular world as the only way to perform lower limb bypasses successfully, and some patients were denied limb-saving procedures because they did not have a vein suitable for in situ use. This fad persisted until level I evidence showed clearly that reversed vein grafts performed as well as in situ vein grafts when the procedures were performed with comparable care and precision and when veins were free of intrinsic defects.

More recent fads include the rush to replace carotid endarterectomy (CEA) with carotid angioplasty and stenting (CAS), and the rush to utilize expensive atherectomy and other devices for the treatment of lower extremity occlusive lesions when simpler techniques may do the job as well at a lower cost. Let us consider these two examples of fads in greater detail and examine some of the forces behind them.

CAS was originally promoted as a less-invasive treatment alternative than open CEA for carotid bifurcation lesions. CAS certainly was attractive when patients needed restoration of carotid flow and were at high risk for open surgery and CEA. However, some enthusiasts advocated the widespread replacement of CEA by CAS in other circumstances without solid evidence of its equivalence or even of a real need for any invasive treatment in asymptomatic patients, many of whom have a benign course, particularly when treated with statins and other effective stroke-prevention drugs.

In my opinion, some of this premature advocacy was fueled by interspecialty turf issues that fanned the flames of the fad. In addition, vascular surgeons--fearing the loss of a common and well-liked open operation--rushed to learn the skills needed to perform CAS, further supporting the faddish nature of the procedure. Although recent evidence from randomized trials and registry data have somewhat dampened the enthusiasm for CAS, it is important that vascular surgeons and other vascular specialists who are interested in CAS recognize its partially faddish nature. If they do, they will keep an open mind about its limitations and embrace it widely only after solid evidence provides good justification to do so.

The interests of their patients will be best served by such a measured, evidence-based approach rather than by an enthusiasts' unfounded support of the fad. To this end, more level I evidence in the form of randomized controlled trials is needed in both symptomatic and asymptomatic patients. Also needed are trials comparing CAS with best current medical treatment in asymptomatic patients with carotid stenosis of varying degrees.

The second current fad that vascular surgeons should be aware of, in my opinion, is the trend to use expensive devices to ablate infrainguinal atherosclerotic lesions. Rotational atherectomy devices are an example. These devices have been widely used and highly touted by many vascular specialists as a better treatment method, despite a remarkable lack of evidence that they provide short-term or long-term outcomes that are better than those of other less costly treatment methods, such as balloon or subintimal angioplasty. A key basis for this fad is intense marketing by some device makers, who haven't supported efficacy trials comparing their device with other treatments.

This commercialization has led to great success in terms of sales and stock prices, without documentation of the durable value of the treatment to patients. Once again, vascular surgeons should base their evaluations of such high-tech treatments on adequate comparative trials rather than on fancy promotional marketing before they embrace the fad.

Awareness that fads can exist in vascular surgery will go a long way toward preventing the harm that such fads can bring to the care of patients. Similarly, such awareness can lessen the unjustified increases in spiraling health care costs to which such fads contribute.