COMMENTARY

Vascular Surgery Must Be Its Own Medical Specialty

Frank J. Veith, MD; Anya Romanowski, MS, RD

Disclosures

September 06, 2017

Anya Romanowski, MS, RD: Hello. I am Anya Romanowski, editorial director at Medscape. Today I have the pleasure to be joined by Dr Frank Veith, professor of surgery at NYU and at the Cleveland Clinic. Thank you, Dr Veith.

Frank J. Veith, MD: A pleasure to be here, Anya.

Ms Romanowski: Tell us: What led you to choose vascular surgery as a specialty?

Dr Veith: Largely, I chose it because it was challenging and the procedures were technically demanding. Most important, the diseases we were treating were either life-threatening, limb-threatening, or stroke-threatening, and the procedures made a real difference and got patients well from conditions that would otherwise cause them great harm.

Ms Romanowski: My understanding is that you were one of the first to perform an endovascular aortic aneurysm repair (EVAR) procedure. Can you talk a little about that experience?

Dr Veith: I can talk a lot about it, but I will try to be brief. We did the first EVAR in the United States. I was a standard, so-called cutting vascular surgeon and was always an endovascular enthusiast, but we weren't doing the procedures ourselves. When we did this case, for me it was an epiphany. It was like a lightning bolt struck me in the head. I said, "If we don't do these procedures ourselves rather than relegate them to other disciplines or specialists, we are going to be out of business." The first case we did worked very well, and I saw the potential for transforming the specialty.

Ms Romanowski: How has vascular surgery changed for the better in the past 20 years, from the time that you initially began doing these procedures up to now?

Dr Veith: Vascular surgery was always very attractive to me because it was difficult, technically demanding, and a lot of benefits could accrue to these very sick patients. The way it technically changed from 25 years ago was that we started doing endovascular procedures to treat lesions that otherwise required very difficult operations. Eureka! We could treat these patients in a much simpler way; there was less morbidity, less mortality, fewer complications.

The idea that vascular surgery embraced this technology early on (in part because of me and others) made vascular surgery a much more interesting specialty. There was a lot of research that could be done, a lot of development. It opened vistas that made vascular surgery even more attractive than it already was.

Ms Romanowski: Why is vascular surgery the specialty best suited to care for patients with vascular diseases?

Dr Veith: Obviously, my answer is going to be a biased one because I am a vascular surgeon. But we are the specialty that devotes itself entirely to the management of vascular diseases. No other specialty does that. We provide conservative medical treatment because we have judgement and we understand the disease. We provide open treatment (the old operations we used to do) and endovascular treatments.

We are the ones who know most about the disease. We are not doing it as an add-on to something else (as do some of the other specialties that deal with it). This is our field, and we can best suit the treatment to make it most appropriate for that patient and his or her disease. No other specialty has that broad approach to vascular diseases.

Vascular Surgery Predictions

Ms Romanowski: In 1996, you gave a Society for Vascular Surgery presidential address on Charles Darwin and vascular surgery in which you had three predictions on vascular surgery.[1] Can you talk a bit about that too?

Dr Veith: Just by way of background, I said that specialties are like species; if they don't evolve, they become extinct. That was the connection to Darwin. In that address, I made three predictions and associated recommendations; two of them turned out to be wrong or unworkable and one was remarkably right.

The wrong ones were that I said that we should work together with other specialists. Typically, interventional specialists like radiologists and cardiologists to work in groups so that we can teach each other and combine our skills. This was a kumbaya, ideal-world recommendation that never works in most places. In a few places it did work, but in 99% of places it didn't because of problems with human nature, greed, desire for control and power, and various other things. It hasn't worked out particularly well. So, that was a bad recommendation.

Cardiology and radiology have contributed enormously to the treatment of vascular disease and deserve to be in the ball game, but they don't all need to be in the ball game.

I also said that we as vascular surgeons should become a separate specialty, independent from general surgery and cardiac surgery. We mounted a big effort to do that.[2] To make a long story short, it failed—again, because of bad tendencies in human nature, I believe.

My third recommendation is that we should become endovascular competent, embrace these techniques, and use them. I thought that maybe 40%-70% of procedures we were then doing as open procedures would be done as endovascular. I was [right about the increase in endovascular procedures but] wrong [on the percentages] there, because now it is probably closer to 60%-90% of all vascular lesions that need treatment are best treated endovascularly.

Ms Romanowski: What challenges does vascular surgery face currently and in the future?

Dr Veith: Enormous challenges. It is a great specialty, the future is bright, and we have a lot of interesting procedures and associations with industry. We have bright students coming into our field. We face enormous challenges because there is competition for patients with other specialties, notably interventional cardiology and interventional radiology.

The competition in the Darwin analogy would be for food and living space. For us, it's patients and resources. We need to get our share of the resources and our share of the patients. Cardiology and radiology have contributed enormously to the treatment of vascular disease and deserve to be in the ball game, but they don't all need to be in the ball game. If you are taking care of hearts (and that is the definition of cardiology), you don't need to expand to take care of every blood vessel in the body, particularly those that you do not know a lot about.

We face the challenges of a small specialty in controlling our destiny and maintaining our food chain, which is patients and resources. As a subspecialty, we have less access to the levers of power, which drive those resources in patients to us.

Vascular Surgery as a Separate Specialty

Ms Romanowski: Why would vascular surgery be better off as a separate specialty than a subspecialty, as it presently is? I have heard you discuss that in previous lectures.

Dr Veith: That is another very good question. It gets back to an institution: Resources and control of access to things is generally determined by levels of power within the institution. Vascular surgery (as a subspecialty) is represented by a general surgeon, a cardiac surgeon, or a cardiologist when the resources are divvied up or distributed.

As a separate specialty, we would have more access to the councils or organizations within an institution where these resources and patients are distributed.

Ms Romanowski: Why does vascular surgery deserve to be a separate specialty now more than in the past?

Dr Veith: The purpose of specialization is to benefit patients by improving patient care. Again, going back to Darwin, our ancestors were either general or cardiac surgeons who got interested in blood vessel treatment, but now that treatment has become far more complex and all-encompassing, it deserves to be a separate specialty.

In addition, we have a relationship with general surgery because we both did open operations. Now we do largely endovascular procedures as well as some open procedures. But we are completely distinct and separate from general surgery, which is now doing most of its procedures laparoscopically. We have no skills in laparoscopy; we have enormous skills in open vascular surgery and endovascular procedures.

Ms Romanowski: Why is there competition from all of these other specialties for vascular disease patients?

Dr Veith: Human nature. People like to control things and they like to make money and be rewarded. Vascular lesions are there for the treatment. Interventional cardiologists have very good catheter and guidewire skills, so they can do the endovascular procedures, and they feel that they should do all of the procedures on the blood vessels.

Some of the interventional cardiologists specialize in blood vessel treatment as opposed to heart treatment. I think those individuals are qualified and should take care of vascular patients. They know about the diseases, they do it well, and they contribute.

The typical interventional cardiologist is taking on the treatment of vascular disease as an add-on or a hobby to his treatment of the heart. He is more inclined to do cases that might not need to be done. Plus, he may not understand the disease process or know enough about the disease to treat it globally and expertly. That is where some of us feel that we deserve to be a specialty.

Ms Romanowski: Why are many of these patients with serious vascular lesions best treated medically or conservatively?

Dr Veith: The bottom line is that everybody has some vascular disease. Arteriosclerosis is our primary disease process and is quite widespread. Just having a lesion doesn't mean that it needs to be treated. We have high-grade carotid stenosis that are asymptomatic and may never cause a stroke. They may look bad on the x-ray or the angiogram, but most of them do not need to be treated.

Similarly, we may have small aneurysms in an old, sick patient that are never going to rupture. They don't need to be treated. We may have occlusive lesions (eg, in the superficial femoral artery in the thigh) that cause either no symptoms or minimal symptoms. If one treats that, he is liable to provoke more aggressive disease or a complication. One has to consider the risks and benefits, and with many vascular lesions, the risks of treatment far outweigh the benefits of treatment.

Of course, there are cost issues. If you don't treat somebody aggressively or interventionally with either a stent or an operation, it is much cheaper.

Ms Romanowski: Thank you, Dr Veith. It's been a pleasure speaking with you. Thank you, everyone, for joining us today. I am Anya Romanowski, editorial director at Medscape. Please join us again in the future.

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