Change in Practice Patterns of an Academic Division of Vascular Surgery

PAPER Change in Practice Patterns of an Academic Division of Vascular Surgery

Houman Solomon, MD; Alexander B. Chao, MD; Fred A. Weaver, MD; Steven G. Katz, MD

Hypothesis: Technological advances have required that Results: In 2000, 453 open and 44 endovascular index faculty of academic divisions of vascular surgery ac- procedures were performed. In contrast, by 2005, open quire new technical skills and significantly alter their past index cases had decreased by 47.0% (239) and endovas- clinical practice patterns. cular index cases had increased by 679.5% (299). Open abdominal aortic aneurysm repairs had decreased by 54.5% (68 vs 31), carotid endarterectomies by 28.8% (139 Design: Retrospective medical record review. vs 99), suprainguinal arterial reconstructions by 47.5% (40 vs 21), infrainguinal arterial reconstructions by 56.5% Setting: An academic tertiary referral center and a com- (186 vs 81), and renal/visceral arterial reconstructions munity teaching hospital. by 65.0% (20 vs 7). In 2005, 62 endovascular abdominal aortic aneurysm repairs and 45 carotid stents were Patients: All patients undergoing 10 specific vascular performed, whereas none were performed in 2000. In ad- procedures during a 5-year period. dition, infrainguinal PTA/S had increased by 675.0% (12 vs 81) and suprainguinal PTA/S by 20.0% (20 vs 24).

Main Outcome Measures: We analyzed volumes for Conclusions: Although the total number of proce- 10 specific open and endovascular index procedures dures performed has remained relatively constant, there performed by 5 vascular surgeons during a 60-month has been a dramatic increase in the number of endovas- period. Procedures reviewed included open abdominal cular procedures as well as an associated decline in the aortic aneurysm repair, endovascular abdominal aortic number of open procedures. This change in practice pat- aneurysm repair, carotid endarterectomy, carotid artery tern has allowed the members of our division to main- stent, suprainguinal arterial reconstruction, suprain- tain a significant role in the care of patients undergoing guinal percutaneous transluminal angioplasty/stent vascular surgery, as evidenced by stable overall proce- (PTA/S), infrainguinal arterial reconstruction, infrain- dural volume. This will provide a platform for future out- guinal PTA/S, renal and visceral arterial reconstruction, come-related analyses of open vs endovascular proce- and renal and visceral PTA/S. In-hospital length of stay dures performed within a single specialty group. was compared between open procedures and their endovascular counterparts. Arch Surg. 2007;142(8):733-737

HE USE OF THE AORTIC HO- the 1950s made the treatment of extracra- mograft by Gross et al,1 Ou- nial carotid disease commonplace. These dot,2,3 and Dubost et al4 in procedures established open surgical tech- the mid-20th century be- niques as the gold standard for the treat- gan the modern era of vas- ment of peripheral vascular disease. cular surgery. Development of fabric grafts More than 50 years ago, Seldinger12 de- T 5 6 by Voorhees et al and DeBakey et al al- veloped the technique of femoral artery lowed abdominal aortic aneurysm (AAA) catheterization used today. In 1964, Dot- repair to become routine. The pioneering ter and Judkins13 performed the first suc- work of Dos Santos7 and Leriche8 in end- cessful arterial dilatation. Ten years later, arterectomy formed the basis for success- Gruntzig14 created the modern angio- Author Affiliations: Division of ful treatment of arterial occlusive dis- plasty catheter. In 1990, Palmaz et al15 pub- Vascular Surgery and ease. Adaptation of Carrel’s suturing lished their initial experience with the de- Endovascular Therapy, Keck 9 School of Medicine, University technique to arterial bypass by Kunlin led ployment of balloon expandable stents, of Southern California to the treatment of infrainguinal occlu- ushering in the modern era of endovas- University Hospital, Los sive disease using vein bypass. The land- cular management of arterial disease. Re- Angeles, and Huntington mark reconstructions of the carotid bifur- searchers such as Fogarty et al,16 Green- Hospital, Pasadena, California. cation by Eastcott et al10 and DeBakey11 in field et al,17 and Parodi et al18 have played

(REPRINTED) ARCH SURG/ VOL 142 (NO. 8), AUG 2007 WWW.ARCHSURG.COM 733

©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 Table 1. Volume and Percentage Change Table 2. Comparison of Median LOS Between Open of the Index Procedures and Endovascular Procedures

Volume, Median No. of Cases Procedure LOS, d P Value Change, Procedure 2000 2005 % Carotid endarterectomy 1.0 .01 Carotid artery stent 1.0 Carotid endarterectomy 139 99 −29 Open AAA repair 7.0 Ͻ.001 Carotid artery stent 0 45 NA EVAR 1.5 Open AAA repair 68 31 −54 Suprainguinal arterial reconstruction 3.5 Ͻ.001 EVAR 0 62 NA Suprainguinal PTA/S 1.0 Suprainguinal arterial reconstruction 40 21 −47 Infrainguinal arterial reconstruction 4.0 Ͻ.001 ϩ Suprainguinal PTA/S 20 24 20 Infrainguinal PTA/S 1.0 Infrainguinal arterial reconstruction 186 81 −56 Renal and visceral arterial reconstruction 6.0 Ͻ.001 ϩ Infrainguinal PTA/S 12 81 675 Renal and visceral PTA/S 1.0 Renal and visceral arterial 20 7 −65 Total open 3.0 Ͻ.001 reconstruction Total endovascular 1.0 Renal and visceral PTA/S 12 6 −50 Total open 453 239 −47 Abbreviations: AAA, abdominal aortic aneurysm; EVAR, endovascular AAA Total endovascular 44 299 ϩ680 repair; LOS, length of stay; PTA/S, percutaneous transluminal ϩ Total 497 538 8 angioplasty/stent.

Abbreviations: AAA, abdominal aortic aneurysm; EVAR, endovascular AAA repair; NA, not applicable; PTA/S, percutaneous transluminal angioplasty/stent. amination passage rates for general and vascular surgery residents during the study period were noted. The Mann- Whitney test was used to determine differences between significant roles in the minimally invasive treatment of variables with continuous outcomes, and the Fisher exact test arterial embolus, pulmonary embolism, and aortic an- was used to analyze differences between the categorical vari- eurysm. However, those in disciplines other than vas- ables. Statistical significance was assumed at PϽ.05. Data cular surgery have advanced most developments in the analysis was performed using SAS statistical software (SAS Inc, endoluminal treatment of arterial disease. With the Cary, NC). ever-increasing demand for minimally invasive procedures, members of our vascular surgery division re- RESULTS trained to develop catheter-based skills. In 2000, we began to perform minimally invasive vascular procedures.19 This In 2000 and 2005, the University of Southern California article describes the evolution of our practice during the Division of Vascular Surgery and Endovascular Therapy ensuing 5 years. performed 1035 index procedures. Of the patients, 62.9% were male and 37.1% were female. Their ages ranged from METHODS 49 to 92 years (mean age, 76.8 years). In addition, 45.9% of the patients confirmed a history of smoking more than We reviewed the records of all patients who had undergone any 20 cigarettes per day, 40.9% had hypercholesterolemia, of 10 open or endovascular index procedures performed by the 37.0% had coronary artery disease, 20.9% had diabetes 5 members of our division during a 60-month period. Patient mellitus, 7.8% had chronic obstructive pulmonary dis- data were collected from inpatient and outpatient medical and ease, and 5.0% had renal impairment. There were no sig- billing records. Patient demographics and comorbidities were nificant differences in the demographics or comorbidi- recorded, and comparisons were made between those under- ties of patients operated on in 2000 and 2005 or in patients going minimally invasive procedures and those undergoing open undergoing open or minimally invasive repair (PϾ.16). repair. Procedures reviewed included open AAA repair (rup- In 2000, 453 open repairs and 44 minimally invasive tured AAAs were excluded), endovascular AAA repair (EVAR), procedures were performed for the 10 index cases. In con- carotid endarterectomy (CEA), carotid artery stent (CAS), suprainguinal arterial reconstruction, suprainguinal percutane- trast, by 2005, 239 open repairs and 299 minimally in- ous transluminal angioplasty/stent (PTA/S), infrainguinal ar- vasive procedures were completed. By the final year of terial reconstruction, infrainguinal PTA/S, renal and visceral the study, CEAs had decreased by 28.8%, open AAA re- artery reconstruction, and renal and visceral PTA/S. pair by 54.5%, suprainguinal arterial reconstructions by The volumes of each of these procedures, as well as their 47.5%, infrainguinal arterial reconstructions by 56.5%, corresponding in-hospital lengths of stay and mortality rates, and renal and visceral arterial reconstructions by 50.0%. were recorded. Length of stay was defined as postoperative days There was a corresponding increase in the number of until discharge or completion of care by the vascular service. minimally invasive procedures performed (Table 1). Postoperative mortality was considered to occur within 30 days When compared, patients undergoing minimally in- of the procedure or during the patient’s procedural hospital- vasive procedures had significantly shorter hospital stays ization. Comparisons of case volume, length of stay, and peri- Ͻ operative mortality rates were made between the first and last than those having open repair (1 day vs 3 days; P .001). years of the study. Vascular procedures performed by the gen- This held true when all endovascular procedures were eral surgery residents in our institution in 2000 and 2005 were compared with their open counterparts (Table 2). Pa- recorded, as were the number of open and endovascular proce- tients undergoing CEA had a much greater variation in dures performed by the vascular surgery residents. Board ex- the range of their length of stay (range: 1-19 days vs 1-8

(REPRINTED) ARCH SURG/ VOL 142 (NO. 8), AUG 2007 WWW.ARCHSURG.COM 734

©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 days). This caused a statistically significant P value even though the median values for CEA and CAS were equal. Table 3. Mortality Data Mortality data were available for 97.2% of patients (1006/ 1035). The 30-day mortality rate was 0.6% for mini- Volume, No. of Mortality, mally invasive procedures and 2.2% for open surgical re- Procedure Cases Deaths % pair (P=.09) (Table 3). In 2000, general surgery residents completing their Carotid endarterectomy 238 1 0.4 Carotid artery stent 45 0 0 training in our institutions performed an average of 83 Open AAA repair 99 5 5.1 defined-category vascular cases, and in 2005 they per- EVAR 62 2 3.2 formed 64. In 2000, the vascular resident performed 179 Suprainguinal arterial reconstruction 61 1 1.6 open and 38 endovascular procedures, and in 2005 he Suprainguinal PTA/S 44 0 0 performed 203 open and 110 catheter-based procedures Infrainguinal arterial reconstruction 267 5 1.9 (only the 10 index cases were tabulated). During the Infrainguinal PTA/S 93 0 0 Renal and visceral arterial 27 3 11.1 study, 90% of the general surgery residents passed the reconstruction American Board of Surgery qualifying examination on Renal and visceral PTA/S 18 0 0 their first attempt, and 86% successfully completed the Total open 692 15 2.2 certifying examination on their first effort. First-attempt Total endovascular 343 2 0.6 board passage rates for vascular surgery residents were 83% for the qualifying examination and 100% for the Abbreviations: AAA, abdominal aortic aneurysm; EVAR, endovascular AAA repair; PTA/S, percutaneous transluminal angioplasty/stent. certifying examination.

COMMENT Postgraduate training will also be greatly influenced by rapid technological advances. Some of these new tech- Surgery has rapidly evolved in the last 2 decades. Lapa- niques will require the acquisition of skill sets that tradi- roscopic techniques have revolutionized the specialty, and tionally lie within other specialties. It is incumbent on those robotic and endoscopic surgery hold promise. Surgeons who train residents to learn to skillfully perform these new have been required to learn and utilize new skill sets to procedures so that they will be able to help their students keep pace with the advancing technology. Demand for appropriately incorporate them into their therapeutic ar- endovascular procedures is rapidly increasing as well. This mamentarium and treatment algorithms. Realizing the im- will oblige vascular surgeons to acquire catheter and guide portance, utility, and prevalence of minimally invasive pro- wire skills or entrust the care of many of their patients cedures, our residency review committee has now required to physicians in other specialties. Members of our divi- all vascular surgery fellowships to incorporate endovas- sion chose to retrain and acquire the requisite skills nec- cular procedures as an integral part of the curriculum. Simi- essary to provide our patients with catheter-based treat- lar requirements have been mandated for general surgery ment options. As a consequence, our practice patterns residencies in the areas of laparoscopy and endoscopy to have been dramatically altered. provide more comprehensive and up-to-date training for The results of our study demonstrate the rapid in- the next generation of general surgeons. Surgeons who increase in minimally invasive procedures that has oc- tegrate these new techniques into their practice will not curred during the last 5 years. The number of EVARs and be required to delegate the training of their house staff to suprainguinal and infrainguinal PTA/Ss has now eclipsed those in other disciplines, who may or may not inflict their the number of their open surgical counterparts. The CAS own treatment bias. They will also serve as role models is beginning to replace traditional CEA as the treatment for future surgeons, who will most likely be required to for patients with extracranial cerebrovascular disease. One retrain several times during their careers. Another conse- result of this change in practice patterns is a dramati- quence of the rapid rise in endovascular procedures is the cally reduced length of stay for those undergoing mini- resultant decrease in traditional open vascular proce- mally invasive procedures. Many of these procedures can dures available in general surgery resident training.21 Cur- be performed on an outpatient basis. This makes inpa- rently our programs graduate 7 to 8 general surgery resi- tient beds, which are increasingly becoming a valuable dents and 1 vascular resident per year. Although the commodity, available, and lowers the cost of patient care.20 number of vascular procedures performed by the general When compared, a reduced mortality rate for endovas- surgery residents has decreased, to date all have ex- cular procedures approached but did not achieve statis- ceeded the minimum requirement set forth by the Ameri- tical significance (P=.09). can Board of Surgery. However, the American Board of Sur- New technologies need to be critically evaluated, and gery may need to reevaluate resident case requirements their efficacy needs to be objectively compared with train the future. Board passage rates for both general and vas- ditional treatment modalities. We believe that surgeons cular surgery residents have remained satisfactory. Since who can perform both minimally invasive and open pro- increasing the length of our vascular surgery residency in cedures will be better able to make these unbiased judg- 2002 from 1 to 2 years, all vascular surgery residents com- ments than physicians who provide only 1 form of care. pleting our program have been able to receive privileges In addition, those who are facile in all modes of therapy for all open and catheter-based procedures with the ex- will be able to offer their patients the best therapeutic op- ception of CAS. We plan to rectify this deficiency in the tion after considering all possible alternatives. near future.

(REPRINTED) ARCH SURG/ VOL 142 (NO. 8), AUG 2007 WWW.ARCHSURG.COM 735

©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 This study demonstrates a dramatic change in the prac- 8. Leriche R. De la resection du Carrefour aortoiliaque avec double sympathecto- tice pattern of 1 group of vascular surgeons. We believe mie lombaire pour thrombose arteritique de l’aorte: le syndrome de “oblitera- tion termino-aortique par arterit.” Presse Med. 1940;48:601-606. that surgeons are best able to care for patients with pe- 9. Kunlin J. Le traitement de l’arterite obliterante par la greffe veineuse longue. Arch ripheral vascular disease. The acquisition of catheter and Malcoeur. 1949;42:371-374. guide wire skills has allowed the members of our divi- 10. Eastcott HHG, Pickering GW, Rob C. Reconstruction of the internal carotid ar- sion to maintain a steady practice volume without ero- tery in a patient with intermittent attacks of hemiplegia. Lancet. 1954;2:994- 998. sion of our patient base. If we had not incorporated these 11. DeBakey ME. Successful carotid endarterectomy for cerebrovascular insuffi- new techniques into our practice, we would likely have ciency: nineteen-year follow-up. JAMA. 1975;233(10):1083-1085. relinquished the care of a large portion of our patients 12. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography. to physicians in other specialties. Acta Radiol. 1953;39(5):368-376. We conclude that rapidly changing technological ad- 13. Dotter CT, Judkins MP. Transluminal treatment of atherosclerotic obstruction: description of a new technique and a preliminary report of its application. vances will greatly influence the practice patterns of phy- Circulation. 1964;30:654-670. sicians, now and in the future. The acquisition of new 14. Gruntzig A, Krumpe D. Technique of percutaneous transluminal angioplasty with skill sets, often outside the bounds of traditional surgi- the Gruntzig balloon catheter. AJR Am J Roentgenol. 1979;132(4):547-552. cal practice, will be required if surgeons are to keep pace. 15. Palmaz JC, Garcia OJ, Schatz RA, et al. Placement of balloon expandable intraluminal stents in iliac arteries: first 171 procedures. Radiology. 1990;174(3, pt A proactive approach to learning will allow surgeons to 2):969-975. offer the best available treatment options while main- 16. Fogarty TJ, Cranley JJ, Krause RJ, et al. A method for extraction of arterial em- taining their patient base. boli and thrombi. Surg Gynecol Obstet. 1963;116:241-244. 17. Greenfield LJ, Peyton MD, Brown PP, et al. Transvenous management of pulmonary embolic disease. Ann Surg. 1974;180(4):461-468. Accepted for Publication: March 16, 2007. 18. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation Correspondence: Steven G. Katz, MD, Office of Medi- for abdominal aortic aneurysms. Ann Vasc Surg. 1991;5(6):491-499. cal Education, Huntington Hospital, 100 W California 19. Weaver FA, Hood DB, Shah H, et al. Current guidelines produce competent en- Blvd, Pasadena, CA 91105 ([email protected]). dovascular surgeons. J Vasc Surg. 2006;43(5):992-998. Author Contributions: Study concept and design: Chao, 20. Akopian G, Katz SG. Peripheral angioplasty with same-day discharge in patients with intermittent claudication. J Vasc Surg. 2006;44(1):115-118. Weaver, and Katz. Acquisition of data: Solomon, Chao, 21. Cronenwett JL. Vascular surgery training: is there enough case material? Semin and Weaver. Analysis and interpretation of data: Solo- Vasc Surg. 2006;19(4):187-190. mon, Chao, Weaver, and Katz. Drafting of the manuscript: Solomon, Chao, Weaver, and Katz. Critical revi- DISCUSSION sion of the manuscript for important intellectual content: Solomon, Chao, and Katz. Statistical analysis: Chao. Ad- Cornelius Olcott, MD, Stanford, California: Many years ago ministrative, technical, and material support: Solomon and when I was preparing to give my first paper, which inciden- Chao. Study supervision: Solomon, Weaver, and Katz. tally was before this association, Dr William Blaisdell told me Financial Disclosure: None reported. that you can judge the success of a paper by how much dis- Previous Presentation: This paper was presented at the cussion it engenders. I anticipate that this paper will stimulate 78th Annual Scientific Meeting of the Pacific Coast Sur- significant thought and discussion. gical Association; February 20, 2007; Kohala Coast, Ha- Dr Solomon and his colleagues describe the changing practice patterns in an academic vascular surgical practice over the waii; and is published after peer review and revision. past 5 years. It should come as no surprise to any of us that the The discussions that follow this article are based on the practice of vascular surgery, like all surgical specialties, has originally submitted manuscript and not the revised changed significantly since 2000. Less invasive procedures have manuscript. been created for the repair of AAAs, carotid stenosis, aorto- Additional Contributions: Gabriel Akopian, MD, iliac and lower extremity occlusive disease, and renal and vis- Haimesh Shah, MD, and Erin Atkinson, BA, provided valu- ceral occlusive disease. These are the index cases for this study. able help with acquisition and analysis of our database. This trend toward increasing numbers of endovascular cases, documented in this paper, is being noted across the country; certainly we see this at Stanford. These endovascular proce- REFERENCES dures are an important addition to the armamentarium of the vascular surgeon, and it is important that established sur- 1. Gross RE, Jurwitt ES, Bill AH Jr, et al. Preliminary observations on the use of geons and trainees become well versed in their use. human arterial grafts in the treatment of certain cardiovascular defects. N Engl J While this paper does not impart any new or unexpected Med. 1948;239:578-581. findings, I believe that it serves an important purpose in that it 2. Oudot J. La greffe vasculaire dans les thrombosis du Carrefour aortique [Vas- cular grafting in thromboses of the aortic bifurcation]. Presse Med. 1951;59 will stimulate discussion among surgeons and educators as to (12):234-236. how best to deal with this change in clinical practice. To this 3. Oudot J. Un deuxieme cas de greffe de la bifurcation aortique pour thrombose end, I would like to raise several questions and issues for the de la fourche aortique [A second case of graft of the aortic bifurcation for authors to address. thrombosis]. Mem Acad Chir (Paris). 1951;77(20-21):644-645. First is the issue of training. The authors correctly point out 4. Dubost C, Allary M, Oeconemous N. Resection of aneurysm of abdominal aorta: the need for surgeons to be open to retraining to keep up with reestablishment of continuity by preserved human arterial graft, with result af- advancing technologies. There is no question that this is true ter 5 months. Arch Surg. 1952;64:405-407. and important. However, the authors do not spell out what con- 5. Voorhees AB Jr, Jaretzki A III, Blakemore AH. The use of tubes constructed from stitutes adequate retraining. Does this require a full fellow- vinyon “N” cloth in bridging arterial defects: a preliminary report. Ann Surg. 1952; 135(3):332-336. ship, a “mini-fellowship” (typically 3 months), or simply on- 6. DeBakey ME, Cooley DA, Crawford ES, et al. Clinical application of a new flexible the-job training by a partner or colleague who has been trained knitted Dacron arterial substitute. Ann Surg. 1958;24:862-868. in endovascular procedures? This is an issue presently being 7. Dos Santos JC. From embolectomy to endarterectomy or the fall of a myth. debated in the Credentials Committee of my hospital. It has J Cardiovasc Surg (Torino). 1976;17(2):113-128. become apparent that what vascular surgeons consider ad-

(REPRINTED) ARCH SURG/ VOL 142 (NO. 8), AUG 2007 WWW.ARCHSURG.COM 736

©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 equate retraining may not be acceptable to interventional ra- eral ways that this can be accomplished. Taking a mini- diologists and cardiologists. What do the authors consider to fellowship for 3 months is one option. However, I think it is be the optimum training for the practicing vascular surgeon? very difficult for practicing physicians to take 3 months out of Also, how should our present vascular trainees be trained in their practice to participate in one of these fellowships. The hos- catheter skills: only by other vascular surgeons, or should phy- pitals in which we practice formed interdisciplinary commit- sicians from other disciplines be included? For example, most tees who chose to adopt the American Heart Association stan- vascular surgeons are pretty good at the endovascular manage- dards of 100 diagnostic and 50 therapeutic interventions for ment of iliac occlusive disease and renal artery stenosis. How- endovascular privileging. We were fortunate to have one of the ever, only a few have significant experience with complex prob- members of our group fully trained in endovascular tech- lems such as fenestration procedures in acute aortic dissections niques. He was kind enough to mentor us through all of those or complex arteriovenous malformations. How should our train- proctored cases. We have previously validated in a recent manu- ees gain experience with these more difficult disease entities? script that these privileging criteria, if adhered to, can help to In addition, how will all these changes impact the training of ensure quality. general surgery residents? This is a concern, I am sure, to many How best to train the residents? We feel that it is most ef- members of this association. ficacious for vascular surgeons to train general and vascular sur- A second issue is quality. While I agree that often the less gery residents. I’m not sure that physicians in other disci- invasive procedure is preferable and equally efficacious, we are plines feel quite the obligation to train our residents that we now learning that this is not always the case. The authors state do. I also do not think that we as vascular surgeons are re- that the CAS is beginning to replace endarterectomy. Indeed, quired to perform every endovascular procedure. We often ask many vascular surgeons now preferentially do angioplasty and our colleagues in interventional radiology to perform throm- stenting. However, as the data come in, we are learning that bolysis and difficult embolization procedures. We have learned CAS may not be as good as TEA (thromboendarterectomy) in from them, and they in turn have learned from us. Although many patients (eg, those older than 80 years to whom one would times were difficult at first, we now have a very collegial rela- like to offer a less invasive procedure). Also, 2 European trials tionship with our interventional radiologists. were recently discontinued because the results of CAS were not The increase in endovascular surgery is sure to eventually as good as anticipated. Certainly, the endovascular treatment impact general surgery training. The number of open vascular of AAAs (EVAR) is accepted treatment for some AAAs. How- cases is clearly decreasing. Unfortunately, these are the cases ever, there are some recognized downsides to EVAR: patients that are most appropriate for general surgery resident train- have to be followed closely, frequently with CT (computed to- ing. Presently we are fortunate enough to be able to provide mographic) angiograms, which are expensive, are frequently sufficient case numbers for both our general surgical and vas- inconvenient, and expose the patient to significant radiation. cular residents. I am not sure, if the trends continue, that we Also, there is a significant reintervention rate with EVAR, which will be able to do so in the future. is not seen with open repair of AAAs. This paper, like many I think first we learn what we can do and then later what papers on endovascular techniques, does not take into ac- we should do. Carotid artery disease provides an excellent ex- count the cost, inconvenience, and potential morbidity of the ample. We are learning that the octogenarian with sympto- required follow-up and reinterventions. We need better out- matic carotid stenosis is probably best treated with surgery rather come data for both open and endovascular procedures so that than stenting. I think as time goes on, we who can provide both we can provide our patients with the best treatment for their open and endovascular therapies will be best able to make ac- particular situation. curate decisions as to what form of treatment is best for pa- A third concern is what is driving this trend. I believe most tients. There is an old saying that when your only tool is a ham- surgeons want to do what is really best for the patient. How- mer, everything looks like a nail. For many of the other specialists ever, there is no question that the quest for market share and who are able to use only 1 treatment modality, that tends to be the desire to increase compensation enter the picture. In the true. I believe that surgeons who are able to offer all therapeu- vascular arena, the endovascular cases typically pay better and tic options will be much more objective, not only in treating do not carry the 90-day global coverage common with open their patients but also in evaluating new technologies. cases. The medical industry also is pushing this trend. We have As mentioned, some of these newer techniques do require all been exposed to advertisements on TV and in the newspa- more frequent follow-up than traditional procedures. We can pers appealing directly to patients to “ask their doctors” if a expect that technologies will continue to improve. As time goes particular drug or device is right for them. This encourages pa- on and the devices become more sophisticated, there will most tients to push for the new technology. It is hard for even the likely be less of a need for frequent evaluation and subsequent most honest of surgeons not to consider these factors when interventions. choosing a procedure. How do surgeons at USC ensure that any As Dr Olcott pointed out, we are now facing pressure from given patient receives the optimum treatment for his or her par- both patients and the industry to perform certain procedures ticular situation, and how do they deal with the differences be- and to employ new technologies. It will be a continual struggle tween open and endovascular reimbursement in their compen- to resist these forces, but we must remain firm in our commit- sation program? ment to providing the best care for our patients. We have not Lastly, I think it will be interesting to see where this all ends considered differential reimbursement to be an important part up. I doubt that vascular surgery will be the same 5 to 10 years of our treatment algorithms. While the maintenance of mar- from now. I would not be surprised to see the vascular sur- ket share is attractive, the ability to deliver optimal treatment geon of the future be either a traditional open surgeon or an to patients with vascular disease should remain paramount. We endovascular specialist. I believe it will be increasingly diffi- believe that vascular surgeons trained in both open and per- cult to maintain optimum skills in both areas. Unfortunately, cutaneous techniques can best deliver this type of care. no one knows what the future will hold. However, Dr Solo- mon and his group have certainly given us food for thought. Dr Katz: I will try to answer your questions in order. With regard to the first question about training, I think there are sev- Financial Disclosure: None reported.

(REPRINTED) ARCH SURG/ VOL 142 (NO. 8), AUG 2007 WWW.ARCHSURG.COM 737