On the Nature of Turf Wars II: Discussing the Anatomy of Vascular Disruptions

I must say it was heartening to hear the many nice comments on my last Editor’s Corner in the September/October issue. And while wanting to believe such reactions were prompted by my sharp pen and lofty writing… I know better than that! Instead, I’m sure they were largely reflective of the relevance and timeliness of the topic itself. Turf Wars have been and are in all of our minds. They exist, powerfully and unequivocally, and — to put it simply — cannot be ignored. Furthermore, they carry significant destructive (and distracting) potential. I have therefore decided to dedicate this issue’s Corner to the same topic — but with a slightly different twist. I will attempt to dig deeper into the “disruption” theory, seeking to gain a more complete understanding of how such disruptive technologies and treatment evolutions have impacted the whole fabric (and inter-chemistries) of the vascular specialties.

Having recognized that disruptive technologies should be thought of as the primary driving force behind these… well, disruptions, it makes conceptual sense to think of them as two-sided phenomena, where someone is the “perpetrator” (or disrupter) and someone else gets disrupted — the ‘disruptee’. It is in such context that we can immediately see that surgeons have been the “disruptees of choice”, and non-surgeons (i.e., cardiologists and others) the disrupters… Why would this be so? It’s hard to be absolutely sure, but one thing is immediately clear: the culprit is not the surgeons’ educational or intellectual inferiority! (or so I hope, given my surgical background). Almost surely, the explanation is a bit more complex and multi-layered. Surgeons are the custodians and practitioners of an art (and science) that started at the very inception of medicine and the healing profession. Surgery, if you will, represents the old and timeless; the past. Most evolutions and technological advances are designed (or meant) to spare patients the need for open surgery. The future aims away from surgery, and it is bound for percutaneous and other “less-invasive destinations.” It’s just the way it is – whether we (surgeons) like it or not. So, it is only natural that the so-called disruptive technologies would create tools and means that tend to drive each and every field (or subspecialty) away from surgery and — even more significantly for the context of this discussion — “away from surgeons”. That’s it. It’s clear and easily understandable — at least to me! It is therefore no surprise that surgeons would become the disrupted, and non-surgical specialists — such as interventional cardiologists, and even interventional radiologists in some cases — the disrupters. Can surgeons avoid getting disrupted and sidelined? Possibly.

“Early adoption”, “re-training”…and the like are the mottos that describe the principal pathways conducive to such goals. In one word: RE-INVENTION. It’s not an easy thing to do, but it is the inescapable thing to do if surgeons are to remain relevant in this fast-paced new world of 21st century vascular and endovascular medicine. Lastly, it may be worth uttering a few words on a couple of “imaginary scenarios” that, while proving unreal, could and would have carried enormous “game changing” potential:

• What if CT surgeons had embraced PTCA and other interventional catheter-based techniques, incorporating them into their armamentarium… from the outset?? What if vascular surgeons — or even surgeons in general — had accepted Dotter’s angioplasty ground-breaking conceptions and joined the endo revolution from the beginning??

• What if interventional radiologists had pursued and “kept” coronary angiography many years ago, and surgeons had held on to and themselves refined the techniques of diagnostic angiography…??

Any such developments could have resulted in a vastly different vascular landscape today, in every way! Keep in mind, however, that history cannot be changed in hind-view. It just doesn’t work! So, I’m afraid those potential realities may have had a chance at one time… however such windows of opportunities were shut for good quite a while ago. What about the future, any “predictions” worth considering vis-a-vis new turf-invasion developments? While not an original thought of mine, the view that diagnostic cardiac cath and coronary angiography should be accessible to all endovascular specialists is one that resonates powerfully with me. Why not? After all, “all you need to do is to use the correct-choice guiding catheter…”

I’d admit this may represent an over simplification of the subject matter, but — unquestionably — there’s some truth to it. More powerful still, present-day rapid evolutions in noninvasive (or puncture-less) cardiovascular imaging — CT angio in particular — will likely result in a dramatically diminished role for stand-alone coronary angiography and all diagnostic vascular catheterizations. And I’d be willing to bet a dime “control of imaging” will be the next huge battleground!

Frank J. Criado, MD

Editor-in-Chief

frank.criado@medstar.net