The Vascular Landscape Transformed: A Personal Reflection

Surely I can get everyone to agree with me on this one point: the vascular landscape has evolved dramatically over the past 20 years. A true transformation has taken place as the winds of change continue to blow mercilessly in every corner of our vascular world. And this is a storm that will not be downgraded any time soon, and a “hurricane season” that lasts all year-round! It made “landfall” in the 1980s, perhaps even earlier than that, as the first transforming breezes reached the vascular shores… And it is here to stay!

Many factors and components are no doubt involved, and it is essentially impossible to classify or even mention them all. But I would insist on an attempt, possibly futile, to provide the VDM reader with an easy-to-read guide to the fundamental changes that explain the root causes of the current state of affairs:

#1. The development and introduction of new less-invasive technologies into daily vascular practice, replacing — gradually but relentlessly — traditional operative approaches; and

#2. The evolution from — essentially — a single specialty-controlled activity to (an all-encompassing) Vascular where multiple specialties aspire to a protagonistic role, most notably Interventional Cardiology that has already achieved a significant foot-hold in the management of non-cardiac vascular disease. Such trends are likely to continue in the foreseeable future.

As powerful as the above-described realities may be, they would probably not have occurred without some underlying fundamental evolutions that — perhaps — made it all possible in the first place. What I’m talking about is the emergence of a truly transforming change, not unlike similar evolutions in other areas of medicine: a new and drastically different mindset. And I think this is how it applies to Vascular:

a. Open traditional (cut-and-sew) surgery is increasingly viewed (by many, in and out of our profession) as a treatment of last resort;

b. Symptom relief and life-style enhancements have risen to prominence at the time of decision-making and as an indication for intervention, even “competing” in some cases with the time-honored “undisputable” objectives of life and limb preservation. For instance, critical ischemia is no longer the only “truly appropriate” indication for limb revascularization.

c. Results still matter of course, but durability and long-term procedural success are no longer the only parameters that specialists and patients take into account. A “compromise” procedure or technology may well be acceptable in a trade-off for less morbidity and increased safety. Endovascular therapy is often less durable than bypass surgery, but frequently preferred as first-line treatment because of its less invasion-related advantages and easily repeatable nature.

Not surprisingly, there remains a group of prominent (albeit decreasingly influential) vascular surgeons who continue to resent how things have evolved in Vascular. They argue that traditional surgery continues (and will continue) to be the standard of care (“gold standard”) for treatment of a majority of vascular ailments, and that alternative interventional approaches have failed to offer a credible or even competitive solution to such problems. They maintain that surgeons have always stood for results (an undeniable truth), and that some of the new devices and specialists “invading” our turf have lowered the standards…and are too quick-and-ready to undertake procedures that are less than proven, and — in some cases — without regard for durability. But at the same time, there is a new generation of vascular surgeons who have received endovascular training and incorporated all of the new technologies into their armamentarium, plus those who were early adopters of such technologies. Together, these endo-competent and endo-practicing vascular surgeons are steering our specialty and the national societies in a whole new direction where surgical instruments and operative intervention are amongst a number of useful treatment tools at out disposal — but no longer the only ones available. Another result will be that, in a few years, intra-specialty frictions and clashes will go away altogether (for the most part). Unfortunately, inter-specialty turf wars will continue in the foreseeable future — perhaps even intensify in some regions. I certainly do not have a remedy to offer other than to say that “solutions” can be found and implemented, at least for a region, a hospital, or individuals if they are willing to think creatively and work together in a way that makes everyone better and more productive. More significantly, patients are likely to benefit in such a process.

In closing, I can only say what should be quite obvious to most of us today: Vascular has evolved into a highly vibrant specialty. It is hard not to feel enthused about all the innovative new technologies that pop into our firmament almost monthly. But it is up to us, the treating physicians, to exercise caution at the time of selecting a given therapy or procedure for an individual patient. To him or her, the outcome of this one-single-treatment or procedure will always represent a “100%” success or failure. And the same goes for the responsible physician.