Disappearing Act

By now you must be tired of my rants about other specialties making inroads into our “turf.” But a brochure came across my desk that really gave me heartburn.

The glossy, multipage flier announced a meeting devoted to the treatment of critical limb ischemia (CLI). The advertisement proudly claimed this 4-day event would be the largest medical conference dedicated to the treatment and prevention of CLI. It would usher in a “new era in limb salvage.” I was intrigued since a web announcement for the same meeting stated that it draws over 800 specialists including vascular surgeons, general surgeons, cardiologists, interventional cardiologists, general medicine/primary care physicians, interventional radiologists, podiatrists, wound care specialists, nurses, vascular technologists, and cardiac catheterization laboratory team members. I was taken aback! Are so many disparate specialists truly involved in the management of CLI?

Hmm, I thought. Maybe this is a meeting I should attend. I have spent most of my 36 years as a vascular surgeon trying to prevent amputations due to CLI, so I am always open to learning new things. I started to page through the calendar of events and talks. There really were some interesting presentations, including how to cross chronic occlusions, what wires to use, the controversy about drug eluting balloons, and many other endovascular techniques.

However, slowly it dawned on me that in the entire program there was not one presentation on surgery for CLI. It appeared that not a word was to be spoken about infrainguinal bypass in any form. Surgical treatment had been all but banished from the program. It was as if surgery for CLI had yet to be invented. DeBakey, Veith, Porter, Mannick, Leather, Dardik, Bergan and Yao … and all the other pioneers of modern vascular surgery, fictional characters in an Alice in Wonderland rabbit hole. Essentially, the entire program was devoted to endovascular therapies, medications for wound healing, hyperbaric oxygen, and other modalities that would not involve a trip to the operating room other than for a digit amputation or a debridement.

I could not understand how it was possible that a symposium dedicated to CLI would completely ignore arterial bypass. So I turned to the back of the program where there were listed approximately 75 authorities in the management of CLI. There were only 11 vascular surgeons listed out of the whole bunch. I scanned through the roster and was baffled to note that none of our thought leaders in vascular surgery were listed. Absent from the list were names like Joe Mills, Mike Conte, and Frank Veith, to name just a few. In fact, I recognized the name of only one, a young vascular surgeon who I know generally favors an endovascular approach. None of the six program course directors were vascular surgeons either.

I can only surmise that the organizers of this event regard surgical bypass as either an anachronism or possibly a procedure that should be listed in the same damning category as frontal lobotomy. No listed discussion of endovascular first or surgical bypass first for CLI. No mention of the BASIL trial and no presentation on the potential value of the BEST trial. Surgery seemed taboo – as if it were a dangerous treatment that causes, rather than prevents, major amputation due to CLI.

What has allowed this almost total denial of the benefits of surgical revascularization? How is it that vascular surgeons have been supplanted as leaders in the management of CLI and possibly all vascular disease processes? How is this going to impact vascular surgeons and, even more importantly, the vascular health of our patients?

In the past I have posited that it is because endovascular procedures can also be performed by specialists other than vascular surgeons. These physicians, facing decreased compensation for treating the conditions usually considered part of their bailiwick, look to vascular treatments to supplant their dwindling income. For example, cardiac surgeons have come to understand that ablating the saphenous vein is more cost-effective than using it for a life-saving CABG. Or dermatologists suddenly finding spider vein sclerotherapy to be the most exciting activity since pimple popping. Or invasive cardiologists discovering that there are a whole lot of arteries other than the coronaries just waiting to be dilated and stented whether they need to be or not. Then, once they become aware of the financial benefits of treating vascular patients they clamor for educational events that will teach them how to do even more – and, hopefully, do it better?