From the editors

Editor’s Note: The associate editors of Vascular Specialist were asked to provide their perspectives on the stenting controversy. Here is a selection.

Dr. Frank J. Veith: The recent lead article in the New York Times on excessive implantation of lower extremity stents highlights one key point. Vascular surgeons and all vascular specialists who treat lower extremity occlusive disease should always clearly inform patients with intermittent claudication that one acceptable treatment option is medical and lipid-lowering therapy without any invasive treatment of their arterial blockage. They should be informed that the condition almost never leads to limb loss and that invasive treatment can safely be delayed until such progression occurs.

Given such honest reassurance and the option to choose their treatment, most patients with claudication will choose a conservative rather than an invasive approach, and unnecessary stent/angioplasty and other lower extremity interventional procedures, as described in the Times article, will be minimized. 

Dr. John F. Eidt: The truth is we all bear responsibility. The treatment of lower extremity peripheral artery disease (PAD) has largely defied prior efforts to define appropriate care. Even the SVS document recommending risk factor modification in the initial management of intermittent claudication leaves substantial room for individualized judgment.

The appropriateness of intervention is largely in the eye of the beholder. “Lifestyle-limiting” claudication can be invoked as justification for intervention in virtually anyone. But I do believe that vascular surgeons are more wary of the adverse consequences of vascular intervention for one important reason – we do amputations. We are unique among vascular specialists in that we deal with the tragedies of unwarranted vascular procedures. For vascular surgeons, failure of intervention means more than binary restenosis or increased target lesion revascularization. Performing an amputation after failed intervention in a claudicant leaves an indelible mark on each of us and may underlie our inherently conservative approach to PAD. But we need to be fearless in speaking the truth and serving as advocates for exemplary patient care. Continuing a relationship with a source of carotid and aortic referrals while turning a blind eye to meddlesome lower extremity intervention sends the wrong message. Our silence constitutes tacit approval. Too frequently I hear a patient say “my cardiologist says there is nothing else he can do, go see a vascular surgeon.” Despite years of branding efforts by the SVS, surveys of primary care providers and the public alike confirm that many remain uncertain of our skills. We need to do a better job of spreading the word that vascular surgeons are “leaders in the minimally invasive treatment of PAD.” Not the last resort.

Dr. Frank Pomposelli: I could not agree more with Dr. Eidt. It’s easy to indict the outpatient labs for obvious reasons but I personally agree that the root of the problem lies in the overly aggressive posture being taken toward treatment of claudication.

It just so happens that outpatient labs are filled with claudicants since they are most likely to have the least complex disease – match made in heaven or hell, depending on your perspective.

One cardiologist quoted in the N.Y. Times piece said patients with claudication have been “grossly under treated” – a convenient posture to take when billing Medicare $4.5 million a year. The other cardiologist who was the focus of the investigation called the charges “baseless and fiction” and stated his center had the lowest rate of amputation in the country.

It gets back to Dr. Eidt’s point how it’s easy for the nonsurgeon to dismiss amputation as an occasional unfortunate byproduct of a busy practice when you never have had to tell a patient they need one and suffer with them through the emotional and physical trauma that always follows. I was taught like many of you, I suspect, that any amputation after treatment for claudication should be considered not only an unacceptable complication but also a failure of the trust the patient placed in me. My mentor was a militant nihilist when it came to surgery for claudication but that concept is always in my mind whenever I treat a patient and has always tempered my decision making.

I like to think our recently published practice guidelines will help but am skeptical that it will make a positive impact where it is most needed; on those who are primarily driven by financial gain. I’d also point out that Dr. Darren B. Schneider was quoted as a member of the Society for Vascular Medicine. I guess we need to work harder on our branding.