Vascular surgeons want interventional skills

But Curtis Lewis, President of the Society of Interventional Radiology, has said the issue is not about which specialist does a procedure, but about who is adequately trained and possesses the skill and the knowledge base to provide quality care.

Ascher began by highlighting how since the early 1990's the number of procedures performed by the vascular surgeon has fallen. Previously, vascular surgeons performed almost 99% of open procedures, be they AAA, CEA, aortofemoral bypasses, femoropopliteal bypasses or infrapopliteal bypasses. However, today's vascular surgeons are being asked to perform increasingly more endovascular procedures such as carotid angioplasty and stenting, EVAR, subintimal dissection balloon angioplasties of lower extremities and aortoIliac angioplasties.

Ascher stated that previously vascular surgeons needed the skills of interventional radiologists to augment their patient care. However, now that vascular surgeons have acquired endovascular skills, it is time to address the necessity of having an on-site interventional radiologist in the vascular center.

Ascher believes the rise in interventional procedures (and those performed by the interventional radiologist) has meant that the vascular surgeon must compensate for decreasing revenues by lowering procedure times and increasing patient volumes. Indeed, Ascher claims that since 2000, diagnostic interventional radiologists have seen a 34% increase in median salary. In 2002, the median income for an interventional radiologist was $401,000, whilst in 2003, the median compensation for an interventional radiologist was $410,250.

Furthermore, Ascher cited that the vascular surgeon, on average, earns less than their contemporaries. For example, in 2003, the median compensation for a cardiac/thoracic surgeon was $416,896, an interventional radiologist $410,250, a diagnostic radiologist $345,619 and a vascular surgeon $269,268. Moreover, the average hospital based interventional radiologist bills $1.58 million annually ($132,000/month or $6,000/day).

However, there has not been a substantial increase in the number of radiologists, which is only increasing by some 2% per year. This is despite the number of interventional/vascular programs increasing from 442 to 458 since 1996. Ascher emphasizes that without taking the significant increase in vascular/ interventional programs into account, the number of radiology residency programs has actually decreased from 372 in 1996 to 356 in 2001.

This is not to say that interventional radiologists are not fundamental to the treatment lab. Ascher cited Dr Richard

Green, who said, "Relationships with both interventional cardiology and interventional radiology are important in developing an institutional perspective in the care of the patient with vascular disease. Each group brings a unique approach and, while competitive in some areas, is synergistic in others".

However, Ascher does have reservations regarding the costs that an interventional radiologist brings, as Medicare reimbursements are more expensive for endovascular procedures than they are for open repair. Although, he acknowledged that there are an ever increasing number of endovascular procedures including; fibroid embolization, liver tumor ablation, intracerebral endotherapy, coronary angiogram, gastrointestinal bleeds and ultrasound guided procedures.

In cooperation with the SVS and the AAVS, Ascher has spent the past two years in a conjoined attempt with interventional radiologists, vascular medicine physicians and cardiologists to define the role of each specialty in a vascular center. Thus far, Ascher conceded, the concept of a vascular center as a means of delivering a multidisciplinary approach to the diagnosis and treatment of vascular diseases has not been widely embraced in the US.

According to Ascher, there should be four primary components of the center, and these are (1) vascular clinic, (2) vascular surgery, (3) endovascular therapy, and (4) vascular laboratory. Secondary components should include six clinics, for (1) diabetic foot and wound treatment, (2) chronic anticoagulation management, (3) lipid control, (4) vein therapy, (5) lymphedema control, and (6) smoking cessation.

To facilitate the creation of a center and to increase accessibility, Ascher claims two levels of complexity should be recognized. Level I vascular centers should offer more complex types of surgical and endovascular treatment, such as open repair of thoracoabdominal aneurysms and embolization of arteriovenous malformations, as well as all secondary components. Level II vascular centers will be required to provide all four primary components with less complex cases and at least 50% of the secondary components. Ensuring a comprehensive approach to total vascular care, including risk factor modification to patient population is not an opportunity; it is an overdue obligation.

Ascher claims that by establishing an appropriate credentialing model a private professional organization could be established that would examine eligible participating vascular centers and grant accreditation to those meeting qualifying standards. This organization, which may be called the Joint Council for the Accreditation of Vascular Centers (JCAVC), would be comprised of elected representatives from several vascular societies, including but not limited to the SCVS, AAVS, SVS, and PVS. The Board of Directors would consist of elected member representatives from each society, with the president serving a one-year term and the secretary and treasurer elected to three-year terms. Several standards would be established to determine eligibility of a vascular center for accreditation. A vascular center must comply with defined criteria to gain and maintain JCAVC-accredited status.

Obvious requirements would be written protocols that establish standards of care and the referral system, as well as patient safety and education. Also, criteria would include the presence of an ICAVL-accredited vascular laboratory and approval by the Joint Commission on Accreditation of Healthcare Organizations, and all professional staff must be board-certified or board-eligible, licensed, and required to maintain continuing medical education credits. Successful initial vascular center accreditation applications may result in a provisionally accredited status, and full status may be granted after two years. Fully accredited status would be valid for five years. In the long-term, site visit application fees alone may suffice to fund the operational costs of the JCAVC. The concept of a vascular center is an idea whose time has arrived. "It is also a vehicle by which we can claim our leadership in this area. Of course, our goal is to optimize total vascular care, not to restrict competition," said Ascher. "So if specialists other than vascular surgeons show interest in participating in this effort, let us open the gangway, but do not let go of the helm."

Ascher believes that vascular surgeons may not be able to create a comprehensive vascular center if they do not possess strong ties to a vascular laboratory. Once considered the domain of vascular surgery, the management of the non-invasive vascular laboratory has increasingly been assumed by radiology and cardiology.

In the year 2000 a survey performed by the SCVS showed that vascular surgeons reported a derived income average of 16% from the vascular laboratory, and fully 40% of vascular surgeons reported no relationship with a non-invasive laboratory. Ascher said, "We must regain control of our laboratories, and maintain our leadership in this rapidly evolving field of technology. On the other hand, we must recognize that work needs to be done to further substantiate this claim. The idea of relying completely on a vascular technologist to select appropriate images for the interpreter to use to determine whether there is presence or absence of disease is not going to help fend off competition from other specialties. We all know too well that ultrasound images alone can be misleading, particularly for those who have not had hands-on experience with a duplex scanner. You may think that a superb vascular technologist is all you need."

"In my view, the combination of a vascular specialist with hands-on experience in duplex scanning and a registered vascular technologist can only improve the accuracy of these tests. Our technologists will also feel less pressured and more at ease if they can discuss complex cases with a knowledgeable specialist. Furthermore, it will allow us to extend the capabilities of this non-invasive diagnostic technique to replace invasive imaging methods," argued Ascher.

To this end, Ascher proposes that the vascular fellow be subjected to a formal period of training in an accredited vascular laboratory that will provide meaningful hands-on skills in the performance of non-invasive diagnostic testing. This can be accomplished by allowing the vascular fellow approximately 200 hours of protected time in the vascular laboratory, an improvement on the current six hours weekly in the laboratory for nine months.

The proposed curriculum would begin with panel and keyboard operation of duplex scanning equipment, as well as probe handling, configuration, and selection of appropriate frequency ranges. In addition, the vascular fellow will learn the appropriate applications of image and hemodynamic measurements.

For diagnostic testing, Ascher suggests the following protocol: 30 carotid duplex examinations; 25 arterial duplex scans of the lower and upper extremities; 20 abdominal vascular studies; surveillance of 15 bypass grafts; 25 venous thrombosis studies to differentiate acute from chronic obstruction in the deep and superficial systems; 25 venous insufficiency studies of the deep, superficial, and perforating veins; 20 upper and lower extremity venous mappings; 20 physiologic evaluations of peripheral arterial and venous diseases; and 20 intraoperative studies. This is with a recommendation of 20 ultrasound guided vascular therapeutic procedures.

During this training period the attending vascular surgeon will review at least 40 tests per week (total, 1000) interpreted by the trainee. A review of subjects with video case presentation by the fellow should be made during weekly scheduled vascular laboratory conferences. At the conclusion of the vascular laboratory rotation, the vascular fellow should be able to demonstrate knowledge of non-invasive testing protocols and provide a list of all studies performed and interpreted. According to Ascher, completion of this proposed vascular laboratory component of the vascular fellowship program should more than satisfy the American Registry of Diagnostic Medical Ultrasonographers requirement for credentialing of an MD to become an RVT. Thus the graduating fellow will be able to adequately assume a prepared leadership role in the establishment of the vascular laboratory.

Ascher claims several vascular surgeons have realized that the current tracking in vascular surgery training is deficient, lengthy, incomplete, and weak, in practical terms. While there is very little disagreement that a shorter surgical track offers many previously reported advantages, controversy remains as to the exact distribution of these years between general and vascular surgery. However, Ascher says the focus is no longer limited to vascular operations, as the specialty has evolved and expanded into endovascular therapy and vascular medicine.

"The vascular surgeon or the vascular specialist of tomorrow will require more time to master the ever-increasing and changing tools required for endovascular techniques," therefore, Ascher claims "fellows also need more time to learn how to direct a vascular laboratory."

As a result, Ascher recommends a new training paradigm for the vascular specialist. The first and second years would include 15 months of general surgery, two months of critical care, two months of trauma, one month of cardiothoracic surgery, one month of transplantation, one month of elective study, and two months of vacation. The third year would include three major rotations. The first rotation would be in diagnostic procedures, including the vascular laboratory for three months, and magnetic resonance angiography and vascular CT for one month. The second rotation would be in medicine, with one month spent in each of the following specialties: cardiology and interventional cardiology, nephrology and haemodialysis, endocrinology and infectious diseases, and haematology. The third rotation would concentrate on perioperative vascular care, as well as basic vascular operations and endovascular interventions for three months, and the year may end with one month of vacation. During the fourth year the fellow would be exposed to moderately complex vascular operations, including access for haemodialysis, and endovascular techniques. In the fifth and last year the fellow would be performing vascular and endovascular procedures of advanced complexity.

Changing the vascular training paradigm will not be possible under the current organisation of the American Board of Surgery. Vascular surgery is a primary core component of the vascular specialist, with endovascular therapy and vascular medicine the remaining core components. "We have gained the respect and the recognition of our colleagues from all medical specialties, who would rather refer their patients with vascular diseases to a vascular surgeon than to any other specialist," commented Ascher.

However, the leadership in general surgery, particularly the American Board of Surgery is slow in recognising the full scope of vascular surgery and its willingness to have its own board. This position has led to major disappointment and frustration among practising vascular surgeons, Ascher said. "Our patients may ultimately be the ones to suffer the consequences of training paradigms that have been designed and implemented by nonvascular specialists."

Ascher concluded that these are the measures, "I believe our profession must charter, not just to survive, but also to flourish in this exciting chapter of medical history. We should recognize that sometimes the most serious threat to survival may come from within."

Interventional News spoke to Curtis Lewis following Ascher's presentation. He said that Ascher had encouraged vascular surgeons to explore new opportunities in endovascular procedures, such as coronary angiography, uterine fibroid embolization, treatment of gastrointestinal bleeding, intracranial aneurysms and arterial stenoses, and tumor embolization.

"What has made vascular surgery great, and indeed all of our medical specialties great, has been mastery of both the technical skills and the disease process being treated with our technical skills," he said.

"Dr Ascher's comments raise concern that vascular surgeons are being encouraged to expand applications of technical procedures into diseases for which they lack training or experience. Vascular surgery has championed the concept that 'outcomes are everything'."

Lewis stressed that for all physicians, outcomes depend on training and expertise in the disease and its treatment. Although some vascular surgeons have acquired catheter skills, this is not sufficient to provide care for diseases outside of their training, even if such care may provide increased income for the physician, he said.

"The issue is not about which specialist does a procedure, but about who is adequately trained and possesses the skill and the knowledge base to provide quality care. These procedures need to be done for the right reasons (when indicated), on the right patients, at the right time, by the right physician (well trained) with the right equipment and support personnel.

"We welcome all well trained physicians to join us in developing and expanding new techniques in minimally invasive therapies that can improve the healthcare of our patients. We must remember that we are physicians first and that patient care is about outcomes and patient safety.

"Society and our patients judge us by our skills, knowledge, compassion, and the healthcare we provide, and not by the size of our bank accounts. This cannot be about who does procedures or about the money. We owe that to our patients."