The honorary lecture of this year's Olbert Symposium, taking place in Salzburg January 10-13, was given by Jim Reekers. In his talk entitled "The emperor's new clothes" Reekers used Andersen's well-known fairytale about a majority of observers willingly sharing in a collective ignorance of an obvious fact to illustrate today's situation with minimally invasive procedures. Reekers could not help but find similarities between the fairytale's king and some today's endovascular physicians, who have been in prominent on the endovascular scene since the 90's and are trying hard to forget that Interventional Radiology has successfully establishing itself since its beginnings in 1963.
In his half hour lecture Reekers observed how some physicians try to continue producing "scientific evidence" for the superiority of certain procedures, while disregarding the fact that in some cases high quality studies leave no room for doubt that some minimally invasive techniques are not a good treatment option. To illustrate his point, Reekers gave the example of Lammer et al.'s prospective, controlled, randomised trial "Pulsed excimer laser versus continuous-wave Nd:YAG laser versus conventional angioplasty of peripheral arterial occlusions", which was published in the Lancet as early as 1992.
In this study Prof. J. Lammer and his colleagues clearly proved that there is no long-term advantage of laser-assisted angioplasty compared to conventional PTA. Nevertheless14 years later Laird JR, et al. conducted a multi-centre, non-randomised, study from which they concluded that excimer laser-assisted angioplasty for CLI offered high technical success. According to Reekers this goes to show that much of the scientific evidence created by interventional radiologists is simply disregarded by endovascular physicians and that treatments which radiologists have proven redundant are back again, looking for recognition through low level evidence registries.
Those who had forgotten how the emperor could succeed in making everybody believe that he was wearing the most wonderful clothes while he was obviously naked were reminded that the emperor would only surround himself with people who never disputed what he said. Most importantly, Reekers added, the emperor would claim that everybody who could not see his beautiful new clothes was ignorant and unfit for his job.
Reekers concluded that closer and earlier cooperation between interventional radiologists and endovascular surgeons could have saved both sides time and energy which could have been used to develop actually new technologies and treatment strategies. He expressed his grave concerns about this, reminding the audience that this missed opportunity was a tragedy for the patient. He added that the bulk of previous redundant or currently unproven technology is growing and overcrowding many medical meetings on endovascular treatment. Reekers also discussed the problem-driven design of interventional radiologists, comparing it to the more and more common technology-driven design, the latter being actually "a solution looking for a problem".
The fact that interventional radiologists do not perform surgery, Reekers claimed, is their strongest drive to investigate new minimally invasive endovascular solutions, while surgeons always have an easy and final solution at hand, i.e. surgery. According to Reekers, Dotter, Rosch and Palmaz would have never invented PTA, GE bleeding embolisation or a stent had they been surgeons, because there would not have been any need for them to avoid surgery. For him, Interventional radiologists are "would-be" surgeons, a fact he does not want to change, for the benefit of minimally invasive treatments. Interventional radiologists are used to look for a solution to a problem rather than creating a problem for a given technological "solution".
Reekers also showed some examples of how data for " new" endovascular technologies had been manipulated to polish the outcome of their respective study. He demonstrated that unclear inclusion, large numbers of patients lost to follow-up and no intention to treat analysis were the main problems with some of the recently published papers. He also showed how an high ranked paper like the EVA-3S study, whose conclusion that stenting of the carotid artery in symptomatic patients had a very high complication rate compared to endarterectomy had clearly been influenced by the fact that many of the participating endovascular operators were extremely inexperienced.
These findings lead Reekers to make a strong plea to obey the rules of evidence-based medicine and to obtain level 1 evidence whenever possible. In this respect he made reference to the EVAR and DREAM trials as examples of how good research should be conducted. Reekers reminded the audience that lack of valid scientific evidence for the use of carotid protection devices, laser, cryoplasty and many other new techniques would eventually be the dead end street for the legitimacy of what interventional physicians offer their patients today. Furthermore he gave various examples to illustrate ethical problems like close relations between doctors, consultancy fees, holding shares while at the same time trying to provide regulatory, unbiased data.
Finally, Jim Reekers assured the audience that for the decades to come Interventional Radiology will continue to be the driving and innovative force in the field of minimally invasive procedures. In this context he pointed out that the Society of Interventional Radiology of Europe (CIRSE) is growing constantly, both in membership (which is also open for endovascular surgeons) and attendance of its annual meetings. Continuing his simile with Andersen's fairytale, Reekers ended his lecture with a call for better and closer cooperation between the new and old emperors for the sake of the patient.
Date: Feb/2007
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