Views from around the world

Vascular News and its sister paper Interventional News have had the honour to profile a number of leading vascular specialists and interventionalists over the past year. The views expressed by these leading figures on the state and future of their specialities have been illuminating.

Since the last Charing Cross international symposium, Vascular News has extended it reach beyond Europe with a North American edition. In addition to coverage of US vascular topics, this has also led the team at Vascular News to conduct profiles of a number of American vascular specialists and hear their views on the state of the specialty in their country, just as the newspaper has done over the last five years with their colleagues in Europe.

Comments from the USA
Dr Craig Kent, Chief of the Combined Columbia and Cornell Division of Vascular Surgery at the New York Presbyterian Hospital, provided Vascular News with his thoughts on the state of vascular surgery. "This is such a critical time for vascular surgery, but a great time. There is so much change and so many things that need to be done."

There are two main areas that Kent feels need addressing. Firstly, the training of surgeons to use endovascular techniques and secondly public education.

"We need to ensure that every vascular surgeon who is not close to retirement has the opportunity to gain endovascular skills. Many of our vascular fellows are now coming out well trained. But this isn't enough. If we wait for our fellows with endovascular training to repopulate our speciality, it will be too late."

The second issue that Craig Kent feels needs addressing is the need for increased public awareness of the causes and symptoms of vascular disease. "I think everyone knows where the heart is and what a heart attack means, and certainly everyone knows what a heart surgeon does," said Kent, "but not everyone knows about aneurysms, claudication, carotid arteries or even that blockages can occur outside of the heart. This lack of awareness leads to many people not receiving necessary treatment and to the catastrophic events that can so often accompany vascular disease."

Kent feels that not only do patients need to be made aware of the symptoms and risks of vascular disease, but they also need to be made aware of the existence of specialists, such as Vascular Surgeons, who can care for them. "For the past 50 years, we have been the medical specialists for patients with vascular disease. We perform minimally invasive catheter interventions as well as complex surgery. Vascular Surgeons have access to all of the tools and when we make recommendations, we can do so without bias for or against any form of treatment," said Kent.

Dr Thomas S. Riles, George David Stewart Professor and Chairman, Department of Surgery, New York University School of Medicine, said that he sees this as a very exciting time for vascular surgery as it can contribute both to the development of less invasive and kinder procedures as well as the prevention of the onset of disease. "Endovascular has rejuvenated vascular surgery and provided new ways to treat patients less invasively. Vascular surgery should get more involved in prevention. We need early screening to prevent vascular disease and we need less expensive tests.

Dr Jay Yadav holds joint appointments in Cardiology, Neurology and Vascular Medicine at the Cleveland Clinic Foundation, where he is also currently the Director of both Carotid and Vascular Intervention. When asked for his thoughts on what developments we could expect to see in vascular surgery in the future Dr Yadav said, "I think certainly drug-eluting stents are coming to the periphery. In the next one to two years we will see several trials starting for drug-eluting stents to prevent restenosis in the renal arteries, and in the superficial femoral arteries. I think that these two key applications will be very important. I also think that we will get substantial improvements in emboli prevention devices making them easier to use and that they will be used more widely than they are at the moment."

"In peripheral intervention, I think that our ability to perform percutaneous bypass in the leg will be available in the next year."

Dr Yadav gave Vascular News his views on how he felt surgical training could be improved. "I think that we are entering the era of multidisciplinary training and treatment of patients. The traditional training pathways, such as in vascular surgery and general surgery, or internal medicine, or cardiology, are outmoded and probably ultimately we will develop a new training pathway called 'endovascular treatment', or something like that, where people will have a basic background in medicine and surgery and then will have specialised training for several years in endovascular treatment. That will probably be the future model, where the endovascular specialist will be able to take care of the patient as well as perform the procedures."

European attitudes
The European profilees this year have come from France, Germany, Finland and Italy.

Professor Edouard Kieffer, Head of the Department of Vascular Surgery, Hôpital Pitié-Salpêtrière, France, told Vascular News that French surgeons are taking endovascular surgery very seriously and have organised training specifically for vascular surgeons. "In private practice many vascular surgeons do a lot of endovascular," said Keiffer, "In our hospital, we can't do as many endovascular procedures, we do endovascular treatment of aneurysms but not other peripheral interventions because we don't have the time or enough operating rooms."

On the subject of carotid stenting, Kieffer said, "I think that the proof of the efficacy of carotid stenting is not given yet. We have to wait until the trials are completed. If the results are equivalent or better than carotid surgery, which would surprise me, I would do it but I don't do it now."

From Germany, Professor Ludger Sunder-Plassmann, Chairman and Head of the Department for Thoracic and Vascular Surgery, University Hospital Ulm, said that German vascular surgeons need to have more independent departments for vascular surgery. "The definition of vascular surgery as equal with visceral or accident surgery has been a clear success that now needs to be implemented in reality," said Sunder-Plassmann. Addressing the future of vascular surgery, Sunder-Plassmann said, "The trend towards endovascular methods cannot be reversed. These methods have won enormous acceptance with laymen, as they only see the less invasiveness aspect and not the lack of proof regarding long-term success with endovascular procedures.

"As a result of this, vascular surgeons need to evaluate and learn these techniques. This demands taking these techniques seriously. For our operative ability we expect three years work, which means thick textbooks and the well-known so-called operation schools. Also endovascular methods demand a learning curve and if we do not take these procedures seriously and leave it to others patients will suffer. "The cardiologists, especially, will not ask if the illness fulfils cardiac criteria, but only if they can be cured using a guidewire, balloon and/or stent (or stent graft)."

Mauri Lepäntalo, Professor of Vascular Surgery at the University of Helsinki and Chief of the Department of Vascular Surgery at Helsinki University Central Hospital, explained how he thinks that a major task for the future is to centralise vascular surgery in Finland. "Vascular surgery", he said, "should be organised into 12-13 centres large enough to accommodate 3-4 vascular surgeons and to be able to take care of emergency service as well."

On the subject of endovascular techniques, Lepäntalo pointed out that these are "evolving, while the number of open procedures is diminishing and their complexity increasing". He continued: "A true challenge is how to teach vascular surgeons to master this growing field with less opportunity to operate." In Lepäntalo's opinion, "The development of vein surgery should be concentrated in the hands of vascular surgeons, who do not necessarily need to do the simple cases. Similarly, access surgery should be done solely by vascular surgeons as haemodynamic thinking and surveillance are essential to improve the results."

"We are in a surprising situation," said Lepäntalo, "Surgeons are believed to be the doers not thinkers, but actually right now we are the gate-keepers, who know and should control which patients need to be treated interventionally.

Giorgio Biasi Professor of Vascular Surgery at University of Milan Bicocca, Italy, had this warning for his fellow vascular surgeons, "Endovascular intervention is very much on the up and we should not just sit still."

Biasi predicts: "In the future there will be a new specialist. There will be developments to create an 'endovascular specialist'. This doctor will have expertise in vascular surgery, guidance and with radiology equipment.

"If you can provide a patient with a number of different treatment options it is likely that he will trust you more," suggested Biasi.

"I have always been excited by surgical, endovascular techniques and teaching, and am very much European."

Interventionalists
The views of the interventional radiologists Dimitrios Kelekis, Professor and Chairman of Radiology, Attikon University Hospital Athens, Greece; Andy Adam, Professor of Interventional Radiology, Guy's and St Thomas' Hospital, London, UK; Fred Keller, Director of the Dotter Interventional Institute and Chair of the Department of Diagnostic Radiology at Oregon Health & Science University, USA; and Josef Rösch, Professor and Director of Research at the Dotter Interventional Institute of the Oregon Health & Science University, Portland, Oregon, USA, can be found in their Interventional News profiles, which are available, along with those from Vascular News and Cardiovascular News, at www.CXvascular.com.