When did you decide you wanted a career in medicine?
I never decided to have a career in medicine. Rather, my mentors (Largiader, Bollinger, Mahler, Isner) influenced me to keep on going, but I never felt forced or even stressed about it. Finally, I had some luck, good timing and probably some support as well. Not that I did not work hard – but 60- to 70-hour weeks never felt like that for me, I always had fun in what I was doing.
Why did you decide to specialise in angiology?
As a medical student, I did a four-month training in surgery and was mainly working in vascular surgery at the University Hospital, Zurich (1985/86). At that time, angiology and interventional therapy was still in its infancy. What I realised was that the vascular surgeon (Prof J Largiader) and the angiologist, one of the very early interventionalists (Dr E Schneider) worked in a complementary fashion, and even were friends. So instead of separating surgery and medicine from each other, they rather treated vascular diseases together, with a high level of expertise from both sides. That impressed me so much that I decided to become an angiologist working in collaboration with the surgical partner for the best interest of patients. Although the surgical side influenced me a lot, it was the interventional part that I was even more impressed with. When compared with surgery, the interventional part is very aesthetic, rather unbloody, highly efficient in skilled hands, and a bit of an artwork – wonderful to watch! (So, although I do not have time to do painting and drawing, because of my time constraints, I still have a bit of artwork in my daily cathlab work. If you have that feeling it will never become boring).
Who have been your greatest influences?
Prof J Largiader, vascular surgeon, influenced me with his lived concept of collaboration between vascular surgery and vascular medicine during my time as a medical student at the University Hospital Zürich. He had a very modern view of uniting medicine and surgery to solve problems of vascular patients in a best fit concept. And I am still convinced that this concept is for the good of patients.
Prof A Bollinger, angiologist, former head of Angiology, University Hospital Zürich, mentored and supported my first academic steps (1989/1990). Despite my very little knowledge on the academic side, he made me become critical and more analytic on the written word. The academic spirit of his clinic at that time made all of us fellows wishing to be involved, be part of the new rising discipline – angiology. Probably it was a combination of his charismatic, academic personality and the rise of the new discipline that influenced my career so strongly.
Prof F Mahler, cardiologist and angiologist, former head of Angiology at University Hospital Bern, also trained me in interventional angiology from scratch onwards. What kept me so long in his institution and still keeps me at this place, is the same point that influenced me initially – the fruitful and peaceful, complementary collaboration between vascular surgery and vascular medicine. Mahler also influenced me a lot with his willingness to step back if needed and to make commitments, important in every partnership. It worked while he was head of angiology and I continue on this, and am convinced that this is the way to a strong future for vascular specialists.
Another great influence was Prof J Isner (who died in 2001), a cardiologist, from Tufts University, Boston. Prof Isner gave me self-esteem and inspired me to continue in my own academic career (1996/97). I worked with him as a research fellow in Boston at the St Elisabeth’s Hospital (Tufts University) and I never in my life met such a charismatic person, positive, gentle and full of energy. This would be the best way of describing his philosophy in life.
What has been your proudest moment?
Becoming a mother.
How has angiology evolved since you began your career?
It started as a baby back in 1986/87 and has grown up in the meantime. However, being in the field for so long, I am worried about the destructive competition that is going on in the interventional field – that might become dangerous and it is highly influenced by the interests of the device industry.
You have been involved in the investigation of stem cell therapy for critical limb ischaemia. What are your expectations regarding this technique?
I am afraid it is not prime time for it yet. Too early, too many unsolved questions and it is too expensive to become a widely used therapy for patients.
How do you see below-the-knee angioplasty results so far?
This is a field that evolved so much over the last five to seven years that I would call it revolutionary. When I started as an interventional trainee below-the-knee interventions were reserved for high profile interventionalists as the material was so poor. There was indeed a high risk of failure and possibility of deteriorating the situation for the patient. Today low profile wires and balloons have opened up a door for highly successful procedures. Although it remains hard to compare angioplasty with surgery, there is common agreement that endovascular should even be the first choice treatment. With the low complication rates, no need for bypass veins, a wider spectrum of elderly, fragile patients can be treated. I think we will see decreasing amputation rates in the coming years. But I also have to raise my finger – it is like modern art, not everyone can do it. A fundamental caveat is that these techniques should be envisioned only in the hands of experienced operators capable of fast and proficient management of potential complications. Technically, the antegrade access is often preferable given the need for long device shafts to reach the foot safely and direct handling and torque of materials. Alternative techniques that should be considered if the antegrade approach has failed are, e.g. direct puncture of foot vessels and retrograde recanalisation of challenging occlusion, or tracking of guide wires and balloons through parallel collaterals that bypass the target lesion.
What would you say in order to persuade physicians about the advantages of endovascular approaches in the treatment of critical limb ischaemia?
- Despite the merits of bypass surgery, the treatment requires excellent surgical skills and venous conduits to prove effective and safe in patients with below-the-knee lesions
- PREVENT reflects contemporary results of limb salvage surgery, with its inherent medical and surgical complications (early occlusion of the index graft [5.2%], wound complications [4.8%], infections [2.8%], 30-day mortality [2.7%], myocardial infarctions [4.7%], cerebrovascular events [1.4%]).
- BASIL has shown that endovascular revascularisation of critical limb ischaemia is equivalent to established standard care; i.e. bypass surgery, but at a significantly lower rate of infective, wound, and cardiovascular complications.
- Endovascular treatment was shown to be equivalent to surgery in a large cohort of all-comers with critical limb ischaemia when treatment modality was chosen individually.
- Plain old balloon angioplasty using low-profile balloons remains the basis of below-the-knee revascularisation with well established pros (ease of use, safety, cost-effectiveness) and limitations (risk of elastic-recoil, dissection, perforation, and abrupt closure).
- Endovascular techniques to treat below-the-knee lesions should be envisioned only in the hands of experienced operators capable to manage potential complications.
Switzerland has had a successful experience with limb salvage. How can this model be exported to other countries?
The secret is the complementary use of surgery and endovascular therapy plus a careful follow-up on patients. Co-factors as wound care, secondary infection, and medical therapy need to be looked at as well, whether this is in collaboration with other specialities or by vascular surgery does not really matter, however, someone has to care for the patient. What makes the system successful in Switzerland is that we see endovascular therapy as important, but not the only thing that matters in critical limb ischaemia. If other specialists start treating these patients as they think it is done with endovascular… it will not work. It seems that we have this understanding in Switzerland.
What other areas of the vascular system are you interested in and why?
Venous disease – unmet needs to prevent post-thrombotic syndrome and mortality from pulmonary embolism.
Tell us about one of your most memorable clinical cases.
A 106-year old female with acute limb ischemia due to a cardiac embolus down to the trifurcation – we got her late in the evening, did an endovascular aspiration of the embolus under local anaesthesia. It was done within 30 minutes and she was at home next day without pain and with a warm foot.
What is the most interesting paper you have come across recently?
Renal denervation – The Lancet 2009.
In this field, you are still one of the few women among men. How do you feel and do you see that changing in the future?
I get this question quite often. There will be more women in the future; however, it will take time to cross the male-dominated hurdles. The other point is that there is a minimum number of females needed in the field to stimulate those still not sure that is possible to make a career. It is also up to females to stand up, like in politics and speak up loud – “Yes, we can” – as we will not get the red carpet from men to come into the job.
Outside of medicine, what other interests do you have?
Flora and fauna are my absolute favourites. I love visiting other countries, to see the zoo, the botanical gardens, the aquarium or just the countryside that is typical for the region. My dream is to sail the Amazon River. Not that I have a green thumb or a big garden, but I love to grow vegetables by myself as well.
My family is important. I have a 12-year-old boy and have been married for 24 years to a neurologist. Although football was never a sport I had a major interest in, this changed due to my son. He is a passionate football player and meanwhile even I am a football fan, not only watching my son playing, but even following Young Boys, when they have home games (YB is a first league football team from Bern, where I live). It is a way to take a step away from the hospital and to socialise with people who are not even close to medicine.
Finally, I do some jogging and am hopefully doing my first marathon this year (NY marathon). I do about 30 to 50km per week plus some gym in the evenings. While I am not particularly a sporty person, running calms me down and makes me feel better “afterwards”.
I love painting and drawing, but I have too little time to continue this hobby.
Head of Angiology and director of Vascular Research, University Hospital, Angiology Division, Bern, Switzerland
Medical education and activities
1980–1986 - Medical studies, University of Hannover, Germany
1983–1985 - Thesis “Activity of aryl- and steroidsulfatases in subcellular compartments of hepatocytes”
1987–1993 - Residency
1987 - Internal Medicine, Walenstadtberg, Switzerland
1988/89 - Radiology, Schaffhausen, Switzerland
1989/90 - Angiology, University Hospital Zürich, Switzerland (Prof A Bollinger)
1991 - Internal Medicine and Cardiovascular Diseases, Heinrich-Heine University Düsseldorf, Germany (Prof B Strauer)
1991–1993 - Internal Medicine, University Hospital Zürich, Switzerland (Prof F Follath)
Since 1993 - Chief resident
1993/94 - Internal Medicine, Hospital Männedorf, Switzerland
1994–1996 - Division Angiology (Prof F Mahler), Department Internal Medicine (Prof W Straub), University Hospital Bern, Switzerland
1996/97 - Cardiovascular Research Fellowship, University Hospital Bern, Switzerland (Prof Th Lüscher), Cardiovascular Research Fellowship, St Elisabeth’s Medical Center, Tufts University, Boston, USA (Prof JM Isner); Finalist: Young Investigator Award, AHA
Since 1997 - Division Angiology, University Hospital Bern, Switzerland
1999 - Lecturer Internal Medicine & Angiology; Swiss Angiology Price: Therapeutic angiogenesis in critical limb ischaemia
2001 - Director of Vascular Research, Division Angiology, University Hospital Bern, Switzerland
2003 - Professor Internal Medicine & Angiology
2006 - Head Division Angiology, University Hospital Bern, Switzerland
Current Drug Targets – Cardiovascular & Haematological Disorders, VASA, Vascular Medicine, Ultraschall in der Medizin, Kardiovaskuläre Medizin, EJVES
Referee work for peer-reviewed journals
Circulation, Ultraschall in der Medizin, VASA, JACC, Ann Int Med, Human Gene Therapy, Gene Therapy, The American Journal of Medicine, Journal of Endovascular Therapy, Vascular Medicine, International Journal of Cardiology, Journal of Gene Medicine