The future of vascular surgery in a rapidly changing world: quo vadis?
(Portuguese PDF version)

Américo Dinis da Gama1

1. Professor, University of Lisbon; Head of the Vascular Surgery Clinic, Hospital de Santa Maria, Lisbon.

Correspondence:
Dr. Américo Dinis da Gama
Av. das Forças Armadas, 133 Lote D 16º E
1600-081 Lisboa, Portugal
E-mail: dinisdagama@clix.pt


ABSTRACT

This article presents an analysis of the evolution of medical specialties with emphasis on the origin, the development and the future of vascular surgery. The author highlights the role of driving forces - such as economy, technology and human resources - in the origin of the specialization process. In addition, the technological advances that established the main changes in the vascular surgery since the 1960s and the consequences of the mastery of these techniques by specialists of other medical fields are presented. In his analysis of the future of vascular surgery, the author focuses on the changes of therapeutic specialties and the emergence of new challenges for specialists and vascular surgeons

Key words: vascular surgery, specialist, endovascular surgery
Palavras-chave: cirurgia vascular, especialista, cirurgia endovascular.

J Vasc Br 2002;1(3):175-80


INTRODUCTION

A specialty is understood as a circumscribed area of the medical sciences, holding specific knowledge and a particular means of action - as it can be observed in cases as diverse as internal medicine, general surgery, anesthesiology, microbiology, psychiatry, pathological anatomy, etc. These areas are established around a body of knowledge, in which their principles and scientific groundwork are laid, and they hold their own courses of action, according to their purposes and objectives.

A clinical specialty is defined as a more or less well delineated area of medical knowledge and practice, which uses a particular means of action in order to prevent, diagnose and treat disorders which are common to this particular area.

In this context, vascular surgery is considered a clinical and scientific discipline concerned with the prevention, diagnosis and treatment of disorders that affect the blood and lymphatic vessels, beyond the heart and the central nervous system. In this sense, it is a peripheral vascular surgery, according to some North American schools, distinct from a central vascular surgery, concerned with the brain, in the field of neurosurgery, and with the heart, in the domain of cardiac surgery.

SPECIALIZATION

The phenomenon of specialization, i.e., the creation of autonomous areas of thought and action, which has hit and fragmented contemporary medicine, is a paradigm of the second half of the 20th century. This phenomenon probably began after the end of World War II, and continued to develop up to the end of the century.

Several circumstances or driving forces (Table 1) have played, and continue to play, a main role in the genesis of the phenomenon of specialization. At the top of these forces is scientific knowledge, closely connected to investigation, aiming at a more deep understanding of nature, in order to better control it. Scientific investigation is, nowadays, supported by large investments, which must be profitable in order to last. In other words, this means there is a strong predisposition for investigating only those topics that appear to be, at first sight, economically lucrative. This attitude seriously compromises the course and destiny of scientific investigation, to the detriment of the health needs of humankind at large.

click hereTable 1 - Driving forces involved in the genesis of specializations

Driving forces

Scientific knowledge - investigation
New technologies
Community's health needs
Human resources - employment

The second factor that has encouraged specialization is, unquestionably, the emergence of new technologies, which came to assist both diagnosis and therapeutics. In fact, most medical specialties have organized themselves around the mastery of a technique: in the past, the discovery of the electrocardiogram allowed for the development of cardiology, and the cystoscope, of urology; more recently, hemodialysis has given rise to nephrology, digestive endoscopy to gastroenterology, and extracorporeal circulation to cardiac surgery, just to mention some of the most magnificent examples.

The third most important driving force has emerged from the community's health needs, along with a set of citizen's rights, contemplated by the statutes of the welfare state. These needs are closely related to the community's level of socioeconomic and cultural development, as well as to the efficiency of the organizational model or models underlying the provision of healthcare services, which are generically designated as "systems".

Finally, the last of the powerful determinant factors of specialization concerns the agents or human resources involved and, more specifically, their education, professional experience and accreditation, all of which aim at satisfying one of the greatest contemporary economic hallmarks, namely employment - an irreplaceable source of subsistence and earning, pertaining to the individual, but with a vast social projection.

With these considerations, we have come to a completely different definition of medical specialty, possibly closer to the reality of the contemporary world: a medical specialty is, therefore, an area of activity organized around an economy, in which market needs, investments and the investigations it brings about play an important role, as well as costs, profits and the benefits it provides, both at the individual and at the collective level.

In other words, a specialty begins to have a reason to be or to exist when the body of scientific knowledge is in a position to satisfy market needs through the use of technology, allowing for profitable investments, aimed at the sick, with physicians acting as qualified agents, i.e., as specialists.

The dominant action that these driving forces exerted and still exert allows the conclusion that, currently, it is out of the scope of doctors to drive the course and destiny of medicine and their specialization. This privilege, which for centuries lay in the hands of the medical community, has eventually been given to economy.

I believe this is a preliminary explanation, which helps us understand the historical path of some medical specialties, such as vascular surgery. Additionally, it allows us to foresee the near future of such fields, which is the question to which I turn now.

VASCULAR SURGERY

Once more, it was the discovery, and the subsequent almost simultaneous development of three techniques (created by physicians) - endarterectomy, bypass and vascular prostheses - that congregated surgeons and motivated the autonomy of vascular surgery (Table 2), in a movement that began in the 1960s and reached its climax in the 1970s and 1980s. Before that, however, only arteriography and lumbar sympathectomy had the specific identity of vascular techniques, as they were part of the diagnostic and therapeutic tools of general surgeons.

click hereTable 2 - The historical course of vascular surgery

Period
Technique
1960s and 1970s
Endarterectomy, bypass, vascular prostheses
1980s
Vascular laboratory
1990s
Intraluminal techniques

The 1980s were marked and almost polarized by the introduction and clinical use of one technology, the ultrasound, which came to help diagnosis, based on the Doppler effect, and on the creation of the vascular laboratory. This new technology came to completely modify diagnosis, and produced a significant impact on the unstable balance of the already mentioned driving forces, namely due to the large market opening that it favored.

The 1990s were characterized by the expansion of therapeutic techniques called minimally invasive, constituted mainly by balloon angioplasty, stents and vascular endoprosthesis. Giving sequence to a truly revolutionary movement, originated in the field of general surgery, the development of minimally invasive techniques aimed at reducing to the minimum the invasive character of surgical interventions; in this context, laparoscopic cholecystectomy became the most significant and representative procedure.

The creation and popularization of ultrasonography and, later, of minimally invasive techniques gave rise to the emergence of an unusual phenomenon, which caught vascular surgeons by surprise and whose shock waves are still felt today: slowly and gradually, these techniques became accessible and began to be mastered by intruders, I mean, specialists from other areas.

In the case of ultrasonography, radiologists began to gain control over the diagnostic methodology of vascular ultrasound and came to euphemistically assume the designation of imagiologist.

ENDOVASCULAR SURGERY

The minimally invasive techniques, commonly known as endovascular surgery, or, more properly, endoluminal intervention, were promptly used by radiologists and, later, by cardiologists, angiologists, vascular medicine specialists, and even by neurologists or urologists (Table 3) to treat patients with peripheral vascular disorders, due to their ready accessibility and ease of use.

click hereTable 3 - Specialists who use endovascular surgery

Cardiovascular interventionists

Vascular surgeons
Cardiologists
Radiologists
Vascular medicine
Angiologists
Neurologists
Angiologists

Radiology, earlier passively oriented towards diagnosis, became aggressively interventionist and therapeutic, consecrating itself as interventional radiology.

It is unnecessary to say that these movements generated and still generate enormous distress and restlessness at all levels, which are expressed in turf wars that gravitate around the main driving forces: market, investments, costs, profitability and employment.

Several movements of dispute and conflict of ideas were carried out by the main agents involved, all calling out for an authentic right to property, but aiming basically at the conquering of new markets and the protection of inherent privileges and benefits.

Vascular surgery was strongly shaken by such an invasion. The most pusillanimous even began to see the extinction of specialty1-3, once its field of action would become so empty to the benefit of interventional radiology, cardiology, vascular medicine and even of other specialties, such as neurology and urology.

The reactions to this confrontation came to the point of raising a deep reflection about the essence, the definition and the space destined for vascular surgery on its road to extinction.2,3 The attitude of vascular surgeons towards the phenomenon of endovascular surgery and the apportionment of their practice among specialists of other areas were also discussed.

The most diverse proposals were continuously being announced, tending either to resist or to ignore the movement, to fight for survival,3 or even to adapt,4 merging with the most enthusiastic promoters of such movement, as we have verified.5,6

An authentic endovascular fundamentalism emerged in the United States and was quickly spread around Europe. This movement, so typical of the North-American culture, and patent in other areas and conducts of that society, can be translated into the following key concepts:

• Endovascular surgery will soon replace conventional vascular surgery;

• Anyone who does not catch the 'train' now will be doomed to the obsolescence of conventional surgical methods, rejected by all, beginning by the patients themselves and ending up with hospital managers, insurance companies and the industry.

Proposals with a conciliatory nature, tending to appease conflicts and tensions, began to appear. Among such proposals, the idea of creating vascular centers 5-9 - vascular departments which would gather, in harmony, vascular surgeons, imaging specialist, interventional radiologists, cardiologists, and vascular medicine specialists - received special attention.

These proposals, in a way illusory or even utopian, had the only merit of temporarily attenuating the tension and conflict, equally dividing market demands, but neglecting, however, the underlying reason for this present reflection: what is, after all, in this highly competitive context, the future of conventional vascular surgery? Will it withstand the impact of new minimally invasive technologies, namely the threat of endovascular surgery? Will it need to open its field to other competitors, surely more numerous, better equipped, with a fast learning pace and with an easy access to patients?

VASCULAR VERSUS ENDOVASCULAR SURGERY

These questions, lived with anxiety and anguish by some, deserve a pondered, objective and justified reflection, distant from the passionate spirit that has, over the last years, fueled controversy, as well as its main agents, who have not always analyzed it with the clear perception and serenity that only a spiritual and temporal distance allows.

Some data are already available for an evaluation of the impact that endovascular surgery has had on conventional vascular surgery. Although this information originates from one sole community (the United States),10,11 it is still of great interest and significance.

In the year 2000, there were 12,390 North-American specialists working on the invasive treatment of cardiovascular disorders. These professionals were grouped as follows: 4,216 interventional cardiologists; 2,058 interventional radiologists; 2,055 peripheral vascular surgeons; and 4,061 cardiothoracic surgeons (Table 4).11

click hereTable 4 - Number of cardiovascular interventionists in the United States in 2000

Specialty
Number
Interventional cardiologists
4,216
Interventional radiologists
2,058
Peripheral vascular surgeons
2,055
Cardiothoracic surgeons
4,061
Total
12,390

In this group, vascular surgeons were the minority, and among them only 19% were actively involved in endovascular procedures.12 Cardiologists (60%) and interventional radiologists (20%) widely controlled the field of endovascular surgery, with a considerable share to be assumed by interventional cardiology.9,11,12

The global results of this activity could not be more surprising: despite the massive invasion of interventional cardiac and vascular surgeons and the significant increase of their productivity, conventional surgical activity was not affected at all, even showing, concomitantly, a growing tendency.

In fact, from 1993 to 1997 (Table 5), the number of interventional cardiology procedures increased by 42.3% and, during the same period, the number of surgeries for myocardial revascularization (coronary bypass) increased by 23%.11 In an equal period of time, procedures performed by interventional radiologists increased by 44.4%, while peripheral vascular surgery experienced an increase of 21.6%.11

click hereTable 5 - Cardiovascular procedures performed in the United States between 1993 and 1997

Specialty
1993 1997 Variation
Interventional cardiology
414,194 589,216 + 42.3%
Myocardial revascularization surgery
312,109 383,788 + 23%
Interventional radiology
171,836 248,198 + 44.4%
Peripheral vascular surgery
514,237 625,413 + 21.6%

The first and most significant conclusion that can be drawn from the analysis of these figures is that endovascular surgery neither affected nor did it prove to be a fierce rival to conventional surgery, either in the case of coronary procedures or peripheral vascular surgeries. Consequently, the immediate impression is that endovascular surgery does not present itself as a therapeutic alternative.

How can this truly paradoxical conclusion be explained, if it goes against a dominant and scientifically correct school of thought?

SELECTIVITY AND DURABILITY

Two reasons seem to be, ab initio, plausible and worthy of discussion: the high selectivity and the low durability that characterize, today, endovascular procedures.13

In fact, endovascular surgery is indicated or effective for only a small number of patients,7 usually those who present the simplest cases or who are treated at an earlier stage, or in cases in which the size or the anatomy favors the procedure, as in aneurysms, contexts that do not belong, commonly and entirely, to the scope of conventional surgery. Conventional procedures operate mainly on extensive and multilevel obstructive processes, and in aneurysms of great volume or unfavorable anatomy, in which an intraluminal intervention is impracticable or counterproductive. In addition, endovascular surgery is frequently directed to patients with high operative risks and who are, therefore, out of the scope of conventional surgery. Thus, the traditional caseload of classic vascular surgery tends to remain unaltered, as it appears to have been the case.10,14,15

On the other hand, the low durability of intraluminal procedures, expressed by frequent occlusive complications or other forms of adverse reaction, tend to hasten their failure and call for a later surgical intervention, in a process that can be labeled late surgical conversion. This contributes to an increase in the activity of conventional surgery, justifying how both therapeutic approaches have shown concurrent developments, chiefly evidenced in coronary revascularization procedures.11

The remarkable expansions recorded in the field of intraluminal intervention, patent not only in cardiology, but also in interventional radiology, within this context, could only be possible at the expense of nonsurgical patients. Thus, it seems plausible to conclude that endovascular surgery is more of an alternative to medical treatment than an alternative to conventional surgery of arteriopathies.15

The threat that endovascular surgery seemed to pose to the field of activity of traditional vascular surgery and the degree of controversy and restlessness it caused among the vascular community ended up to be a fallacy, a true myth. Conventional vascular surgery is not on its way to extinction and has its near future guaranteed, as an expanding, diversified and strongly motivating field of activity. And, last but not least, conventional vascular surgery persists because it still fully satisfies the requirements and demands of the main driving forces involved in the phenomenon of specialization.

THE FUTURE OF VASCULAR SURGERY

In the beginning of this new millennium, the real threat against the destiny of vascular surgery lies, in fact, not in endovascular surgery, but mainly in the progress achieved with scientific knowledge, in the discovery of fine-grained details of the biophysiology of the arterial wall, and in the better understanding of its disorders. The advances in genetic manipulation and engineering, in molecular biology, in pharmacotherapy, as well as in the judicious use of factors that promote or inhibit cellular growth and multiplication, will certainly become fundamental for the prevention and control of arteriopathies, in a not so remote future, and will dictate the definite end of invasive treatments, both in the fields of vascular and endovascular surgery.

These therapeutic models were and still are mere chapters in a historical process that had to resort to mechanical interventions, since there were no other options available, and which will be substituted, inexorably, by biological actions. A vascular biologist7 or specialist will then take the place of the vascular surgeon (Table 6) and vascular medicine will substitute vascular surgery or, for the most conservative, it will simply preserve the classic designation of angiology.

click hereTable 6 - The future of vascular surgery

Present
Future
Vascular surgeon
Vascular specialist or biologist
Vascular surgery
Vascular medicine or angiology

REFERENCES

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2. Veith FJ. The S. Stanley Crawford Critical Issue Forum 1995: The future of vascular surgery in a changing world. J Vasc Surg 1996;23:894-5.

3. Veith FJ. Presidential address: Charles Darwin and vascular surgery. J Vasc Surg 1997;25:8-18.

4. Moore WS, Clagett GP, Hobson II RW, et al. Vision of optimal vascular surgical training in the next two decades: Strategies for adapting to new technologies. J Vasc Surg 1996;23:926-31.

5. Hiatt WR, Creager MA, Cooke JP, Hirsch AT. Building a partnership between vascular medicine and vascular surgery: a coalition for the future of vascular care. J Vasc Surg 1996;23:918-25.

6. Green RM. Collaboration between vascular surgeons and interventional radiologists: reflections after two years. J Vasc Surg 2000;31:826-30.

7. DeWeese JA, Baker JD, Ernest CB, et al. Vision of the vascular surgeons as the vascular specialist of the future. J Vasc Surg 1996;23:896-901.

8. Becker GJ, Katzen BT. The vascular center: a model for multidisciplinary delivery of vascular care for the future. J Vasc Surg 1996;23:907-12.

9. Sicard GA. El cirujano vascular en el nuevo milenio. Arch Cir Vasc 2001;10:1-4.

10. Stanley JC, Barnes RW, Ernest CB, et al. Vascular Surgery in the United States: workforces issues. J Vasc Surg 1996;23:172-81.

11. Wieslander CK, Huang CC, Omura MC, Ahn SS. Endovascular workforce for peripheral vascular disease: current and future needs. J Vasc Surg 2002;35:1218-25.

12. Kashyap VS, Ahn SS, Petrik PV, et al. Apprentissage et pratique actuels de la chirurgie endovasculaire: Resultats d'une enquête. Ann Chir Vasc 2001;15:294-305.

13. Hallett JW. Presidential address: Back to the future of vascular surgery - why certain procedures become obsolete. J Vasc Surg 1997;25:791-5.

14. Arko FR, Lee A, Hill BB, et al. Impact of endovascular repair on open aortic aneurysm surgical training. J Vasc Surg 2001;34:885-91.

15. Dinis da Gama A. Angioplastia/stent na isquemia dos membros inferiores: a perspectiva de um cirurgião vascular. Rev Port CCT e Vascular 1999;13/14:91-5.


J Vasc Br - Official Publication of the Brazilian Society of Angiology and Vascular Surgery