Russell Samson, MD

Congratulations! You noticed that Vascular Specialist has a new look. And with your well-honed powers of observation you also noticed the inauguration of the new logo for the Society for Vascular Surgery. However, you may be somewhat nonplussed. Because of the new logo you may have to buy a whole new wardrobe of SVS garments. I must admit I was confused as to the rationale behind changing the logo.

Surely it wasn’t because patients went elsewhere for treatment because they didn’t approve of the old one. I had never heard “Sorry Dr. Samson, I’m going to a cardiologist, I prefer the American College of Cardiology logo,” However, I now understand the reason behind this change is not so trivial. Rather, the new logo and Vascular Specialist’s appearance portends momentous changes in the aspirations and objectives of SVS and its publications.

Let me start with SVS. Long considered a staid, conservative organization geared mainly to promote academic and research achievements, it now fully embraces a commitment to the entire field of vascular surgery, its practitioners and patients. Under the leadership of current President Bruce Perler, the Executive Committee realized it is an imperative that government, health industries, and other medical specialists recognize the uniqueness of the spectrum of vascular surgeons’ services. Further, that this message is conveyed by SVS as our official mouthpiece.

You may ask how changing the logo conveys such a message. Simply put, the old logo does not work well with different color backgrounds and modern electronic media. It does not scale in updated websites, web browsers, or mobile apps. The new logo overcomes all these problems and by so doing confirms a change in direction for SVS. It acknowledges that our Society is part of the “Now” generation that understands the importance of all these new forms of communication. It affirms that branding and marketing the Society and its member vascular surgeons has become a priority.

Also, SVS recognized that this could only be achieved through an aggressive marketing campaign utilizing all that modern media has to offer. The first item on the Executive’s agenda was updating the SVS web site and for this a more workable logo was essential. The new website is in development and will debut soon. Concurrently, all aspects of branding will be revamped and the new logo will become omnipresent. It will now appear proudly on position papers, the JVS, SVS guidelines and all documents authored by the Society. I admit that to bolster this effort I have championed a complete name change to the American College of Vascular Surgery –  but I have come to believe that this would be time consuming and entail so much cajoling that it would delay the SVS’s program. The website is a priority and our Society needs to move forward with its marketing campaign. The new logo is symbolic of the new SVS and it looks great!

The new design for Vascular Specialist begins as it enters its second decade as the official newspaper of SVS. Like SVS, our newspaper has also changed with the times. Although print has become very expensive, through the generosity of our many industry supporters, we have been able to expand the print editions to at least 20 pages every month and it is now mailed to over 5,000 members and affiliates worldwide.

A recent survey of SVS members confirmed that Vascular Specialist is the most widely read of all the vascular related periodicals. Importantly, Vascular Specialist also takes advantage of all the new methods of communication. It is now not only presented in print, but has an electronic presence with a website (www.vascularspecialistonline.com) and a mobile app containing many articles beyond those you will read in the print edition. We hope that vascular specialistonline.com will become your go to site for news and conversation related to all things vascular. One of my goals as Medical editor is to encourage you to not only be an avid reader, but also a contributor.

There are many ways you can help grow Vascular Specialist. Write a letter to the editor, contribute a Tips and Tricks, volunteer to write a Point/Counter Point column, submit an Opinion piece or simply respond to one of our online polls. Perhaps you wrote an article or made a presentation that you would like to reach a wider audience. You could send it to us and our reporters will convert it into newsworthy reports that can be printed or added to our online edition. Don’t fret over the chore of grammar and style; our writing staff will help make you seem like Shakespeare!

Of course patients did not avoid us because of our old logo and members read Vascular Specialist even though the font was old fashioned. However, these are important and exciting times and we want you to take part. We hope you will continue to read about your accomplishments and SVS achievements in print and electronic versions of Vascular Specialist. And yes, you may have to spring for a new SVS tie or scarf because the old ones are no longer current.
But, hopefully, the powers that be will recognize that a document or electronic media emblazoned with speaks authoritatively on behalf of vascular surgeons and our patients.

Dr. Samson is clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists.

Congratulations! You noticed that Vascular Specialist has a new look. And with your well-honed powers of observation you also noticed the inauguration of the new logo for the Society for Vascular Surgery. However, you may be somewhat nonplussed. Because of the new logo you may have to buy a whole new wardrobe of SVS garments. I must admit I was confused as to the rationale behind changing the logo.

Surely it wasn’t because patients went elsewhere for treatment because they didn’t approve of the old one. I had never heard “Sorry Dr. Samson, I’m going to a cardiologist, I prefer the American College of Cardiology logo,” However, I now understand the reason behind this change is not so trivial. Rather, the new logo and Vascular Specialist’s appearance portends momentous changes in the aspirations and objectives of SVS and its publications.

Let me start with SVS. Long considered a staid, conservative organization geared mainly to promote academic and research achievements, it now fully embraces a commitment to the entire field of vascular surgery, its practitioners and patients. Under the leadership of current President Bruce Perler, the Executive Committee realized it is an imperative that government, health industries, and other medical specialists recognize the uniqueness of the spectrum of vascular surgeons’ services. Further, that this message is conveyed by SVS as our official mouthpiece.

You may ask how changing the logo conveys such a message. Simply put, the old logo does not work well with different color backgrounds and modern electronic media. It does not scale in updated websites, web browsers, or mobile apps. The new logo overcomes all these problems and by so doing confirms a change in direction for SVS. It acknowledges that our Society is part of the “Now” generation that understands the importance of all these new forms of communication. It affirms that branding and marketing the Society and its member vascular surgeons has become a priority.

Also, SVS recognized that this could only be achieved through an aggressive marketing campaign utilizing all that modern media has to offer. The first item on the Executive’s agenda was updating the SVS web site and for this a more workable logo was essential. The new website is in development and will debut soon. Concurrently, all aspects of branding will be revamped and the new logo will become omnipresent. It will now appear proudly on position papers, the JVS, SVS guidelines and all documents authored by the Society. I admit that to bolster this effort I have championed a complete name change to the American College of Vascular Surgery –  but I have come to believe that this would be time consuming and entail so much cajoling that it would delay the SVS’s program. The website is a priority and our Society needs to move forward with its marketing campaign. The new logo is symbolic of the new SVS and it looks great!

The new design for Vascular Specialist begins as it enters its second decade as the official newspaper of SVS. Like SVS, our newspaper has also changed with the times. Although print has become very expensive, through the generosity of our many industry supporters, we have been able to expand the print editions to at least 20 pages every month and it is now mailed to over 5,000 members and affiliates worldwide.

A recent survey of SVS members confirmed that Vascular Specialist is the most widely read of all the vascular related periodicals. Importantly, Vascular Specialist also takes advantage of all the new methods of communication. It is now not only presented in print, but has an electronic presence with a website (www.vascularspecialistonline.com) and a mobile app containing many articles beyond those you will read in the print edition. We hope that vascular specialistonline.com will become your go to site for news and conversation related to all things vascular. One of my goals as Medical editor is to encourage you to not only be an avid reader, but also a contributor.

There are many ways you can help grow Vascular Specialist. Write a letter to the editor, contribute a Tips and Tricks, volunteer to write a Point/Counter Point column, submit an Opinion piece or simply respond to one of our online polls. Perhaps you wrote an article or made a presentation that you would like to reach a wider audience. You could send it to us and our reporters will convert it into newsworthy reports that can be printed or added to our online edition. Don’t fret over the chore of grammar and style; our writing staff will help make you seem like Shakespeare!

Of course patients did not avoid us because of our old logo and members read Vascular Specialist even though the font was old fashioned. However, these are important and exciting times and we want you to take part. We hope you will continue to read about your accomplishments and SVS achievements in print and electronic versions of Vascular Specialist. And yes, you may have to spring for a new SVS tie or scarf because the old ones are no longer current.
But, hopefully, the powers that be will recognize that a document or electronic media emblazoned with speaks authoritatively on behalf of vascular surgeons and our patients.

Dr. Samson is clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists.

Congratulations! You noticed that Vascular Specialist has a new look. And with your well-honed powers of observation you also noticed the inauguration of the new logo for the Society for Vascular Surgery. However, you may be somewhat nonplussed. Because of the new logo you may have to buy a whole new wardrobe of SVS garments. I must admit I was confused as to the rationale behind changing the logo.

Surely it wasn’t because patients went elsewhere for treatment because they didn’t approve of the old one. I had never heard “Sorry Dr. Samson, I’m going to a cardiologist, I prefer the American College of Cardiology logo,” However, I now understand the reason behind this change is not so trivial. Rather, the new logo and Vascular Specialist’s appearance portends momentous changes in the aspirations and objectives of SVS and its publications.

Let me start with SVS. Long considered a staid, conservative organization geared mainly to promote academic and research achievements, it now fully embraces a commitment to the entire field of vascular surgery, its practitioners and patients. Under the leadership of current President Bruce Perler, the Executive Committee realized it is an imperative that government, health industries, and other medical specialists recognize the uniqueness of the spectrum of vascular surgeons’ services. Further, that this message is conveyed by SVS as our official mouthpiece.

You may ask how changing the logo conveys such a message. Simply put, the old logo does not work well with different color backgrounds and modern electronic media. It does not scale in updated websites, web browsers, or mobile apps. The new logo overcomes all these problems and by so doing confirms a change in direction for SVS. It acknowledges that our Society is part of the “Now” generation that understands the importance of all these new forms of communication. It affirms that branding and marketing the Society and its member vascular surgeons has become a priority.

Also, SVS recognized that this could only be achieved through an aggressive marketing campaign utilizing all that modern media has to offer. The first item on the Executive’s agenda was updating the SVS web site and for this a more workable logo was essential. The new website is in development and will debut soon. Concurrently, all aspects of branding will be revamped and the new logo will become omnipresent. It will now appear proudly on position papers, the JVS, SVS guidelines and all documents authored by the Society. I admit that to bolster this effort I have championed a complete name change to the American College of Vascular Surgery –  but I have come to believe that this would be time consuming and entail so much cajoling that it would delay the SVS’s program. The website is a priority and our Society needs to move forward with its marketing campaign. The new logo is symbolic of the new SVS and it looks great!

The new design for Vascular Specialist begins as it enters its second decade as the official newspaper of SVS. Like SVS, our newspaper has also changed with the times. Although print has become very expensive, through the generosity of our many industry supporters, we have been able to expand the print editions to at least 20 pages every month and it is now mailed to over 5,000 members and affiliates worldwide.

A recent survey of SVS members confirmed that Vascular Specialist is the most widely read of all the vascular related periodicals. Importantly, Vascular Specialist also takes advantage of all the new methods of communication. It is now not only presented in print, but has an electronic presence with a website (www.vascularspecialistonline.com) and a mobile app containing many articles beyond those you will read in the print edition. We hope that vascular specialistonline.com will become your go to site for news and conversation related to all things vascular. One of my goals as Medical editor is to encourage you to not only be an avid reader, but also a contributor.

There are many ways you can help grow Vascular Specialist. Write a letter to the editor, contribute a Tips and Tricks, volunteer to write a Point/Counter Point column, submit an Opinion piece or simply respond to one of our online polls. Perhaps you wrote an article or made a presentation that you would like to reach a wider audience. You could send it to us and our reporters will convert it into newsworthy reports that can be printed or added to our online edition. Don’t fret over the chore of grammar and style; our writing staff will help make you seem like Shakespeare!

Of course patients did not avoid us because of our old logo and members read Vascular Specialist even though the font was old fashioned. However, these are important and exciting times and we want you to take part. We hope you will continue to read about your accomplishments and SVS achievements in print and electronic versions of Vascular Specialist. And yes, you may have to spring for a new SVS tie or scarf because the old ones are no longer current.
But, hopefully, the powers that be will recognize that a document or electronic media emblazoned with speaks authoritatively on behalf of vascular surgeons and our patients.

Dr. Samson is clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists.

Once again hospital administrators in their never-ending quest to reduce expenditures have placed vascular surgeons at a disadvantage. First they reduce the inventory of necessary items. Now they want to keep sales representatives out of the operating room. Their thought process is industry representatives will seduce us to use an expensive product which we otherwise would not consider using. Further, companies build support into the cost of their devices. Thus they would be expected to reduce prices if their personnel were no longer required in the OR.

Administrators as well as many lay public must also wonder why a nonphysician representative of a device company should be present in the operating room. This is certainly a valid question. The answer requires an understanding of how the complexity of vascular interventions has evolved in the era of endovascular procedures.

The vascular surgeon of yore learned basic vascular skills of dissection, excision, needles, and thread which could be applied with equal skill throughout the vascular system. Although they used multiple conduits as grafts, the technique of sewing an anastomosis was a general skill. Then, as surgeons still do now, they needed to know the benefits and drawbacks of the various graft materials and sutures. However, they certainly did not require a company representative to be in the room nor to instruct them on how to sew in the graft or how to deal with a broken suture.

But now vascular surgeons use wires, stents, catheters, balloons, lasers, and drills. When I last counted there were at least eight different companies selling aortic endografts and promoting never-ending variations or replacements for their ‘last year’s device.’ Often the advent of a new device produced an expanded repertoire of new procedures each with their own specific nuances many of which were device specific. Accordingly, it is essential that a surgeon become experienced with the new device in order to prevent or overcome glitches that otherwise might result in serious complications.

However, only the busiest vascular surgeons or those specifically involved in industry-supported trials may ever achieve sufficient experience to be able to use all these products. Certainly, a surgeon may elect to become familiar with just a few of the available choices. However, occasionally a specific indication may require them to use a device they seldom utilized. For example only certain endografts can be used in short or angulated aortic necks.

It must be stated emphatically that surgeons should be completely comfortable with the device and its instructions for use. It would be entirely inappropriate for a vascular surgeon to enter the operating room so ill-prepared as to require the company employee to walk him or her through the use of their device.

However, since some surgeons may have limited experience it would be beneficial to have someone else present who has more familiarity with its use. It is true that most companies have technical advisers who could come to the operating room but they are far and few between. Accordingly, sales representatives are well suited to be the other knowledgeable individual.

Most companies train their sales persons to have the core knowledge to function as advisers. They are well schooled in their device probably even more so than most surgeons. They know all its indications and the dangers in using the device outside of the instructions for use (IFU’s) published by the manufacturer. They also know the subtleties that make the device work more optimally. Many will have witnessed complications and so they will have learned how to overcome them. In some instances their accumulated knowledge may forestall an incorrect insertion or manipulation of the device. Of course salespersons will not have performed procedures themselves but most will have learned by attending many procedures, usually far more than performed by any one surgeon. Is it a coincidence that ‘rep,’ the diminutive word for representative, is the same word for the shortened form of ‘repetition?’

Once a trusting relationship develops between the surgeon and the sales rep, having both in the operating room can mean the difference between life and death for the patient. The security gained by knowing there will be another experienced person in the room is reassuring and should be reassuring to the patient and to the hospital administrators as well. After all, what is worse for the surgeon’s reputation, the hospital’s bottom line, or more importantly the patient, than an unnecessary complication that could have been easily avoided by a few cautionary words?Even when I use a device I have used many times, it has not been unusual for the sales rep in the operating room to help me work out a difficult portion of the procedure. How reassuring it is to have another educated adviser in there with you. Professional tennis players have their coach in the stands. Dr. O. William Brown, our associate editor, makes the point that even professional golfers have their caddy with them on the course. The caddy does not hit the ball nor play the course just like the rep does not touch the patient nor do the procedure. However the caddy (rep) knows the course, the player, ball and clubs and can read the greens and knows the distance to the hole. Advice from the supporting caddy can make the difference between winning and losing. Advice from the rep can save a life.

I used an automobile analogy in one of my last editorials and there is one which applies here as well.

Almost all of us by the time we are in our 30s or 40s can drive safely. However, when we buy a new car the sales person drives with us the first few times so we may become comfortable with the new features. When it comes to driving so-called exotics like a Ferrari or Lamborghini, potential buyers (such as hospital CEO’s) will go to a special track where they will drive with an accomplished company driver before they feel safe to drive the car on their own. The company drivers know the limits of their car and they know the limits of drivers unaccustomed to advanced automobiles. Press the gas pedal too soon or push too hard on the brake pedal and the car will spin out of control with fatal results. In the operating room, press the wrong button or push too hard and the device may deploy too soon and the procedure may spin out of control also with potentially fatal results.

It seems to me the whole controversy revolves around the phrase “sales-representative” since it implies at all times their sole goal is to increase sales. Perhaps if they were simply called “representatives” there would be no issue. Yes, it may be true that in some instances the selection of a device may be based on the relationship a surgeon has with a company’s sales representative rather than the quality of the company’s device.

However, administrators are misguided when they consider excluding the sales rep from the operating room or endovascular suite will achieve cost savings. Usually the decision to select a company’s device was made many days before the procedure. If the rep was going to influence the surgeon, it would have been done prior to the surgeon entering those sacrosanct spaces.

Thus, in their never-ending onslaught on cost, administrators who restrict sales reps from the operating room may be impeding quality care. Accordingly, ‘“the elephant in the room” may not be the sales representative but rather the administrator in the office down the corridor.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president, Mote Vascular Foundation, Inc., and is an attending vascular surgeon, Sarasota Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

Once again hospital administrators in their never-ending quest to reduce expenditures have placed vascular surgeons at a disadvantage. First they reduce the inventory of necessary items. Now they want to keep sales representatives out of the operating room. Their thought process is industry representatives will seduce us to use an expensive product which we otherwise would not consider using. Further, companies build support into the cost of their devices. Thus they would be expected to reduce prices if their personnel were no longer required in the OR.

Administrators as well as many lay public must also wonder why a nonphysician representative of a device company should be present in the operating room. This is certainly a valid question. The answer requires an understanding of how the complexity of vascular interventions has evolved in the era of endovascular procedures.

The vascular surgeon of yore learned basic vascular skills of dissection, excision, needles, and thread which could be applied with equal skill throughout the vascular system. Although they used multiple conduits as grafts, the technique of sewing an anastomosis was a general skill. Then, as surgeons still do now, they needed to know the benefits and drawbacks of the various graft materials and sutures. However, they certainly did not require a company representative to be in the room nor to instruct them on how to sew in the graft or how to deal with a broken suture.

But now vascular surgeons use wires, stents, catheters, balloons, lasers, and drills. When I last counted there were at least eight different companies selling aortic endografts and promoting never-ending variations or replacements for their ‘last year’s device.’ Often the advent of a new device produced an expanded repertoire of new procedures each with their own specific nuances many of which were device specific. Accordingly, it is essential that a surgeon become experienced with the new device in order to prevent or overcome glitches that otherwise might result in serious complications.

However, only the busiest vascular surgeons or those specifically involved in industry-supported trials may ever achieve sufficient experience to be able to use all these products. Certainly, a surgeon may elect to become familiar with just a few of the available choices. However, occasionally a specific indication may require them to use a device they seldom utilized. For example only certain endografts can be used in short or angulated aortic necks.

It must be stated emphatically that surgeons should be completely comfortable with the device and its instructions for use. It would be entirely inappropriate for a vascular surgeon to enter the operating room so ill-prepared as to require the company employee to walk him or her through the use of their device.

However, since some surgeons may have limited experience it would be beneficial to have someone else present who has more familiarity with its use. It is true that most companies have technical advisers who could come to the operating room but they are far and few between. Accordingly, sales representatives are well suited to be the other knowledgeable individual.

Most companies train their sales persons to have the core knowledge to function as advisers. They are well schooled in their device probably even more so than most surgeons. They know all its indications and the dangers in using the device outside of the instructions for use (IFU’s) published by the manufacturer. They also know the subtleties that make the device work more optimally. Many will have witnessed complications and so they will have learned how to overcome them. In some instances their accumulated knowledge may forestall an incorrect insertion or manipulation of the device. Of course salespersons will not have performed procedures themselves but most will have learned by attending many procedures, usually far more than performed by any one surgeon. Is it a coincidence that ‘rep,’ the diminutive word for representative, is the same word for the shortened form of ‘repetition?’

Once a trusting relationship develops between the surgeon and the sales rep, having both in the operating room can mean the difference between life and death for the patient. The security gained by knowing there will be another experienced person in the room is reassuring and should be reassuring to the patient and to the hospital administrators as well. After all, what is worse for the surgeon’s reputation, the hospital’s bottom line, or more importantly the patient, than an unnecessary complication that could have been easily avoided by a few cautionary words?Even when I use a device I have used many times, it has not been unusual for the sales rep in the operating room to help me work out a difficult portion of the procedure. How reassuring it is to have another educated adviser in there with you. Professional tennis players have their coach in the stands. Dr. O. William Brown, our associate editor, makes the point that even professional golfers have their caddy with them on the course. The caddy does not hit the ball nor play the course just like the rep does not touch the patient nor do the procedure. However the caddy (rep) knows the course, the player, ball and clubs and can read the greens and knows the distance to the hole. Advice from the supporting caddy can make the difference between winning and losing. Advice from the rep can save a life.

I used an automobile analogy in one of my last editorials and there is one which applies here as well.

Almost all of us by the time we are in our 30s or 40s can drive safely. However, when we buy a new car the sales person drives with us the first few times so we may become comfortable with the new features. When it comes to driving so-called exotics like a Ferrari or Lamborghini, potential buyers (such as hospital CEO’s) will go to a special track where they will drive with an accomplished company driver before they feel safe to drive the car on their own. The company drivers know the limits of their car and they know the limits of drivers unaccustomed to advanced automobiles. Press the gas pedal too soon or push too hard on the brake pedal and the car will spin out of control with fatal results. In the operating room, press the wrong button or push too hard and the device may deploy too soon and the procedure may spin out of control also with potentially fatal results.

It seems to me the whole controversy revolves around the phrase “sales-representative” since it implies at all times their sole goal is to increase sales. Perhaps if they were simply called “representatives” there would be no issue. Yes, it may be true that in some instances the selection of a device may be based on the relationship a surgeon has with a company’s sales representative rather than the quality of the company’s device.

However, administrators are misguided when they consider excluding the sales rep from the operating room or endovascular suite will achieve cost savings. Usually the decision to select a company’s device was made many days before the procedure. If the rep was going to influence the surgeon, it would have been done prior to the surgeon entering those sacrosanct spaces.

Thus, in their never-ending onslaught on cost, administrators who restrict sales reps from the operating room may be impeding quality care. Accordingly, ‘“the elephant in the room” may not be the sales representative but rather the administrator in the office down the corridor.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president, Mote Vascular Foundation, Inc., and is an attending vascular surgeon, Sarasota Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

Once again hospital administrators in their never-ending quest to reduce expenditures have placed vascular surgeons at a disadvantage. First they reduce the inventory of necessary items. Now they want to keep sales representatives out of the operating room. Their thought process is industry representatives will seduce us to use an expensive product which we otherwise would not consider using. Further, companies build support into the cost of their devices. Thus they would be expected to reduce prices if their personnel were no longer required in the OR.

Administrators as well as many lay public must also wonder why a nonphysician representative of a device company should be present in the operating room. This is certainly a valid question. The answer requires an understanding of how the complexity of vascular interventions has evolved in the era of endovascular procedures.

The vascular surgeon of yore learned basic vascular skills of dissection, excision, needles, and thread which could be applied with equal skill throughout the vascular system. Although they used multiple conduits as grafts, the technique of sewing an anastomosis was a general skill. Then, as surgeons still do now, they needed to know the benefits and drawbacks of the various graft materials and sutures. However, they certainly did not require a company representative to be in the room nor to instruct them on how to sew in the graft or how to deal with a broken suture.

But now vascular surgeons use wires, stents, catheters, balloons, lasers, and drills. When I last counted there were at least eight different companies selling aortic endografts and promoting never-ending variations or replacements for their ‘last year’s device.’ Often the advent of a new device produced an expanded repertoire of new procedures each with their own specific nuances many of which were device specific. Accordingly, it is essential that a surgeon become experienced with the new device in order to prevent or overcome glitches that otherwise might result in serious complications.

However, only the busiest vascular surgeons or those specifically involved in industry-supported trials may ever achieve sufficient experience to be able to use all these products. Certainly, a surgeon may elect to become familiar with just a few of the available choices. However, occasionally a specific indication may require them to use a device they seldom utilized. For example only certain endografts can be used in short or angulated aortic necks.

It must be stated emphatically that surgeons should be completely comfortable with the device and its instructions for use. It would be entirely inappropriate for a vascular surgeon to enter the operating room so ill-prepared as to require the company employee to walk him or her through the use of their device.

However, since some surgeons may have limited experience it would be beneficial to have someone else present who has more familiarity with its use. It is true that most companies have technical advisers who could come to the operating room but they are far and few between. Accordingly, sales representatives are well suited to be the other knowledgeable individual.

Most companies train their sales persons to have the core knowledge to function as advisers. They are well schooled in their device probably even more so than most surgeons. They know all its indications and the dangers in using the device outside of the instructions for use (IFU’s) published by the manufacturer. They also know the subtleties that make the device work more optimally. Many will have witnessed complications and so they will have learned how to overcome them. In some instances their accumulated knowledge may forestall an incorrect insertion or manipulation of the device. Of course salespersons will not have performed procedures themselves but most will have learned by attending many procedures, usually far more than performed by any one surgeon. Is it a coincidence that ‘rep,’ the diminutive word for representative, is the same word for the shortened form of ‘repetition?’

Once a trusting relationship develops between the surgeon and the sales rep, having both in the operating room can mean the difference between life and death for the patient. The security gained by knowing there will be another experienced person in the room is reassuring and should be reassuring to the patient and to the hospital administrators as well. After all, what is worse for the surgeon’s reputation, the hospital’s bottom line, or more importantly the patient, than an unnecessary complication that could have been easily avoided by a few cautionary words?Even when I use a device I have used many times, it has not been unusual for the sales rep in the operating room to help me work out a difficult portion of the procedure. How reassuring it is to have another educated adviser in there with you. Professional tennis players have their coach in the stands. Dr. O. William Brown, our associate editor, makes the point that even professional golfers have their caddy with them on the course. The caddy does not hit the ball nor play the course just like the rep does not touch the patient nor do the procedure. However the caddy (rep) knows the course, the player, ball and clubs and can read the greens and knows the distance to the hole. Advice from the supporting caddy can make the difference between winning and losing. Advice from the rep can save a life.

I used an automobile analogy in one of my last editorials and there is one which applies here as well.

Almost all of us by the time we are in our 30s or 40s can drive safely. However, when we buy a new car the sales person drives with us the first few times so we may become comfortable with the new features. When it comes to driving so-called exotics like a Ferrari or Lamborghini, potential buyers (such as hospital CEO’s) will go to a special track where they will drive with an accomplished company driver before they feel safe to drive the car on their own. The company drivers know the limits of their car and they know the limits of drivers unaccustomed to advanced automobiles. Press the gas pedal too soon or push too hard on the brake pedal and the car will spin out of control with fatal results. In the operating room, press the wrong button or push too hard and the device may deploy too soon and the procedure may spin out of control also with potentially fatal results.

It seems to me the whole controversy revolves around the phrase “sales-representative” since it implies at all times their sole goal is to increase sales. Perhaps if they were simply called “representatives” there would be no issue. Yes, it may be true that in some instances the selection of a device may be based on the relationship a surgeon has with a company’s sales representative rather than the quality of the company’s device.

However, administrators are misguided when they consider excluding the sales rep from the operating room or endovascular suite will achieve cost savings. Usually the decision to select a company’s device was made many days before the procedure. If the rep was going to influence the surgeon, it would have been done prior to the surgeon entering those sacrosanct spaces.

Thus, in their never-ending onslaught on cost, administrators who restrict sales reps from the operating room may be impeding quality care. Accordingly, ‘“the elephant in the room” may not be the sales representative but rather the administrator in the office down the corridor.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president, Mote Vascular Foundation, Inc., and is an attending vascular surgeon, Sarasota Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

In my past editorials I have made it abundantly clear that I believe that vascular surgeons, like the Knights of the Round Table in the Arthurian legend, follow a chivalrous code of honor that guides us in placing a patient’s well-being ahead of financial reward. We ride out, catheter and knife at the ready, to defeat the malevolent atherosclerotic enemy. Yet I am now chagrined to acknowledge that we, too, have knights who have forsaken their code of chivalry – vascular surgeons who value the attainment of wealth or prestige as their raison d’être.

Our cadre of ethical doctors far outnumbers the avaricious few. But I am increasingly aware of board certified vascular surgeons offering or carrying out egregious or unnecessary interventions.

The following are but a few illustrations of this behavior:

• A website suggesting all men older than 40 years have a self-paid screening for AAA.

• An 80-year-old woman with recurrent swelling of her right leg being told that she needed an emergency ablation of her saphenous vein.

• An obese 50-year-old with no abdominal symptoms and a patent SMA having a stent placed in his celiac artery.

• A 20-year-old who had her saphenous vein ablated because she had a few spiders on her thigh.

• I encountered a patient after a vascular surgeon had inserted an endograft in an 85-year-old male with a 4.5-cm AAA.

• Another vascular surgeon performs yearly carotid arteriography to evaluate the possible progression of asymptomatic stenoses.

• Yet another vascular surgeon carried out a carotid endarterectomy for a 60% asymptomatic stenosis in a patient with end-stage lung cancer.

If you find your skin crawling as you read these examples, you are not the perpetrators. If you are blushing, you may be. If you don’t see the problems with these cases you are naive, very poorly educated, or simply greedy. Regardless, these examples shame us all because they bring discredit to a specialty long dedicated to appropriate care. Vascular surgeons are not only our patients’ treating physicians but also their ombudspersons. How is our specialty to be taken seriously when our own members deviate so dramatically from accepted practice guidelines?

The advent of endovascular treatments may explain some of these unnecessary procedures. Endovascular procedures, in general, are much easier to perform than open surgery. Frequently, resultant complications may not be as devastating, so surgeons may be more inclined to intervene earlier in the disease process. Also, it is more cost effective for a vascular surgeon to perform a quick SFA angioplasty and stent rather than a time-consuming and undercompensated femoropopliteal vein bypass. This is especially so if it is performed in the surgeon‘s outpatient facility.

Endovascular technologies also have the cache of being novel and state-of-the-art. Therefore, it is tempting for surgeons to promote their reputation by preferentially performing these ‘advanced’ procedures. New trainees may be especially seduced by the novelty of these techniques, but their lack of clinical experience may result in overutilization.

Clearly, the answer is not that we should perform surgery for surgery’s sake. If a patient has a valid reason for an endovascular procedure, so be it. But if an open procedure is the better option, we must not shy away from it for fear of being regarded as old fashioned.

The increasing adoption of endovascular therapies may not only explain unnecessary procedures but also why vascular surgeons are involved in an identity crisis. As endovascular procedures replace open surgeries, new graduates and even older surgeons may begin to feel uncomfortable performing complex surgeries. As a result, vascular surgeons are now so endo-oriented that we hardly operate. Further, it appears as if our vascular training programs are producing interventional radiologists or cardiologists and not vascular surgeons. If all we offer are endovascular therapies, we will not be able to delineate ourselves from other physicians. We need to reassure our patients and referring doctors that we are still the only specialty that can perform all methods of treatment for our patients, be it medications, surgery, balloons, stents, or whatever. Equally important is that we assure them that the therapeutic modality that we select will be the most appropriate and will not be driven by extraneous factors. Accordingly, we must reign in our wayward colleagues or face unacceptable repercussions.

University institutions have Morbidity and Mortality conferences to evaluate staff surgeons’ performance. Credentials committees have the ability to withdraw privileges for persistent inappropriate indications. Outpatient centers need to establish similar panels so that peer pressure can ensure appropriate treatment. The goal should be remedial education and not punishment. We need to make these “Dark Knights” aware of how their actions have a negative effect on the rest of us. Because, if left unchecked, castigation in the media and government action will punish all vascular surgeons and our legendary contributions to the management of vascular disease will fade from memory, just like Arthur and his knightly court.

Dr. Samson is a physician in the practice of Samson, Showalter, Lepore, and Nair, and clinical professor of surgery, Florida State University.

In my past editorials I have made it abundantly clear that I believe that vascular surgeons, like the Knights of the Round Table in the Arthurian legend, follow a chivalrous code of honor that guides us in placing a patient’s well-being ahead of financial reward. We ride out, catheter and knife at the ready, to defeat the malevolent atherosclerotic enemy. Yet I am now chagrined to acknowledge that we, too, have knights who have forsaken their code of chivalry – vascular surgeons who value the attainment of wealth or prestige as their raison d’être.

Our cadre of ethical doctors far outnumbers the avaricious few. But I am increasingly aware of board certified vascular surgeons offering or carrying out egregious or unnecessary interventions.

The following are but a few illustrations of this behavior:

• A website suggesting all men older than 40 years have a self-paid screening for AAA.

• An 80-year-old woman with recurrent swelling of her right leg being told that she needed an emergency ablation of her saphenous vein.

• An obese 50-year-old with no abdominal symptoms and a patent SMA having a stent placed in his celiac artery.

• A 20-year-old who had her saphenous vein ablated because she had a few spiders on her thigh.

• I encountered a patient after a vascular surgeon had inserted an endograft in an 85-year-old male with a 4.5-cm AAA.

• Another vascular surgeon performs yearly carotid arteriography to evaluate the possible progression of asymptomatic stenoses.

• Yet another vascular surgeon carried out a carotid endarterectomy for a 60% asymptomatic stenosis in a patient with end-stage lung cancer.

If you find your skin crawling as you read these examples, you are not the perpetrators. If you are blushing, you may be. If you don’t see the problems with these cases you are naive, very poorly educated, or simply greedy. Regardless, these examples shame us all because they bring discredit to a specialty long dedicated to appropriate care. Vascular surgeons are not only our patients’ treating physicians but also their ombudspersons. How is our specialty to be taken seriously when our own members deviate so dramatically from accepted practice guidelines?

The advent of endovascular treatments may explain some of these unnecessary procedures. Endovascular procedures, in general, are much easier to perform than open surgery. Frequently, resultant complications may not be as devastating, so surgeons may be more inclined to intervene earlier in the disease process. Also, it is more cost effective for a vascular surgeon to perform a quick SFA angioplasty and stent rather than a time-consuming and undercompensated femoropopliteal vein bypass. This is especially so if it is performed in the surgeon‘s outpatient facility.

Endovascular technologies also have the cache of being novel and state-of-the-art. Therefore, it is tempting for surgeons to promote their reputation by preferentially performing these ‘advanced’ procedures. New trainees may be especially seduced by the novelty of these techniques, but their lack of clinical experience may result in overutilization.

Clearly, the answer is not that we should perform surgery for surgery’s sake. If a patient has a valid reason for an endovascular procedure, so be it. But if an open procedure is the better option, we must not shy away from it for fear of being regarded as old fashioned.

The increasing adoption of endovascular therapies may not only explain unnecessary procedures but also why vascular surgeons are involved in an identity crisis. As endovascular procedures replace open surgeries, new graduates and even older surgeons may begin to feel uncomfortable performing complex surgeries. As a result, vascular surgeons are now so endo-oriented that we hardly operate. Further, it appears as if our vascular training programs are producing interventional radiologists or cardiologists and not vascular surgeons. If all we offer are endovascular therapies, we will not be able to delineate ourselves from other physicians. We need to reassure our patients and referring doctors that we are still the only specialty that can perform all methods of treatment for our patients, be it medications, surgery, balloons, stents, or whatever. Equally important is that we assure them that the therapeutic modality that we select will be the most appropriate and will not be driven by extraneous factors. Accordingly, we must reign in our wayward colleagues or face unacceptable repercussions.

University institutions have Morbidity and Mortality conferences to evaluate staff surgeons’ performance. Credentials committees have the ability to withdraw privileges for persistent inappropriate indications. Outpatient centers need to establish similar panels so that peer pressure can ensure appropriate treatment. The goal should be remedial education and not punishment. We need to make these “Dark Knights” aware of how their actions have a negative effect on the rest of us. Because, if left unchecked, castigation in the media and government action will punish all vascular surgeons and our legendary contributions to the management of vascular disease will fade from memory, just like Arthur and his knightly court.

Dr. Samson is a physician in the practice of Samson, Showalter, Lepore, and Nair, and clinical professor of surgery, Florida State University.

In my past editorials I have made it abundantly clear that I believe that vascular surgeons, like the Knights of the Round Table in the Arthurian legend, follow a chivalrous code of honor that guides us in placing a patient’s well-being ahead of financial reward. We ride out, catheter and knife at the ready, to defeat the malevolent atherosclerotic enemy. Yet I am now chagrined to acknowledge that we, too, have knights who have forsaken their code of chivalry – vascular surgeons who value the attainment of wealth or prestige as their raison d’être.

Our cadre of ethical doctors far outnumbers the avaricious few. But I am increasingly aware of board certified vascular surgeons offering or carrying out egregious or unnecessary interventions.

The following are but a few illustrations of this behavior:

• A website suggesting all men older than 40 years have a self-paid screening for AAA.

• An 80-year-old woman with recurrent swelling of her right leg being told that she needed an emergency ablation of her saphenous vein.

• An obese 50-year-old with no abdominal symptoms and a patent SMA having a stent placed in his celiac artery.

• A 20-year-old who had her saphenous vein ablated because she had a few spiders on her thigh.

• I encountered a patient after a vascular surgeon had inserted an endograft in an 85-year-old male with a 4.5-cm AAA.

• Another vascular surgeon performs yearly carotid arteriography to evaluate the possible progression of asymptomatic stenoses.

• Yet another vascular surgeon carried out a carotid endarterectomy for a 60% asymptomatic stenosis in a patient with end-stage lung cancer.

If you find your skin crawling as you read these examples, you are not the perpetrators. If you are blushing, you may be. If you don’t see the problems with these cases you are naive, very poorly educated, or simply greedy. Regardless, these examples shame us all because they bring discredit to a specialty long dedicated to appropriate care. Vascular surgeons are not only our patients’ treating physicians but also their ombudspersons. How is our specialty to be taken seriously when our own members deviate so dramatically from accepted practice guidelines?

The advent of endovascular treatments may explain some of these unnecessary procedures. Endovascular procedures, in general, are much easier to perform than open surgery. Frequently, resultant complications may not be as devastating, so surgeons may be more inclined to intervene earlier in the disease process. Also, it is more cost effective for a vascular surgeon to perform a quick SFA angioplasty and stent rather than a time-consuming and undercompensated femoropopliteal vein bypass. This is especially so if it is performed in the surgeon‘s outpatient facility.

Endovascular technologies also have the cache of being novel and state-of-the-art. Therefore, it is tempting for surgeons to promote their reputation by preferentially performing these ‘advanced’ procedures. New trainees may be especially seduced by the novelty of these techniques, but their lack of clinical experience may result in overutilization.

Clearly, the answer is not that we should perform surgery for surgery’s sake. If a patient has a valid reason for an endovascular procedure, so be it. But if an open procedure is the better option, we must not shy away from it for fear of being regarded as old fashioned.

The increasing adoption of endovascular therapies may not only explain unnecessary procedures but also why vascular surgeons are involved in an identity crisis. As endovascular procedures replace open surgeries, new graduates and even older surgeons may begin to feel uncomfortable performing complex surgeries. As a result, vascular surgeons are now so endo-oriented that we hardly operate. Further, it appears as if our vascular training programs are producing interventional radiologists or cardiologists and not vascular surgeons. If all we offer are endovascular therapies, we will not be able to delineate ourselves from other physicians. We need to reassure our patients and referring doctors that we are still the only specialty that can perform all methods of treatment for our patients, be it medications, surgery, balloons, stents, or whatever. Equally important is that we assure them that the therapeutic modality that we select will be the most appropriate and will not be driven by extraneous factors. Accordingly, we must reign in our wayward colleagues or face unacceptable repercussions.

University institutions have Morbidity and Mortality conferences to evaluate staff surgeons’ performance. Credentials committees have the ability to withdraw privileges for persistent inappropriate indications. Outpatient centers need to establish similar panels so that peer pressure can ensure appropriate treatment. The goal should be remedial education and not punishment. We need to make these “Dark Knights” aware of how their actions have a negative effect on the rest of us. Because, if left unchecked, castigation in the media and government action will punish all vascular surgeons and our legendary contributions to the management of vascular disease will fade from memory, just like Arthur and his knightly court.

Dr. Samson is a physician in the practice of Samson, Showalter, Lepore, and Nair, and clinical professor of surgery, Florida State University.

It is apparent from the many letters I have received as medical editor of Vascular Specialist that vascular surgeons are disappointed that our patients, insurance companies, hospital administrators, and the government do not recognize the special skills we provide.

I believe there are two principal reasons that, although different, may be related. First may be that we are still not recognized as a separate specialty from General Surgery. This despite the fact that, for most of us, endovascular procedures have supplanted a significant number of open operations. Second may be the failure of the Society for Vascular Surgery’s name to define its relevance or attract new members. If I am correct then perhaps SVS should be renamed the American College of Vascular Surgery. A brief review of past events may help explain why this name change would be beneficial.

Some years ago a poll of vascular surgeons favored establishing vascular surgery as a distinct specialty. However, despite considerable effort Frank Veith, Jim Stanley, and others were unsuccessful in creating a recognized American Board of Vascular Surgery.

In part this was because the leadership at the time did not support separation from the American Board of Surgery. Further, the American Board of Medical Specialties (ABMS) would not recognize Vascular Surgery as a distinct specialty.

Today our small group of actively practicing vascular surgeons, perhaps no more than 2,500, have splintered our institutional organizations. Cynics may suggest that we have almost as many societies as we have members.

We have SVS, SCVS, VESS, AVF, and even the new American Academy of Peripheral Vascular Surgeons, as well as many regional societies. Further, even though SVS may be the de facto umbrella organization, it is hampered by its restrictive name. The Society for Vascular Surgery sounds like an elitist club and not the governing body that we need to represent us on the national and international stage.

Accordingly there are still many vascular surgeons who, incorrectly, consider themselves unwelcome. They also may not realize just how involved the SVS has become in every aspect of our vascular practices.

SVS, with almost 50 committees staffed by paid employees as well as numerous volunteers, is involved in nearly every aspect of vascular surgery as well as postgraduate education. It represents us on the RUC and CMS and our active (but poorly supported) PAC represents our interests in Washington.

SVS generates research dollars and supports numerous grants and fellowships and encourages medical students to become vascular surgeons. It runs the most prestigious and all-encompassing scientific and social meeting. Vascular surgeons from all over the world are honored to be affiliated members of our Society yet some local surgeons still remain nonmembers.

By changing the SVS name to the American College of Vascular Surgery (ACVS) we provide our organization with a monicker that has the same gravitas as professional Societies that are recognized by the ABMS. It also demonstrates that our members, rather than being a select clique, have collegiality.

Furthermore, it confirms that it is our governing body and is the voice of all American vascular surgeons. It reaffirms that it is a unique organization dedicated to treating patients with vascular conditions and composed of surgeons who “operate, dilate, and medicate.”

We will not need the ABMS to approve this change. We don’t even need to sever our association with the American Board of Surgery. After all we are still surgeons!

We can continue to get Board certification through that body since our Board examination is, for practical purposes, developed and run by SVS. Members who pass the exam will become Fellows of the ACVS and will have the privilege of adding FACVS to their professional signature rather than FACS. Our Distinguished Fellows will use DFACVS. We can even have a formal convocation.

Certainly, some structural changes may need to accompany this name change in order for the American College of Vascular Surgeons to be fully representative of all vascular surgeons. But for now, with this simple change, we will encourage more vascular surgeons to join our ranks and advance the recognition of vascular as a distinct specialty.

It is apparent from the many letters I have received as medical editor of Vascular Specialist that vascular surgeons are disappointed that our patients, insurance companies, hospital administrators, and the government do not recognize the special skills we provide.

I believe there are two principal reasons that, although different, may be related. First may be that we are still not recognized as a separate specialty from General Surgery. This despite the fact that, for most of us, endovascular procedures have supplanted a significant number of open operations. Second may be the failure of the Society for Vascular Surgery’s name to define its relevance or attract new members. If I am correct then perhaps SVS should be renamed the American College of Vascular Surgery. A brief review of past events may help explain why this name change would be beneficial.

Some years ago a poll of vascular surgeons favored establishing vascular surgery as a distinct specialty. However, despite considerable effort Frank Veith, Jim Stanley, and others were unsuccessful in creating a recognized American Board of Vascular Surgery.

In part this was because the leadership at the time did not support separation from the American Board of Surgery. Further, the American Board of Medical Specialties (ABMS) would not recognize Vascular Surgery as a distinct specialty.

Today our small group of actively practicing vascular surgeons, perhaps no more than 2,500, have splintered our institutional organizations. Cynics may suggest that we have almost as many societies as we have members.

We have SVS, SCVS, VESS, AVF, and even the new American Academy of Peripheral Vascular Surgeons, as well as many regional societies. Further, even though SVS may be the de facto umbrella organization, it is hampered by its restrictive name. The Society for Vascular Surgery sounds like an elitist club and not the governing body that we need to represent us on the national and international stage.

Accordingly there are still many vascular surgeons who, incorrectly, consider themselves unwelcome. They also may not realize just how involved the SVS has become in every aspect of our vascular practices.

SVS, with almost 50 committees staffed by paid employees as well as numerous volunteers, is involved in nearly every aspect of vascular surgery as well as postgraduate education. It represents us on the RUC and CMS and our active (but poorly supported) PAC represents our interests in Washington.

SVS generates research dollars and supports numerous grants and fellowships and encourages medical students to become vascular surgeons. It runs the most prestigious and all-encompassing scientific and social meeting. Vascular surgeons from all over the world are honored to be affiliated members of our Society yet some local surgeons still remain nonmembers.

By changing the SVS name to the American College of Vascular Surgery (ACVS) we provide our organization with a monicker that has the same gravitas as professional Societies that are recognized by the ABMS. It also demonstrates that our members, rather than being a select clique, have collegiality.

Furthermore, it confirms that it is our governing body and is the voice of all American vascular surgeons. It reaffirms that it is a unique organization dedicated to treating patients with vascular conditions and composed of surgeons who “operate, dilate, and medicate.”

We will not need the ABMS to approve this change. We don’t even need to sever our association with the American Board of Surgery. After all we are still surgeons!

We can continue to get Board certification through that body since our Board examination is, for practical purposes, developed and run by SVS. Members who pass the exam will become Fellows of the ACVS and will have the privilege of adding FACVS to their professional signature rather than FACS. Our Distinguished Fellows will use DFACVS. We can even have a formal convocation.

Certainly, some structural changes may need to accompany this name change in order for the American College of Vascular Surgeons to be fully representative of all vascular surgeons. But for now, with this simple change, we will encourage more vascular surgeons to join our ranks and advance the recognition of vascular as a distinct specialty.

It is apparent from the many letters I have received as medical editor of Vascular Specialist that vascular surgeons are disappointed that our patients, insurance companies, hospital administrators, and the government do not recognize the special skills we provide.

I believe there are two principal reasons that, although different, may be related. First may be that we are still not recognized as a separate specialty from General Surgery. This despite the fact that, for most of us, endovascular procedures have supplanted a significant number of open operations. Second may be the failure of the Society for Vascular Surgery’s name to define its relevance or attract new members. If I am correct then perhaps SVS should be renamed the American College of Vascular Surgery. A brief review of past events may help explain why this name change would be beneficial.

Some years ago a poll of vascular surgeons favored establishing vascular surgery as a distinct specialty. However, despite considerable effort Frank Veith, Jim Stanley, and others were unsuccessful in creating a recognized American Board of Vascular Surgery.

In part this was because the leadership at the time did not support separation from the American Board of Surgery. Further, the American Board of Medical Specialties (ABMS) would not recognize Vascular Surgery as a distinct specialty.

Today our small group of actively practicing vascular surgeons, perhaps no more than 2,500, have splintered our institutional organizations. Cynics may suggest that we have almost as many societies as we have members.

We have SVS, SCVS, VESS, AVF, and even the new American Academy of Peripheral Vascular Surgeons, as well as many regional societies. Further, even though SVS may be the de facto umbrella organization, it is hampered by its restrictive name. The Society for Vascular Surgery sounds like an elitist club and not the governing body that we need to represent us on the national and international stage.

Accordingly there are still many vascular surgeons who, incorrectly, consider themselves unwelcome. They also may not realize just how involved the SVS has become in every aspect of our vascular practices.

SVS, with almost 50 committees staffed by paid employees as well as numerous volunteers, is involved in nearly every aspect of vascular surgery as well as postgraduate education. It represents us on the RUC and CMS and our active (but poorly supported) PAC represents our interests in Washington.

SVS generates research dollars and supports numerous grants and fellowships and encourages medical students to become vascular surgeons. It runs the most prestigious and all-encompassing scientific and social meeting. Vascular surgeons from all over the world are honored to be affiliated members of our Society yet some local surgeons still remain nonmembers.

By changing the SVS name to the American College of Vascular Surgery (ACVS) we provide our organization with a monicker that has the same gravitas as professional Societies that are recognized by the ABMS. It also demonstrates that our members, rather than being a select clique, have collegiality.

Furthermore, it confirms that it is our governing body and is the voice of all American vascular surgeons. It reaffirms that it is a unique organization dedicated to treating patients with vascular conditions and composed of surgeons who “operate, dilate, and medicate.”

We will not need the ABMS to approve this change. We don’t even need to sever our association with the American Board of Surgery. After all we are still surgeons!

We can continue to get Board certification through that body since our Board examination is, for practical purposes, developed and run by SVS. Members who pass the exam will become Fellows of the ACVS and will have the privilege of adding FACVS to their professional signature rather than FACS. Our Distinguished Fellows will use DFACVS. We can even have a formal convocation.

Certainly, some structural changes may need to accompany this name change in order for the American College of Vascular Surgeons to be fully representative of all vascular surgeons. But for now, with this simple change, we will encourage more vascular surgeons to join our ranks and advance the recognition of vascular as a distinct specialty.

In a previous editorial  I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.

This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.

Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.

Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.

For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?

Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?

On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.

Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?

So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.

Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.

In a previous editorial  I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.

This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.

Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.

Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.

For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?

Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?

On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.

Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?

So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.

Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.

In a previous editorial  I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.

This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.

Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.

Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.

For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?

Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?

On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.

Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?

So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.

Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.

I suspect that most members of the SVS are aware of the recent New York Times article entitled “Medicare payments surge for stents to unblock blood vessels in limbs” and which was the subject of our front page news article last month (http://vswebn.org/NYTstents). In that article Dr. Peter Lawrence, the President of the SVS, described steps that the SVS has taken to address the appropriateness of vascular interventions. It was his inspired leadership that led to his devoting the Stanley Crawford symposium at last year’s Vascular Annual Meeting specifically to the problem of unnecessary procedures. Those of you who have read my editorials over the last year will recognize that I also have been on a campaign against the indiscriminate use of both venous and endovascular procedures, especially by non–vascular physicians. However, we must acknowledge that even some of our own are abusing the system for financial gain.

One of the major points made by the New York Times article is that many of these unnecessary procedures are being performed by cardiologists in outpatient centers with little or no oversight. In full disclosure I must admit that my group does lease space in an outpatient center. I have also published on the benefits of such a center and the mechanism for its installation (J. Vasc. Surg. 2009; 49:1073-6).

The reimbursement for a procedure performed in a physician-owned or -leased outpatient facility is far greater than can be achieved in a hospital-owned facility. However, since the physician is responsible for the expenses incurred in such outpatient facilities, there is a financial incentive to do more with inexpensive devices that may be less effective. However, most vascular surgeons who utilize such centers will nevertheless do what is best for the patient in spite of higher costs. Further, patients may benefit from these centers because of convenience and for the provision of a more personable environment than can be found in a hospital inpatient or outpatient facility. Additionally, since the risk of complications from complex interventions, which can be difficult to manage in an outpatient facility, most ethical physicians will ensure that only the safest procedures are undertaken. Personally, I have performed more than 500 procedures in our facility over the last 7 years and have never encountered a pseudoaneurysm, retroperitoneal hematoma, or other complication needing hospitalization.

It is my belief that the excessive procedures delineated in the New York Times article are probably not representative of the majority of such centers. It is, however, quite true that there is no oversight or ombudsman to protect the patient in these outpatient facilities. Hospital-employed or university vascular surgeons may correctly imply that there is more oversight of procedures performed in hospital facilities and that this should limit unnecessary procedures. Needless to say, that is not the case in all institutions.

In our 600-bed municipal hospital, there is limited peer review and the few times when it has been applied it has, on occasion, resulted in legal suits against the reviewing medical staff. Additionally, institutions that reward practitioners based on relative value units may also induce a perverse incentive to overuse procedures.

As Dr. Lawrence describes in his article, site of service may not be the only driving force behind unnecessary interventions. In fact the Clinical Council of the SVS has seized upon appropriate care in office-based centers and is working on constructive suggestions to ensure not only that site of service is convenient for patients, but also that it provides appropriate high quality care. For the time being the SVS recognizes that we need improved oversight and peer review in these physician-owned centers, and that we should not simply abandon them because of the abusive behavior of a few unethical practitioners.

The New York Times article and Dr. Lawrence’s article and letter to the New York Times struck a chord with our membership. It has provoked an outpouring of comments and suggestions from our membership. Some of these are to be found in this edition as letters to the editor. It is apparent that many of us are horrified by what we are seeing, not only in outpatient facilities but also in hospitals.

I believe this is such an important issue that I have requested our associate editors to write a brief comment on their views on the matter and to specifically identify methods of rectifying the current overuse of vascular procedures (see the following 2 pages).

I am hopeful that the NY Times article and the responses we publish will instigate vascular surgeons to stand up for our profession and the well-being of our patients. For if we do not, we will continue to be marginalized by newspaper reporters and government agencies. They will continue to lump us together with interventionalists who may not follow the same ethical road that most of us travel.

I suspect that most members of the SVS are aware of the recent New York Times article entitled “Medicare payments surge for stents to unblock blood vessels in limbs” and which was the subject of our front page news article last month (http://vswebn.org/NYTstents). In that article Dr. Peter Lawrence, the President of the SVS, described steps that the SVS has taken to address the appropriateness of vascular interventions. It was his inspired leadership that led to his devoting the Stanley Crawford symposium at last year’s Vascular Annual Meeting specifically to the problem of unnecessary procedures. Those of you who have read my editorials over the last year will recognize that I also have been on a campaign against the indiscriminate use of both venous and endovascular procedures, especially by non–vascular physicians. However, we must acknowledge that even some of our own are abusing the system for financial gain.

One of the major points made by the New York Times article is that many of these unnecessary procedures are being performed by cardiologists in outpatient centers with little or no oversight. In full disclosure I must admit that my group does lease space in an outpatient center. I have also published on the benefits of such a center and the mechanism for its installation (J. Vasc. Surg. 2009; 49:1073-6).

The reimbursement for a procedure performed in a physician-owned or -leased outpatient facility is far greater than can be achieved in a hospital-owned facility. However, since the physician is responsible for the expenses incurred in such outpatient facilities, there is a financial incentive to do more with inexpensive devices that may be less effective. However, most vascular surgeons who utilize such centers will nevertheless do what is best for the patient in spite of higher costs. Further, patients may benefit from these centers because of convenience and for the provision of a more personable environment than can be found in a hospital inpatient or outpatient facility. Additionally, since the risk of complications from complex interventions, which can be difficult to manage in an outpatient facility, most ethical physicians will ensure that only the safest procedures are undertaken. Personally, I have performed more than 500 procedures in our facility over the last 7 years and have never encountered a pseudoaneurysm, retroperitoneal hematoma, or other complication needing hospitalization.

It is my belief that the excessive procedures delineated in the New York Times article are probably not representative of the majority of such centers. It is, however, quite true that there is no oversight or ombudsman to protect the patient in these outpatient facilities. Hospital-employed or university vascular surgeons may correctly imply that there is more oversight of procedures performed in hospital facilities and that this should limit unnecessary procedures. Needless to say, that is not the case in all institutions.

In our 600-bed municipal hospital, there is limited peer review and the few times when it has been applied it has, on occasion, resulted in legal suits against the reviewing medical staff. Additionally, institutions that reward practitioners based on relative value units may also induce a perverse incentive to overuse procedures.

As Dr. Lawrence describes in his article, site of service may not be the only driving force behind unnecessary interventions. In fact the Clinical Council of the SVS has seized upon appropriate care in office-based centers and is working on constructive suggestions to ensure not only that site of service is convenient for patients, but also that it provides appropriate high quality care. For the time being the SVS recognizes that we need improved oversight and peer review in these physician-owned centers, and that we should not simply abandon them because of the abusive behavior of a few unethical practitioners.

The New York Times article and Dr. Lawrence’s article and letter to the New York Times struck a chord with our membership. It has provoked an outpouring of comments and suggestions from our membership. Some of these are to be found in this edition as letters to the editor. It is apparent that many of us are horrified by what we are seeing, not only in outpatient facilities but also in hospitals.

I believe this is such an important issue that I have requested our associate editors to write a brief comment on their views on the matter and to specifically identify methods of rectifying the current overuse of vascular procedures (see the following 2 pages).

I am hopeful that the NY Times article and the responses we publish will instigate vascular surgeons to stand up for our profession and the well-being of our patients. For if we do not, we will continue to be marginalized by newspaper reporters and government agencies. They will continue to lump us together with interventionalists who may not follow the same ethical road that most of us travel.

I suspect that most members of the SVS are aware of the recent New York Times article entitled “Medicare payments surge for stents to unblock blood vessels in limbs” and which was the subject of our front page news article last month (http://vswebn.org/NYTstents). In that article Dr. Peter Lawrence, the President of the SVS, described steps that the SVS has taken to address the appropriateness of vascular interventions. It was his inspired leadership that led to his devoting the Stanley Crawford symposium at last year’s Vascular Annual Meeting specifically to the problem of unnecessary procedures. Those of you who have read my editorials over the last year will recognize that I also have been on a campaign against the indiscriminate use of both venous and endovascular procedures, especially by non–vascular physicians. However, we must acknowledge that even some of our own are abusing the system for financial gain.

One of the major points made by the New York Times article is that many of these unnecessary procedures are being performed by cardiologists in outpatient centers with little or no oversight. In full disclosure I must admit that my group does lease space in an outpatient center. I have also published on the benefits of such a center and the mechanism for its installation (J. Vasc. Surg. 2009; 49:1073-6).

The reimbursement for a procedure performed in a physician-owned or -leased outpatient facility is far greater than can be achieved in a hospital-owned facility. However, since the physician is responsible for the expenses incurred in such outpatient facilities, there is a financial incentive to do more with inexpensive devices that may be less effective. However, most vascular surgeons who utilize such centers will nevertheless do what is best for the patient in spite of higher costs. Further, patients may benefit from these centers because of convenience and for the provision of a more personable environment than can be found in a hospital inpatient or outpatient facility. Additionally, since the risk of complications from complex interventions, which can be difficult to manage in an outpatient facility, most ethical physicians will ensure that only the safest procedures are undertaken. Personally, I have performed more than 500 procedures in our facility over the last 7 years and have never encountered a pseudoaneurysm, retroperitoneal hematoma, or other complication needing hospitalization.

It is my belief that the excessive procedures delineated in the New York Times article are probably not representative of the majority of such centers. It is, however, quite true that there is no oversight or ombudsman to protect the patient in these outpatient facilities. Hospital-employed or university vascular surgeons may correctly imply that there is more oversight of procedures performed in hospital facilities and that this should limit unnecessary procedures. Needless to say, that is not the case in all institutions.

In our 600-bed municipal hospital, there is limited peer review and the few times when it has been applied it has, on occasion, resulted in legal suits against the reviewing medical staff. Additionally, institutions that reward practitioners based on relative value units may also induce a perverse incentive to overuse procedures.

As Dr. Lawrence describes in his article, site of service may not be the only driving force behind unnecessary interventions. In fact the Clinical Council of the SVS has seized upon appropriate care in office-based centers and is working on constructive suggestions to ensure not only that site of service is convenient for patients, but also that it provides appropriate high quality care. For the time being the SVS recognizes that we need improved oversight and peer review in these physician-owned centers, and that we should not simply abandon them because of the abusive behavior of a few unethical practitioners.

The New York Times article and Dr. Lawrence’s article and letter to the New York Times struck a chord with our membership. It has provoked an outpouring of comments and suggestions from our membership. Some of these are to be found in this edition as letters to the editor. It is apparent that many of us are horrified by what we are seeing, not only in outpatient facilities but also in hospitals.

I believe this is such an important issue that I have requested our associate editors to write a brief comment on their views on the matter and to specifically identify methods of rectifying the current overuse of vascular procedures (see the following 2 pages).

I am hopeful that the NY Times article and the responses we publish will instigate vascular surgeons to stand up for our profession and the well-being of our patients. For if we do not, we will continue to be marginalized by newspaper reporters and government agencies. They will continue to lump us together with interventionalists who may not follow the same ethical road that most of us travel.

This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.

Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.

Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.

By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.

A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.

Dr. Samson is the medical editor of Vascular Specialist.

This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.

Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.

Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.

By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.

A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.

Dr. Samson is the medical editor of Vascular Specialist.

This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.

Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.

Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.

By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.

A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.

Dr. Samson is the medical editor of Vascular Specialist.

Recently I read a blog by Dr. Ira Nash at the blog site, KevinMD, where Dr. Nash suggests that it behooves physicians to fully inform patients with carotid stenosis about the pros and cons of proposed treatment. This is in keeping with a general crusade to involve patients in so-called shared decision making.

Dr. Nash points out that “it is a truism that the outcomes of interest to the patient are not necessarily the outcomes that interest the physician, and neither set necessarily includes the outcomes for which reliable evidence exists.” This is especially relevant when one considers treatment for an asymptomatic carotid stenosis.

Depending on the point of view of either the physician or patient, the most important outcome may be long-term survival, prevention of cardiac events or the avoidance of short- or long-term stroke. On the other hand, a trumpet player or opera singer may be more concerned about a career-ending cranial nerve injury. Further, there still is considerable debate about the treatment of asymptomatic carotid stenosis.

I do not want to trivialize this important issue, but if we are to follow Dr. Nash’s directive, perhaps the following scenario could be an example of my future office consultations.

8 a.m.: “Mrs. Jones, our duplex scan has shown that you have an 80% stenosis of your carotid artery and we are concerned this may lead to a stroke. Oh, you want to know how we can tell it’s showing an 80% stenosis that can cause a stroke. Well, that’s complicated. It’s all about blood flow and the Circle of Willis. No, that’s not the roundabout where you had that traffic accident. It’s an anatomical structure in your brain. OK let me explain....”

8:45 a.m.: “So, that’s how it works. Some doctors believe that we should operate now and some believe we should wait until the blockage reaches 90%, and some even think we should not operate at all. You probably need to know how they come to those conclusions. OK, let’s see …. Well there were some studies such as NASCET, SAPPHIRE, and CREST and many others. No, Mrs. Jones, they have nothing to do with the stock market, jewelry and toothpaste!!! Yes, I know it’s very confusing even for me.”

9:50 a.m.: “That’s the problem with those studies. Some people think we should repeat them with patients getting statins and antiplatelet agents. What are statins? You read in the National Enquirer that thousands of patients died because of statins. Hmmm, that’s not really accurate.”

10:45 a.m.: “Yes, I have heard of carotid stents. Of course, I do them myself. You want to know why I’m not recommending one for you. Well, let’s see .… You are an 85-year old female with a type III aorta. Yes, that’s just like the drawing I made of your aortic arch. How do I know that’s what it looks like? You want to see for yourself? OK, come over to this monitor...”

1:10 p.m.: “You agree perhaps a carotid endarterectomy is best but you want to know if I use a shunt. Do you know what a shunt is? Your friend told you it’s a plastic tube that I put in your brain!”

2:14 p.m.: “You heard most surgeons are using a patch. Can your husband donate his leg vein? No that’s not a good idea. Why? Well ….”

2:45 p.m.: “You’re hungry? OK, let’s get a bite and resume at 3 p.m.”

3:00 p.m.: “You forgot what I told you and you want me to refresh. You’re kidding right? No? OK then…”

Certainly, this inane scenario should not happen. No patient needs such detailed information and no surgeon could provide such in-depth information. But proponents of shared decision making insist we make the patient an equal partner in treatment. The claim is that without such involvement patients would not make the right choices nor would they be fully committed to the therapy.

Thus we are faced with a dilemma. The benefit of CEA or CAS for asymptomatic carotid stenosis may be minimal in comparison to medical therapy alone. Yet based on the information we provide, patients are expected to make a decision on one regimen or another in spite of the complexity of the arguments. So, how do we discuss treatment options? How much information do we provide and on what data do we base this discussion?

Do we quote NASCET or some other trial? What about SAPPHIRE and CREST? Do we let them know that CREST II is in the works? Do we quote published results from Centers of Excellence or our own results, and, if so, how many of us have accurate data about our short-term results let alone long-term outcomes? Further, how do we avoid our own subjective bias in the discussion, and how do we phrase statistics? This is especially relevant in discussing stroke rates.

A surgeon may tell a patient that without surgery there is a 2% risk of stroke a year, whereas someone motivated toward medical therapy may rather state that there is a 98% likelihood that the patient will not have a stroke. Confusing? You bet!

As physicians and surgeons, we reach our conclusions after diligently evaluating the literature and our own clinical experience. Our judgment may take years to hone and may change as new developments occur, making it almost impossible to discuss options with a patient on a peer-to-peer level. It is therefore inappropriate to expect that we will be able to instruct the patient enough for them to make a truly educated decision. But in the spirit of “shared decision making,” we all should develop a simplified method of informing our patients so that they will be advised without becoming overly confused.

In my practice I make a point of discussing the controversy regarding asymptomatic carotid stenosis. I let them know that there are surgeons who operate for 60%, 70%, 80%,or not at all. I also try to instruct them on how difficult it is to be sure how tight the stenosis actually is. I discuss the difference between CEA and CAS and the pros and cons of each. I explain that many patients that we treat by CEA or CAS may never have needed the procedure, even if their carotid artery eventually occluded.

I tell them that over the years I believe I have helped prevent strokes but equally, some of the patients I treated may never have had a stroke even without CEA or CAS. And, of course, in trying to prevent strokes, I have caused them with my surgery. Lastly, I almost never tell patients what they should do, but leave the decision entirely up to them because they may be making the most important gamble of their lives, since the outcome of therapy is an odds game. By now you may be wondering how on earth any of my patients actually come to a decision. I am sure most patients would prefer that I make their choice easier by being more forceful in my recommendation. Unfortunately, their insecurity is the price they must pay for sharing in the decision-making process.

Recently I read a blog by Dr. Ira Nash at the blog site, KevinMD, where Dr. Nash suggests that it behooves physicians to fully inform patients with carotid stenosis about the pros and cons of proposed treatment. This is in keeping with a general crusade to involve patients in so-called shared decision making.

Dr. Nash points out that “it is a truism that the outcomes of interest to the patient are not necessarily the outcomes that interest the physician, and neither set necessarily includes the outcomes for which reliable evidence exists.” This is especially relevant when one considers treatment for an asymptomatic carotid stenosis.

Depending on the point of view of either the physician or patient, the most important outcome may be long-term survival, prevention of cardiac events or the avoidance of short- or long-term stroke. On the other hand, a trumpet player or opera singer may be more concerned about a career-ending cranial nerve injury. Further, there still is considerable debate about the treatment of asymptomatic carotid stenosis.

I do not want to trivialize this important issue, but if we are to follow Dr. Nash’s directive, perhaps the following scenario could be an example of my future office consultations.

8 a.m.: “Mrs. Jones, our duplex scan has shown that you have an 80% stenosis of your carotid artery and we are concerned this may lead to a stroke. Oh, you want to know how we can tell it’s showing an 80% stenosis that can cause a stroke. Well, that’s complicated. It’s all about blood flow and the Circle of Willis. No, that’s not the roundabout where you had that traffic accident. It’s an anatomical structure in your brain. OK let me explain....”

8:45 a.m.: “So, that’s how it works. Some doctors believe that we should operate now and some believe we should wait until the blockage reaches 90%, and some even think we should not operate at all. You probably need to know how they come to those conclusions. OK, let’s see …. Well there were some studies such as NASCET, SAPPHIRE, and CREST and many others. No, Mrs. Jones, they have nothing to do with the stock market, jewelry and toothpaste!!! Yes, I know it’s very confusing even for me.”

9:50 a.m.: “That’s the problem with those studies. Some people think we should repeat them with patients getting statins and antiplatelet agents. What are statins? You read in the National Enquirer that thousands of patients died because of statins. Hmmm, that’s not really accurate.”

10:45 a.m.: “Yes, I have heard of carotid stents. Of course, I do them myself. You want to know why I’m not recommending one for you. Well, let’s see .… You are an 85-year old female with a type III aorta. Yes, that’s just like the drawing I made of your aortic arch. How do I know that’s what it looks like? You want to see for yourself? OK, come over to this monitor...”

1:10 p.m.: “You agree perhaps a carotid endarterectomy is best but you want to know if I use a shunt. Do you know what a shunt is? Your friend told you it’s a plastic tube that I put in your brain!”

2:14 p.m.: “You heard most surgeons are using a patch. Can your husband donate his leg vein? No that’s not a good idea. Why? Well ….”

2:45 p.m.: “You’re hungry? OK, let’s get a bite and resume at 3 p.m.”

3:00 p.m.: “You forgot what I told you and you want me to refresh. You’re kidding right? No? OK then…”

Certainly, this inane scenario should not happen. No patient needs such detailed information and no surgeon could provide such in-depth information. But proponents of shared decision making insist we make the patient an equal partner in treatment. The claim is that without such involvement patients would not make the right choices nor would they be fully committed to the therapy.

Thus we are faced with a dilemma. The benefit of CEA or CAS for asymptomatic carotid stenosis may be minimal in comparison to medical therapy alone. Yet based on the information we provide, patients are expected to make a decision on one regimen or another in spite of the complexity of the arguments. So, how do we discuss treatment options? How much information do we provide and on what data do we base this discussion?

Do we quote NASCET or some other trial? What about SAPPHIRE and CREST? Do we let them know that CREST II is in the works? Do we quote published results from Centers of Excellence or our own results, and, if so, how many of us have accurate data about our short-term results let alone long-term outcomes? Further, how do we avoid our own subjective bias in the discussion, and how do we phrase statistics? This is especially relevant in discussing stroke rates.

A surgeon may tell a patient that without surgery there is a 2% risk of stroke a year, whereas someone motivated toward medical therapy may rather state that there is a 98% likelihood that the patient will not have a stroke. Confusing? You bet!

As physicians and surgeons, we reach our conclusions after diligently evaluating the literature and our own clinical experience. Our judgment may take years to hone and may change as new developments occur, making it almost impossible to discuss options with a patient on a peer-to-peer level. It is therefore inappropriate to expect that we will be able to instruct the patient enough for them to make a truly educated decision. But in the spirit of “shared decision making,” we all should develop a simplified method of informing our patients so that they will be advised without becoming overly confused.

In my practice I make a point of discussing the controversy regarding asymptomatic carotid stenosis. I let them know that there are surgeons who operate for 60%, 70%, 80%,or not at all. I also try to instruct them on how difficult it is to be sure how tight the stenosis actually is. I discuss the difference between CEA and CAS and the pros and cons of each. I explain that many patients that we treat by CEA or CAS may never have needed the procedure, even if their carotid artery eventually occluded.

I tell them that over the years I believe I have helped prevent strokes but equally, some of the patients I treated may never have had a stroke even without CEA or CAS. And, of course, in trying to prevent strokes, I have caused them with my surgery. Lastly, I almost never tell patients what they should do, but leave the decision entirely up to them because they may be making the most important gamble of their lives, since the outcome of therapy is an odds game. By now you may be wondering how on earth any of my patients actually come to a decision. I am sure most patients would prefer that I make their choice easier by being more forceful in my recommendation. Unfortunately, their insecurity is the price they must pay for sharing in the decision-making process.

Recently I read a blog by Dr. Ira Nash at the blog site, KevinMD, where Dr. Nash suggests that it behooves physicians to fully inform patients with carotid stenosis about the pros and cons of proposed treatment. This is in keeping with a general crusade to involve patients in so-called shared decision making.

Dr. Nash points out that “it is a truism that the outcomes of interest to the patient are not necessarily the outcomes that interest the physician, and neither set necessarily includes the outcomes for which reliable evidence exists.” This is especially relevant when one considers treatment for an asymptomatic carotid stenosis.

Depending on the point of view of either the physician or patient, the most important outcome may be long-term survival, prevention of cardiac events or the avoidance of short- or long-term stroke. On the other hand, a trumpet player or opera singer may be more concerned about a career-ending cranial nerve injury. Further, there still is considerable debate about the treatment of asymptomatic carotid stenosis.

I do not want to trivialize this important issue, but if we are to follow Dr. Nash’s directive, perhaps the following scenario could be an example of my future office consultations.

8 a.m.: “Mrs. Jones, our duplex scan has shown that you have an 80% stenosis of your carotid artery and we are concerned this may lead to a stroke. Oh, you want to know how we can tell it’s showing an 80% stenosis that can cause a stroke. Well, that’s complicated. It’s all about blood flow and the Circle of Willis. No, that’s not the roundabout where you had that traffic accident. It’s an anatomical structure in your brain. OK let me explain....”

8:45 a.m.: “So, that’s how it works. Some doctors believe that we should operate now and some believe we should wait until the blockage reaches 90%, and some even think we should not operate at all. You probably need to know how they come to those conclusions. OK, let’s see …. Well there were some studies such as NASCET, SAPPHIRE, and CREST and many others. No, Mrs. Jones, they have nothing to do with the stock market, jewelry and toothpaste!!! Yes, I know it’s very confusing even for me.”

9:50 a.m.: “That’s the problem with those studies. Some people think we should repeat them with patients getting statins and antiplatelet agents. What are statins? You read in the National Enquirer that thousands of patients died because of statins. Hmmm, that’s not really accurate.”

10:45 a.m.: “Yes, I have heard of carotid stents. Of course, I do them myself. You want to know why I’m not recommending one for you. Well, let’s see .… You are an 85-year old female with a type III aorta. Yes, that’s just like the drawing I made of your aortic arch. How do I know that’s what it looks like? You want to see for yourself? OK, come over to this monitor...”

1:10 p.m.: “You agree perhaps a carotid endarterectomy is best but you want to know if I use a shunt. Do you know what a shunt is? Your friend told you it’s a plastic tube that I put in your brain!”

2:14 p.m.: “You heard most surgeons are using a patch. Can your husband donate his leg vein? No that’s not a good idea. Why? Well ….”

2:45 p.m.: “You’re hungry? OK, let’s get a bite and resume at 3 p.m.”

3:00 p.m.: “You forgot what I told you and you want me to refresh. You’re kidding right? No? OK then…”

Certainly, this inane scenario should not happen. No patient needs such detailed information and no surgeon could provide such in-depth information. But proponents of shared decision making insist we make the patient an equal partner in treatment. The claim is that without such involvement patients would not make the right choices nor would they be fully committed to the therapy.

Thus we are faced with a dilemma. The benefit of CEA or CAS for asymptomatic carotid stenosis may be minimal in comparison to medical therapy alone. Yet based on the information we provide, patients are expected to make a decision on one regimen or another in spite of the complexity of the arguments. So, how do we discuss treatment options? How much information do we provide and on what data do we base this discussion?

Do we quote NASCET or some other trial? What about SAPPHIRE and CREST? Do we let them know that CREST II is in the works? Do we quote published results from Centers of Excellence or our own results, and, if so, how many of us have accurate data about our short-term results let alone long-term outcomes? Further, how do we avoid our own subjective bias in the discussion, and how do we phrase statistics? This is especially relevant in discussing stroke rates.

A surgeon may tell a patient that without surgery there is a 2% risk of stroke a year, whereas someone motivated toward medical therapy may rather state that there is a 98% likelihood that the patient will not have a stroke. Confusing? You bet!

As physicians and surgeons, we reach our conclusions after diligently evaluating the literature and our own clinical experience. Our judgment may take years to hone and may change as new developments occur, making it almost impossible to discuss options with a patient on a peer-to-peer level. It is therefore inappropriate to expect that we will be able to instruct the patient enough for them to make a truly educated decision. But in the spirit of “shared decision making,” we all should develop a simplified method of informing our patients so that they will be advised without becoming overly confused.

In my practice I make a point of discussing the controversy regarding asymptomatic carotid stenosis. I let them know that there are surgeons who operate for 60%, 70%, 80%,or not at all. I also try to instruct them on how difficult it is to be sure how tight the stenosis actually is. I discuss the difference between CEA and CAS and the pros and cons of each. I explain that many patients that we treat by CEA or CAS may never have needed the procedure, even if their carotid artery eventually occluded.

I tell them that over the years I believe I have helped prevent strokes but equally, some of the patients I treated may never have had a stroke even without CEA or CAS. And, of course, in trying to prevent strokes, I have caused them with my surgery. Lastly, I almost never tell patients what they should do, but leave the decision entirely up to them because they may be making the most important gamble of their lives, since the outcome of therapy is an odds game. By now you may be wondering how on earth any of my patients actually come to a decision. I am sure most patients would prefer that I make their choice easier by being more forceful in my recommendation. Unfortunately, their insecurity is the price they must pay for sharing in the decision-making process.

In November I attended the VEITHsymposium in New York. Almost 600 experts from around the world gave lectures on every aspect of vascular surgery. Given 5 minutes per talk, the presenters had to carefully select data they believed would bolster their viewpoint. So will someone please explain to me why some speakers still feel obliged to include target lesion revascularization (TLR) in their presentations? Furthermore, it’s not just in talks but also in peer-reviewed journals that we seem to be bombarded with this useless and often deceiving piece of information. I know that many feel the same way about TLR. However, for those not yet convinced, let me outline why I think TLR should rather stand for “The Least Relevant.”

The concept of TLR materialized during the early days of coronary balloon angioplasty and stenting. In the coronary arteries it is difficult to determine the restenosis rate of a treated lesion without repeating another coronary arteriogram. Accordingly, researchers resorted to TLR as an alternative method of evaluating whether a new treatment worked. However, in the peripheral circulation we have other methods of evaluating the lesion such as duplex scanning, CTA and MRA. This allows us minimally invasive and noninvasive means to evaluate the fate of the lesion itself. Thus, we are able to evaluate TLR as target lesion recurrence rather than target lesion revascularization.

Subsequently, companies and researchers have developed new devices such as balloons, stents, atherectomy devices, and drug-eluting variations that directly target peripheral vascular lesions. Despite the availability of noninvasive techniques to evaluate the target lesion itself, they use TLR data to convince physicians and purchasing entities to buy and use their device. The implication is that avoidance of another procedure to achieve the desired clinical endpoint proves that the new instrument works. However, as I have mentioned in previous editorials, semantics can have negative consequences. Here the problem arises when we attempt to define “works.” The inventor of a device that opens a narrowed or blocked artery wants to make sure that the device indeed does just that. In that case it would be appropriate to claim that it “works.”

If the lesion remains open and does not re-narrow we may conclude the device not only works but is also “effective.” The manufacturer and the FDA will want to make sure that it also does no harm and is “safe.” All are hopeful that it will improve the patient’s condition and have “clinical utility.” Certainly, success can be defined in many ways and clinical benefit must reign supreme. Accordingly, a device that is effective, safe and has clinical utility may be considered “successful” and, if cost effective, worth using. However, we are all aware that some procedures can improve a patient’s condition through a placebo effect. Therefore, it is incorrect for researchers to suggest that low TLR rates equate with clinical success. The most reliable judge of the efficacy of the procedure will be what happens to the targeted lesion and not what happens to the patient. It is more salient that we are assured that the device provides persistent improvement in luminal diameter at the site of the treated lesion.

It may help to further define the problem with TLR if we use a hypothetical example of a new medicated stent inserted to open a single SFA lesion responsible for toe gangrene. If that stent keeps the stenotic lesion widely patent, it should be considered effective even if the patient ultimately requires an above-knee amputation. On the other hand if the stent occludes in the recovery room, yet the toe subsequently heals without any further intervention, that stent did not work. In the latter scenario the patient will not have had a revascularization and so will not be included with the patients requiring TLR. Thus the stent would appear to have had more clinical utility or to have been more”successful” than it really was. Similarly, TLR will not be negatively impacted when, as in some circumstances of stent occlusion, a patient decides to live with discomfort rather than consent to another procedure. Furthermore, investigators of that stent may have a perverse incentive after occlusion to minimize TLR by not performing another procedure. On the other hand a bypass of an artery with an open and functional stent would negatively impact TLR statistics for that type of stent. This may occur if the stented lesion was not the only cause of distal ischemia.What concerns me most about TLR, even more than its limited relevance, is that this statistic is used to support data that otherwise would not stand up to scrutiny. It is often included in trials where numbers are small or where Industry bias is obvious. Accordingly, I am hopeful that researchers seriously consider describing TLR as target lesion recurrence rates omitting target lesion revascularization from their presentations and manuscripts. If they insist on using this irrelevant statistic then they should provide information as to why the revascularization was performed.

Was it for lesion recurrence or failure to improve the indicated condition? If the lesion recurred but TLR was not performed, was that because recovery had been achieved despite restenosis of the target lesion? Was it because the patient was not offered further treatment? Perhaps the patient succumbed before TLR could have been provided?

I may be accused of being overly cynical, but it may have been because the patient had decided that the better part of valor would be to run away and join a witness protection program rather than take part in that clinical trial.

In November I attended the VEITHsymposium in New York. Almost 600 experts from around the world gave lectures on every aspect of vascular surgery. Given 5 minutes per talk, the presenters had to carefully select data they believed would bolster their viewpoint. So will someone please explain to me why some speakers still feel obliged to include target lesion revascularization (TLR) in their presentations? Furthermore, it’s not just in talks but also in peer-reviewed journals that we seem to be bombarded with this useless and often deceiving piece of information. I know that many feel the same way about TLR. However, for those not yet convinced, let me outline why I think TLR should rather stand for “The Least Relevant.”

The concept of TLR materialized during the early days of coronary balloon angioplasty and stenting. In the coronary arteries it is difficult to determine the restenosis rate of a treated lesion without repeating another coronary arteriogram. Accordingly, researchers resorted to TLR as an alternative method of evaluating whether a new treatment worked. However, in the peripheral circulation we have other methods of evaluating the lesion such as duplex scanning, CTA and MRA. This allows us minimally invasive and noninvasive means to evaluate the fate of the lesion itself. Thus, we are able to evaluate TLR as target lesion recurrence rather than target lesion revascularization.

Subsequently, companies and researchers have developed new devices such as balloons, stents, atherectomy devices, and drug-eluting variations that directly target peripheral vascular lesions. Despite the availability of noninvasive techniques to evaluate the target lesion itself, they use TLR data to convince physicians and purchasing entities to buy and use their device. The implication is that avoidance of another procedure to achieve the desired clinical endpoint proves that the new instrument works. However, as I have mentioned in previous editorials, semantics can have negative consequences. Here the problem arises when we attempt to define “works.” The inventor of a device that opens a narrowed or blocked artery wants to make sure that the device indeed does just that. In that case it would be appropriate to claim that it “works.”

If the lesion remains open and does not re-narrow we may conclude the device not only works but is also “effective.” The manufacturer and the FDA will want to make sure that it also does no harm and is “safe.” All are hopeful that it will improve the patient’s condition and have “clinical utility.” Certainly, success can be defined in many ways and clinical benefit must reign supreme. Accordingly, a device that is effective, safe and has clinical utility may be considered “successful” and, if cost effective, worth using. However, we are all aware that some procedures can improve a patient’s condition through a placebo effect. Therefore, it is incorrect for researchers to suggest that low TLR rates equate with clinical success. The most reliable judge of the efficacy of the procedure will be what happens to the targeted lesion and not what happens to the patient. It is more salient that we are assured that the device provides persistent improvement in luminal diameter at the site of the treated lesion.

It may help to further define the problem with TLR if we use a hypothetical example of a new medicated stent inserted to open a single SFA lesion responsible for toe gangrene. If that stent keeps the stenotic lesion widely patent, it should be considered effective even if the patient ultimately requires an above-knee amputation. On the other hand if the stent occludes in the recovery room, yet the toe subsequently heals without any further intervention, that stent did not work. In the latter scenario the patient will not have had a revascularization and so will not be included with the patients requiring TLR. Thus the stent would appear to have had more clinical utility or to have been more”successful” than it really was. Similarly, TLR will not be negatively impacted when, as in some circumstances of stent occlusion, a patient decides to live with discomfort rather than consent to another procedure. Furthermore, investigators of that stent may have a perverse incentive after occlusion to minimize TLR by not performing another procedure. On the other hand a bypass of an artery with an open and functional stent would negatively impact TLR statistics for that type of stent. This may occur if the stented lesion was not the only cause of distal ischemia.What concerns me most about TLR, even more than its limited relevance, is that this statistic is used to support data that otherwise would not stand up to scrutiny. It is often included in trials where numbers are small or where Industry bias is obvious. Accordingly, I am hopeful that researchers seriously consider describing TLR as target lesion recurrence rates omitting target lesion revascularization from their presentations and manuscripts. If they insist on using this irrelevant statistic then they should provide information as to why the revascularization was performed.

Was it for lesion recurrence or failure to improve the indicated condition? If the lesion recurred but TLR was not performed, was that because recovery had been achieved despite restenosis of the target lesion? Was it because the patient was not offered further treatment? Perhaps the patient succumbed before TLR could have been provided?

I may be accused of being overly cynical, but it may have been because the patient had decided that the better part of valor would be to run away and join a witness protection program rather than take part in that clinical trial.

In November I attended the VEITHsymposium in New York. Almost 600 experts from around the world gave lectures on every aspect of vascular surgery. Given 5 minutes per talk, the presenters had to carefully select data they believed would bolster their viewpoint. So will someone please explain to me why some speakers still feel obliged to include target lesion revascularization (TLR) in their presentations? Furthermore, it’s not just in talks but also in peer-reviewed journals that we seem to be bombarded with this useless and often deceiving piece of information. I know that many feel the same way about TLR. However, for those not yet convinced, let me outline why I think TLR should rather stand for “The Least Relevant.”

The concept of TLR materialized during the early days of coronary balloon angioplasty and stenting. In the coronary arteries it is difficult to determine the restenosis rate of a treated lesion without repeating another coronary arteriogram. Accordingly, researchers resorted to TLR as an alternative method of evaluating whether a new treatment worked. However, in the peripheral circulation we have other methods of evaluating the lesion such as duplex scanning, CTA and MRA. This allows us minimally invasive and noninvasive means to evaluate the fate of the lesion itself. Thus, we are able to evaluate TLR as target lesion recurrence rather than target lesion revascularization.

Subsequently, companies and researchers have developed new devices such as balloons, stents, atherectomy devices, and drug-eluting variations that directly target peripheral vascular lesions. Despite the availability of noninvasive techniques to evaluate the target lesion itself, they use TLR data to convince physicians and purchasing entities to buy and use their device. The implication is that avoidance of another procedure to achieve the desired clinical endpoint proves that the new instrument works. However, as I have mentioned in previous editorials, semantics can have negative consequences. Here the problem arises when we attempt to define “works.” The inventor of a device that opens a narrowed or blocked artery wants to make sure that the device indeed does just that. In that case it would be appropriate to claim that it “works.”

If the lesion remains open and does not re-narrow we may conclude the device not only works but is also “effective.” The manufacturer and the FDA will want to make sure that it also does no harm and is “safe.” All are hopeful that it will improve the patient’s condition and have “clinical utility.” Certainly, success can be defined in many ways and clinical benefit must reign supreme. Accordingly, a device that is effective, safe and has clinical utility may be considered “successful” and, if cost effective, worth using. However, we are all aware that some procedures can improve a patient’s condition through a placebo effect. Therefore, it is incorrect for researchers to suggest that low TLR rates equate with clinical success. The most reliable judge of the efficacy of the procedure will be what happens to the targeted lesion and not what happens to the patient. It is more salient that we are assured that the device provides persistent improvement in luminal diameter at the site of the treated lesion.

It may help to further define the problem with TLR if we use a hypothetical example of a new medicated stent inserted to open a single SFA lesion responsible for toe gangrene. If that stent keeps the stenotic lesion widely patent, it should be considered effective even if the patient ultimately requires an above-knee amputation. On the other hand if the stent occludes in the recovery room, yet the toe subsequently heals without any further intervention, that stent did not work. In the latter scenario the patient will not have had a revascularization and so will not be included with the patients requiring TLR. Thus the stent would appear to have had more clinical utility or to have been more”successful” than it really was. Similarly, TLR will not be negatively impacted when, as in some circumstances of stent occlusion, a patient decides to live with discomfort rather than consent to another procedure. Furthermore, investigators of that stent may have a perverse incentive after occlusion to minimize TLR by not performing another procedure. On the other hand a bypass of an artery with an open and functional stent would negatively impact TLR statistics for that type of stent. This may occur if the stented lesion was not the only cause of distal ischemia.What concerns me most about TLR, even more than its limited relevance, is that this statistic is used to support data that otherwise would not stand up to scrutiny. It is often included in trials where numbers are small or where Industry bias is obvious. Accordingly, I am hopeful that researchers seriously consider describing TLR as target lesion recurrence rates omitting target lesion revascularization from their presentations and manuscripts. If they insist on using this irrelevant statistic then they should provide information as to why the revascularization was performed.

Was it for lesion recurrence or failure to improve the indicated condition? If the lesion recurred but TLR was not performed, was that because recovery had been achieved despite restenosis of the target lesion? Was it because the patient was not offered further treatment? Perhaps the patient succumbed before TLR could have been provided?

I may be accused of being overly cynical, but it may have been because the patient had decided that the better part of valor would be to run away and join a witness protection program rather than take part in that clinical trial.

In the dream I had an asymptomatic 5.7-cm juxtarenal abdominal aortic aneurysm. Like most of my patients I also had a 70% left internal carotid stenosis and nondisabling right leg claudication due to a superficial femoral artery stenosis. Having stood at the operating table for most of my life, my varicose veins were ugly but fortunately did not hurt.

In this dream I decided to first visit my family physician. He insisted that I stop smoking, but I had already quit 30 years ago. He was unaware of this as he had not updated his new electronic medical record system. He said “Jim, you have to take a statin. I would like to treat you with Crestor but your insurance carrier won’t pay for it. Try some red rice yeast.” I forgave him for not knowing that my name was Russell. After all, he was seeing 150 patients that day just to make ends meet and seemed rushed.

Unhappy with this consultation, I sought out one of the new concierge doctors in town. He gave me professional courtesy and charged me only a retainer of $7,000 a year. He ordered a stress test, CTA, MRI, bone scan, hypercoagulable and lipid blood analysis, and full metabolic profile. A vascular lab tech who came to his office once a week repeated my aortic, venous, carotid, and lower-extremity arterial vascular studies.

The doctor informed me that a radiologist in some other country would be reading the test, but he was sure it would be reliable. When the results came back I now had “Critical 95% carotid stenoses bilaterally,” and my AAA had “inexplicably” grown to 8.5 cm. I also had “limb-threatening severe PAD.” He recommended that I see his favorite cardiologist whom he felt could easily treat all these conditions and my aneurysm. Then, as a favor, he drove me to that appointment in his new Ferrari.

The cardiologist’s eyes gleamed when he saw me. He was an older gentleman wearing a tight-fitting all-in-one red satin suit and constantly plucked at his pointy beard. He had breath that smelled of sulfur. He seemed distracted by something pointed that appeared to be coming out of the back of his pants. His sharp ears tilted forward as he listened to me. He tried to convince me that no matter how I elected to have my aneurysm treated he should stent my carotid first, followed by an atherectomy and stent to open up my superficial femoral artery to prevent an amputation.

Furthermore, he was quite certain that I would get a DVT if I did not let him laser my great saphenous veins. After he had performed these procedures he would treat my AAA with a percutaneous endograft which he was planning to do in his outpatient cath lab. As this was early in my dream, my subconscious still had some control, and so, wisely, I declined to consent. He told me that “One way or another I will eventually get to take care of you!” I must say I was disconcerted by his words since I had a feeling he implied something entirely different.

Terrified, I sought someone competent to take care of my aneurysm. Clearly, as a practicing vascular surgeon myself, I had a pretty good idea as to who would be best, but I could not decide between the young, hotshot endovascular surgeon or the older vascular surgeon who had performed hundreds of open procedures and also performed many endovascular aneurysm repairs. I decided to visit the young surgeon first. After all, even though I was in a dream, I didn’t want to suffer the pain and recovery of an open procedure. He was confident he could help me by was using a new self-constructed fenestrated graft that he had made from scratch in his research lab at the university. Recently he had presented his series of two patients at Vascular Interventional Advances. Both patients had done “very well.” The first patient was still in the intensive care unit 4 weeks after the implant but he expected she would be off the respirator and dialysis soon. The second patient was thrilled that he was getting back some function in his toes after developing spinal paresis.

The older surgeon was also not reassuring. Although he had done hundreds of open AAAs in the past, with the advent of endovascular therapies, over the last few years he felt compelled to use this new less invasive technology. Furthermore, he was quite sure that virtually every aneurysm in his community had already been treated by a gamut of different specialists. The result was that he was performing only a handful of open aneurysms a year. Like many other surgeons of his era he had become less certain of his open surgical skills. He told me that, whereas when he was younger he would sleep soundly the night before a major complex aortic procedure, he now spent the night worrying. Perhaps it was the bags around his eyes, the drooping shoulders, and the slight tremor in his hands that suggested that he might not be the best surgeon for my aneurysm.

So I went back to the young surgeon and asked him if he could do an open operation. He shrugged his shoulders, and with some chagrin he explained he had done only one in his vascular residency. This was not only because there were so few aneurysms treated open, but because his OR time was reduced as a result of a mandate that residents could not work more than 40 hours a week and had to have at least 8 hours of sleep every night.

On the other hand, he had won the “Top Gun” competition at the Society for Clinical Vascular Surgery where he had successfully completed an aortic aneurysm surgery on a plastic mannequin. However, now in his first 3 years in practice he employed only endovascular techniques. He assured me, though, that he would read a textbook before the operation. Walking out of his office I noticed a framed picture in which he was surrounded by his beaming mother and grandmother as he was delivering the valedictorian speech at his grade school graduation.

The sheets were drenched with perspiration, and I cried out in my sleep, waking my wife.

“Who is going to be able to fix my aneurysm?” I said, waking myself.

“Calm down,” she said. “It’s only a dream.”

But was it? Are we training enough young surgeons in open surgery to maintain the surgical skills necessary to safely perform complex aneurysm surgery? Are our older surgeons maintaining proficiency as more and more procedures are performed percutaneously? Are the inroads from other specialties reducing overall aneurysm experience? Is the improvement in medical management slowing aneurysm growth and prevalence? Time will tell, but I believe training programs should be developing shared opportunities where programs strong in open procedures exchange their fellows with programs incorporating high-volume endovascular approaches. Further, older surgeons may need to refresh their skills in both open and endovascular procedures. Otherwise we may have to concede that Centers of Excellence may be the only way that patients can receive optimal care.

In the dream I had an asymptomatic 5.7-cm juxtarenal abdominal aortic aneurysm. Like most of my patients I also had a 70% left internal carotid stenosis and nondisabling right leg claudication due to a superficial femoral artery stenosis. Having stood at the operating table for most of my life, my varicose veins were ugly but fortunately did not hurt.

In this dream I decided to first visit my family physician. He insisted that I stop smoking, but I had already quit 30 years ago. He was unaware of this as he had not updated his new electronic medical record system. He said “Jim, you have to take a statin. I would like to treat you with Crestor but your insurance carrier won’t pay for it. Try some red rice yeast.” I forgave him for not knowing that my name was Russell. After all, he was seeing 150 patients that day just to make ends meet and seemed rushed.

Unhappy with this consultation, I sought out one of the new concierge doctors in town. He gave me professional courtesy and charged me only a retainer of $7,000 a year. He ordered a stress test, CTA, MRI, bone scan, hypercoagulable and lipid blood analysis, and full metabolic profile. A vascular lab tech who came to his office once a week repeated my aortic, venous, carotid, and lower-extremity arterial vascular studies.

The doctor informed me that a radiologist in some other country would be reading the test, but he was sure it would be reliable. When the results came back I now had “Critical 95% carotid stenoses bilaterally,” and my AAA had “inexplicably” grown to 8.5 cm. I also had “limb-threatening severe PAD.” He recommended that I see his favorite cardiologist whom he felt could easily treat all these conditions and my aneurysm. Then, as a favor, he drove me to that appointment in his new Ferrari.

The cardiologist’s eyes gleamed when he saw me. He was an older gentleman wearing a tight-fitting all-in-one red satin suit and constantly plucked at his pointy beard. He had breath that smelled of sulfur. He seemed distracted by something pointed that appeared to be coming out of the back of his pants. His sharp ears tilted forward as he listened to me. He tried to convince me that no matter how I elected to have my aneurysm treated he should stent my carotid first, followed by an atherectomy and stent to open up my superficial femoral artery to prevent an amputation.

Furthermore, he was quite certain that I would get a DVT if I did not let him laser my great saphenous veins. After he had performed these procedures he would treat my AAA with a percutaneous endograft which he was planning to do in his outpatient cath lab. As this was early in my dream, my subconscious still had some control, and so, wisely, I declined to consent. He told me that “One way or another I will eventually get to take care of you!” I must say I was disconcerted by his words since I had a feeling he implied something entirely different.

Terrified, I sought someone competent to take care of my aneurysm. Clearly, as a practicing vascular surgeon myself, I had a pretty good idea as to who would be best, but I could not decide between the young, hotshot endovascular surgeon or the older vascular surgeon who had performed hundreds of open procedures and also performed many endovascular aneurysm repairs. I decided to visit the young surgeon first. After all, even though I was in a dream, I didn’t want to suffer the pain and recovery of an open procedure. He was confident he could help me by was using a new self-constructed fenestrated graft that he had made from scratch in his research lab at the university. Recently he had presented his series of two patients at Vascular Interventional Advances. Both patients had done “very well.” The first patient was still in the intensive care unit 4 weeks after the implant but he expected she would be off the respirator and dialysis soon. The second patient was thrilled that he was getting back some function in his toes after developing spinal paresis.

The older surgeon was also not reassuring. Although he had done hundreds of open AAAs in the past, with the advent of endovascular therapies, over the last few years he felt compelled to use this new less invasive technology. Furthermore, he was quite sure that virtually every aneurysm in his community had already been treated by a gamut of different specialists. The result was that he was performing only a handful of open aneurysms a year. Like many other surgeons of his era he had become less certain of his open surgical skills. He told me that, whereas when he was younger he would sleep soundly the night before a major complex aortic procedure, he now spent the night worrying. Perhaps it was the bags around his eyes, the drooping shoulders, and the slight tremor in his hands that suggested that he might not be the best surgeon for my aneurysm.

So I went back to the young surgeon and asked him if he could do an open operation. He shrugged his shoulders, and with some chagrin he explained he had done only one in his vascular residency. This was not only because there were so few aneurysms treated open, but because his OR time was reduced as a result of a mandate that residents could not work more than 40 hours a week and had to have at least 8 hours of sleep every night.

On the other hand, he had won the “Top Gun” competition at the Society for Clinical Vascular Surgery where he had successfully completed an aortic aneurysm surgery on a plastic mannequin. However, now in his first 3 years in practice he employed only endovascular techniques. He assured me, though, that he would read a textbook before the operation. Walking out of his office I noticed a framed picture in which he was surrounded by his beaming mother and grandmother as he was delivering the valedictorian speech at his grade school graduation.

The sheets were drenched with perspiration, and I cried out in my sleep, waking my wife.

“Who is going to be able to fix my aneurysm?” I said, waking myself.

“Calm down,” she said. “It’s only a dream.”

But was it? Are we training enough young surgeons in open surgery to maintain the surgical skills necessary to safely perform complex aneurysm surgery? Are our older surgeons maintaining proficiency as more and more procedures are performed percutaneously? Are the inroads from other specialties reducing overall aneurysm experience? Is the improvement in medical management slowing aneurysm growth and prevalence? Time will tell, but I believe training programs should be developing shared opportunities where programs strong in open procedures exchange their fellows with programs incorporating high-volume endovascular approaches. Further, older surgeons may need to refresh their skills in both open and endovascular procedures. Otherwise we may have to concede that Centers of Excellence may be the only way that patients can receive optimal care.

In the dream I had an asymptomatic 5.7-cm juxtarenal abdominal aortic aneurysm. Like most of my patients I also had a 70% left internal carotid stenosis and nondisabling right leg claudication due to a superficial femoral artery stenosis. Having stood at the operating table for most of my life, my varicose veins were ugly but fortunately did not hurt.

In this dream I decided to first visit my family physician. He insisted that I stop smoking, but I had already quit 30 years ago. He was unaware of this as he had not updated his new electronic medical record system. He said “Jim, you have to take a statin. I would like to treat you with Crestor but your insurance carrier won’t pay for it. Try some red rice yeast.” I forgave him for not knowing that my name was Russell. After all, he was seeing 150 patients that day just to make ends meet and seemed rushed.

Unhappy with this consultation, I sought out one of the new concierge doctors in town. He gave me professional courtesy and charged me only a retainer of $7,000 a year. He ordered a stress test, CTA, MRI, bone scan, hypercoagulable and lipid blood analysis, and full metabolic profile. A vascular lab tech who came to his office once a week repeated my aortic, venous, carotid, and lower-extremity arterial vascular studies.

The doctor informed me that a radiologist in some other country would be reading the test, but he was sure it would be reliable. When the results came back I now had “Critical 95% carotid stenoses bilaterally,” and my AAA had “inexplicably” grown to 8.5 cm. I also had “limb-threatening severe PAD.” He recommended that I see his favorite cardiologist whom he felt could easily treat all these conditions and my aneurysm. Then, as a favor, he drove me to that appointment in his new Ferrari.

The cardiologist’s eyes gleamed when he saw me. He was an older gentleman wearing a tight-fitting all-in-one red satin suit and constantly plucked at his pointy beard. He had breath that smelled of sulfur. He seemed distracted by something pointed that appeared to be coming out of the back of his pants. His sharp ears tilted forward as he listened to me. He tried to convince me that no matter how I elected to have my aneurysm treated he should stent my carotid first, followed by an atherectomy and stent to open up my superficial femoral artery to prevent an amputation.

Furthermore, he was quite certain that I would get a DVT if I did not let him laser my great saphenous veins. After he had performed these procedures he would treat my AAA with a percutaneous endograft which he was planning to do in his outpatient cath lab. As this was early in my dream, my subconscious still had some control, and so, wisely, I declined to consent. He told me that “One way or another I will eventually get to take care of you!” I must say I was disconcerted by his words since I had a feeling he implied something entirely different.

Terrified, I sought someone competent to take care of my aneurysm. Clearly, as a practicing vascular surgeon myself, I had a pretty good idea as to who would be best, but I could not decide between the young, hotshot endovascular surgeon or the older vascular surgeon who had performed hundreds of open procedures and also performed many endovascular aneurysm repairs. I decided to visit the young surgeon first. After all, even though I was in a dream, I didn’t want to suffer the pain and recovery of an open procedure. He was confident he could help me by was using a new self-constructed fenestrated graft that he had made from scratch in his research lab at the university. Recently he had presented his series of two patients at Vascular Interventional Advances. Both patients had done “very well.” The first patient was still in the intensive care unit 4 weeks after the implant but he expected she would be off the respirator and dialysis soon. The second patient was thrilled that he was getting back some function in his toes after developing spinal paresis.

The older surgeon was also not reassuring. Although he had done hundreds of open AAAs in the past, with the advent of endovascular therapies, over the last few years he felt compelled to use this new less invasive technology. Furthermore, he was quite sure that virtually every aneurysm in his community had already been treated by a gamut of different specialists. The result was that he was performing only a handful of open aneurysms a year. Like many other surgeons of his era he had become less certain of his open surgical skills. He told me that, whereas when he was younger he would sleep soundly the night before a major complex aortic procedure, he now spent the night worrying. Perhaps it was the bags around his eyes, the drooping shoulders, and the slight tremor in his hands that suggested that he might not be the best surgeon for my aneurysm.

So I went back to the young surgeon and asked him if he could do an open operation. He shrugged his shoulders, and with some chagrin he explained he had done only one in his vascular residency. This was not only because there were so few aneurysms treated open, but because his OR time was reduced as a result of a mandate that residents could not work more than 40 hours a week and had to have at least 8 hours of sleep every night.

On the other hand, he had won the “Top Gun” competition at the Society for Clinical Vascular Surgery where he had successfully completed an aortic aneurysm surgery on a plastic mannequin. However, now in his first 3 years in practice he employed only endovascular techniques. He assured me, though, that he would read a textbook before the operation. Walking out of his office I noticed a framed picture in which he was surrounded by his beaming mother and grandmother as he was delivering the valedictorian speech at his grade school graduation.

The sheets were drenched with perspiration, and I cried out in my sleep, waking my wife.

“Who is going to be able to fix my aneurysm?” I said, waking myself.

“Calm down,” she said. “It’s only a dream.”

But was it? Are we training enough young surgeons in open surgery to maintain the surgical skills necessary to safely perform complex aneurysm surgery? Are our older surgeons maintaining proficiency as more and more procedures are performed percutaneously? Are the inroads from other specialties reducing overall aneurysm experience? Is the improvement in medical management slowing aneurysm growth and prevalence? Time will tell, but I believe training programs should be developing shared opportunities where programs strong in open procedures exchange their fellows with programs incorporating high-volume endovascular approaches. Further, older surgeons may need to refresh their skills in both open and endovascular procedures. Otherwise we may have to concede that Centers of Excellence may be the only way that patients can receive optimal care.