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Presidential Address: Endovascular Techniques and the Vascular Surgeon
Papers from the French Vascular Surgical Society 1990 Meeting
Presidential Address: Endovascular Techniques and the Vascular Surgeon Robert Frisch, MD, Nancy, France
Active " i n t e r v e n t i o n a l " treatment of occlusive arterial disease is presently undergoing radical changes. Several new endovascular procedures have been proposed to clear blood vessels either in competition with or as complementary measures to classic vascular surgical procedures. These are now being developed or undergoing experimental evaluation. These new methods are gaining popularity in the medical community and, through the mass media, have made an enormous impact on the public. Several of us can therefore rightfully ask the question, where does the future of vascular surgery lay? At the present time it seems appropriate to stop and think about the evolution of our speciality and the directions that it might or should take in the future. To think about this problem and to give opinions or even advice is perhaps one of the roles our older colleagues in this speciality can play best. It is in the light of past progress, as well as of the facts and lessons learned in the past, that we might be able, if not to foresee the future, at least to try to imagine the options that should be explored in the years to come. I myself belong to the generation of vascular surgeons who dealt with hemodynamics, the generation that succeeded, without disowning, the surgeons who put so much value in the sympathetic nerve, as disciples of Rend Leriche. My generation From the Service de Chirurgie Gdn&'ale et Vasculaire, HOpital Central, Nancy, France. Presidential Address delivered at the Annual Meeting of the SociOtO de Chirurgie Vasculaire de Langue Franqaise, May 18-19, 1990, Nanev, France. Reprint requests: R. Friseh, MD, Service de Chirurgie GdnOrale et Vasculaire, HOpital Central, 54037 Nancy, France.
is that which has attached itself to the restoration of vessels occluded by disease as taught by Kunlin, Oudot, Dubost, and the American schools of thought, among many others. I participated with mixed success in the attempts at bypass using the bizarre material without any future called "Ivalon," as well as other types of prosthetic graft material before the ingenious discovery of knitted Dacron grafts by DeBakey, the founding father of our discipline as we know it today. I performed long, open, or semiclosed endarterectomies using Vollmar's rings or similar procedures such as carbonic gas, wherein success was satisfactory but short-lived. Thirty odd years ago, surgeons who submitted ~'scientific" publications to a Society could content themselves to announce, not without certain pride, "this is what I did, here are my immediate results, they are satisfactory, my technique is good!!!" A typical example of this would be the paper I presented in 1958 to the French Society of Thoracic and Cardiovascular Surgery, the first in France on the subject. It concerned a dozen cases of reconstruction of the supraaortic arteries. Although the presentation was noted, it had little real value, because it was not based on any objective findings, and the indications for these operations were not discussed. Further knowledge of this problem has been brought to light by the progress made in the indications for reconstruction of the left subclavian artery. The discovery of the vertebrosubclavian "steal s y n d r o m e " prompted several different operations including carotid-subclavian anastomoses or bypasses, initially performed through a left thoracotomy, fortunately without any adverse consequences. We now know that this condition is common, benign, and that operation should be indicated in this anomaly in no more than one case out of ten.
2
PRESIDENTIAL ADDRESS
There are other examples of changing trends in vascular surgery. Surgery for stenosis of the vertebral artery ostium was promoted and performed actively at one time. As neurologic conceptions advanced, however, this operation disappeared only to reappear during these last years, this time based on highly refined diagnostic criteria and very selective indications. Carotid artery surgery, as well, has been severely criticized in recent years. The list of arguments raised against it would be much too long to enumerate here [1]. Among them is the notion that there have been far too many operations easily and hastily imposed on patients with asymptomatic and "moderately" tight stenoses. Why recall these facts, some old, others more recent? Presently, I believe, it is no longer possible to recommend new therapeutic regimens without considering their justification, advantages, possible risks, and sequels, and, above all, their outcome within the general framework of arterial disease which we know to be progressive. Additionally, indications must take into account patient status, objective functional needs, life expectancy, and many other factors. Based on criticisms stemming from analysis of long-term results, comparison with results obtained by other techniques, and, whenever possible, consideration of the natural history of the disease, several operations performed in the past have disappeared. The semi-closed aortofemoral and femoropopliteal endarterectomies are just one example. Other indications have regressed enormously, for example, the femoropopliteal bypass for moderately severe intermittent claudication which we now know how to control with well-planned medical treatment. On the other hand, the number of limb salvages has increased because of the technical progress made in distal bypass procedures. The examples I have cited are only a few of philosophical changes in the concept of active conventional vascular therapeutic policy. They are important to consider if we want to avoid committing the errors of the past in the presently explosive and Slightly anarchic development of endovascular interventional techniques. I affirm, I insist, that I am not at all opposed to the development of these new techniques. Dilatation techniques have already proven their utility, whereas laser or mechanical channeling, endoprostheses, and endovascular endarterectomies are still in their experimental stages: all merit further development and improvement in material and user-friendliness. In the future, some of them will perhaps disappear while others will rightly find their place and remain in the therapeutic armamentarium. Alarming, however, are the difficulties encountered in experimental assessment of these techniques. Although immediate results of one or another endoluminal technique are often satisfactory,
ANNALS OF VASCULAR St:WGERY
we do not know the conditions under which they should be performed, their risks, or whether the results will stand the test of time. Experimentation on animal atheromatous vessels presents insurmountable difficulties. What.happens in reality is that as soon as the feasibility of a new procedure has been determined, it is used on what I call the human "guinea pig". While this might be conceivable when we are talking about salvage procedures, it is less so when dealing with treatment of short, slightly symptomatic lesions, which is what I see being done sometimes. Obviously good results are easy to come by without risks, and, statistically, immediate and medium-term results are enticing. I would like to take a stand for more progressive and prudent clinical experimentation, in the hands of, or under the control of, teams concerned by the scientific quality of studies and sufficiently disinterested to allow objective evaluation and comparison with gold standard surgical techniques. However, I have noticed that these still experimental, as well as expensive tools, are difficult to obtain and are deployed less rapidly in university hospitals in comparison with private institutions. This, unfortunately, seems to be due only to financial and administrative considerations. I do not question the integrity or the objectivity of most of our colleagues in private practice, but when I see these techniques publicized to the medical and nonmedical communities as harmless, elegant, ambulatory, salvaging, and even, "preventive" without any mention of or caution as to difficulties, or risks, I cannot help but be alarmed. There is a lack of informed consent of patients, and I am forced to conclude that publicity for commercial reasons is misleading if only by certain omissions of information. I make a plea that, in the future, new techniques, which certainly represent progress in treatment of disease, are not compromised by financial interest or the dire need for publication, which, done too hastily, will be a detriment to vascular surgery. My major concern for the future, not only for vascular surgery in itself, but for the future of interventional therapy of arterial disease as well, is that my message will be heard. What about the future of vascular surgery and the surgeons that perform it? There is presently little doubt as to the increasing availability of patients. The general population is getting older; the proportion of patients at the age where peripheral arterial occlusive disease occurs will increase in significant proportions in the decades to come; prevention of atheroma is not making any headway. Vascular disease is apparently and unfortunately here to stay. On the other hand, the advent of these new techniques will undoubtedly lead to important
VOLUME 5 N o 1 - 1991
PRESIDENTIAL ADDRESS
changes in the activity of vascular surgeons. One thing is certain, however, the surgeon must not let his all-important place in vascular therapy disappear. Surgeons are and have been at the origin of all active phases of vascular management. The history of our speciality has shown that all diagnostic and therapeutic initiatives in vascular disease have been proposed and developed by surgeons. These same surgeons must retain their central and strong position in decision-making and performance of the therapeutic procedure. They may be backed up but not dominated by angiologists and radiologists who have also contributed to the progress of vascular disease management. This means that the surgeon himself must be able to perform all the endovascular procedures: dilatation, boring, endoscopy, and sonography, as well as those to come. When the choice of a treatment, whether medical, surgical, or radiointerventional, is open, the final therapeutic decision will lie in the hands of those who possess and can perform the entire range of treatments. They alone can judge with full knowledge the advantages, the disadvantages, and the risks of each technique, especially when confronted with the individual patient and with his or her future interests in mind. Obviously, one excellent solution is to form a multidisciplinary team, grouping surgeons, radiologists, and angiologists in the same way that cancer centers have grouped together therapeutic teams composed of surgeons, radiation therapists, and oncologists. My wish is to see such teams develop. Whether we call them departments, institutions,
m m n
3
clinics, or something else matters little. Bylaws and rules must be established to make sure that the surgeon retains his central role in order to avoid all problems of competition within the group. This is probably not easy, but certainly is possible. This idea has already stood the test of time. It must be developed to avoid the dispersion of pathology and corresponding therapy to the detriment to patients who should receive the best possible treatment for their disease independent of all other, especially extramedical, considerations. This can be accomplished only if vascular surgeons are willing to change their attitudes and their habits, and they are willing to accept that therapy of vascular disease can still progress as it has in the past. Techniques are becoming diversified: they call for good training, solid indications based on sound judgment, and a large experience based on lessons learned from the past. "Sir, how does one acquire the judgment you spoke of in your lecture? "Son, judgment comes from experience. "But how does one acquire experience? "From bad judgement, son!" E.J. Wylie [2]
REFERENCES 1. H E R T Z E R NR. Carotid e n d a r t e r e c t o m y - - a crisis in confidence. J Vasc Surg 1988;7:611-619. 2. W Y L I E EJ. Vascular Surgery--reflections of the past three decades. Surg'eJT 1980;88:743-747.
Presidential Address: Endovascular Techniques and the Vascular Surgeon Robert Frisch, MD, Nancy, France
Active " i n t e r v e n t i o n a l " treatment of occlusive arterial disease is presently undergoing radical changes. Several new endovascular procedures have been proposed to clear blood vessels either in competition with or as complementary measures to classic vascular surgical procedures. These are now being developed or undergoing experimental evaluation. These new methods are gaining popularity in the medical community and, through the mass media, have made an enormous impact on the public. Several of us can therefore rightfully ask the question, where does the future of vascular surgery lay? At the present time it seems appropriate to stop and think about the evolution of our speciality and the directions that it might or should take in the future. To think about this problem and to give opinions or even advice is perhaps one of the roles our older colleagues in this speciality can play best. It is in the light of past progress, as well as of the facts and lessons learned in the past, that we might be able, if not to foresee the future, at least to try to imagine the options that should be explored in the years to come. I myself belong to the generation of vascular surgeons who dealt with hemodynamics, the generation that succeeded, without disowning, the surgeons who put so much value in the sympathetic nerve, as disciples of Rend Leriche. My generation From the Service de Chirurgie Gdn&'ale et Vasculaire, HOpital Central, Nancy, France. Presidential Address delivered at the Annual Meeting of the SociOtO de Chirurgie Vasculaire de Langue Franqaise, May 18-19, 1990, Nanev, France. Reprint requests: R. Friseh, MD, Service de Chirurgie GdnOrale et Vasculaire, HOpital Central, 54037 Nancy, France.
is that which has attached itself to the restoration of vessels occluded by disease as taught by Kunlin, Oudot, Dubost, and the American schools of thought, among many others. I participated with mixed success in the attempts at bypass using the bizarre material without any future called "Ivalon," as well as other types of prosthetic graft material before the ingenious discovery of knitted Dacron grafts by DeBakey, the founding father of our discipline as we know it today. I performed long, open, or semiclosed endarterectomies using Vollmar's rings or similar procedures such as carbonic gas, wherein success was satisfactory but short-lived. Thirty odd years ago, surgeons who submitted ~'scientific" publications to a Society could content themselves to announce, not without certain pride, "this is what I did, here are my immediate results, they are satisfactory, my technique is good!!!" A typical example of this would be the paper I presented in 1958 to the French Society of Thoracic and Cardiovascular Surgery, the first in France on the subject. It concerned a dozen cases of reconstruction of the supraaortic arteries. Although the presentation was noted, it had little real value, because it was not based on any objective findings, and the indications for these operations were not discussed. Further knowledge of this problem has been brought to light by the progress made in the indications for reconstruction of the left subclavian artery. The discovery of the vertebrosubclavian "steal s y n d r o m e " prompted several different operations including carotid-subclavian anastomoses or bypasses, initially performed through a left thoracotomy, fortunately without any adverse consequences. We now know that this condition is common, benign, and that operation should be indicated in this anomaly in no more than one case out of ten.
2
PRESIDENTIAL ADDRESS
There are other examples of changing trends in vascular surgery. Surgery for stenosis of the vertebral artery ostium was promoted and performed actively at one time. As neurologic conceptions advanced, however, this operation disappeared only to reappear during these last years, this time based on highly refined diagnostic criteria and very selective indications. Carotid artery surgery, as well, has been severely criticized in recent years. The list of arguments raised against it would be much too long to enumerate here [1]. Among them is the notion that there have been far too many operations easily and hastily imposed on patients with asymptomatic and "moderately" tight stenoses. Why recall these facts, some old, others more recent? Presently, I believe, it is no longer possible to recommend new therapeutic regimens without considering their justification, advantages, possible risks, and sequels, and, above all, their outcome within the general framework of arterial disease which we know to be progressive. Additionally, indications must take into account patient status, objective functional needs, life expectancy, and many other factors. Based on criticisms stemming from analysis of long-term results, comparison with results obtained by other techniques, and, whenever possible, consideration of the natural history of the disease, several operations performed in the past have disappeared. The semi-closed aortofemoral and femoropopliteal endarterectomies are just one example. Other indications have regressed enormously, for example, the femoropopliteal bypass for moderately severe intermittent claudication which we now know how to control with well-planned medical treatment. On the other hand, the number of limb salvages has increased because of the technical progress made in distal bypass procedures. The examples I have cited are only a few of philosophical changes in the concept of active conventional vascular therapeutic policy. They are important to consider if we want to avoid committing the errors of the past in the presently explosive and Slightly anarchic development of endovascular interventional techniques. I affirm, I insist, that I am not at all opposed to the development of these new techniques. Dilatation techniques have already proven their utility, whereas laser or mechanical channeling, endoprostheses, and endovascular endarterectomies are still in their experimental stages: all merit further development and improvement in material and user-friendliness. In the future, some of them will perhaps disappear while others will rightly find their place and remain in the therapeutic armamentarium. Alarming, however, are the difficulties encountered in experimental assessment of these techniques. Although immediate results of one or another endoluminal technique are often satisfactory,
ANNALS OF VASCULAR St:WGERY
we do not know the conditions under which they should be performed, their risks, or whether the results will stand the test of time. Experimentation on animal atheromatous vessels presents insurmountable difficulties. What.happens in reality is that as soon as the feasibility of a new procedure has been determined, it is used on what I call the human "guinea pig". While this might be conceivable when we are talking about salvage procedures, it is less so when dealing with treatment of short, slightly symptomatic lesions, which is what I see being done sometimes. Obviously good results are easy to come by without risks, and, statistically, immediate and medium-term results are enticing. I would like to take a stand for more progressive and prudent clinical experimentation, in the hands of, or under the control of, teams concerned by the scientific quality of studies and sufficiently disinterested to allow objective evaluation and comparison with gold standard surgical techniques. However, I have noticed that these still experimental, as well as expensive tools, are difficult to obtain and are deployed less rapidly in university hospitals in comparison with private institutions. This, unfortunately, seems to be due only to financial and administrative considerations. I do not question the integrity or the objectivity of most of our colleagues in private practice, but when I see these techniques publicized to the medical and nonmedical communities as harmless, elegant, ambulatory, salvaging, and even, "preventive" without any mention of or caution as to difficulties, or risks, I cannot help but be alarmed. There is a lack of informed consent of patients, and I am forced to conclude that publicity for commercial reasons is misleading if only by certain omissions of information. I make a plea that, in the future, new techniques, which certainly represent progress in treatment of disease, are not compromised by financial interest or the dire need for publication, which, done too hastily, will be a detriment to vascular surgery. My major concern for the future, not only for vascular surgery in itself, but for the future of interventional therapy of arterial disease as well, is that my message will be heard. What about the future of vascular surgery and the surgeons that perform it? There is presently little doubt as to the increasing availability of patients. The general population is getting older; the proportion of patients at the age where peripheral arterial occlusive disease occurs will increase in significant proportions in the decades to come; prevention of atheroma is not making any headway. Vascular disease is apparently and unfortunately here to stay. On the other hand, the advent of these new techniques will undoubtedly lead to important
VOLUME 5 N o 1 - 1991
PRESIDENTIAL ADDRESS
changes in the activity of vascular surgeons. One thing is certain, however, the surgeon must not let his all-important place in vascular therapy disappear. Surgeons are and have been at the origin of all active phases of vascular management. The history of our speciality has shown that all diagnostic and therapeutic initiatives in vascular disease have been proposed and developed by surgeons. These same surgeons must retain their central and strong position in decision-making and performance of the therapeutic procedure. They may be backed up but not dominated by angiologists and radiologists who have also contributed to the progress of vascular disease management. This means that the surgeon himself must be able to perform all the endovascular procedures: dilatation, boring, endoscopy, and sonography, as well as those to come. When the choice of a treatment, whether medical, surgical, or radiointerventional, is open, the final therapeutic decision will lie in the hands of those who possess and can perform the entire range of treatments. They alone can judge with full knowledge the advantages, the disadvantages, and the risks of each technique, especially when confronted with the individual patient and with his or her future interests in mind. Obviously, one excellent solution is to form a multidisciplinary team, grouping surgeons, radiologists, and angiologists in the same way that cancer centers have grouped together therapeutic teams composed of surgeons, radiation therapists, and oncologists. My wish is to see such teams develop. Whether we call them departments, institutions,
m m n
3
clinics, or something else matters little. Bylaws and rules must be established to make sure that the surgeon retains his central role in order to avoid all problems of competition within the group. This is probably not easy, but certainly is possible. This idea has already stood the test of time. It must be developed to avoid the dispersion of pathology and corresponding therapy to the detriment to patients who should receive the best possible treatment for their disease independent of all other, especially extramedical, considerations. This can be accomplished only if vascular surgeons are willing to change their attitudes and their habits, and they are willing to accept that therapy of vascular disease can still progress as it has in the past. Techniques are becoming diversified: they call for good training, solid indications based on sound judgment, and a large experience based on lessons learned from the past. "Sir, how does one acquire the judgment you spoke of in your lecture? "Son, judgment comes from experience. "But how does one acquire experience? "From bad judgement, son!" E.J. Wylie [2]
REFERENCES 1. H E R T Z E R NR. Carotid e n d a r t e r e c t o m y - - a crisis in confidence. J Vasc Surg 1988;7:611-619. 2. W Y L I E EJ. Vascular Surgery--reflections of the past three decades. Surg'eJT 1980;88:743-747.