Well folks, after more than two years of the pandemic, racial injustice, and medical misinformation, I have decided it is time to return to writing about what I truly love: fake feuds with other specialties. Remember the heady days of 2019 when surgeons took on the Association of periOperative Registered Nurses (AORN) in the Bouffant War? All it took was a global plague and international shortages of personal protective equipment (PPE) to prove that AORN’s 47 evidence-free recommendations for surgical attire might not be addressing the most pressing needs in modern medicine. Today, we are free to put on our skullcaps and bask in our victory, earlobes and napes of our necks exposed like the day our mamas made us.
Now we are being pulled into a new, ridiculous feud. I think the millennials would describe it like this:
Absolutely no one:
Trauma surgeons: Hey, I don’t think we need vascular surgeons anymore!
The first salvo came in 2020 with the Annals of Surgery perspective article “Beyond the crossroads: Who will be the caretakers of vascular injury management?” The authors of this piece made several salient points detailing the lack of adequate training in vascular injuries for trauma and acute care surgeons. Our esteemed profession, however, endured several cheap shots in the process. “As vascular practitioners become more focused on elective endovascular procedures, they often develop ‘lesion vision,’ similar to ‘tunnel vision,’ focusing on obtaining gratifying before/after images, whereas failing to use the patient’s other injuries or physiology in the decision making of how the vascular injury should be managed.”
Lesion vision? That’s not even catchy. I mean come on, “stenosis psychosis” is right there. Besides, who has lesion vision? Vascular surgeons, or the people calling us at 4 a.m. because they think they see a 5mm blush near the superficial femoral artery on an 18-year-old with palpable pulses?
Elsewhere in the article, the authors declare without evidence that “Patients with injuries that may be best treated by open surgery receive endovascular care because that is what the local vascular surgeon knows.” Other random grievances are aired. Vascular surgeons are apparently so afflicted with Lesion VisionTM that we fail “to fully prepare and drape the trunk and extremities to allow for rapid default for open proximal control or a later fasciotomy…” A remarkably specious accusation to cast at a specialty who routinely prep their endovascular aneurysm repairs (EVARs) from nipples to groins despite last performing an open conversion before the iPad was invented.
I was fortunate to contribute to the response to this article organized by Drs. Brigitte Smith and Erica Mitchell. The resulting perspective was thoughtful and measured (despite my best efforts). The answer, we maintained, was collaboration between vascular surgeons and trauma surgeons.
It certainly says something about our commitment to patients that we are so willing to battle over the management of vascular trauma. These cases live in that godless patch of night starting around 3 a.m., where you leave the comfort of your bed with the terrible knowledge that your day has now begun, and an Odyssean journey separates your return. Masochistically, I run the dispiriting math on the way to the hospital. Let’s see, I can finish this trauma by 7, get to my clinic at 8, grab a fast lunch, make war with the Trojans, three quick cath lab cases, then sail home to Penelope. Hopefully, there won’t be traffic on the Aegean.
The back and forth in Annals of Surgery should have been the end of it, but, ladies and gentlemen, I regret to inform you that the trauma surgeons are back on their bullstuff. In the recently published study “Trauma surgeon-performed peripheral arterial repairs are associated with equivalent outcomes when compared with vascular surgeons,” the trauma surgeons from the Medical College of Wisconsin purport that their brachial and femoral artery repairs had the same short-term outcomes as those performed by their institution’s vascular surgeons. In an unfortunate blow to the scientific validity of this conclusion, the femoral injuries treated by the vascular surgeons were significantly more complex and more likely to be associated with other operative injuries. The brachial injuries treated by the vascular surgeons had a higher rate of gunshot mechanism, complete transection, and associated non-vascular injuries requiring surgery, although these factors did not achieve significance, likely due to the small sample size. The authors also cited a faster transition time to the operating room (OR) for the trauma surgeons, which they postulated may be due to the vascular surgeons ordering more imaging studies.
While it is certainly possible that the generally more complicated cases being managed by vascular surgeons required a longer workup, a simpler explanation lies in the laws of physics. It is probably quicker to get to the OR from the emergency room than it is from your bed at home.
Based on their data, the authors concluded they had “no difference in short-term clinical outcomes” compared to the work performed by their vascular surgeons. While that is one way to interpret the numbers, isn’t it also true that the vascular surgeons repaired more complex injuries with more associated orthopedic injuries without an increase in reinterventions, complications or mortality?
I spoke with Dr. Peter Rossi, chief of vascular surgery at the Medical College of Wisconsin, regarding this paper from his trauma colleagues. He expressed disappointment and noted that “what should have been an opportunity for learning and collaboration” was instead conducted without their input.
Accompanying this paper in the Journal of Trauma and Acute Care Surgery is a commentary written by Dr. Thomas Scalea, one of the co-authors of the original “Beyond the crossroads” piece. Titled “Caring for vascular injuries: Training more vascular surgeons may not be the answer,” the article provides no evidence to support its provocative title but does give Dr. Scalea a chance to roll out his Lesion VisionTM zinger once again. Dr. Scalea also provides anecdotal evidence of young trauma patients being treated in the community with stents, which he has had to subsequently remove. He also bemoans the lack of data supporting the increase in endovascular interventions. This is decidedly misleading. An analysis of matched patients in the National Trauma Data Bank found that those undergoing endovascular repair had nearly half the in-hospital mortality compared with the open surgery cohort.
Some of the greatest advances in trauma care this century have been led by endovascular innovations. The benefits of stent grafting in aortic repair are obvious, but it also improves outcomes in other locations, such as axillosubclavian injuries where “…the morbidity of the operation is much less given that large complex incisions do not need to be made, there is much lower blood loss, and less operative time is needed.” Of course, there is no need to remind Dr. Scalea of these facts as I pulled the quote directly from his recent article, “Endovascular management of axillosubclavian artery injuries.”
Finally, Dr. Scalea notes, “The decisions, when to do definitive repair versus damage control and how to order the repair of vascular injuries in patients with multisystem trauma must remain the purview of the injury specialists, that is, the trauma surgeon.” Here we agree. Too often I have arrived at the hospital to find a patient with concomitant vascular and orthopedic injuries left in the ER for the respective specialists to battle it out. Early in my career, I was quick to repair these vessels only to find my bypass perplexingly thrombosed after the ensuing ortho procedure. After taking the time to actually witness an open reduction and internal fixation, let’s just say I am no longer perplexed!
While trauma surgeons may bemoan the ceding of vascular injury expertise to us, they have made little effort to correct the current status quo. Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowships in surgical critical care require no case minimums and can be essentially non-operative. The Acute Care Fellowship sponsored by the American Association for the Surgery of Trauma (AAST) mandates the management of only 10 vascular injuries: certainly not a pathway to competence. In 2021, general surgery graduates reported an average of 2.8 vascular trauma procedures over their five years of training—including 1.3 fasciotomies. Even experience does not automatically translate to aptitude and proficiency. Competence must be acquired from the competent.
Vascular surgeons may not be the heroes the trauma surgeons want, but we are the ones they need. The only sane pathway forward is collaboration. Recognition of the importance of the vascular surgeons to a trauma center is key, and the trauma surgeons need to support our efforts here.
In the United States, trauma centers are designated by regional governments and most rely on the standards set by the American College of Surgeons (ACS). The trauma center verification program was approved by the ACS Board of Regents in 1986, and the first Level I trauma center was verified in 1987. The most recent standards were published in March of this year in the Resources for Optimal Care of the Injured Patient manual.
There is often confusion regarding the prerequisites for vascular surgery coverage in trauma centers. The ACS manual is partly to blame. On page 45, “Specialty Liaisons to the Trauma Service” are listed. Here orthopedics and neurosurgery are required but vascular is not mentioned. Flip to page 61, however, and expertise in vascular surgery is mandatory with continuous 24-7, 365-day availability for all Level I and Level II adult and pediatric trauma centers. This is a Type I standard, meaning verification is automatically withheld if it is not met.
I know for a fact there are many trauma centers in the U.S. without continuous vascular coverage. Perhaps there is a perceived loophole in the “expertise” designation? The ACS guidelines require physicians with board certification or eligibility in general surgery, neurosurgery, orthopedic surgery, anesthesia, emergency medicine, and radiology, but it is not specified for vascular surgery. We need the ACS to hold those claiming vascular surgery “expertise” to the same standards. Stricter enforcement by the ACS will incentivize institutions to offer equitable call pay to vascular surgeons, as they do for our orthopedic and neurosurgery colleagues.
The modern care of vascular injuries requires training and proficiency in both open surgical and endovascular techniques. In the U.S., completion of an ACGME-certified vascular training program, and subsequent Vascular Surgery Board (VSB) certification, is the sole pathway designed and proven to ensure these competencies.
The “expertise” loophole is arbitrary, disingenuous, and a danger to the public. To safeguard the care of vascular trauma patients, we need to continue to grow the vascular surgeon workforce and take the steps needed to ensure their proper valuation by trauma centers.
Malachi Sheahan III, MD, is the Claude C. Craighead Jr. professor and chair in the division of vascular and endovascular surgery at Louisiana State University Health Sciences Center in New Orleans. He is medical editor of Vascular Specialist.