Editor’s Note: The associate editors of Vascular Specialist were asked to provide their perspectives on the stenting controversy. Here is a selection.
Dr. Frank J. Veith: The recent lead article in the New York Times on excessive implantation of lower extremity stents highlights one key point. Vascular surgeons and all vascular specialists who treat lower extremity occlusive disease should always clearly inform patients with intermittent claudication that one acceptable treatment option is medical and lipid-lowering therapy without any invasive treatment of their arterial blockage. They should be informed that the condition almost never leads to limb loss and that invasive treatment can safely be delayed until such progression occurs.
Given such honest reassurance and the option to choose their treatment, most patients with claudication will choose a conservative rather than an invasive approach, and unnecessary stent/angioplasty and other lower extremity interventional procedures, as described in the Times article, will be minimized.
Dr. John F. Eidt: The truth is we all bear responsibility. The treatment of lower extremity peripheral artery disease (PAD) has largely defied prior efforts to define appropriate care. Even the SVS document recommending risk factor modification in the initial management of intermittent claudication leaves substantial room for individualized judgment.
The appropriateness of intervention is largely in the eye of the beholder. “Lifestyle-limiting” claudication can be invoked as justification for intervention in virtually anyone. But I do believe that vascular surgeons are more wary of the adverse consequences of vascular intervention for one important reason – we do amputations. We are unique among vascular specialists in that we deal with the tragedies of unwarranted vascular procedures. For vascular surgeons, failure of intervention means more than binary restenosis or increased target lesion revascularization. Performing an amputation after failed intervention in a claudicant leaves an indelible mark on each of us and may underlie our inherently conservative approach to PAD. But we need to be fearless in speaking the truth and serving as advocates for exemplary patient care. Continuing a relationship with a source of carotid and aortic referrals while turning a blind eye to meddlesome lower extremity intervention sends the wrong message. Our silence constitutes tacit approval. Too frequently I hear a patient say “my cardiologist says there is nothing else he can do, go see a vascular surgeon.” Despite years of branding efforts by the SVS, surveys of primary care providers and the public alike confirm that many remain uncertain of our skills. We need to do a better job of spreading the word that vascular surgeons are “leaders in the minimally invasive treatment of PAD.” Not the last resort.
Dr. Frank Pomposelli: I could not agree more with Dr. Eidt. It’s easy to indict the outpatient labs for obvious reasons but I personally agree that the root of the problem lies in the overly aggressive posture being taken toward treatment of claudication.
It just so happens that outpatient labs are filled with claudicants since they are most likely to have the least complex disease – match made in heaven or hell, depending on your perspective.
One cardiologist quoted in the N.Y. Times piece said patients with claudication have been “grossly under treated” – a convenient posture to take when billing Medicare $4.5 million a year. The other cardiologist who was the focus of the investigation called the charges “baseless and fiction” and stated his center had the lowest rate of amputation in the country.
It gets back to Dr. Eidt’s point how it’s easy for the nonsurgeon to dismiss amputation as an occasional unfortunate byproduct of a busy practice when you never have had to tell a patient they need one and suffer with them through the emotional and physical trauma that always follows. I was taught like many of you, I suspect, that any amputation after treatment for claudication should be considered not only an unacceptable complication but also a failure of the trust the patient placed in me. My mentor was a militant nihilist when it came to surgery for claudication but that concept is always in my mind whenever I treat a patient and has always tempered my decision making.
I like to think our recently published practice guidelines will help but am skeptical that it will make a positive impact where it is most needed; on those who are primarily driven by financial gain. I’d also point out that Dr. Darren B. Schneider was quoted as a member of the Society for Vascular Medicine. I guess we need to work harder on our branding.
Dr. Mark Morasch: Remember, all politics are local, and any meaningful change needs to come from the grass roots.
Experts can write guidelines, specialty societies can make statements, and newspapers can print articles but the most influential transaction occurs in the exam room when we are face to face with our patients.
Remember, even though we are a small group, we can have great influence when we always, always, always do what we know is right.
Dr. Alan M. Dietzek: Dear Patient, Let me introduce myself. I am a Board-Certified Vascular Surgeon. My specialty is unique in that I am well versed and formally trained in both the medical and surgical management of peripheral vascular disease. No other specialist can make this claim.
Most often, vascular problems can be managed conservatively with a combination of risk factor and lifestyle modification, and occasionally prescription medications, all of which I can outline and or prescribe for you. When necessary, however, I am prepared to treat your vascular problem with either a minimally invasive procedure or open surgery depending on which treatment will provide you with the best outcomes. Again, only a vascular surgeon is capable of offering you these treatment options. I am dedicated to your well-being. I am a Board-Certified Vascular Surgeon
Dr. Murray L. Shames: The recent New York Times article, “Medicare payments surge for stents to unblock blood vessels in limbs,” brings up a critical issue in how we train our residents to think and practice in the future.
Our current generation of residents is faced with a tremendous financial burden of medical school debt, and they are being offered highly competitive salaries after graduation.
The motivation to join groups with outpatient vascular centers is certainly attractive: Why not have autonomy from the hospital, control your work environment, and increase efficiency. As educators we must continue to use clinical evidence and societal guidelines (J. Vasc. Surg. 2015:1-40) to guide our clinical practice.
As vascular surgeons we have been trained to manage asymptomatic PAD and intermittent claudication nonoperatively due to it’s relatively benign natural history; endovascular interventions have dramatically increased the treatment of claudication, even in our own hands. We must continue to teach our residents restraint and to consider the impact of the interventions we perform. That way we can maintain our status as the leaders in vascular disease management and not just “interventionalists” that treat lesions.
Dr. Joann Lohr: The presence of a stenotic lesion does not mandate treatment either with a stent or surgical intervention but needs critical assessment of the impact on the patient’s quality of life. Risk factor modification needs to be undertaken before any intervention and will improve outcomes and durability of repairs. The only outcome that matters is the patient’s.
“How does treatment of this lesion change my lifestyle?” is a question that needs to be answered for each patient. Treating physicians need to establish long-term relationships.
Never be afraid to tell patients a procedure is not the first line of treatment. Thoughtful application of new technology is needed in all areas of medicine. Just because we can, should we? Appropriate individualized treatment plans and goals need to be established for each patient we treat.
Dr. Larry Kraiss: Vascular surgeons provide the full spectrum of care for PAD from medical management through intervention to the unfortunate situations when amputation is necessary.
The more sobering of these experiences have imbued most of us with a healthy respect for how an intervention can go wrong. If you haven’t had to explain to a patient or family why an amputation is necessary, you probably don’t have the same concern.
Thus, many of us have a very conservative approach to PAD intervention; primum non nocere is the governing principle. This principle is supposed to guide the actions of all physicians but I can’t help but wonder if something happened to primum non nocere on the way to the outpatient endovascular center.
When physicians become financial stakeholders in these enterprises, a pernicious incentive is introduced that is almost impossible to exclude from daily clinical decision making. Hospital-based physicians are also subject to temptation to perform unnecessary yet lucrative procedures but at least these are being done more in the open.
I suspect that the development of these centers has allowed much activity to occur that would rightly be condemned under the scrutiny of one’s hospital peers.
Dr. Laura Drudi: It really comes down to adequately informing the patient. I always find it astounding how many patients I encounter asking me in a timid tone, “What exactly did I have done on my leg?” I question what patients actually understand and retain after being overwhelmed by the informed consent we have prior to an intervention.
I see first hand the catastrophic failures of intervening on severe claudication leading to limb loss and worsening of quality of life. It’s disheartening to see adverse outcomes following vascular interventions either by vascular surgeons or other interventionalists, but I believe that if you are performing an intervention you should have the expertise and technical skills to deal with the complications.
The best interventionalists know when not to intervene and that should be the mantra we live by. We should be advocates for our patients at a local institutional level as well as a public level. I believe that following the New York Times article the public will be more aware of the potential for inappropriate or unnecessary interventions, many of which are being performed by specialists other than vascular surgeons.
The Society and individual vascular surgeons should capitalize on this opportunity to educate patients as to the benefits of consulting with a vascular surgeon before undertaking any endovascular procedure.
Dr. Elliot L. Chaikof: Both government and private payers have a vested interest in ensuring that patients receive the highest quality care, while reducing the unsustainable rate of increase in health care costs. In Massachusetts and elsewhere in the United States, this has led to the introduction of new risk contracting models that features a global payment with incentives linked to efficiency and quality.
At our institution, approximately 60% of patients are now in such risk contracts. Primary care physicians are most directly incentivized and, along with government and private payors, are highly motivated to ensure that our population of patients receives the right care, at the right time, from the right physician. The U.S. health care system continues to be in a state of flux with substantial regional variations in the delivery of care and how that care is financed.
Despite these challenges, the Society for Vascular Surgery can best serve our patients through advocacy and education, including promoting the need for full transparency of costs to our patients and their physicians. This would be most effective in active partnership with primary care providers, along with regional and national payors.
Dr. Erica L. Mitchell: The line separating a business from a profession is not entirely clear when professionals engage in business practices that serve to benefit the individual financially.
One crucial difference distinguishing the profession of medicine from other professions is that physicians have a fiduciary duty toward those whom they serve. This means that we have a legal duty to provide services to our patients that place the patient’s interest above our own financial interest.
This article highlights how legal and ethical issues arise if health care professionals forgo their fiduciary duties for personal gain. Unethical physicians should be held accountable for unethical practices.
Dr. Larry Scher: The recent article by Julie Creswell and Reed Abelson in the Jan. 29, 2015, New York Times highlights a recent problem in the care of patients with peripheral vascular disease. Vascular surgeons have been treating peripheral arterial disease for over 50 years and have generally adopted a conservative approach toward patients with claudication, emphasizing risk factor modification and exercise.
This is based on an understanding that the disease is benign, rarely progressive, and only occasionally disabling to the point that intervention is indicated for symptom relief.
With new minimally invasive techniques available and specialists other than vascular surgeons performing peripheral catheter based procedures we seem to have forgotten all that vascular surgeons have learned over the past 5 decades.
Most patients with claudication do not benefit from and may be harmed by interventions when long-term rather than short-term outcomes are analyzed. Although practitioners such as those identified in this article may believe they are pioneers in the treatment of peripheral arterial disease and specifically claudication, I would consider them cowboys who have forgotten the lessons of the past.