Future challenges for vascular surgeons


How does one talk about the future? We start with a look at our recent past. We looked at our recent work in five areas, carotid disease, aortic disease, peripheral vascular disease, basic science research, and outcomes research published in our “Bible,” the Journal of Vascular Surgery.

First let’s talk about carotid disease. We chose the article from the Vascular Study Group of New England titled Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival by Wallaert et al. (J. Vasc. Surg. 2013;58:112-9). This article emphasized the importance of our Vascular Quality Initiative (VQI). I believe our VQI registry is one of the most important contributions that SVS has made to outcomes research. In this article, they look at the optimal selection of patients with asymptomatic carotid artery disease to answer the question, when do you do CEA in asymptomatic patients?

Dr. Julie A. Freischlag

The current guidelines tell us that it is when your risk of perioperative stroke or death is less than three percent and patient’s life expectancy is greater than five years. The Vascular Study Group of New England looked at long-term survival in their database to see if they could predict who would benefit from a CEA. All of us have a thought about what it is, but this study actually gives us data. They looked at minor risk factors and major risk factors, such as age, renal failure, diabetes, and contralateral occlusion and high stenosis, and showed those patients don’t do as well. There is a differentiation in five years.

That doesn’t mean that every old, contralateral occluded, diabetic person you see shouldn’t get an operation, but it does show that it’s something you should know in your practice. It’s something you should review with your patient, that there is a differentiation between patients and their outcomes.

If you are doing a prophylactic operation, the patient needs to live in order for you to prophylax them, and this article helps you determine which patients will benefit.

For aortic disease, we chose this article from the Cleveland Clinic, titled Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms by Kitagawa et al. (J. Vasc. Surg. 2013;58:625-34).

This group examined the use of fenestrated devices in the repair of chronic type B aortic dissections, using good data and follow-up. The authors looked at dissections that were very limited and those that were complicated. What they found is that the outcomes with limited dissections are quite good, but extensive dissections do have more problems, specifically endoleaks. However, the bottom line is that this new endovascular approach gives very good results for high-risk patients who would not do well with open surgery for this complex problem.

Now, for peripheral vascular disease, we really are lucky to have this study, Three-year results of the VIBRANT trial of VIABAHN endoprosthesis versus bare nitinol stent implantation for complex superficial femoral artery occlusive disease by Geraghty et al. (J. Vasc. Surg. 2013;58:386-95), because one of our strengths as vascular surgeons is the prospective randomized trial.

The VIBRANT trial looked at the Viabahn endoprosthesis versus the bare nitinol stent in complex superficial femoral artery occlusive disease.

The study shows that primary patency – which now goes out to almost three to five years – primary assisted patency, and secondary patency were similar in both groups. Thus the more expensive covered stent is not better than the bare nitinol stent in SFA disease. What I found impressive is that patency overall is quite good. It does appear, with our medications and our choices of patients, that patency rates are reasonable three to four years out.

Our basic science research study, Alpha1-adregergic receptors mediate combined signals initiated by mechanical stretch stress and norepinephrine leading to accelerated mouse vein graft atherosclerosis, by Liu et al. (J. Vasc. Surg. 2013;57:1645-56), focuses on intimal hyperplasia.

The authors examined the effects of mechanical stretch, which we know causes intimal hyperplasia, and norepinephrine on vascular remodeling. They found that adrenergic receptors mediate both pathways, leading to proliferation of vascular smooth muscle cells and accelerated intimal hyperplasia. Their data suggest that perhaps a drug aimed at these receptors could ameliorate some of the development of intimal hyperplasia. They go on to show that this is indeed the case in their model, and this has important clinical implications.

Lastly, we come to outcomes research. We chose this article by Vogel and Kruse, titled Risk factors for readmission after lower extremity procedures for peripheral artery disease (J. Vasc. Surg. 2013;58:90-7). We’ve heard for years from many of our heroes in vascular surgery, that outcomes are everything. We have outcomes–we know if our patients are dead or alive, leg on or not, stroke, yes or no. But now we are going to be able to do that with VQI.

This study looked at whether our minimally invasive procedures are associated with decreased readmission, versus our open ones with peripheral arterial work. They looked at what made people come back in the hospital, and it doesn’t look like it’s the procedure. It’s the patient. We’ve seen this in many other diseases. It’s the frailty and the inability of the patients to take care of themselves at home that gets them back. In this study, risk factors are male gender, sepsis, longer hospital stay, elevated liver enzymes, and increased medication use.

That’s a snapshot of what I see of our issues, making sure we have outcomes registries, continuing prospective randomized trials, basic science research, and if you are using new devices, comparing them to know whether they’re better, or at least as good as current ones. As we go forward, we will have to prove those things. I am confident that we will face whatever challenges happen with good data and excellent care for our patients.

Dr. Freischlag is the SVS President. Her comments were edited and condensed by Natalia Glebova, MD, from a presentation at the Northwestern Vascular Symposium in December 2013.


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