IIb or not IIb?

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I must admit that Shakespeare was not one of my favorite subjects at school. However, his words have relevance to some of my thoughts about vascular surgical issues. In a previous editorial I adopted his words to describe how, with the increasing representation of women and minorities, we have matured from a “Band of Brothers” to a “Band of Brothers and Sisters.” Now, Shakespeare once again resonates with Hamlet’s inward-looking and existential “To be or not to be?”

For vascular surgeons are in an introspective mood as we re-evaluate our collaboration with other specialties to determine the best treatments for our patients. Increasingly we are developing our own guidelines, white papers, and position papers rather than appending our insights to initiatives originated by the American College of Cardiology. Whereas we were fundamental in the formation of the original “Trans-Atlantic Societal Consensus (TASC)1,” SVS as well as the European Society for Vascular Surgery (ESVS) and the World Federation of Vascular Societies (WFVS) have declined participation in further TASC iterations.

Dr. Russell H. Samson

The fracturing of TASC began with controversy and strong differences of opinions raised by TASC IIb. Fundamental issues of process, governance, conflict of interest (COI), evidence base, and appropriate representation were raised and debated. In the end the SVS and other international vascular societies determined the TASC construct was not workable, and a new Global Vascular Guidelines initiative was born.

Under the co-leadership of Mike Conte (SVS), Andrew Bradbury (WFVS), and Philippe Kolh (ESVS), our surgical societies are developing practice guidelines reflecting the international consensus of vascular surgeons as well as other specialists directly involved in the care of vascular patients. This group is committed to an evidence-based approach and a strong COI policy that will hopefully insulate treatment algorithms from what many believed was the excessive influence of industry and “market forces” reflected in TASC IIb.

The proposed guidelines will no longer simply be lesion based. Rather, they will evaluate the patient and disease process, taking into account the potential benefit of both endo and open vascular procedures. It’s not that vascular surgeons are unsupportive of endo techniques. In fact many endo procedures have emerged from the inventive minds of vascular surgeons from all over the world. But only surgeons who can offer all treatment modalities can fully appreciate when an open procedure is still the best option, or that the disease process may be more benign than the planned treatment.

What we have gained and what have we lost by our withdrawal from communal involvement with other specialists is not altogether clear. Vascular surgeons have pioneered many of the major advances in our understanding and treatment of vascular diseases from the various bypass operations, through vascular lab testing to advances in endovascular therapy.

Nonetheless, we should not discount the contributions of our medical colleagues. Physicians from other disciplines pioneered endovascular therapies that many of our vascular surgeon predecessors claimed would never work. Medical management prevents thrombosis, keeps our patients alive and our bypasses and stents open. We must also acknowledge that there are many highly qualified physicians in other specialties who are equally devoted to improving the care of patients with vascular disease.

At present there are almost 5,000 U.S. vascular surgeons, and even more globally. Almost every developed nation has a vascular surgical society, and some even have a designated specialty of vascular surgery. Yet it seems we still do not have the numbers to be universally recognized for our expertise. However, our comprehensive training and knowledge have given us the self-assurance and confidence to claim that our specialty is uniquely qualified to take the leadership position in the management of vascular conditions.

So, “IIb, unquestionably, will not be” but, unlike Hamlet, we need not despair. TASC may have failed but we will not!

1) Eur. J. Vasc. Endovasc. Surg. 2007;33 Suppl 1:S1-75.

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