It all started around the late 1970s, early 1980s. Back then, recalls Frank J. Veith, MD, the notion of aggressively pursuing limb salvage in a gangrenous foot or toe went against the grain of current thinking. What Veith and his colleagues were undertaking represented “very distal bypasses,” and, at the time, what he was doing seemed to amount to virtual heresy, he muses. No one else seemed to accept the legitimacy of the surgeries. Yet they worked, says the vascular surgery luminary, former Society for Vascular Surgery (SVS) president, and current chairman of the internationally renowned VEITHsymposium.
“Everybody thought, if you had a gangrenous foot, toe or any kind of ischemic lesion of the foot that was due to atherosclerosis below the groin, that the right treatment was an amputation,” Veith tells Vascular Specialist. “We were amongst the first to start advocating aggressive limb salvage. We were able to save, I guess, more than 90% of the patients that presented with limb-threatening ischemia, to save their leg.”
Veith was speaking shortly after the occasion of a new Vascular Annual Meeting (VAM) named lectureship being announced by the SVS—in his honor—that will focus on peripheral arterial disease (PAD) and, in particular, limb salvage. Coined the Frank J. Veith Lecture, the maiden talk is set to take place next year at VAM 2023 in National Harbor, Maryland (June 14–17).
The focus of the lecture, Veith says, bears particular importance for the SVS amid the currently crowded field of physicians from other specialties involved in the treatment of PAD. It was vascular surgeons who originated the treatment for limb salvage, he continues, and so it is vascular surgeons who should lead the limb salvage charge going forward. “Now, of course [limb salvage] surgery has been accepted around the world, and, even more importantly, we were among the first to do percutaneous angioplasties in association sometimes with a bypass,” Veith elaborates. “But now the treatment has largely become interventional—I’d say 75–80% of limb salvage procedures are done endovascularly—and the field has exploded. Now the other interventional specialists, like interventional cardiology and interventional radiology, are becoming strong advocates of limb salvage.”
Despite being progenitors of the procedure, Veith says, in many communities vascular surgery is gradually losing out to these other specialties. “I think the SVS putting emphasis on these procedures, some of which are going to require open vascular surgery, many of which will be done interventionally by vascular surgeons, I think is going to go a long way to maintaining vascular surgery’s leadership in this area.”
Placing a focus on limb salvage might also help attract up-and-coming vascular trainees and surgeons to a largely unglamorous area of the specialty, Veith adds. “We think that this lectureship will promote progress by vascular surgeons in the sometimes-unpopular field of lower-extremity revascularization. Right now, everybody is interested in fenestrated and branched endografts and treating big, complex aneurysms. That is an important field, and the advances are really quite dramatic. But the less glamorous field of treating patients with limb-threatening ischemia, I think, is extremely important for vascular surgery to maintain a leadership position in.”
For medical students, trainees and emerging surgeons who might be viewing the broad swathe of vascular surgery with a curious eye, Veith has a succinct message. “Sometimes it’s best, if you want to achieve leadership in a specialty, to go into a field that is not primarily popular,” he says. “In other words, don’t try and replace all of the extremely skillful vascular surgeons doing these complex aneurysm repairs endovascularly—go into a field that is maybe a little less glamorous and sub-specialize in it, and you may achieve prominence more quickly than you might if you went with the crowd.”
