Malachi Sheahan III, MD, Vascular Specialist’s medical editor, speaks to living legend and limb-salvage pioneer Frank J. Veith, MD, on the contents of his hard-hitting new book, The Medical Jungle: A Pioneering Surgeon’s Battle to Revolutionize Vascular Care and Challenge the Medical Mafia, ahead of the inaugural named lecture established in his honor taking place at this month’s Vascular Annual Meeting (VAM).
Frank Veith needs little introduction to the world of vascular surgery, either in the United States or anywhere around the globe. He is one of the profession’s pioneers. A vascular working life that started more than a half century ago, Veith’s book—memoir-cum-manifesto—covers the highlights from the start, middle and later parts of his career. VAM will see the birth of its fulcrum: The Frank J. Veith Distinguished Lecture was announced during VAM 2022 in honor of the former SVS president’s near-career-long dedication to the avoidance of amputation, and will focus on the recently published BEST-CLI trial. The talk is to be delivered by trial principal investigators, Alik Farber, MD, and Matthew Menard, MD, and will look at the journey that resulted in BEST-CLI’s evidence, and what lies beyond it for the treatment of CLTI.
Veith devotes a significant portion of The Medical Jungle to limb salvage, as well as topics ranging from his early work in lung transplantation, his involvement in North America’s first-ever endovascular aneurysm repair (EVAR), to the question of vascular surgery as an independent specialty and his philosophy on the mentorship of trainees. Here, he tackles these themes and more in a frank exchange, which is an edited version of a video interview that features as a VAM 2023 special on the Vascular Specialist website.
MS: Dr. Veith, in your book, you describe yourself as extremely shy as a student and early trainee. How do you account for the evolution in your personality?
FV: That’s a great question. I don’t know how to answer. I still consider myself pretty shy. You know, I don’t jump up and ask questions at meetings, and stuff like that. I had to be a little more forceful and outgoing. With practice, you get better at public speaking, but I would always get nervous when I would give a talk, particularly at a big meeting. But somehow, you get through it. And if you prepare, things usually go pretty well.
MS: For vascular surgeons of my generation, it’s really fascinating to see how much we were involved with transplant surgery in the early days. Can you describe how you got interested in transplant surgery—and as a profession, did we drop the boat on this?
FV: Well, it was very simple. I trained at the Brigham with Franny Moore and Joe Murray, who were pioneers in kidney transplantation and, to some extent, in liver transplantation … But I also wanted to be in an area that was somewhat unconquered and that got me into lung transplantation, which really had not been done with any degree of success. So we started out by trying to figure out why [lung transplantation] hadn’t been successful. Because it was just another organ that involved some vascular surgical techniques [in order] to do the transplant.
MS: You describe very well in the book how you looked to differentiate yourself—and you really took to limb salvage early on. Can you describe how that came about?
FV: It was, of course, when I went to Montefiore, which was, in New York City, really a second-rate, or somewhat second-rate, institution in the Bronx. It was not glamorous, like Cornell, Columbia, Mount Sinai, NYU [New York University]. I wanted to do the normal stuff, aneurysms, carotid, etc., and we didn’t have many of those cases for a variety of reasons. We did have an abundance of poor patients with threatened limbs—with gangrene or ulceration—who were faced with amputation, and the thinking of the day was, well, “If they have such a limb-threatening lesion, they need a below-knee amputation and ‘rapid rehabilitation.’” We found that that didn’t work. So we started with great care and concern, obviously, to challenge the thinking of the day, which was not to do reconstructive vascular surgery for limb salvage. We found that if we were very careful with our techniques, using some of the methods that I’d learned to do—AV [arteriovenous] fistulas, micro and semi-micro anastomoses—that many of these limbs could be saved. We were able to save more than 90% of the patients who presented to us with a threatened limb.
MS: You were also one of the early advocates—maybe the first—for EVAR for ruptured aneurysms. Can you tell us a bit more about that?
FV: We actually did the first-ever EVAR outside of Argentina. That was a stroke of good fortune. As I say, I had always been interested in endovascular techniques because I’d become very friendly with Barry Katzen, a well-known interventional radiologist. Because of our friendship and my early support for him, he used to invite me to his interventional meetings. So I was exposed to the benefits of those endovascular techniques. And I was a very early believer, despite many of my colleagues not being believers in angioplasty, stenting, and so forth. I was always interested in the idea of doing EVAR because we had a lot of very sick aneurysm patients who didn’t do well with an open aneurysm repair. When that became available, we embraced it. Remarkably, we were very lucky that the procedure proved to be a big success. The patient— who was totally inoperable and with very bad heart and lung disease—got better. He was up and sitting in a chair reading Playboy the next day. For me, that was an epiphany. I said, “God, if we don’t—as vascular surgeons—learn how to do these techniques, we’re going to be out of a job and become extinct.” … Of course, nobody believed us again. It was very discouraging. But then, with time, after about four or five years, and persistence in presenting our work, and because of our unbelievable successes in these very difficult patients, other vascular surgeons started to embrace the technology.
MS: You were an early proponent of collaboration with interventional radiology. And during your SVS Presidential Address, collaboration was one of your three missions for our specialty. You say later that we failed. Why do you think things happened that way?
FV: Human nature. The book highlights a lot of the frailties, or bad traits, of human nature that you don’t think are going to apply in medicine. I mean: lust for power, control, self interest, greed and, sometimes, jealousy. We’re certainly as separate as neurosurgery or orthopedic surgery, or gynecology, and, yet, that barrier has not yet been breached. I’m not fighting it anymore, but I think, sooner or later, we have to come into accordance with other countries. Vascular surgery should be a totally separate specialty. Why? Because we sort of are: we don’t do general surgery anymore. We may cover for them, but we really are separate because we’re different. Our techniques are different. And we certainly need the separation from interventional cardiology and interventional radiology that will allow us to compete with them on a level playing field. Because interventional cardiology, who are very talented and very much supported by institutions, outnumber us by about five to one.
MS: Your ideas were in many ways the father of the Heart and Vascular Center concept.
FV: Yes. We tried to do that. [But] either a chairman of radiology, or perhaps the chairman of surgery, and other places, didn’t want to let go of their patient loads, etc. One of the recommendations that I made, way back in 1996, was that we have vascular centers that were independent of medicine and surgery, and radiology, and could function as isolated centers. That just didn’t work in many cases. In a few places it worked, but, in most cases, either a surgeon or medical specialist, or interventionalists, wanted to be dominant. We felt that that is not going to work—that you have to share leadership, you have to share financial rewards, and you have to teach each other without being threatened. And that, of course, is not easy.
MS: Turning toward the creation of the VEITHsymposium and your ideas in developing it—what was lacking in terms of vascular gatherings at that time? What was the niche you were trying to fill with the symposium?
FV: I had great good fortune because the meeting was started as a very small meeting by Dr. Henri Haimovici, who was a prominent vascular surgeon, very academically oriented, and very smart in writing and speaking. It was a tiny meeting. It had maybe 10 or 12 faculty and less than 100 attendees. It was in a fleabag hotel in New York. So when I became chief [at Montefiore], I inherited that meeting. Again, we were lucky. It was in New York, which was easy to get to. We embraced industry from the beginning, which no one else was doing at that time. Coming up with the idea of the short talk—again, good luck, more than good thinking—was so I could get more faculty on the program. And, gradually, we grew to the point where it became a major international vascular meeting. We also embraced—from the very beginning—interventional radiologists and cardiologists because they had a lot to contribute.
MS: One of your other goals for the specialty outlined in your Presidential Address—which I think you have falsely characterized as having failed—was independence for vascular surgery. I think that what I hear from you is you don’t understand how much you actually won, and how different things are than when you started. It is difficult for people of a certain generation to know how subservient we were to general surgery, especially in the 1970s, 80s and 90s ,when we were basically not even a subspecialty of general surgery at times.
FV: We did make some inroads. I mean, we got residencies that were zero and five—vascular surgery residency. But the problem now is in many institutions—and I’ve been in two of them, or maybe three actually, because you can include the Cleveland Clinic—vascular surgery doesn’t [have independence] because it’s not a separate specialty. It doesn’t have a seat at the table where resources are doled out. You have to go through your general surgery chairman, or your cardiac surgery chairman, in order to get a sign off on what you want to do—and we really are a separate specialty. We’re certainly as separate as neurosurgery or orthopedic surgery, or gynecology, and, yet, that barrier has not yet been breached. I’m not fighting it anymore, but I think, sooner or later, we have to come into accordance with other countries. Vascular surgery should be a totally separate specialty. Why? Because we sort of are: we don’t do general surgery anymore. We may cover for them, but we really are separate because we’re different. Our techniques are different. And we certainly need the separation from interventional cardiology and interventional radiology that will allow us to compete with them on a level playing field. Because interventional cardiology, who are very talented and very much supported by institutions, outnumber us by about five to one.
MS: This brings us to the topic of energy. With all of the things you’ve achieved, I think what we all want to know is: where do you get your energy?
FV: It’s luck and genes. I mean, the two things that you obviously have, and I was greatly fortunate to have, was pretty good health. And if you don’t have your health, you don’t have your energy. If I get tired now, everything sort of stops. So you have to keep at it. That’s your genes and your parents, and you can’t do anything to pick them. And then commitment to want to do stuff that matters.
MS: The last section of the book is on mentorship. I think I’m probably one of the last American vascular surgeons who you did not train. What do you think is the key to mentoring our trainees?
FV: Some of it is luck. I always picked people who wanted to go into academics, and then I would beat them unmercifully to publish stuff, and they used to joke about it and belittle me for it. But the other thing is to treat people at all levels well and as equals. You’ve got to pay people well. You split the income pretty much—as bad as that can be in vascular surgery. Sometimes, you split the good cases and you put your trainees as first authors on papers, even though you may end up writing the paper. And, they sort of get the bug. Nobody is going to remember what I did in 10 or 20 years. But hopefully the people that I train know that I helped them get to where they are—that’s a good legacy, because they’ll be around for a long time. It goes against human nature, but you’ve got to be forcefully unselfish. Because, in the end, it comes back to benefit your interest a lot more if you support people than if you exploit them.