Jean Panneton, MD, considers himself what he terms a “blue-collar” vascular surgeon as much as one engaged in academic practice and the necessity of helping contribute to the next generation of vascular surgeons. He operates. And he operates a lot. But he is also a professor of surgery, and a program director in charge of turning out vascular trainees so important to the future of the specialty. For him, the rigors of both silos, brisk practice and academia, coalesce in his everyday working life—and they also underpin the thrust of the message he was trying to send in a recent turn at the lectern as well as in this interview.
“Blue refers to the fact you have to take care of business, take care of patients,” Panneton, a vascular surgeon with Sentara Vascular Specialists and chief of vascular surgery at Eastern Virginia Medical School in Norfolk, Virginia, tells Vascular Specialist. “Because when you work in a non-academic center per se, and non-university hospitals, some of these places are very busy, high volume, so that is where that statement comes from.” When he used the phrase as he delivered the Robert R. Linton Lecture at the 2024 annual meeting of the New England Society for Vascular Surgery (NESVS) in Portland, Maine (Oct. 25–27), he got a few laughs, but a seriousness underpinned it. “The changing landscape of aortic surgery” was the title. The message was twofold: the shift in volume from open surgery to endovascular therapy and the new language and complications that have come with it, alongside the impact this evolution has had on the open surgical skills with which graduating trainees emerge from residency and fellowship.
“With endovascular therapy comes an increased need for reintervention and the concept of new types of complication—endoleaks for example, graft migration too,” he says. “These never existed before. And how has this shift affected training? Nowadays, a lot of the recent graduates are not comfortable with open aortic surgery.”
Nationwide, there is a growing realization of the issue and the need to address it—regionalized aortic care, an aortic fellowship, simulation, trainees rotating to high-volume centers are among the remedies circulating— but Panneton is not sure scalable solutions to remedy the deficit are close. “For now, it’s not necessarily a crisis but it could become one,” he says. “Because when you look at the median age of currently practicing vascular surgeons, and how a lot of them have significant open aortic skills, in the next 10 to 15 years, a lot of those surgeons will end up retiring. It’s crucial that before this wave of vascular surgeons with open aortic skills retire that they transmit the skills to the younger generation. Some of those surgeons do not work in a place where there is a formal ACGME [Accreditation Council for Graduate Medical Education] training program. One way for these skills to be transferred might be for trainees to continue to look, wherever they end up after completing training, at their job as an apprenticeship mode, where junior surgeons can really be tagged to more senior surgeons who can share some of that experience with open aortic surgery to junior partners.” Still, Panneton adds, absent a formal way of measuring knowledge transfer and aortic care skill acquisition outside of the standard structures of ACGME programs and American Board of Surgery (ABS) exams, scalable solutions remain to be developed.
On the other hand, there is the other side of that training deficit, the endovascular revolution, the one for which Panneton had to learn a new language and new way of doing things, and it has tracked his 35-year career. The new language signposted those new complications but, importantly, came along with reduced mortality and morbidity. “One of the exciting things of this move toward endo has definitely been the evolving technology that has gone hand in hand with that shift,” he says. “Over 30 years of implanting endografts, from gen-one devices to the next-gen devices, has been phenomenal. Industry has done a fantastic job of trying to improve devices year after year. We started with simple EVAR [endovascular aneurysm repair], to now being able to do fenestrated or branched repairs for TAAA [thoracoabdominal aortic aneurysm] and endovascular repair of aortic arch pathology as well.”
Complex problems and devices to match brought with them not only issues related to complications but others like repair complexity, high costs and the need for additional devices such as bridging stents. Thus, Panneton says, the necessity of simple solutions and devices endures. He points to in situ laser fenestration, for example, which “can be done in a very simple, effective manner, and those devices have a smaller delivery profile than more complex devices. The operations tend to be quicker, and with less manipulation.” On the topic of in situ fenestration, Panneton’s group has a paper due at the 2025 annual meeting of the Southern Association for Vascular Surgery (SAVS) in St. Thomas, the U.S. Virgin Islands ( Jan. 22–25), in which they look at a 15-year experience of the technique in zone 2 thoracic EVAR (TEVAR). The paper will report “a very, very low stroke rate,” Panneton says. “It’s also very durable.” His first patient received the procedure in August 2009, with that subject representative of quite a few others among the cohort, he adds: an intact fenestration, patent vessel and no fenestration-related complications.
Alongside complexity sit an aging patient population, increasing prevalence of vascular disease, and, therefore, a need for more vascular surgeons. Up come those training questions again: Panneton sees a need for an increase in the number of vascular surgery training programs. While the level has been steadily increasing, he notes, it “is not increasing fast enough. What’s predicted is a deficit in vascular surgeons. There is also a generational shift, with the newer generation not necessarily looking at working as a surgeon in the same way we previous generations looked at it.” Which is to say, work-life balance has taken root, further shaping the face of the workforce and needs of the workplace, Panneton observes. Running in tandem are increased demands on vascular surgeons—the expansion of peripheral arterial disease (PAD) treatment, pulmonary embolism response teams (PERTs), wound care, and, an area previously the preserve of cardiac surgery, the aortic arch. “When a hospital has a TAVR [transaortic valve replacement] program, they cannot exist without vascular surgeons,” he continues. “We get called a few times per week for structural heart. There has been an increase in the demand for vascular surgeons because the work has diversified even more.”
As a result, another evolution plays out. “Vascular surgery is evolving like general surgery,” Panneton reasons. “In the past, general surgeons took care of everything. But now, there are general surgeons who do only trauma, or oncology surgery, or colorectal surgery. We are seeing that start to happen with vascular surgery. Some only do vein procedures, because they tend to be elective, which is a much more controlled thing. Some do wound care or work in a limb salvage clinic. There are some, like me, who you might consider an aortic surgeon, as the majority of my practice is aortic stuff. That is one way for the workforce to deal with the demands of practice in the future.”
Yet, the training imperatives of aortic surgery remain, adds Panneton. “That is the most high-risk and most likely to be the one to require additional training, as opposed to other ‘sub-specialties’ within vascular surgery, which are not quite the same level of complexity and risk.”
