Still no matter what anyone said, I knew in my heart that endovascular grafts and endovascular aneurysm repair were going to be a game-changer and that vascular surgeons had to get involved to prevent interventional specialists from taking the lead in this technology. In other words, if vascular surgeons did not embrace endovascular skills and techniques, they would rapidly be replaced by interventionalists in cardiology and radiology, and vascular surgery would become diminished or extinct as a specialty. We would be out of the game. And I did not want this to happen.
I made this point most emphatically in 1996 as the president of the Society for Vascular Surgery. My presidential address to the esteemed SVS was titled: “Charles Darwin and Vascular Surgery.” It was a speech that certainly went against the grain as it dealt with the evolution of vascular surgery and how we had to change and evolve as a specialty in order to survive and prosper.
For starters, you might wonder: What was the possible relevance Darwin, the famous English naturalist and the father of the theory of evolution, could have to vascular surgery?!
I first recounted Darwin’s theory of evolution by natural selection, first formulated in his book, On the Origin of Species by Means of Natural Selection, or the Preservation of Favoured Races in the Struggle for Life. In this classic volume, published first in 1859, Darwin pointed out the process by which organisms change over time as a result of changes in heritable physical or behavioral traits. Changes that allow an organism to better adapt to its environment will help it survive and have more offspring.
Using Darwin’s work as a metaphor, I likened specialties to species and indicated that medical specialties, like species, had to evolve and become different from their ancestors if they were to avoid extinction and survive. I also made three predictions and associated recommendations for future survival adaptations. Two of these recommendations proved to be unworkable or unsuccessful. One proved to be remarkably right.
One errant recommendation was that we work collaboratively and congenially with interventional radiologists or cardiologists in dedicated vascular centers. The idea was that we could learn from one another, sharing our skill sets for the betterment of all. That kumbaya recommendation proved unworkable because of medical tribalism, competitive human nature, and greed. The three specialties involved in treating blood vessels—vascular surgeons, interventional radiologists, and interventional cardiologists—all wanted to be dominant and in control of patients and the resultant dollars earned.
A second recommendation was that vascular surgery become more independent as a specialty, separate from general and cardiac surgery, just like the specialties of neurosurgery, orthopedics, urology, obstetrics and gynecology, plastic surgery, and cardiothoracic surgery.
As I wrote: “Vascular Surgery’s evolution and separation are inevitable because its members are better adapted, more ‘fit’ by virtue of training and experience to care for vascular disease patients … Darwin would predict that forces of evolution will result in the distinct separation of our specialty … which would eliminate much conflict of interest and probably be best for all concerned,” most notably the vascular patients that we served.
With that point in mind, I knew that we, as vascular surgeons, needed to separate administratively and gain an American Board of Medical Specialties (ABMS)–recognized governing board and Residency Review Committee (RRC). A vigorous attempt to accomplish this was made between 1996 and 2007, but failed. As a result, vascular surgery still remains a subservient subspecialty in North America, although it is not in most other parts of the civilized world.
My third recommendation in 1996 was prophetic and fared better. I predicted an endovascular revolution and recommended that vascular surgeons had to become competent in all endovascular techniques, embracing and practicing these new techniques. Otherwise, they would risk extinction.
In this 1996 address, I predicted that within ten years, 40 percent to 70 percent of the open operations we were then doing would be replaced by endovascular procedures. And many of the remaining “open” operations would be improved and simplified by using the endovascular adjuncts that were available (such as catheters, guidewires, sheaths, digital fluoroscopy, balloons, stents, and EVGs). All this certainly turned out to be true in spades!
Accordingly, in this 1996 address I recommended that vascular surgeons, if they wished to survive, had to become endo-competent, acquiring catheter-guidewire-imaging skills that would enable them to perform all sorts of endovascular treatments.
Although this recommendation was greeted with disdain and strongly resisted by many senior vascular surgeons at the time, this resistance was gradually overcome. Our specialty has embraced the endovascular revolution and become endo-competent. This is why vascular surgery is doing as well as it is today. Indeed, vascular surgeons often lead in developing many of the evolving endovascular procedures that are currently the standard of care.
Yet this speech, like the one two years before, was greeted as far-fetched and wrong-headed by many of the vascular leaders of the day—certainly by the older ones. But no matter. Here it is twenty-six years later and up to 80 to 95 percent of all vascular lesions are or will be best treated by endovascular means, though some vascular patients still require open operations.
Frank Veith is a vascular surgeon and author of The Medical Jungle: A Pioneering Surgeon’s Battle to Revolutionize Vascular Care and Challenge the Medical Mafia.