Cardiac Surgeons performing Vascular procedures?

[Mitral_Prolapse]

Hey,

I have noticed this question posted more lately and was wondering what the deal was with this. Are cardiac guys doing vascular work since there is apparently a vascular surgery shortage? Is this allowed without B/C in vascular surgery? Are the vascular procedures all open or some endovascular? I'm just a lowly DO med student still so excuse me if I come off as ignorant with these questions. I'm not trying to spark a turf war or anything and never wanted to be "that guy" who is B/C in 4 different sub-specialties for hubris I just find it kinda cool that these guys could do some valve and aorta work as well as a AAA or PAD or fistula creation, really well-rounded. Do you learn these skills in CT or General Surgery (if you took that route which most CTs did at this time) since Vascular Surgery was once a big part of the General Surgery umbrella? What about the endovascular part? Also I found this article which has some of my questions answered https://www.annalsthoracicsurgery.org/article/S0003-4975(16)00089-8/pdf but I would like to hear it from some of the pros in the community.

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[Dr.LeoSpaceman]

My outsiders view of the situation:

 

[LucidSplash]

Some CTS do some vascular work like carotids, AAA, bypasses, basic PAD stenting, basic dialysis access. Most that I know of don't really WANT to do most of this, but if they are not at an academic center and are private practice, many will do because there is a need and to supplement their income. But not all do it an you can avoid doing it as CTS if you really want to.

 

[Mitral_Prolapse]

Some CTS do some vascular work like carotids, AAA, bypasses, basic PAD stenting, basic dialysis access. Most that I know of don't really WANT to do most of this, but if they are not at an academic center and are private practice, many will do because there is a need and to supplement their income. But not all do it an you can avoid doing it as CTS if you really want to.

Thanks for the response! This might sound noobish but where do the CT guys learn how to do the more peripheral and endovascular stuff?

 

[LucidSplash]

Thanks for the response! This might sound noobish but where do the CT guys learn how to do the more peripheral and endovascular stuff?

Peripheral open stuff: a lot of the CTS guys who do this are old-school general surgery trained. So they did it in gen surg residency and then doing a fem-pop isn't that hard if you can do a cardiac anastamosis. Most of the ones I know aren't doing too many limb-salvage type bypasses with splice vein or distal pedal but then again not all vascular guys do that. As far as basic stenting, they pick it up from their colleagues who are already doing it. But they don't provide a full range of services like a vascular-trained surgeon would. They are generally dependent on their IR colleagues for catheter-directed lysis and the like.

Like I said. Most of the ones I know would prefer not to do it. It isn't what the like to do.

 

[ThoracicGuy]

Peripheral open stuff: a lot of the CTS guys who do this are old-school general surgery trained. So they did it in gen surg residency and then doing a fem-pop isn't that hard if you can do a cardiac anastamosis. Most of the ones I know aren't doing too many limb-salvage type bypasses with splice vein or distal pedal but then again not all vascular guys do that. As far as basic stenting, they pick it up from their colleagues who are already doing it. But they don't provide a full range of services like a vascular-trained surgeon would. They are generally dependent on their IR colleagues for catheter-directed lysis and the like.

Like I said. Most of the ones I know would prefer not to do it. It isn't what the like to do.

Indeed. Most cardiac surgeons go into because they want to do cardiac surgery. Some in private practice will need to do vascular to make ends meet, but that's a minority of surgeons. I agree with everything you've said here.

 

[Mitral_Prolapse]

Peripheral open stuff: a lot of the CTS guys who do this are old-school general surgery trained. So they did it in gen surg residency and then doing a fem-pop isn't that hard if you can do a cardiac anastamosis. Most of the ones I know aren't doing too many limb-salvage type bypasses with splice vein or distal pedal but then again not all vascular guys do that. As far as basic stenting, they pick it up from their colleagues who are already doing it. But they don't provide a full range of services like a vascular-trained surgeon would. They are generally dependent on their IR colleagues for catheter-directed lysis and the like.

Like I said. Most of the ones I know would prefer not to do it. It isn't what the like to do.

That makes sense, I'm sure they didn't bust their a$$ throughout residency and fellowship to be a CT surgeon just to end up doing peripheral artery work. I was more curious how they obtained the training to be able to do this but it makes sense that the general surgery pathway would probably gain them a decent vascular skillet for some procedures in addition to working with the great vessels.

 

[Mitral_Prolapse]

Indeed. Most cardiac surgeons go into because they want to do cardiac surgery. Some in private practice will need to do vascular to make ends meet, but that's a minority of surgeons. I agree with everything you've said here.

Crazy how they have to do that "to make ends meet"! What kind of cardiac procedures are they still doing in the community? Are they taking care of the thoracic/lung stuff too?

 

[ThoracicGuy]

Crazy how they have to do that "to make ends meet"! What kind of cardiac procedures are they still doing in the community? Are they taking care of the thoracic/lung stuff too?

Most cardiac surgeons do cardiac surgery with some also doing general thoracic. There are some, typically in smaller hospitals, that will add vascular as their volume of CT surgery might not be enough alone. It's rare to find in academics, though not unheard of.

 

[LucidSplash]

Crazy how they have to do that "to make ends meet"! What kind of cardiac procedures are they still doing in the community? Are they taking care of the thoracic/lung stuff too?

My CTS partner at our satellite hospital does CABG (both open and minimally invasive but not robotic), AVR/MVR, general thoracic as well as cancer cases, AFib ablation if failed percutaneous measures. He also has privileges at the mothership downtown though (as we all do), and will do his ascending aneurysm/combo AVRs downtown. He doesn’t do vascular because he has 2 partners that are. My friend from residency who is PP, does all of the above plus carotids, peripheral bypass work, open AAA.

 

[Mitral_Prolapse]

My CTS partner at our satellite hospital does CABG (both open and minimally invasive but not robotic), AVR/MVR, general thoracic as well as cancer cases, AFib ablation if failed percutaneous measures. He also has privileges at the mothership downtown though (as we all do), and will do his ascending aneurysm/combo AVRs downtown. He doesn’t do vascular because he has 2 partners that are. My friend from residency who is PP, does all of the above plus carotids, peripheral bypass work, open AAA.

Are hospitals typically ok with CT guys like your friend doing vascular work?

 

[Jolie South]

Are hospitals typically ok with CT guys like your friend doing vascular work?

It depends on what the standard is. Where I live now, a midsize metropolitan area, cardiac surgery does everything bc that’s all there is. It’s an abomination but that is our “standard of care.”

 

[LucidSplash]

Are hospitals typically ok with CT guys like your friend doing vascular work?

He works at non-academically affiliated hospitals within the Houston suburbs. There aren’t any vascular surgeons at those hospitals so he takes vascular call when he is on for CTS call. It’s either that or try to transfer everything to TMC but that loses the hospitals money so they’d rather keep it inhouse.

 

[Mitral_Prolapse]

This has been extremely informative, thank you all!

 

[Circ Arrest]

There are a lot of overlapping skill sets in cardiac surgery and vascular surgery and its very translatable. A blood vessel is a blood vessel. You sew a graft to the axillary artery the same way whether you are doing an ax-fem bypass or an axillary cannulation. Sewing a vascular anastomosis is a fundamental skill set that you will find necessary in a lot of fields of surgery. Cardiac, vascular, thoracic, transplant, and surgical oncology. I would say that most graduate from general surgery residency knowing how to sew from point A to point B. Once you get into the more advanced endovascular work then I think most cardiac surgeons would feel a little bit out of their element. Basic, straight forward stuff, maybe, but not anything complex. A lot of vascular surgery is taking care of the disease process and the judgement that comes along with it.

 

[Circ Arrest]

This is a good recent discussion by some of the folks at Methodist hospital about the current training paradigms.

 

[Jolie South]

There are a lot of overlapping skill sets in cardiac surgery and vascular surgery and its very translatable. A blood vessel is a blood vessel. You sew a graft to the axillary artery the same way whether you are doing an ax-fem bypass or an axillary cannulation. Sewing a vascular anastomosis is a fundamental skill set that you will find necessary in a lot of fields of surgery. Cardiac, vascular, thoracic, transplant, and surgical oncology. I would say that most graduate from general surgery residency knowing how to sew from point A to point B. Once you get into the more advanced endovascular work then I think most cardiac surgeons would feel a little bit out of their element. Basic, straight forward stuff, maybe, but not anything complex. A lot of vascular surgery is taking care of the disease process and the judgement that comes along with it.

I agree that the open surgical skills translate, but the whole paradigm of vascular is shifting more and more to endovascular. So i feel like someone that can't offer those options is really behind and shouldn't be taking primary peripheral vascular call. Even limb salvage, I am of the belief that endo attempts in most cases are first line. And interventionalists that don't have that in their tool box...if all you have is a hammer, everything is a nail. Be that cardiology doing only endo limb salvage or cardiac surgeons who don't have endovascular skills.

I might be bitter because I work in an environment that is cardiac surgery "leading" limb salvage. They frequently say if there is disease below the trifurcation, there is nothing to do and recommend amputation. IR doesn't want to do tibial endo work either. So the patients get amps by general surgeons for disease that is treatable. And no one follows these patients to surveil them after bypass/endo intervention.

I had surgery last week and asked IR to help do an angio while I was recovering. Disease was tibial; single vessel diseased AT runoff, but not CTO. They did a diagnostic study only, did not attempt to intervene and demanded a CTA before even doing that. So on POD3 from my own personal surgery, I was up and freaking doing atherectomy and PTA of the lesions to save the foot. In addition, the patient got extra radiation, contrast loads, and procedures that were unnecessary. THIS S*&T IS STRAIGHT MALPRACTICE.

 

[Mitral_Prolapse]

That video was very insightful into a lot of my questions. Although the one surgeon did both a CT and Vasc fellowship after GS (talk about a long road!) it sound sounds like in the community setting, it is not entirely necessary to be boarded in vasc do some peripheral work as a CT surgeon.

 

[deleted50541]

When I interviewed at one three-year CT program for fellowship, you took vascular call along with CT so that some vascular was integrated into your training. But this was the exception. I'd be curious to know how many people in training these days have an interest in peripheral vascular disease.

We did very limited procedures below the arch outside of TEVAR in my training. Any open thoraco-abdominal work we did was combined with the vascular surgeons. The cardiac guys who trained me talked about how they did a lot of peripheral vascular work 15+ years ago until vascular took over. They were plenty busy now and didn't seem to mind not doing it anymore.

 

[dodolol21]

This is a good recent discussion by some of the folks at Methodist hospital about the current training paradigms.

@TypeADissection @LucidSplash interested to hear what you think about training cardiovascular surgeons who are double boarded in CTS/VS. For those who are interested in all vascular work and not as interested in cancer/lung/esophagus work, this seems like the perfect pathway

 

[LucidSplash]

@TypeADissection @LucidSplash interested to hear what you think about training cardiovascular surgeons who are double boarded in CTS/VS. For those who are interested in all vascular work and not as interested in cancer/lung/esophagus work, this seems like the perfect pathway

I think it is perfectly fine if that’s what one wants to do. Just not many people that are interested in that.

 

[Mitral_Prolapse]

I think it is perfectly fine if that’s what one wants to do. Just not many people that are interested in that.

What do you personally think is the best pathway for that? Considering not everyone may be competitive for I6 or V5...

 

[LucidSplash]

What do you personally think is the best pathway for that? Considering not everyone may be competitive for I6 or V5...

Best? I mean whatever works for you. If you aren’t competitive for integrated, then you’ll need to do GenSurg and then pick which fellowship you think you’d be most happy with if you only get to do one. Because a lot of people will burn out before doing the 2nd fellowship or maybe not get in.

I’m really not the best to speak on this because it was never an interest of mine. I have a couple partners who did it (but who work at different hospitals and I don’t know them well). One of my residents is thinking about doing it. But I don’t think I can give any meaningful advice on the topic.

 

[TypeADissection]

@TypeADissection @LucidSplash interested to hear what you think about training cardiovascular surgeons who are double boarded in CTS/VS. For those who are interested in all vascular work and not as interested in cancer/lung/esophagus work, this seems like the perfect pathway

The impression that I've gotten along the way is that cardiac surgeons really don't want to do vascular surgery. They don't want to take vascular call and deal with cold legs, failing fistulas, and ruptures. The other thing is how you're going to maintain both practices. Do you see yourself in an environment where you're taking 10-15 days of call a month in a community hospital alternating between CTS and VS? Because the reality of doing both would be difficult in an academic setting with divisional politics and arranging call schedules and clinics between multiple partners.

Ex: Let's say you're in the middle of a 3-vessel CABG w/ AVR. Someone then calls you and says that the fem-distal you did 3 months ago is now in the ED w/ a cold leg. Or you're doing a wedge resection and MARS line wants to transfer an infected aortic endograft. The reality is very few people want the full gamut of both cardiac and vascular. The knowledge bases are different and the clinical decision making is very nuanced. So as Ron Swanson once said, "Never half ass two things. Whole ass one thing." There may be a handful of dudes/dudettes out there who truly do both and more power to them. My suspicion is that those who do an integrated VS and then continue on to CTS, will most likely end up staying predominantly in the chest. But what do I know? I'm just a random, incredibly goodlooking and talented vascular surgery fellow who is also extraordinarily humble. Hope this helps. Cheers.

 

[Jolie South]

The impression that I've gotten along the way is that cardiac surgeons really don't want to do vascular surgery. They don't want to take vascular call and deal with cold legs, failing fistulas, and ruptures. The other thing is how you're going to maintain both practices. Do you see yourself in an environment where you're taking 10-15 days of call a month in a community hospital alternating between CTS and VS? Because the reality of doing both would be difficult in an academic setting with divisional politics and arranging call schedules and clinics between multiple partners.

Ex: Let's say you're in the middle of a 3-vessel CABG w/ AVR. Someone then calls you and says that the fem-distal you did 3 months ago is now in the ED w/ a cold leg. Or you're doing a wedge resection and MARS line wants to transfer an infected aortic endograft. The reality is very few people want the full gamut of both cardiac and vascular. The knowledge bases are different and the clinical decision making is very nuanced. So as Ron Swanson once said, "Never half ass two things. Whole ass one thing." There may be a handful of dudes/dudettes out there who truly do both and more power to them. My suspicion is that those who do an integrated VS and then continue on to CTS, will most likely end up staying predominantly in the chest. But what do I know? I'm just a random, incredibly goodlooking and talented vascular surgery fellow who is also extraordinarily humble. Hope this helps. Cheers.

First off, a cardiac surgeon wouldn’t do a fem distal. But beyond that, this is exactly what happens. “Oh sorry that patient in the ED is bleeding to death from an infected fistula, but I am in an elective CABG at hospital across the street. You’ll have to figure it out. Oh you can’t? Call IR.“

It is criminal.

 

[dodolol21]

The impression that I've gotten along the way is that cardiac surgeons really don't want to do vascular surgery. They don't want to take vascular call and deal with cold legs, failing fistulas, and ruptures. The other thing is how you're going to maintain both practices. Do you see yourself in an environment where you're taking 10-15 days of call a month in a community hospital alternating between CTS and VS? Because the reality of doing both would be difficult in an academic setting with divisional politics and arranging call schedules and clinics between multiple partners.

Ex: Let's say you're in the middle of a 3-vessel CABG w/ AVR. Someone then calls you and says that the fem-distal you did 3 months ago is now in the ED w/ a cold leg. Or you're doing a wedge resection and MARS line wants to transfer an infected aortic endograft. The reality is very few people want the full gamut of both cardiac and vascular. The knowledge bases are different and the clinical decision making is very nuanced. So as Ron Swanson once said, "Never half ass two things. Whole ass one thing." There may be a handful of dudes/dudettes out there who truly do both and more power to them. My suspicion is that those who do an integrated VS and then continue on to CTS, will most likely end up staying predominantly in the chest. But what do I know? I'm just a random, incredibly goodlooking and talented vascular surgery fellow who is also extraordinarily humble. Hope this helps. Cheers.

First off, a cardiac surgeon wouldn’t do a fem distal. But beyond that, this is exactly what happens. “Oh sorry that patient in the ED is bleeding to death from an infected fistula, but I am in an elective CABG at hospital across the street. You’ll have to figure it out. Oh you can’t? Call IR.“

It is criminal.

Thanks you guys these are both great perspectives. It brings up the question though that couldn't that scenario happen to several surgical subs in their own specialty? i.e. can't you be a vascular surgeon performing an elective case at a hospital across the street and get a call about fem-distal you did 3 months ago that's now in the ED with a cold leg?

Also, how about in private practice, where you are really doing bread and butter cardiac and vascular surgery, and sending complex cases in both to specialized centers. I don't think anyone who does 0+5/CTS is planning to practice the whole gamut of both fields, rather building the skills to ultimately be proficient in treating pathologies via medical, end, and open approaches. Additionally, would you have to take call in both fields? My understanding is that could vary depending on your hospital/program setting.

 

[Jolie South]

Thanks you guys these are both great perspectives. It brings up the question though that couldn't that scenario happen to several surgical subs in their own specialty? i.e. can't you be a vascular surgeon performing an elective case at a hospital across the street and get a call about fem-distal you did 3 months ago that's now in the ED with a cold leg?

This is true. I am basing this on my local experience. However, when they say to talk to their partners, conveniently the partners are also doing a CABG/valve at the same time making virtually no one available.

When you start an elective CABG, the surgeon is committed for 4 h. Unless you are doing complex open or endo aortic work, most vascular cases are not that long. And if I was in a case, I would say start the patient on heparin, I will be there in x time when I finish the case, board it with OR, keep NPO. If I thought for whatever reason I couldn’t be out in an appropriate amount of time I would call my resident and have a colleague see the patient.

I have, in my local experience, never seen a CABG bumped so they can do a vascular case. ‍♀️

 

[SpliceOfLife]

I met a cardiac surgeon who started doing some peripheral vascular work and obtained certification through the American Board of Vascular Medicine.

ABVM - Requirements

It can be helpful for employment in some settings. This certification is probably not meant to be comparable to that offered by the ABS so you will never replace a peripheral vascular surgeon. However, you can learn some things and expand the current scope of your CTS practice.

 

[Jolie South]

I met a cardiac surgeon who started doing some peripheral vascular work and obtained certification through the American Board of Vascular Medicine.

ABVM - Requirements

It can be helpful for employment in some settings. This certification is probably not meant to be comparable to that offered by the ABS so you will never replace a peripheral vascular surgeon. However, you can learn some things and expand the current scope of your CTS practice.

ABVM is a medical board certification.

Medicine doctors get that. I don’t see how it helps you know endo or hybrid techniques.

 

[SpliceOfLife]

ABVM is a medical board certification.

Medicine doctors get that. I don’t see how it helps you know endo or hybrid techniques.

There are 2 different pathways. The ABVM Endovascular pathway includes a practice training pathway to certify non-vascular surgeons interested in peripheral procedures. You are thinking of the ABVM General pathway. Both are on the webpage.

 

[ThoracicGuy]

There are 2 different pathways. The ABVM Endovascular pathway includes a practice training pathway to certify non-vascular surgeons interested in peripheral procedures. You are thinking of the ABVM General pathway. Both are on the webpage.

Specifically for endovascular work. This does not certify anything for traditional surgical procedures. I'm not sure how much relevance this would actually have to getting a job.

 

[oldiebutgoodie1211]

I agree that the open surgical skills translate, but the whole paradigm of vascular is shifting more and more to endovascular. So i feel like someone that can't offer those options is really behind and shouldn't be taking primary peripheral vascular call. Even limb salvage, I am of the belief that endo attempts in most cases are first line. And interventionalists that don't have that in their tool box...if all you have is a hammer, everything is a nail. Be that cardiology doing only endo limb salvage or cardiac surgeons who don't have endovascular skills.

I might be bitter because I work in an environment that is cardiac surgery "leading" limb salvage. They frequently say if there is disease below the trifurcation, there is nothing to do and recommend amputation. IR doesn't want to do tibial endo work either. So the patients get amps by general surgeons for disease that is treatable. And no one follows these patients to surveil them after bypass/endo intervention.

I had surgery last week and asked IR to help do an angio while I was recovering. Disease was tibial; single vessel diseased AT runoff, but not CTO. They did a diagnostic study only, did not attempt to intervene and demanded a CTA before even doing that. So on POD3 from my own personal surgery, I was up and freaking doing atherectomy and PTA of the lesions to save the foot. In addition, the patient got extra radiation, contrast loads, and procedures that were unnecessary. THIS S*&T IS STRAIGHT MALPRACTICE.

did you report them to anyone?

 

[Jolie South]

did you report them to anyone?

I have not. Standard of care is defined by the environment that you practice in. Where I am this is what happens and how patients get care. ALL OVER TOWN. It doesn’t make it right, but that’s the bar you are judged against.

I am trying to take over the world by educating referring physicians and taking as many direct consults as I can, even if they are the most redo redo garbage. So people understand this isn’t how we do this.

 

[oldiebutgoodie1211]

I have not. Standard of care is defined by the environment that you practice in. Where I am this is what happens and how patients get care. ALL OVER TOWN. It doesn’t make it right, but that’s the bar you are judged against.

I am trying to take over the world by educating referring physicians and taking as many direct consults as I can, even if they are the most redo redo garbage. So people understand this isn’t how we do this.

if you don’t report him, you are implicitly saying that you are ok with your mother or daughter receiving that kind of care..if that’s true then good, otherwise there needs to be a report even if no change comes from it in the short term

 

[Jolie South]

if you don’t report him, you are implicitly saying that you are ok with your mother or daughter receiving that kind of care..if that’s true then good, otherwise there needs to be a report even if no change comes from it in the short term

I can report them to hospital admin, but they already know this is happening. I am implicit in nothing. That’s why I am there. To take away the peripheral business and improve limb salvage outcomes. There have been complaints over and over from trauma and general surgery about their management.

 

[Triple_AAA]

Would it be possible if you were boarded in both CT and Vasc to do the endovascular work in addition to the open CT and Vasc cases? Would a hospital allow this or is it something you need to be in private practice for?

For example would you find a surgeon doing an angio for PAD, an open aortic valve replacement, CABGs and an open or endovascular AAA repair all part of their skill set?

Sorry for asking such noob question

 

[SociableJimmy]

Would it be possible if you were boarded in both CT and Vasc to do the endovascular work in addition to the open CT and Vasc cases? Would a hospital allow this or is it something you need to be in private practice for?

For example would you find a surgeon doing an angio for PAD, an open aortic valve replacement, CABGs and an open or endovascular AAA repair all part of their skill set?

Sorry for asking such noob question

I know if a couple dual-boarded CT/vascular attendings - John Kern at UVA and Marvin Atkins at Methodist - can’t really say exactly how they’ve shaped their practice however. I imagine dual-boarding tailors itself well to complex aortic work.

 

[TypeADissection]

I know if a couple dual-boarded CT/vascular attendings - John Kern at UVA and Marvin Atkins at Methodist - can’t really say exactly how they’ve shaped their practice however. I imagine dual-boarding tailors itself well to complex aortic work.

I'm fairly certain I've commented on this before on a different post, but I'm gonna go out on a pretty sturdy limb here and say that anyone who is dually boarded by both STS and SVS, will predominantly be doing more cardiac cases than vascular cases. They'll do their CEAs, EVARs along with their bread and butter CABGs and valves. For anyone, regardless of training, wanting to do complex aortic work, you're gonna need a good referral base usually in an academic setting to get the steady flow of cases to keep your skills and the ICU sharp.

 

[Billroth_III]

This residency comes to mind:

Vascular Surgery Residency Program | AHN

Learn more about the AHN Vascular Surgery Residency Program, including application information, faculty, curriculum, and contact information.

www.ahn.org

Wouldn't mind hearing what some of the attendings, fellows and residents think of this type of program.

 

[KaBoom'd]

Would it be possible if you were boarded in both CT and Vasc to do the endovascular work in addition to the open CT and Vasc cases? Would a hospital allow this or is it something you need to be in private practice for?

For example would you find a surgeon doing an angio for PAD, an open aortic valve replacement, CABGs and an open or endovascular AAA repair all part of their skill set?

Sorry for asking such noob question

The vascular surgery fellowship PD at the University of Tennessee in Memphis does nearly 50/50 cardiac and peripheral vascular. He's now solo private practice. I know he has done all of the above cases in a week. He regularly does CABGs, endovascular, open peripheral vascular, and TAVRs in the same day. There is at least one other younger surgeon at that hospital, also private practice, that is dual boarded and doing both but I don't know his mix of case volume. He's still doing transplants so I assume he leans cardiac, but he also teaches vascular fellows so maintains some peripheral vascular work.

 

[Mitral_Prolapse]

The vascular surgery fellowship PD at the University of Tennessee in Memphis does nearly 50/50 cardiac and peripheral vascular. He's now solo private practice. I know he has done all of the above cases in a week. He regularly does CABGs, endovascular, open peripheral vascular, and TAVRs in the same day. There is at least one other younger surgeon at that hospital, also private practice, that is dual boarded and doing both but I don't know his mix of case volume. He's still doing transplants so I assume he leans cardiac, but he also teaches vascular fellows so maintains some peripheral vascular work.

This has been more or less my main interest (coming from someone who hasn't even started rotations yet). I just love the whole vascular system and love the idea of being able to treat / handle problems (outside the brain) that affects it with open surgery or endovascular techniques in the peripheral vascular system.

 

[Mitral_Prolapse]

I'm fairly certain I've commented on this before on a different post, but I'm gonna go out on a pretty sturdy limb here and say that anyone who is dually boarded by both STS and SVS, will predominantly be doing more cardiac cases than vascular cases. They'll do their CEAs, EVARs along with their bread and butter CABGs and valves. For anyone, regardless of training, wanting to do complex aortic work, you're gonna need a good referral base usually in an academic setting to get the steady flow of cases to keep your skills and the ICU sharp.

Thank you for your response, the consensus I am getting from this thread that it is absolutely possible just a very long road and not necessarily the most popular route people are willing to take.

 

[Mitral_Prolapse]

This residency comes to mind:

Vascular Surgery Residency Program | AHN

Learn more about the AHN Vascular Surgery Residency Program, including application information, faculty, curriculum, and contact information.

www.ahn.org

Not my area of interest but wouldn't mind hearing what some of the attendings, fellows and residents think of this type of program.

I'm sure that program is extremely competitive but I don't know much lol. Plus I would think having the general surgery training would put you at an overall advantage for the open thoracic cases you will encounter in the CT fellowship years. I was once told that going through general surgery really makes you a well-rounded surgeon but would love to hear what others have to say too.

 

[TypeADissection]

There were a handful of integrated vascular residents that I met that were either applying or already had matched into a CTS fellowship. It seemed like their intent was to own the entire aortic arch and be able to provide the full gamut of surgery as one person, as well as do CABGs (and why the hell not - I friggin love CABGs). As stated before, I think this is the ideal route if one aspired to do such a practice. If thoracic work is not your jam then hopefully you're in a situation where you have partners who are already committed to providing the best thoracic care. Once you leave the cities, it really does seem like the field really opens up in regards to what you're allowed to do in a community setting.

I have had a rather skewed experience with CTS surgeons doing peripheral work. Poor judgment. Inadequate understanding of pathology and disease process of infrainguinal atherosclerotic disease. They angio anybody and everybody that walks through the door and promise things like, "Hey you're going down to Florida for the winter to do some golfing. Come see me and I can touch up your arteries with a balloon so you can walk better." Next thing you know, they've dissected, had to bailout stent, jailed out the profunda, occluded CFA with closure devices. Do they bother to fix it? Nah. They send it down to the university and now I'm the ***** doing the case at 2100 on a Friday night. I've seen this practice take claudicants who just need an exercise program and reassurance, and now their leg is in a bucket because they hastened the disease process. Or the number of redo CEAs/TCARs I've done because they do piss poor CEAs the first time and leave a bad distal endpoint. Now they come to me and are super pissed because they just had surgery less than a year ago. I just want surgeons who are committed to the patient. Rant over. Cheers.

 

[Billroth_III]

There were a handful of integrated vascular residents that I met that were either applying or already had matched into a CTS fellowship. It seemed like their intent was to own the entire aortic arch and be able to provide the full gamut of surgery as one person, as well as do CABGs (and why the hell not - I friggin love CABGs). As stated before, I think this is the ideal route if one aspired to do such a practice. If thoracic work is not your jam then hopefully you're in a situation where you have partners who are already committed to providing the best thoracic care. Once you leave the cities, it really does seem like the field really opens up in regards to what you're allowed to do in a community setting.

I have had a rather skewed experience with CTS surgeons doing peripheral work. Poor judgment. Inadequate understanding of pathology and disease process of infrainguinal atherosclerotic disease. They angio anybody and everybody that walks through the door and promise things like, "Hey you're going down to Florida for the winter to do some golfing. Come see me and I can touch up your arteries with a balloon so you can walk better." Next thing you know, they've dissected, had to bailout stent, jailed out the profunda, occluded CFA with closure devices. Do they bother to fix it? Nah. They send it down to the university and now I'm the ***** doing the case at 2100 on a Friday night. I've seen this practice take claudicants who just need an exercise program and reassurance, and now their leg is in a bucket because they hastened the disease process. Or the number of redo CEAs/TCARs I've done because they do piss poor CEAs the first time and leave a bad distal endpoint. Now they come to me and are super pissed because they just had surgery less than a year ago. I just want surgeons who are committed to the patient. Rant over. Cheers.

What's your take on the integrated route vs GS first? Do you see a big difference in surgical/medical judgement and open case skill?

 

[TypeADissection]

What's your take on the integrated route vs GS first? Do you see a big difference in surgical/medical judgement and open case skill?

Short answer: No. There are merits to both and the traditional route will never completely go away to the same extent that plastics is going. Knowing what I know now, I would have gone integrated all the way from the very beginning. It's more time spent living, breathing and doing vascular. Spending time in clinic, in the vascular lab, in the OR. Sure I've opened hundreds of bellies in GS and fellowship, but it's nothing that an integrated resident can't do. There was a study that came out probably in the last year where they compared the two and integrated residents did better on in-service exams and traditional was more comfortable in the OR, or something like that. It all evens out in the end. Go integrated if you know you want to be a vascular surgeon. Doing hot gallbags, booby lumps and colons does little for you in the long run from a skills standpoint since everything is moving towards lap/robotic. Hope this helps. Cheers.

 

[ESU_MD]

The best cardiac surgeons are triple threats- cardiac, thoracic & vascular